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Tourniquet failure during total knee replacement due to arterial calcification: case report and review of the literature.


The aim of tourniquet use during total knee replacement is to obtain as bloodless a field as possible to facilitate accurate dissection, optimise the bone-cement interface, and to reduce perioperative blood loss. Current practice involves the use of a pneumatic tourniquet which overlies the proximal part of the limb being operated on. It is inflated to a sufficient pressure above the patient's systolic blood pressure to occlude the artery supplying that limb (usually around 100mmHg above systolic for lower limb and 50mmHg above systolic for the upper limb). For total knee replacement surgery a tourniquet is therefore applied around the thigh to occlude the femoral artery.

Tourniquet use is not without risk: complications such as nerve paralysis (Shaw & Murray 1982), rhabdomyolysis (Shenton et al 1990) and pulmonary embolism (Berman et al 1998, Cohen et al 1994, McGrath et al 1991) have all been reported.

In the presence of arterial calcification tourniquets may not be able to completely occlude the arterial supply of the limb. A case is reported of tourniquet failure during total knee replacement in a patient with calcification in his femoral and popliteal arteries. The implications of using a tourniquet in such patients are highlighted, and awareness of the possibility of tourniquet failure, particularly during the preoperative assessment, is encouraged.


An 85 year old gentleman presented to the orthopaedic clinic with a two year history of bilateral knee pain, the left worse than the right. The pain was such that he required regular analgesia with paracetamol and ibuprofen, and his mobility was restricted. On examination both knees had reduced range of motion (right 10-130 degrees; left 10-120 degrees) and the left knee had 5 degrees of fixed varus alignment. Both dorsalis pedis and posterior tibial pulses were palpable bilaterally. Radiographs revealed severe degenerative changes in all compartments of both knees.

The patient had a history of myocardial infarction two years previously, followed by coronary artery bypass surgery the same year, and an abdominal aortic aneurysm repair done 15 years earlier. On preoperative assessment, he was noted to have no ongoing cardiac symptoms and had a good effort tolerance (New York Heart Association (NYHA) class II). His preoperative ECG was unremarkable and his other laboratory values, including a coagulation screen were also within the normal range. His regular medications included amlodipine, frusemide, ramipril, simvastatin, tamsulosin and aspirin.

One month after this presentation, the patient was scheduled for a left total knee replacement without patellar resurfacing using a Genesis II[TM] PCL (posterior cruciate ligament) sparing prosthesis (Smith & Nephew). An informed consent was obtained prior to surgery. After basic monitoring with pulse oximeter, noninvasive blood pressure monitor and ECG, a spinal anaesthetic was administered in the lumbar 4-5 interspace using a 25G pencil point needle and 2.8 mls of 0.5% heavy bupivacaine. A femoral block with 20mls of 0.375% levo-bupivacaine was performed under ultrasound guidance followed by a sciatic nerve block with 15 mls of 0.125% levo-bupivacaine for perioperative analgesia.

A thigh tourniquet was applied and inflated to 300mmHg after exsanguination of the limb. On commencing the operation the tourniquet was found to be ineffective leading to continued bleeding throughout the procedure. Suspecting a nonfunctioning tourniquet, the pump was replaced with a spare one with no improvement. Instead of brisk arterial bleeding, a slow capillary ooze persisted throughout the procedure. Surgery proceeded uneventfully, with an estimated blood loss of 1 litre at the end of the surgery. Postoperatively the foot pulses remained palpable and capillary refill time was less than 2 seconds. The tourniquet was checked following the procedure and was found to be functioning properly. Review of the preoperative (Figure 1) and postoperative (Figure 2) radiographs confirmed the presence of calcification in the popliteal and femoral vessels.



Tourniquets (from the French 'tourner' to turn--referring to the original screw device used by Jean Louis Petit) have been used for centuries to occlude blood flow to sites undergoing surgery. The modern pneumatic tourniquet was introduced by Harvey Cushing in the early 20th century (Cushing 1904). The aim of tourniquet use during total knee arthroplasty is to obtain a bloodless field in order to aid dissection, optimise the bone-cement interface, and to reduce blood loss.


Recent reports of tourniquet failure are rare in the literature, and this has possibly led to practitioners being less aware of the potential of failure and its consequences. Frequent causes of tourniquet failure are improper application, leak in the circuit, and faulty pressure gauges. Apparent tourniquet failure may also be due to medullary ooze (Fletcher & Healy 1983), which is due to failure of the tourniquet to compress medullary vessels within the bones, however this is rarely of significance. More commonly reported causes of failed tourniquets are calcified incompressible arteries due to atherosclerosis or Monckeberg's medial calcinosis (Jeyaseelan et al 1981, Bunker & Ratcliffe 1984). Deposition of calcium in the intimal layer of the vessels often occurs in atherosclerosis this is the most plausible reason as to why the patient in the current case had calcification in his femoral vessels. Atherosclerosis affects the entire arterial system and therefore, given his history of ischaemic heart disease and previous abdominal aortic aneurysm repair, some degree of peripheral vascular disease and arterial calcification may be expected.

Could the knee replacement have been done without a tourniquet? Abdel-Salam and Eyres (1995) found no significant difference in operating time or perioperative blood loss, and a reduction in postoperative complications including infection, postoperative pain and deep vein thrombosis (DVT) when total knee replacement was carried out without a tourniquet. Other studies have shown that tourniquet use increases postoperative wound hypoxia (Clark et al 2001) with possible consequent delayed healing and wound infection. These studies have given rise to the argument that knee arthroplasty may be safely carried out without tourniquet, and omission of the tourniquet may be beneficial. However, a recent study by Fukuda et al (2007) has shown that tourniquet use during knee replacement reduces blood loss and does not significantly increase the incidence of DVT. Similarly, Wakankar et al (1999) studied knee arthroplasty with or without tourniquet, and found no significant difference between the two groups with regards to surgical time, postoperative pain and swelling, blood loss into the drains, wound complications and DVT. Harvey et al (1997) have shown that tourniquet use does not produce any significant increase in DVT. These studies also suggest that surgery may be carried out without a tourniquet, however this is at the risk of increased blood loss and possible prolonged surgical time if difficulties are encountered in maintaining a bloodless field.

In many cases the benefit of not using a tourniquet may outweigh the risks, particularly in patients who have calcified arteries. In the event of not using a tourniquet and consequent anticipated blood loss, use of cell saver devices for autologous transfusion would be a viable option. Patients with arterial calcification may have undetected cardiac disease which is often manifest when the patient becomes anaemic due to operative blood loss. Cell saver use and autologous transfusion would therefore be of additional benefit in such patients in whom a tourniquet is not used by restoring some of the operative blood loss and minimising the risk of cardiac ischaemic events.

Is it dangerous to apply a tourniquet in presence of calcified vessels? Calcified vessels in the lower limb present a problem with regards to intraoperative tourniquet use. The consequences of calcified arteries and therefore failed tourniquets are myriad. Firstly, inability to compress the artery due to arterial calcification, whilst still occluding venous return may compound the bleeding. Release of tourniquet and proceeding with surgery without a tourniquet should be an option under these circumstances. Secondly, further increase in tourniquet pressures in the presence of arterial calcification poses the risk of fracture of the vessel. While this may remain a theoretical risk with no published report of this event, the concern is real and the consequences disastrous. Next, the calcified vessels may be susceptible to acute occlusion (Kumar et al 1998, Hagan & Kaufmann 1990) or aneurysm formation, ultimately leading to vascular compromise, acute ischaemia and possible amputation (Zahrani & Cuschieri 1989). Another concern with the use of tourniquet in the presence of calcified arteries is dislodgement of an atheromatous plaque therefore leading to distal arterial occlusion (Giannestras et al 1977).

A preoperative assessment should include vascular assessment of all patients listed for joint replacement, especially as increasingly older patients with vascular comorbidities are presenting for this frequently performed surgery. In addition to palpation of proximal and distal pulses, examination of the state of the skin, nails and hair, radiographic assessment of the vascular supply should be checked for visible calcification of arteries (Klenerman 1982). Presence of linear tram-track radio-opaque lesions along the course of an artery indicates intimal calcification (Raggi & Bellasi 2007). Ultrasound technology also can be used in the diagnosis of major arterial calcification and, together with radiological imaging, increases the yield of positive diagnosis of arterial calcification (Raggi & Bellasi 2007). In the presence of arterial calcification before major limb surgery, a vascular surgeon's opinion may be valuable to assess the capacity of the limb to withstand the stress imposed by a tourniquet (Klenerman 1982).


Practitioners must be aware of the possibility of tourniquet failure in patients with arterial calcification undergoing surgery. Unexpected tourniquet failure can lead to increased blood loss and prolonged surgical time. The benefits of tourniquet use in these patients must be balanced against the risks such as acute occlusion and ischaemia, aneurysm formation, and possible fracture of the vessel. Thorough preoperative assessment should identify patients at risk and allow planning for alternative perioperative management leading to safer outcomes in this high risk group. Perioperative management options in the presence of calcified arteries may include performing surgery without tourniquet and the use of a cell saver device and autologous transfusion.

KEYWORDS Tourniquet / Orthopaedics / Arterial calcification

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication October 2009.


Abdel-Salam A, Eyres KS 1995 Effects of tourniquet during total knee arthroplasty. A prospective randomised study Journal of Bone and Joint Surgery (British) 77 (20) 250-3

Berman AT, Parmet JL Harding SP, Israelite CL, Chanrasekaran K, Horrow JC, Singer R, Rosenberg H 1998 Emboli observed with use of transesophageal echocardiography immediately after tourniquet release during total knee arthroplasty with cement Journal of Bone and Joint Surgery (American) 80 (3) 389-96

Bunker TD, Ratcliffe AH 1984 Uncontrollable bleeding under tourniquet British Medical Journal 288 1905-6

Clark MT, Longstaff L, Edwards D, Rushton N 2001 Tourniquet-induced wound hypoxia after total knee replacement Journal of Bone and Joint Surgery (British) 83 (1) 40-4

Cohen JD, Keslin JS, Nili M, Yosipovitch Z, Gassner S 1994 Massive pulmonary embolism and tourniquet deflation Anesthesia & Analgesia 79 (3) 583-5

Cushing H 1904 Pneumatic tourniquets- with special reference to their use in craniotomies Medical News 84 557

Fletcher IR, Healy TEJ 1983 The arterial tourniquet Annals of the Royal College of Surgeons of England 65 (6) 409-17

Fukuda A, Hasegawa M, Kato K, Shi D, Sudo A, Uchida A 2007 Effect of tourniquet on deep vein thrombosis after total knee arthroplasty Archives of Orthopaedic and Trauma Surgery 127 671-5

Giannestras NJ, Cranley JJ, Lentz M 1977 Occlusion of the tibial artery after a foot operation under tourniquet Journal of Bone and Joint Surgery 59 682-3

Hagan PF, Kaufmann EE 1990 Vascular complication of knee arthroplasty under tourniquet. A case report Clinical Orthopaedics and Related Research 257 159-61

Harvey EJ, Leclerc J, Brooks CE, Burke DL 1997 Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty Journal of Arthroplasty 12 291-6

Jeyaseelan S, Stevenson TM, Pfitzner J 1981 Tourniquet failure and arterial calcification Anaesthesia 36 (1) 48-50

Klenerman L 1982 The tourniquet in operations on the knee: a review Journal of the Royal Society of Medicine 75 (1) 31-2

Kumar SN, Chapman JA, Rawlins I 1998 Vascular injuries in total knee arthroplasty. A review of the problem with special reference to the possible side effects of tourniquets Journal of Arthroplasty 13 (2)211-6

McGrath BG, Hsia J, Epstein B 1991 Massive pulmonary embolism following tourniquet deflation Anesthesiology 74 618-20

Raggi P, Bellasi A 2007 Clinical assessment of vascular calcification Advances in Chronic Kidney Disease 14 (1) 37-43

Shenton DW, Spitzer SA, Mulrennan BM 1990 Tourniquet-induced rhabdomyolysis Journal of Bone and Joint Surgery (American) 72-A (9) 1405-6

Shaw JA, Murray DG 1982 The relationship between tourniquet pressure and underlying soft-tissue pressure in the thigh Journal of Bone and Joint Surgery (American) 64 (8) 1148-52

Wakankar HM, Nicholl JE, Koka R, D'Arcy JC 1999 The tourniquet in total knee arthroplasty--A prospective randomised study Journal of Bone and Joint Surgery 81-B (1) 30-3

Zahrani HA, Cuschieri RJ 1989 Vascular complications after total knee replacement Journal of Cardiovascular Surgery 30 (6) 951-2

Miss Lynne Barr MA, MBBS, MRCS

Specialist Registrar, Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge

Dr Uma Shridhar Iyer MBBS, MD, Mmed

Associate Consultant, Anaesthesia, Alexandra Hospital, Singapore

Dr Anand Sardesai MBBS, MD, DA, FRCA

Consultant Anaesthetist, Cambridge University Hospital NHS Trust, Cambridge

Mr Jai Chitnavis MA MChir FRCS(Tr & Orth)

Consultant Orthopaedic Surgeon, University Hospitals, Cambridge

No competing interests declared

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Correspondence address: Miss Lynne Barr, Specialist Registrar, Department of Trauma & Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ.

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Title Annotation:CASE REPORT
Author:Barr, Lynne; Iyer, Uma Shridhar; Sardesai, Anand; Chitnavis, Jai
Publication:Journal of Perioperative Practice
Article Type:Case study
Date:Feb 1, 2010
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