The relationship between tourniquet time and Il-6, D-Dimer and visual analogue scale in total knee arthroplasty

I. Ketut Suyasa, I. Ketut Siki Kawiyana, Ketut Gede Mulyadi Ridia, Komang Mahendra Laksana


Background: The use of tourniquet during TKA aside from having several advantages, is also accompanied by several risks. This study was performed to prove the relation between the duration of tourniquet application to inflammatory response, pro-thrombotic condition, and pain response of the patients undergoing TKA procedures.

Methods: This study is a cross-sectional analytical experimental research. A femoral tourniquet was applied to 34 primary osteoarthritis (OA) patients undergoing the standard procedure of TKA and the duration of tourniquet application data was noted and collected. Pain assessment was performed by using Visual Analogue Scale (VAS), whereas blood samples are taken from the patients and IL-6 cytokine and D-dimer levels were identified at 12 hours and 24 hours post-operatively. Statistical analysis (Pearson correlation) was performed to see the correlation of tourniquet duration to the VAS, IL-6, and D-dimer serum level at 12 hours and 24 hours post-operatively.

Results: The result of this study showed a positive correlation between the duration of tourniquet use with IL-6 at 12 hours post operation (r=0.359) and 24 hours post operation (r=0.658); with D-dimer at 12 hours post operation (r=0.491) and 24 hours post operation (r=0.483); and with VAS at 12 hours post operation (r=0.647) and 24 hours post operation (r=0.507) with p<0,05. A positive correlation was found between tourniquet time and IL-6, D-dimer and VAS.

Conclusions: The duration of tourniquet cut-off time of more than 122.5 minutes elevates IL-6 and D-Dimer which increases the risk for SIRS and DVT.


Ascorbic acid, Interleukin-6, Open fractures, Staphylococcus aureus

Full Text:



Deloughry JL, Griffiths R. Arterial tourniquets. Contin Educ Anaesthesia, Crit Care Pain. Epub ahead of print 2009.

Desai K, Dinh TP, Chung S, Pierpont YN, Naidu DK, Payne WG. Upper extremity deep vein thrombosis with tourniquet use. Int J Surg Case Rep. 2015;6:55-7.

Ahmed I, Fraser L, Sprowson A. Tourniquets for the use of total knee arthroplasty: are patients aware of the risks? Ann Orthop Rheumatol. 2016;4(3):1071.

Williams DH, Garbuz DS, Masri. Total knee arthroplasty; techniques and results. Bc Med J. 2010;52(9):447-54.

Noordin S, McEwen JA, Kragh Jr CJ, Eisen A, Masri BA. Surgical tourniquets in orthopaedics. JBJS. 2009;91(12):2958-67.

Oragui E, Parsons A, White T. Tourniquet use in upper limb surgery. Hand. 2011;6(2):165-73.

Stensballe J, Christiansen M, Tønnesen E, Espersen K, Lippert FK, Rasmussen LS. The early IL‐6 and IL‐10 response in trauma is correlated with injury severity and mortality. Acta anaesthesiologica Scandinavica. 2009;53(4):515-21.

Kugisaki H, Sonohata M, Komine M, Tsunoda K, Someya S, Honke H, et al. Serum concentrations of interleukin-6 in patients following unilateral versus bilateral total knee arthroplasty. J Orthopaed Sci. 2009 Jul 1;14(4):437-42.

Tsunoda K, Sonohata M, Kugisaki H. The Effect of Air Tourniquet on Interleukin-6 Levels in Total Knee Arthroplasty. Open Orthop J. 2017;11:20-8.

Tick LW, Nijkeuter M, Kramer MH, Hovens MM, Büller HR, Leebeek FW, Huisman MV, Christopher Study Investigators. High D‐dimer levels increase the likelihood of pulmonary embolism. J Int Med. 2008;264(2):195-200.

Adhikari GH, Nekkanti S. A clinical study of the safe use of pneumatic tourniquet in orthopaedic surgery. Int J Orthop Sci. 2017;3:74-8.

Naeem MA, Usman M, Latif MK AM. The relationship of D-dimer levels with risk for developing deep-vein thrombosis and/or pulmonary thromboembolism after orthopaedic trauma surgery. J Ayub Med Coll Abbottabad. 2009;21:113-6.

Adam SS, Key NS, Greenberg CS. D-dimer antigen: current concepts and future prospects. Blood, The Journal of the American Society of Hematology. 2009;113(13):2878-87.

World Health Organization. C-reactive protein concentrations as a marker of inflammation or infection for interpreting biomarkers of micronutrient status. Vitamin asn Mineral Nutrition Information System. Vmnis; 2014:1-4.

Worland RL, Arredondo J, Angles F, Lopez-Jimenez F, Jessup DE. Thigh pain following tourniquet application in simultaneous bilateral total knee replacement arthroplasty. The J Arthroplasty. 1997;12(8):848-52.

Tai TW, Chang CW, Lai KA, Lin CJ, Yang CY. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial. JBJS. 2012;94(24):2209-15.

Rao MRM, Gopal SD. C-Reactive Protein - A critical Review. Int J Curr Microbiol Appl Sci. 2015;4:55-61.

Barker T, Rogers VE, Brown KB, Henriksen VT, Rasmussen GL et al. Tourniquet use during total knee arthroplasty does not modulate the neutrophil-to-lymphocyte ratio, pain, or activity. J Orthop Traumatol. 2017;18(3):283-7.