Quadriceps Sparing, Tourniquetless Total Knee Replacement: The Ideal Recipe for Rapid Recovery

Apr 7, 2019

As baby boomers are now reaching retirement age and as people are living longer than at any time in the past, the number of people undergoing total knee replacement has surpassed 500,000 annually in the United States. This number is projected to rise exponentially over the next 20-30 years as shown to the right. As joint replacements have become more durable over time, patient expectations about activity level after surgery, restrictions and duration of recovery have come to demand solutions that lead to rapid return to high levels of function. Improvements in implant design have sought to make knee replacements feel more natural during activities and improvements in perioperative care have allowed patients to return home early after surgery including same-day surgery for appropriate patients.

Surgical technique is also important for rapid recovery after surgery, both to limit scar tissue formation and to promote early return of quadriceps function. Surgical technique can also influence postoperative pain levels which can affect patient engagement in necessary postoperative exercises. Studies have shown that early mobilization leads to improved results after knee replacement, not only in terms of joint function, but also overall physiologic well-being.


With this goal in mind, we have adopted a surgical technique that avoids division of the important quadriceps tendon, keeping the extensor mechanism of the knee in continuity. Traditional approaches divide the tendon (red line in picture to the right) leading to more disruption of the quadriceps mechanism and more potential for scar tissue formation around this tendon. Violation of this tendon can inhibit quad function after surgery leading to a more prolonged recovery and more rehabilitative efforts to regain function. We now use a midvastus approach makes a small split in the muscle and keeps the entire extensor mechanism intact (blue line in picture to the right).


In addition, we have abandoned the use of a tourniquet (shown at right) during the case. A tourniquet is like a blood pressure cuff that is placed around the upper thigh and squeezes the leg at very high pressures to prevent any blood loss during the case. Studies have shown that tourniquet inflation can lead to quadriceps muscle damage and delayed return of quad function. In addition, it can cause more immediate and delayed postoperative pain and swelling that does not respond to nerve blocks or local anesthesia.

Studies have shown that while intraoperative blood loss is more with the use of a tourniquet, overall blood loss is on different whether it is used or not. By avoiding tourniquet use, we can also better control surgical bleeding in real time during the dissection so that by the end of the case there is no active bleeding. Many centers do not deflate tourniquets until the wound is closed and the dressing applied. This can result in unseen blood vessels continuing to bleed after surgery leading to knee swelling and hematoma formation. This has been shown to result in delayed recovery and inferior results.


Combined with the use of long-acting local anesthetics which are injected around the knee at the time of surgery, and nerve blocks which anesthetize the sensory nerves around the knee at the time of the operation, these surgical techniques can result in a dramatic reduction in postoperative pain and immediate return of quad function. As part of our AVATAR program, the quad-sparing tourniquetless total knee replacement boasts the fastest recovery for the majority of patients. This has allowed a high percentage of our patients to return home the same day as their surgery, avoiding an overnight stay in the hospital.


Drs. King and Parsons are currently the only surgeons in the region performing this improved technique of knee replacement. Our center specializes in promoting the fastest recovery after knee, hip and shoulder replacement and customizing care to each patient.