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Hip and Knee Section, Prevention, Surgical Technique: Proceedings of International Consensus on Orthopedic Infections

Question 1: Does the use of a tourniquet influence the rates of surgical site infections/periprosthetic joint infections (SSIs/ PJIs) in primary or revision TKA? Recommendation: The literature is inconclusive regarding the use of tourniquet during total knee arthroplasty and its potential to increase the risks for surgical site infections/periprosthetic joint infections (SSIs/PJIs) in TKAs. Tourniquet times and pressures should be minimized to reduce this risk. Level of Evidence: Limited Delegate Vote: Agree: 89%, Disagree: 9%, Abstain: 2% (Super Majority, Strong Consensus) Rationale: The use of a pneumatic tourniquet during total knee arthroplasty (TKA) has long been a standard for this procedure. However, concerns have arisen over the ischemic injury that can occur from tourniquet use. This has prompted many authors to conduct studies evaluating the use and nonuse of a tourniquet and its effect on perioperative blood loss, postoperative pain and function, and postoperative complications [1e7]. However, many of these studies are small, randomized, controlled trials that lack the power to definitively state the influence of tourniquet use of surgical site infections (SSIs) and periprosthetic joint infections (PJIs). Liu et al [8] showed in a randomized controlled trial of 52 patients undergoing simultaneous bilateral TKA that tourniquet use was associated with greater wound ooze and blistering, as well as the only deep infection in the cohort occurring in a TKAcase that had been performed while using a tourniquet. In a 31- patient randomized controlled trial, Clarke et al [9] demonstrated that increased tourniquet pressures led to sustained wound hypoxia up to 1 week after surgery. A meta-analysis by Yi et al [6] evaluated 13 randomized controlled trials of tourniquet use comprising 859 patients. Of these 13 studies, 3 evaluated infection risk, SSI, and PJI together, and they found that tourniquet use was significantly associated with an increased risk of infection. A meta-analysis by Zhang et al [10] found a similar pooled result with tourniquet use associated with a greater risk of nonthrombotic complications, infection included. Longer tourniquet times, and by virtue longer surgical times, have been associated with an increased risk for both SSI and PJI [11-13]. Willis-Owen et al [11] in a series of 3449 consecutive TKA found that patients who went on to have a SSI/PJI had significantly longer tourniquet times than noninfected patients. Ricciardi et al [12] found a similar result in their analysis of perioperative variables affecting 30-day readmission. Na et al [14] evaluated early release of the tourniquet following cementation of components vs reinflation of the tourniquet after controlling bleeding in 206 patients and found that the increased tourniquet time for patients in the reinflation group did not affect the rate of wound complications, SSI, or PJI. However, none of these studies were able to propose a cutoff for tourniquet time over which the risk of SSI and PJI begins to increase. These studies also did not differentiate between operative time and tourniquet time. As increased surgical time is a known risk factor for SSI and PJI, the confounding effect of increased surgical time may be influencing the relationship between tourniquet time and postoperative infections. There is still much debate over the efficacy of tourniquet use to decrease perioperative blood loss. Ledin et al [15] conducted a randomized controlled trial on 50 consecutive TKAs on the use of a tourniquet and found no difference in calculated perioperative blood loss. The meta-analysis by Zhang et al [10] found that calculated blood loss was greater without the use of a tourniquet ; however, this did not result in a greater transfusion requirement. Conversely, a meta-analysis by Jiang et al [16] found that tourniquet use did decrease transfusion requirement in the pooled analysis of 1450 knees. As allogeneic blood transfusion is a known risk factor for SSI and PJI, limiting blood loss is an important aspect of infection prevention [17e20]. Another concern with the use of a tourniquet during TKA is whether appropriate antibiotic prophylaxis is administered to the surgical site. Friedman et al [21] evaluated soft tissue and bone concentrations of antibiotics given 1 minute, 2 minutes, and 5 minutes before tourniquet inflation and found the highest concentrations when antibiotics were administered 5 minutes before inflation. Yamada et al [22] found that when cefazolin was administered 15 minutes before inflation, the concentration in the bone and soft tissue at the surgical site was above the MIC90 for methicillin-sensitive Staphylococcus aureus, but below the MIC90 for cephazolin-resistant coagulase-negative staphylococcal species. Young et al [23] found that by administering antibiotic prophylaxis intraosseously, higher regional antibiotic concentrations could be achieved ; however, the clinical efficacy of this in reducing the rates of SSI and PJI still need to be evaluated. The effect that the use of a tourniquet has on the incidence of SSIs and PJIs after TKA has not been fully evaluated. The randomized controlled trials of this subject have been of small cohorts of patients that lack the power to evaluate these complications. The meta-analyses on this topic also have not been able to definitively comment, as many studies did not report the incidence of SSI and PJI in their cohorts. Moving forward, studies evaluating the use of a tourniquet during TKA should consider SSI and PJI as a secondary end point so that future pooled analyses may be better able to elucidate a connection, if one exists.

tourniquet, tourniquet time, tourniquet pressure, total knee arthroplasty, surgical approach

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