Tips for Arthroscopic Anterior Cruciate Reconstruction without the Tourniquet^*

Abstract

The arthroscopic reconstruction of the anterior cruciate ligament is a common surgery performed by the orthopedic surgeons willing to restore the knee stability of physically active patients. Despite the fact that it is usually an uneventful procedure, surgeons must always look for better post-operative results; in this scenario, the arthroscopic reconstruction of the anterior cruciate ligament without a tourniquet is a promising alternative. The aim of the present paper is to share with other orthopedic surgeons around the world our experience with this procedure and some technical tips that may be helpful.

Keywords
anterior cruciate ligament reconstruction; tourniquets; anterior cruciate ligament injuries

Resumo

A reconstrução artroscópica do ligamento cruzado anterior é uma cirurgia comum realizada pelos cirurgiões ortopédicos dispostos a restaurar a estabilidade do joelho de pacientes fisicamente ativos. Apesar de ser geralmente um procedimento sem intercorrências, os cirurgiões devem sempre procurar melhores resultados pós-operatórios; neste cenário, a reconstrução artroscópica do ligamento anterior sem torniquete é uma alternativa promissora. O objetivo deste artigo é compartilhar com outros cirurgiões ortopédicos ao redor do mundo nossa experiência com este procedimento e algumas dicas técnicas que podem ser úteis.

Palavras-chave
reconstrução do ligamento cruzado anterior; torniquetes; lesões do ligamento cruzado anterior

Introduction

The arthroscopic reconstruction of the anterior cruciate ligament (ARACL) is one of the most performed orthopedic surgeries. In the Unites States, the incidence of ARACL is estimated to be over 130 thousand,¹ and it may reache over than 400 thousand worldwide.

The main goals of the ARACL are to restore knee stability and enable patients to return without restrictions to sports and daily life activities. Reaching these goals with diminished iatrogenic complications should be an effort made by all orthopedic surgeons.

Recently, ARACL without a tourniquet became an emerging trend worldwide, since the operative time does not seem to increase,^2,3 and the patients seem to fare better in the early pos-operative weeks.^4,5 The supposed benefits of the reconstruction without a tourniquet are an earlier recovery of quadriceps strength, smaller thigh girth atrophy,⁴ decreased blood loss,² smaller postoperative pain,⁶ and fewer electromyographic effects.⁵ The use of the tourniquet was also associated to postoperative tibial, femoral, and saphenous nerve palsy.^7,8

In the last few years, due to the logistic difficulties in having a good working tourniquet in a public hospital in a developing country, our team performed a few ARACLs without tourniquets. Our anecdotal experience is similar to that of some other groups: patients subjected to an ARACL without tourniquet fare better than the ones subjected to the same procedure with a tourniquet.

Despite the potential benefits of the ARACL without a tourniquet, the perioperative period can be tricky due to the intra-articular bleeding, especially after drilling the bone tunnels. Blood makes it almost impossible for the surgeon to identify the structure in the first few minutes, and for those not prepared for this scenario the surgery may become strenuous. It is our intention with the present paper to share some tips acquired with the forced experience we have had, and maybe in the near future better trials comparing ARACL with or without the use of a tourniquet will help the orthopedic surgeon in the clinical decision.

Surgical Technique

Our tips are:

• Start trying with a deflated tourniquet in place, and, whenever you fill uncomfortable, inflate the tourniquet and go ahead.

• When harvesting the hamstring autograft, be sure to cut all of the vincula, and split the semitendinosus and the gracillis from the sartorius fasciae before using the tendon striper.

• Keep away from the Hoffa fat-pad as much as possible. The anterolateral portal should be made high and tight, the anteromedial portal should be made a bit more medial than usual.

• Be patient. The surgeon must keep calm throughout the first few minutes of bleeding. It will get better.

• Increase the pressure and the flow in the saline pump. If you do not use a pump, place the saline bag as high as possible.

• Cold saline is also a good option to decrease the bleeding

• Endovenous tranexamic acid (1 g) may be helpful.

• Prefer to shave the ligamentum mucosum instead of shaving the Hoffa fat-pad.

• Adrenaline at 1mg for each 1L of saline may be helpful, mainly in the first few minutes. If necessary, 1mg of adrenaline directly in the joint will definitely help.

• Start with the arthroscopic steps that do not require shaving of the synovia: inspection and meniscal tears.

• Avoid unnecessary bone shaving or bone curettage.

• Place both tibial and femoral guide pins in the desired location before drilling the bone tunnels.

• If you chose a femoral outside-in technique, try to not open thee capsule with the scalp.

• If you have chosen a transportal technique, start with the tibial guide pin before flexing the knee to place the femoral guide pin.

• Always start by drilling the femoral tunnel.

Final Considerations

Despite the fact that most surgeons do no0t feel comfortable with the ARACL without a tourniquet, it is a feasible and safe procedure that has potential short-term benefits to the patients. These elementary technical tips, will surely make the surgery easier and the surgeons more confident to no longer use the tourniquet.

• *
  Work performed at Hospital do Servidor Público Municipal, Aclimação, São Paulo, SP, Brazil.

References

• ¹
  Mall NA, Chalmers PN, Moric M, et al. Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med 2014;42(10):2363–2370
• ²
  Kuo LT, Yu PA, Chen CL, Hsu WH, Chi CC. Tourniquet use in arthroscopic anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials. BMC Musculoskelet Disord 2017;18(01):358–358
• ³
  Wu H, Chen LX, Li YL, et al. Tourniquet used in anterior cruciate ligament reconstruction: a system review. Eur J Orthop Surg Traumatol 2014;24(06):999–1003
• ⁴
  Daniel DM, Lumkong G, Stone ML, Pedowitz RA. Effects of tourniquet use in anterior cruciate ligament reconstruction. Arthroscopy 1995;11(03):307–311
• ⁵
  Arciero RA, Scoville CR, Hayda RA, Snyder RJ. The effect of tourniquet use in anterior cruciate ligament reconstruction. A prospective, randomized study. Am J Sports Med 1996;24(06): 758–764
• ⁶
  Reda W, ElGuindy AMF, Zahry G, Faggal MS, Karim MA. Anterior cruciate ligament reconstruction; is a tourniquet necessary? A randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2016;24(09):2948–2952
• ⁷
  Guanche CA. Tourniquet-induced tibial nerve palsy complicating anterior cruciate ligament reconstruction. Arthroscopy 1995;11 (05):620–622
• ⁸
  Kornbluth ID, Freedman MK, Sher L, Frederick RW. Femoral, saphenous nerve palsy after tourniquet use: a case report. Arch Phys Med Rehabil 2003;84(06):909–911

Publication Dates

• Publication in this collection
  04 June 2021
• Date of issue
  Mar-Apr 2021

History

• Received
  14 Aug 2020
• Accepted
  17 Sept 2020