Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty

Nerve injury after prolonged tourniquet inflation results from the combined effects of ischemia and mechanical trauma. Tourniquet release, allowing a reperfusion interval of 10-30 min followed by re-inflation, has been recommended to extend the duration of total tourniquet time. However, this practice has not been confirmed clinically. We retrospectively reviewed the medical records of 1001 patients undergoing 1166 primary or revision knee replacements with tourniquet time more than 120 min during a 5-yr interval. Mean total tourniquet time was 145 +/- 25 min (range, 120-308 min). In 759 patients, the tourniquet inflation was uninterrupted. Two tourniquet inflations, interrupted by a single deflation, were noted in 371 patients, and 3 tourniquet inflations interrupted by 2 deflation intervals were noted in 23 patients. A total of 129 neurologic complications (peroneal and/or tibial nerve palsies) were noted in 90 patients for an overall incidence of 7.7%. Eighty-five cases involved the peroneal nerve and 44 cases involved the tibial nerve. In 39 cases, both peroneal and tibial deficits were noted. Complete neurologic recovery occurred in 76 (89%) peroneal and 44 (100%) tibial palsies. Postoperative neurologic dysfunction was associated with younger age (P < 0.001; odds ratio = 0.7 per 10-yr increase), longer tourniquet time (P < 0.001; odds ratio = 2.8 per 30-min increase), and preoperative flexion contracture > 20 degrees (P = 0.002; odds ratio = 3.9). In a subset of 116 patients with tourniquet times >= 180 min, longer duration of deflation was associated with a decreased frequency of neurologic complications (P = 0.048). We conclude that the likelihood of neurologic dysfunction increases with total tourniquet time and that a reperfusion interval only modestly decreases the risk of nerve injury.