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SURGICAL REVIEW

Tourniquet Vs Surgical Diathermy In Total Knee Arthroplasty
A Review Of Literature

 

* Dr. Gopinathan P

Asst Professor
Department of Orthopaedics, Medical College, Calicut.

Address for Correspondence

Dr. P Gopinathan,
Asst Professor, Department of Orthopaedics, Medical College, Calicut.
drpgopinath@yahoo.com

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 reduce infection. 

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 pain.(5) 

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 al.(6) 

 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 infection.(9) 

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 patient.(9-10)

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 surgical diathermy.

References:

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; 12(3): 291-6.
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

 

 

 

 This is a peer reviewed paper 

Please cite as :

P Gopinathan,
Tourniquet Vs Surgical Diathermy In Total Knee Arthroplasty
A Review Of Literature
J.Orthopaedics 2004;1(2)e5

URL: http://www.jortho.org/2004/1/2/e5

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