C McLean, S Molloy, R Hargrove ,V Price
Department of Orthopaedic Surgery
Frimley Park Hospital
Portsmouth Road
Frimley
Surrey
United Kingdom


Address for Correspondence

Surgeon Lieutenant Commander C McLean, 
SpR Trauma and Orthopaedics, 
Frimley Park Hospital, telephone (UK) 01276 604604, 
email chrismclean@supanet.com 

Letter to the editor regarding:

Gopinath P. Non Cauterised Total Knee Replacement - A different concept 
Calicut Medical Journal 2004;2(1):e3
URL: http://www.calicutmedicaljournal.org/2004/2/1/e3/index.html




Sir,

We read with interest the article Gopinath P. Non Cauterised Total Knee Replacement - A different concept, [Calicut Medical Journal 2004;2(1):e3 ]and we agree that every effort should be made to attempt to reduce the incidence of wound sepsis post total knee arthroplasty nevertheless we have a number of points we would like to raise with the author.

We acknowledge that risk factors for superficial wound infection include diabetes mellitus, rheumatoid arthritis and morbid obesity and we note that the described series included six patients with diabetes mellitus [5]. We would be interested to know if the author's series included patients with the other risk factors. Furthermore we are aware that the presence of a superficial wound infection is correlated with subsequent late deep joint infection that may cause septic failure of the joint. It has been shown that haematoma formation and persistence of post-operative drainage increase the risk of superficial wound infection [4]. In addition to other factors we consider that the prevention of haematoma formation is important in decreasing the incidence of superficial wound infection. We are concerned that the absence of diathermy haemostasis may predispose to haematoma formation and potential wound and deep joint sepsis. We are not convinced that tourniquets provide adequate haemostasis. It has been shown that blood loss is less in total knee arthroplasty when a tourniquet is not used and that under these circumstances patients may experience less post-operative pain and achieve better ranges of knee flexion [6,7]. In addition, tourniquets have been demonstrated to promote the risk of deep vein thrombosis and pulmonary embolism [8]. We are also not convinced that diathermy produces a significant amount of 'killed tissue' and in order to be more convinced by the 'cooked meat media concept' we would like to see bacteriological studies that demonstrate increased bacterial counts on tissue sections subjected to diathermy. We performed a Medline search (1966 to present) and found 184 papers reporting adverse effects of diathermy, none of these papers reported wound complications secondary to the presence of diathermy induced devitalised tissue. We suggest that unlike tourniquets diathermy helps achieve haemostasis and thereby aids in the prevention of haematoma formation, we also recognise that tourniquets cause tissue hypoxia [1]. We are unable to identify studies that confirm the incidence of haematoma formation is changed by the use of a tourniquet in total knee arthroplasty. However, it has been shown in animal models that tourniquet release after wound closure is associated with greater haematoma formation. It is conceivable that tourniquet usage, as a mode of haemostasis, may be associated with wound haematoma and hypoxia. This combination could result in the formation of a media favourable to bacterial growth in the wound and we appreciate that few organisms are required to initiate infection [2]. Using lower tourniquet pressure may decrease the wound hypoxia and we wonder what pressure the author uses. We would like to know, in addition to prophylactic antibiotics, what other measures are used by the author to decrease infection such as ultra-clean airflow, whole body exhaust suits and theatre discipline. We would also be interested to know how long the post-operative drains are retained in the author's series and whether there were any drain related complications. We do not recommend the use of suction drains as a matter of routine however we accept that they may well have a role to play in reducing post-operative haematoma formation but the evidence is inconclusive [3]. Our final point concerns the author's conclusions based upon the number of patients in his series. We note that the author refers in his discussion to an infection rate of between 1 and 4%. His series only includes twenty-two arthroplasties and he bases his conclusions regarding the non-cauterised technique upon the absence of infection in his patients. We note that on the basis of his figures, in order to detect an infection rate of 4% the author would have to perform twenty-five arthroplasties before one case was observed. We wonder if the author has based his conclusions upon insufficient evidence.

We look forward to the author's comments and we await with the interest the results of more arthroplasties with longer follow-up to see if the non-cauterised technique does indeed reduce superficial and deep wound sepsis after total knee arthroplasty.

References

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

2) Himel HM, Ahmad, M, Parmett SR, Strauss HW, May JW Jr. Effect of the timing of tourniquet release on postoperative haematoma formation: an experimental animal study. Plastic & Reconstructive Surgery. 83(4):692-700, 1989.

3) Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Bacteria isolated from deep joint sepsis after operation for total hip or knee replacement and the sources of the infections with Staphylococcus aureus. Journal of Hospital Infection. 4(1):19-29, 1983.

4) Parker MJ, Roberts C. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database of Systematic Reviews. (4):CD001825, 2001.

5) Saleh K, Olson M, Resig S, Bershadsky B, Kuskowski M, Gioe T, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. Journal of Orthopaedic Research. 20(3):506-15, 2002.

6) Syahrizal AB, Kareem BA, Anbanadan S, Harwant S. Risk factors for infection in total knee replacement surgery at hospital Kuala Lumpur. Medical Journal of Malaysia. 56S D:5-8, 2001.

7) Tero AM, Rudan JF. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Canadian Journal of Surgery. 44(1):33-8, 2001.

8) Vandenbussche E, Duranthon LD, Couturier M, Pidhorz L, Augereau B. The effect of tourniquet use in total knee arthroplasty. International Orthopaedics. 26(5):306-9, 2002.

9) Wauke K, Nagashima M, Kato N, Ogawa R, Yoshimo S. Comparative study between thromboembolism and total knee arthroplasty with or without tourniquet in rheumatoid arthritis patients. Archives of Orthopaedic & Trauma Surgery. 122(8):442-6, 2002.

Authors' Reply

Address for Correspondence:

Dr.P.Gopinathan, MS(Ortho);DNB;MNAMS
Asst.Professor of Orthopaedics
Medical College, Calicut 673008
Kerala,India
E-Mail: drpgopinath@yahoo.com

I appreciate your opinion that tourniquet is not a must in TKR and whether to use tourniquet or not is not the point in this study. We were concerned with the harmful effects of cautery. How ever, it is not true that tourniquet should not be used in TKR. 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 opinion 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) 

Your opinion 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)

In this study, no comparison was made between non cauterized and cauterized TKR. I stress that infection is multifactorial in origin. I have also added that further studies are needed to confirm the claim. I will be publishing a large series of cases in future as I am continuing to do the TKR in the same technique. 

Finally I should say 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

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