Dr. Gopinathan P
Department of Orthopaedics, Medical College, Calicut.
Address for Correspondence
Dr. P Gopinathan,
Asst Professor, Department of Orthopaedics, Medical College,
Tourniquet is complimentary in TKR even
though it is not a must. Wakankar HM et al in their study
concluded that tourniquet is safe in TKR and the current
practice of using it should be continued.(1) Barwell et al
concluded in their study that tourniquet should be routinely
used in TKR.(2)
Use of tourniquet will not lead to haematoma or post operative
swelling. There is no increase of post operative pain, DVT or
wound complications.(1) Since there is no chance of haematoma
formation, there are no favourable media for the bacteria to
multiply and establish infection. Hence tourniquet use will
The argument that tourniquet use will lead to DVT is not
correct.(1) Harvey EJ et al in their study concluded that DVT
not related to tourniquet use.(3) In fact, Aglietti P et al.(4)
have concluded that tourniquet increases fibrinolysis and leads
to reduction of chances of DVT. Applying tourniquet with lower
pressure than normal is sufficient in TKR.(5) Reduction of the
pressure in tourniquet leads to reduction in post operative
Tourniquet use will not increase Reactive Oxygen Species injury
(ROS). (Ischaemic injury), because ischaemic pre condition
reduces tissue injury. This is the conclusion from Cheng YJ et
The claim that suction drain should be discouraged in TKR
because of wound complications is not correct. Seyfort et al (7)
in their study concluded that suction drain usage will not
increase wound complications.
So the use of tourniquet(1,2,3,4,5,7,8) and suction drain(7) are
highly beneficial in TKR. More over, CDC (Centre for Disease
Control) has strongly recommended restriction and if possible
abandoning of surgical diathermy in any surgery to reduce
chances of infection.(9) Surgical diathermy , which is used to
cut or coagulate tissues produces a temperature of around 1000
degrees(10) which really kills, cooks Up & burns the tissues.
This produces a medium around the prosthesis which is something
like a cooked meat media. Surgical diathermy causes considerable
tissue damage which is produced by deliberate heating.(10) The
dead tissue in any surgical wound increases chance of
CDC(9) continues to state that surgeon's skill is the most
important factor to reduce infection and he should not produce
devitalization of the tissues during surgery. A surgeon trained
with cauterized TKR will continue to do so in his life time.
Similarly a surgeon well trained with non cauterized TKR will
continue to do it. The CDC states that a surgeon with a bad
habit acquired during his training will rarely change his
habit.(9) The cautery makes the surgery easy by increasing the
surgeons comfort, but is definitely harmful for the
The final conclusion is that, while a surgeon skilled in doing
TKR without cautery should continue that practice, a surgeon who
is not not well versed with this technique should continue to
use cautery till he gets adequate exposure to do it without
1) Wakanakar HM, Nicholl JE, Koka R, D'Arcy JC. The tourniquet
in total knee arthroplasty : A prospective randomized study.
JBJS Br. 1999; 81(5): 932-4
2) Barwell J, Anderson G, Hassan A, Rawlings I, Barwell NJ. The
effects of early tourniquet release during total knee
arthroplasty : a prospective randomized double-blind study. JBJS
Br. 1997; 79(4): 693.
3) Harvey EJ, Leclere J, Brooks CE, Burke DL. Effect of
tourniquet use on blood loss and incidence of deep vein
thrombosis in total knee arthroplasty. J Arthroplasty. 1997;
4) Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M.
Effects of tourniquet use on activation of coagulation in total
knee replacement. Clin. Orthop. 2000 Feb. (371): 169-77.
5) Manen Berga P, Novellas Canosa M, Angles Crespo F, Bernal
Dzekonski J. Effect of ischaemic tourniquet pressure on the
intensity of post operative pain. Rev Esp Anestesiol Reanim
2002, 49(3): 131-5.
6) Cheng YJ, Chien CT, Chen CF. Oxidative stress in bilateral
total knee replacement, under ischaemic tourniquet. J BJS Br.
2003; 85(5): 679-82.
7) Seyfert C, Schulz K, Pap G. The influence of the drain in
knee arthroplasty. Zentralbl Chir. 2002; 127(10): 886-9.
8) Vandenbussche E, Duranthon LD, Couturier M, Pidhorz L,
Augereau B. The effect of tourniquet use in total knee
arthroplasty. Int. Orthop. 2002; 6(5): 306-9. Epub 2002; Aug.02.
9) Julia S, Garner RN. MN Hospital Infections Program Centres
for Infectious Diseases Centre for Disease Control. http://wonder.cdc.gov.
Guideline for prevention of surgical wound infections, 1985.
10) Surgical diathermy. www3.oup.co.uk/bjarev/hdb/Volume_03/Issue_01