The tourniquet in total knee arthroplasty

issue entitled 'The tourniquet in total knee arthroplasty'.There are several points which we wish to raise.It is unclear how many surgeons, and of what grade, operated and where the surgery was performed.It is not stated what problems were encountered with bleeding when a tourniquet was not used.Although they conclude that the tourniquet can be used satisfactorily, more wound problems were observed in this group, including one wound still leaking at six weeks.Concern was expressed about haemostasis and the ability to create an appropriate bone surface for applying cement when a tourniquet was not used.A combination of regional anaesthesia, exposure of the joint with the knee flexed and the use of intraosseous suction applied within 1 cm of the cut bone surfaces with lavage, creates an ideal environment and considerably reduces airborne debris.If a tourniquet is used the cuff pressure should be restricted to 100 mmHg above the systolic pressure.2 Its use is strongly contraindicated in the presence of diabetes, peripheral vascular disease, rheumatoid disease, previous thromboembolism, active malignancy, multiply scarred legs, obese thighs and for revision surgery.Since so many authors have attributed complications to the use of the tourniquet, such as nerve paralysis, vascular injury, circulatory changes on exsanguination with cardiac or respiratory problems, cardiac arrest, pulmonary oedema, increased rates of DVT and, recently, increased rates of embolism, 3 does it not seem that the best practice is to avoid its use?We have shown that knee replacement surgery can now be performed with confidence without the use of the tourniquet and that many of the local and systemic complications of operating in a bloodless field can be avoided.