A low-cost, DIY tourniquet simulator with built-in self-assessment for prehospital providers in Guatemala city.

BACKGROUND: Hemorrhage is the leading cause of preventable death after trauma. In high-income countries first responders are trained in hemorrhage control techniques but this is not the case for developing countries like Guatemala. We present a low-cost training model for tourniquet application using a combination of virtual and physical components. METHODS: The training program includes a mobile application with didactic materials, videos and a gamified virtual reality environment for learning. Additionally, a physical training model of a bleeding lower extremity is developed allowing learners to practice tourniquet application using inexpensive and accessible materials. Validation of the simulator occurred through content and construct validation. Content validation involved subjective assessments by novices and experts, construct validation compared pre-training novices with experts. Training validation compared pre and post training novices for improvement. RESULTS: Our findings indicate that users found the simulator useful, realistic, and satisfactory. We found significant differences in tourniquet application skills between pre-training novices and experts. When comparing pre- and post-training novices, we found a significantly lower bleeding control time between the groups. CONCLUSION: This study suggests that this training approach can enhance access to life-saving skills for prehospital personnel. The inclusion of self-assessment components enables self-regulated learning and reduces the need for continuous instructor presence. Future improvements involve refining the tourniquet model, validating it with first-responder end users, and expanding the training program to include other skills.

Prognostic and reproductive outcomes in women who had uterine myomas removed during cesarean section and sutured using different techniques.

BACKGROUND: In this study, the prognostic and reproductive outcomes of women who underwent excision of uterine myomas and were sutured using different techniques while undergoing a cesarean section were investigated. METHODS: A total of 299 females who underwent cesarean section between January 2015 and June 2022 due to a scarred uterus were enrolled in this study. These participants were segregated into two categories: the experimental group (comprising 155 cases) in which uterine myoma (single lesion) was excised during the cesarean procedure, and the control group (consisting of 144 cases) in which only the cesarean section was conducted. A comparison between the two groups was carried out based on the following parameters: volume of intraoperative bleeding (mL), additional measures taken for intraoperative hemostasis (n, %), percentage (%) of patients experiencing postoperative fever, duration required for the passage of gas (hours [h]), length of hospital stay (days [d]), weight of newborns (kg) and their Apgar scores, and the reproductive outcomes of the experimental group assessed two years after the surgical procedure. RESULTS: In the experimental group, the amount of bleeding during surgery, occurrence of postoperative fever among women, time taken for patients to resume passing gas, and length of hospital stay were 540.65 ± 269.12 mL, 9.03%, 15.99 ± 4.68 h, and 5.08 ± 1.18 days, respectively. In contrast, the control group had values of 409.03 ± 93.24 mL, 2.77%, 16.24 ± 4.92, and 4.47 ± 0.70 days, respectively (P < 0.05). No notable increase was observed in the need for additional intraoperative hemostasis measures, and there was no significant difference in the time it took for patients to pass gas after the surgery. All newborns had positive health status. In the experimental group, 25 patients underwent subsequent pregnancies, and 15 of them successfully reached full-term deliveries, all of which had positive outcomes. CONCLUSION: Combining myomectomy with various suture methods during cesarean delivery did not cause excessive bleeding and resulted in healthy newborns. This approach offers the advantage of avoiding additional surgeries under anesthesia and can be considered a viable option. Subsequent pregnancies after myomectomy were considered high-risk.

Evaluating time until ligation in a novel tourniquet - A crossover randomized-controlled trial.

INTRODUCTION AND AIM: Severe external hemorrhage is a significant reason for morbidity and mortality in adults; thus, the swift and correct application of a tourniquet by laypersons can be lifesaving. We conducted this randomized-controlled cross-over study to investigate the use of a novel tourniquet. METHODS: Participants were recruited at the Heidelberg University Hospital. Eligible participants were ≥ 18 years old with a medical background but without prior experience in applying a tourniquet. Participants were 1:1 randomized to the intervention group (PAX tourniquet) or the control group (SAM or CAT tourniquet). In the control group, participants underwent another randomization to either the SAM or CAT tourniquet without a predefined allocation ratio. Hyperspectral measurements were undertaken (i) before ligation, (ii) 30 s after ligation, and (iii) 30 s after the reopening of the tourniquet. The primary outcome was time until ligation before crossover between the respective groups. The analysis of secondary endpoints included all attempts to assess a possible learning effect, intraoperator variability, and hyperspectral measurements. Participants were crossed to the other study group after a brief wash-out phase. RESULTS: In total, 50 participants were recruited, resulting in 100 attempts. A success rate of 98% was observed across the study population. Time until ligation was 49 s and 56 s (p = 0.572) in the intervention and control group, respectively. However, there was a significant difference between the PAX and SAM (54 vs 75 s; p = 0.037) and the SAM and CAT tourniquet (75 vs. 47 s; p = 0.015). Further, we observed a significant learning effect in participants allocated to the control group first, with a median reduction of 9 s in the time until ligation. Hyperspectral measurements showed a significant decrease in perfusion and tissue oxygenation after ligation. Further, a significant increase in perfusion and tissue oxygenation was found after reopening the tourniquet compared to the baseline measurement. CONCLUSION: The novel PAX tourniquet can be applied quickly and effectively by medical personnel without prior experience in applying a tourniquet.

Tourniquet application in time-critical aquatic emergencies on a moving rescue water craft (RWC): Can speed and precision coexist?

Lifeguards are the first responders to any type of aquatic incident, including rapid rescue situations such as boating and sporting accidents, animal bites/attacks, and cases involving massive bleeding. In their line of work, rescue boats such as Rescue Water Craft (RWC) are commonly utilized the aim of this study is to evaluate the time and technique of placing a tourniquet on the sled of an RWC navigating at full speed. METHODS: A randomized crossover study design was used with a sample of 44 lifeguards. The inclusion criteria required that participants be certified lifeguards with experience in RWC operations and possess knowledge of responding to massive bleeding. Two CAT tourniquet placement tests were performed. In the 1) Beach-Tourniquet (B-TQ) test: it was performed on land and in the 2) Rescue Water Craft-tourniquet (RWC-TQ) test, sailing at a cruising speed of 20 knots. The evaluation was recorded in a checklist on the steps and timing of the correct application TQ by direct observation by an expert instructor. RESULTS: The tourniquet placement on RWC was an average of 11 s slower than when placed on the beach (BT-TQ 35.7 ± 8.0 vs. 46.1 ± 10.9 s, p > 0.001). In the percentage analysis of the results on correct execution of the skills, higher values are obtained for the B-TQ test than in RWC-TQ in Distance to the wound (into 5-7 cm), band adjustment, checking the radial pulse and reporting the time of tourniquet placement (p > 0.005). CONCLUSION: The placement of a tourniquet on a RWC navigating at 20 knots is feasible, relatively quick, and technically well executed.

Comparison of exsanguination and hemostasis devices for Limb surgery: a multicenter randomized controlled study.

BACKGROUND: Excessive intraoperative bleeding remains a challenge in limb surgeries. The exsanguination tourniquet ring has emerged as a potential solution for effective exsanguination and hemostasis. This study aims to evaluate its efficacy and safety compared to the conventional exsanguination and hemostasis approach (pneumatic tourniquet combined with Esmarch bandage). METHODS: This randomized controlled trial evaluates the exsanguination tourniquet ring's effectiveness and safety versus the conventional approach in 220 participants undergoing various limb surgeries. Allocation included experimental and control groups, assesses through efficacy (including intraoperative and total blood loss, hemoglobin levels, and exsanguination and hemostasis effectiveness) and safety (adverse event occurrence) indicators. RESULTS: The experimental group (n = 110) utilizes the exsanguination tourniquet ring, while the control group (n = 110) employs the conventional approach. As for intraoperative blood loss, the experimental group is non-inferior to the control group (p-value < 0.001). While no significant difference is found in total blood loss (for the full analysis set, p-value = 0.442; for the per protocol set, p-value = 0.976) and differences in postoperative and preoperative hemoglobin levels (for the full analysis set, p-value = 0.502; for the per protocol set, p-value = 0.928). Regarding exsanguination and hemostasis effectiveness, the full analysis set reveals significantly superior ratings in the experimental group compared to the control group (p-value = 0.002 < 0.05), while the per protocol set analysis indicates no significant difference between the groups (p-value = 0.504). As for safety indicators, adverse events related to the device are minimal in two groups, with only one severe event unrelated to the device. CONCLUSIONS: The exsanguination tourniquet ring is an effective and safe device for intraoperative blood loss control in various limb surgeries. TRIAL REGISTRATION: Comparison of Exsanguination and Hemostasis Devices for Limb Surgery A Prospective Multicenter Randomized Controlled Study, ChiCTR2300077998, 11/27/2023.

Uterine isthmic tourniquet left in situ as a new approach for placenta previa-accreta surgery: a comparative study.

OBJECTIVES: Placenta previa-accreta spectrum disorders are a cause of obstetric hemorrhage that can lead to maternal fetal mortality and morbidity. We aimed to describe the use of a uterine isthmic tourniquet left in situ as a new uterus-preserving approach for patients with placenta previa-accreta. METHODS: In this retrospective comparative study, the patients who underwent surgery for placenta previa between 2017 and 2024 at our tertiary hospital were reviewed. Primary outcome of the study is to evaluate feasibility of uterine isthmic tourniquet left in situ for uterine preserving by preventing postpartum hemorrhage for patients with placenta previa-accreta. As a secondary outcome, group 1 (n=28) patients who were managed with uterine isthmic tourniquet left in place were compared with patients in group 2 (n=32) who were managed with only bilateral uterine artery ligation. RESULTS: This new approach uterine isthmic tourniquet technique prevented postpartum hemorrhage with a rate of 100 percent in group 1 patients, while uterine artery ligation prevented postpartum hemorrhage with a rate of 75 % in group 2. Postoperative additional interventions (relaparotomy hysterectomy, balloon tamponade application, uterine or vaginal packing) were performed for eight patients in group 2 (25 %) but not in group 1 (0 %) (p=0.015). The haemoglobin levels before caesarean section were similar in both groups (p=0.235), while the postoperative haemoglobin levels were lower in group 2 (9.69 ± 1.37 vs. 8.15 ± 1.32) (p=0.004). Erythrocyte suspension was given to two patients in group 1 and 12 patients in group 2 (2/28 7 % vs. 12/32 37 %, p=0.018). CONCLUSIONS: The uterine isthmic tourniquet left in situ technique is a safe, simple and effective for preventing postpartum hemorrhage and preserving uterus during placenta previa accreta surgery as superior to uterine artery ligation alone.

Tourniquet does not affect intraoperative kinematics during total knee arthroplasty: Results of a prospective study using a robotic assistance system.

PURPOSE: Tourniquet use during total knee arthroplasty (TKA) remains controversial. There are limited data demonstrating the effect of tourniquet use on flexion and extension gaps. The use of a tourniquet can theoretically affect the kinematics of the knee joint, specifically the extension and flexion gaps and the laxity, by mechanically compressing the soft tissues including the muscles above the knee joint. Therefore, this study was designed to prospectively evaluate changes in flexion and extension gaps with and without the use of a tourniquet. METHODS: The following prospective study included 50 consecutive patients who underwent TKA using a surgical robot. The inclusion criteria were advanced osteoarthritis (OA) and varus-alignment or valgus-alignment <3° (hip-knee-ankle angle, standing long-leg X-ray), and the exclusion criteria were BMI >35 kg/m2 and mechanical axis in >3° valgus. A CR-TKA was performed, and the medial and lateral gaps (in mm) throughout the full range of motion in 10° increments were recorded. The procedure was conducted both with and without an applied tourniquet (350 mmHg). RESULTS: No significant differences were observed in the medial joint space. By contrast, the lateral gap showed significant differences in 10-20° of flexion (with a tourniquet 1.9 mm vs. without a tourniquet 2.1 mm, p = 0.018), 20-30° (1.6 vs. 1.8 mm, p = 0.02), 100-110° (0.9 vs. 1.1 mm, p = 0.021), and 110-120° (0.8 vs. 1 mm, p = 0.038). Thus, at the above degrees of flexion on the lateral side, there was a decrease in the mean of 0.2 mm with the use of a tourniquet. CONCLUSION: Although the use of a tourniquet showed a detectable change in the lateral gap in four 10° segments of flexion, clinical relevance with an average difference of 0.2 mm is not achieved. Thus, the use of a tourniquet in TKA can still be advocated based on the presented data. LEVEL OF EVIDENCE: Level I.

Tight application of a surgical tourniquet prior to inflation increases venous pressure in the upper limb; Potentially resulting in increased blood loss and poorer visibility.

BACKGROUND: Tourniquets are commonly used in extremity surgery to help provide a bloodless operative field to improve visibility and reduce length of procedures. With the development of WALANT (wide awake, local anaesthetic, no tourniquet) techniques, many surgeons undertake surgery without tourniquet inflation. The correct technique of pneumatic tourniquet application is poorly understood by healthcare staff. The application of a tight tourniquet when applied for optional use or use for only a portion of a procedure, rather than for inflation throughout can cause venous engorgement of an extremity leading to increased blood loss and reduced operative field visualisation thereby discouraging surgeons from persevering with WALANT strategies. AIM: To determine the effect of tourniquet application tension on limb volume prior to skin incision. METHODS: 30 volunteers had the volume of their non-dominant forearm measured post-inflation of a surgical tourniquet using two different application techniques. Tight application was defined as the tourniquet fastened using a dynamometer to a tension of 100 N. Loose application was defined as the tourniquet fastened using a dynamometer to a tension of 50 N. The tourniquet was then inflated to 200 mmHg after both application techniques. Exsanguination was performed by elevation of the arm for 1 min prior to tourniquet inflation. At 5 min the forearm volume was measured using a volume displacement technique. RESULTS: 93 % of participants (28/30) had a higher volume of water displaced when the tourniquet was applied tightly. The mean difference between the loose and tight applications was 30.06 mls. CONCLUSION: The increase in volume in tightly applied tourniquets is believed to result from increased intravascular volume. This increase in blood volume can lead to increased intra-operative blood loss and poor intra-operative visualisation when operating without tourniquet inflation. Loose application of the tourniquet pre-inflation appears to prevent sequestration of venous blood in the limb, therefore decreasing operative blood loss and improving view for operating. LEVEL OF EVIDENCE: Level 1; Symptom Prevalence Study.

The effects of Tourniquet use in elbow surgery: A retrospective analysis.

BACKGROUND: Pneumatic tourniquets are frequently employed in extremity surgeries, aiming to enhance intraoperative visibility and minimize blood loss. While their benefits and drawbacks have been extensively studied in lower limb operations, their impact on upper limb procedures, particularly elbow surgery, remains poorly understood. This study investigates the advantages and risks associated with pneumatic tourniquet utilization in elbow surgery. METHODS: A retrospective analysis was conducted on 183 patients who underwent elbow surgery for fractures between January 2019 and September 2023. Patients were categorized into two groups: those who underwent surgery with a tourniquet (WT) and those without a tourniquet (NT). Subgroup analyses were performed based on fracture complexity. Data collected included patient characteristics, tourniquet usage, surgical duration, pre- and postoperative hemoglobin levels, C-reactive protein levels, pain assessments, opioid administration, hospital stay duration, follow-up, complications, and revisions. Statistical analyses were used to identify significant differences and correlations. RESULTS: The use of a tourniquet in elbow surgery yielded several notable outcomes. Patients in the WT group experienced significantly shorter surgical durations and hospital stays. Hemoglobin drop was lower in the WT group, indicating reduced blood loss. However, there were no significant differences in postoperative pain, opioid consumption, or complications between the WT and NT groups. Subgroup analysis revealed that the recorded differences, particularly shorter surgical durations, were more pronounced in complex fractures. CONCLUSIONS: This study shows promising results in the use of pneumatic tourniquets in elbow surgery in terms of enhanced efficiency, reduced blood loss, and overall safety, without compromising patient outcomes. However, the potential influence of perioperative decision-making on tourniquet usage underscores the need for further research to elucidate its role and optimize its application, especially in complex elbow fractures.

COMBAT-C: COntrol of Major Bleeding by Application of Tourniquets over Clothing.

INTRODUCTION: External bleeding is the leading cause of preventable trauma-related death. In certain circumstances, tourniquet application over clothing may be necessary. Therefore, the aim of this study was to assess the effectiveness of tourniquets over different clothing setups. METHODS: Three windlass tourniquets (CAT, SAMXT, SOFTT-W) were applied over nine different clothing setups and without clothing on the Hapmed™ Tourniquet Trainer. We compared each tourniquet in each clothing setup to the tourniquet trainer that was not dressed, and we compared the three tourniquets within each clothing setup concerning blood loss, applied pressure and application time. Regression analysis of the effect of thickness, mean weight, mean deformation, application time, and applied pressure on blood loss was performed. RESULTS: Although blood loss was significantly greater in the CAT and SAMXT tourniquets when they were applied over leather motorcycle trousers, the overall findings showed that the clothing setups significantly reduced or did not affect blood loss. The mean blood loss was the lowest with CAT and the highest with SOFTT-W. The measured mean pressures were lower than 180 mmHg in four out of nine clothing setups with SOFTT-W, but CAT and SAMXT always exceeded this threshold. CAT had the fastest application time. Blood loss was significantly influenced by applied pressure and application time but was influenced to a far lesser degree by clothing parameters. CONCLUSION: The effects of the clothing setups were of little clinical relevance, except for leather motorcycle trousers. The effects of rugged protective equipment, e.g., hazard suits, are conceivable and need to be tested for specific garments with the tourniquet intended for use. No clothing parameter for predicting tourniquet effectiveness could be identified.

The history of tourniquet use in limb surgery.

PURPOSE: As tourniquets have been present in medicine since almost its conception, understanding and following their development through time is not only an exercise in history but also an insight into the evolution of medical devices over more than two millennia. From simple leather bands wrapped around patients' limbs to the modernised digital devices used widely in surgical theatres globally, tourniquets have undergone tectonic change both in their design and application, moving from battlefields to hospitals. Hence, the aim of this article is to outline the historical development of these devices alongside their present and modern use. METHODS: The historical development of emergency and surgical tourniquets is chronologically outlined, with particular emphasis on the impact of warfare on their widespread adoption in trauma and emergency medicine and elective surgery. Novel surgical trends and their impact on the future of tourniquet use are evaluated. RESULTS: The development of tourniquets across two millennia has closely reflected both the scientific understanding of human physiology and anatomy as well as technological discoveries and advancements that have reshaped their design and application. Prominent figures in the field of surgery, such as Sushruta, Fabricius Hildanus, John Louis Petit, Joseph Lister, Harvey Cushing and James McEwen, all fundamentally influenced their evolution and helped popularise and modernise them. The views on their use have been controversial and drastically changed across different eras, with data collected from modern warfare serving to embed their use in clinical practice. CONCLUSION: The historical development of tourniquets since pre-historic times represents an excellent outline of the adaptive nature of medicine, led, firstly, by scientific rigour and discipline and, secondly, by pioneers who serve as catalysts for change and improvement. The modern inflatable cuff tourniquets that are omnipresent in theatres globally will undoubtedly remain the standard of care for the foreseeable future. Tourniquets that can dynamically monitor blood pressure and consequently adjust inflation pressures, as well as ones with inbuilt axonal excitability monitoring, will further improve their safety profile, reduce associated complication rates and represent the next step in the evolution of these devices. Notably, there might be a shift away from tourniquet use altogether, reflected by the wide use of the wide-awake local anaesthesia no-tourniquet technique that has become the new norm in hand surgery.

Impact of tourniquet use in total knee arthroplasty on functional recovery and postoperative pain: a prospective study.

BACKGROUND: Tourniquet use during total knee arthroplasty (TKA) remains controversial. The purpose of this study is to determine the impact of tourniquet use only during cementation compared with its use throughout the entire surgery concerning early outcomes in functional recovery, pain, quadriceps function, and rehabilitation. METHODS: Between November 2019 and March 2020, 118 patients were enrolled in this study, with 59 patients undergoing TKA with a tourniquet during the entire surgery (group 1) and 59 patients with a tourniquet only during cementation (group 2). Twenty-eight patients were unable to complete follow-up leaving fifty in group 1 and forty in group 2. Primary endpoints were surgical time, postoperative knee and thigh pain, and functional recovery. Secondary endpoints were 6-month clinical scores and blood loss. RESULTS: Patients in group 1 had statistically significantly increased knee pain on postoperative day 3 (p = 0.004), and thigh pain on postoperative day 1 (p < 0.001), 2 (p < 0.001), and 3 (p = 0.027), and longer time intervals to achieve straight leg raise maneuver (p = 0.006) compared to group 2. However, it did not affect overall narcotic consumption, knee pain (day 1-2), functional recovery, ROM, ability to do the first walk, Oxford knee score, length of stay, and complication rate. There was no statistically significant difference in terms of 6-month postoperative knee score, surgical time, and blood loss between the two groups. CONCLUSION: Tourniquet use diminishes quadriceps function and increases postoperative thigh pain and, to a lesser extent, knee pain. We, therefore, recommend the use of a tourniquet only during cementing. LEVEL OF EVIDENCE: 1; prospective randomized study.

A staged use of tourniquet does not influence the fast-track recovery after total knee arthroplasty: a prospective randomized study.

INTRODUCTION: Upper-tight tourniquet is widely used in Total Knee Arthroplasty in different modalities. However, it has been associated with a negative impact on post-operative muscle strength end pain. This study aimed to investigate the effect of tourniquet on post-operative pain and recovery in enhanced recovery joint surgery. MATERIALS AND METHODS: In this prospective randomized study, we included 116 patients undergoing to TKA. Surgery was performed with a staged use of tourniquet in Group A (58 patients) and without tourniquet in Group B. In the former group a low-pressure tourniquet was deflated after bone cuts to allow hemostasis of posterior recess and re-inflated for cementation. For all patients a multimodal fast-track recovery protocol was used. Time to reach rehabilitation milestones was recorded as primary endpoint. Range of motion, pain, hemarthrosis, total blood loss, surgical field visualization, Knee Score (KS) and Oxford Knee Score (OKS) were considered as secondary outcomes. RESULTS: . No statistically significant differences were found (group B: average 1.3 ± 0.6 day; group A: average 1.2 ± 0.5 day). Group A had a shorter mean surgical time and a clearer surgical field visualization. Group B had a larger estimated blood loss and hemoglobin drop without a statistically significant difference in the transfusion rate. No differences between the groups were seen in the KS, OKS and range of motion (ROM) and post-operative joint swelling. Pain score was similar between cohorts and recorded thigh pain was surprisingly greater in group B. DISCUSSION: The use of tourniquet in TKA surgery helps to minimize intraoperative blood loss and improves surgical field visualization. Its application with a modern and staged protocol does not affect the functional outcomes (OKS, KSS, ROM) of the early post operative period without compromising the fast-track recovery.

Implementing Tourniquet Conversion Guidelines for Civilian EMS and Prehospital Organizations : A Case Report and Review.

Since the first documented use of a tourniquet in 1674, the popularity of tourniquets has waxed and waned. During recent wars and more recently in Emergency Medical Services systems, the tourniquet has been proven to be a valuable tool in the treatment of life-threatening hemorrhage. However, tourniquet use is not without risk, and several studies have demonstrated adverse events and morbidity associated with tourniquet use in the prehospital setting, particularly when left in place for more than 2 h. Consequently, the US military's Committee on Tactical Combat Casualty Care has recommended guidelines for prehospital tourniquet conversion to reduce the risk of adverse events associated with tourniquets once the initial hemorrhage has been controlled. Emergency Medical Services systems that operate in rural, frontier, and austere environments, especially those with transport times to definitive care that routinely exceed 2 h, may consider implementing similar tourniquet conversion guidelines.

Depression as a Prognostic Factor in Lower Extremity Amputation for Diabetic Foot: Insights From a Prospective Study on Wound Healing, Infections, and Early Mortality.

This study addresses the challenges faced by diabetic patients undergoing lower extremity amputation due to diabetic foot, particularly focusing on the implications for wound healing and early mortality. The wounds at the amputation stump may necessitate multiple surgical interventions. The aim is to identify prognostic factors associated with these outcomes, shedding light on the complexities surrounding the postamputation phase. A prospective study was conducted on 39 diabetic patients who underwent lower extremity amputation due to diabetic foot between 2021 and 2022. Comprehensive preoperative data, encompassing parameters such as blood count, erythrocyte sedimentation rate, C-reactive protein, procalcitonin, hemoglobin A1c, albumin, protein, transferrin, ferritin levels, age, gender, body mass index, smoking habits, dialysis, revascularization, duration of surgery, and the use of tourniquet during the procedure were meticulously recorded. Additionally, cognitive performance and depression status were assessed preoperatively using the Mini-Mental State Examination (MMSE) and Beck Depression Inventory (BDI), respectively. A follow-up period of 3 months postsurgery allowed for the comparison of patients who developed infections at the amputation stump with those who did not, as well as the distinction between patients who survived and those who succumbed to mortality. The study revealed that the use of a tourniquet during surgery significantly increased the risk of infection (p = .027), and higher BDI scores were associated with increased risks of both infection (AUC = 0.814) and mortality (AUC = 0.769), with cut-off scores of 24.0 and 23.5 predicting these outcomes with high sensitivity and specificity, respectively. Additionally, lower MMSE scores were associated with increased short-term postoperative mortality. There were no statistically significant differences between the groups in parameters such as complete blood count, ESR, CRP, procalcitonin, HbA1c, albumin, total protein, transferrin, ferritin levels, age, gender, BMI, smoking, dialysis, revascularization, and surgery duration. This investigation highlights the significance of considering tourniquet usage during amputation, preoperative depression status, and cognitive function in patients who undergo amputation due to diabetic foot. The use of a tourniquet during surgery is a significant risk factor for infection, and elevated BDI scores are strong predictors of both infection and mortality in patients undergoing amputations. The findings underscore the importance of a multidisciplinary neuropsychiatric evaluation preoperatively to enhance patient care and outcomes.

Tourniquet use in ankle arthroscopy: A systematic review.

BACKGROUND: Ankle arthroscopy is commonly performed using a thigh tourniquet and is thought to improve visibility and reduce operative time. However, the current evidence is unclear as to whether the use of a tourniquet provides these benefits. The aim of this study was to investigate whether there is any clinical benefit of using a tourniquet in ankle arthroscopy. METHODS: A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, PubMed and the Cochrane Library Database from inception until January 2023 reporting on the use of a tourniquet in ankle arthroscopy were included. RESULTS: 180 studies were identified of which 3 (164 patients) met the inclusion criteria. All studies showed no statistically significant difference in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. Overall, the quality of the evidence was moderate to poor without data in favour or against the routine use of tourniquets in ankle arthroscopy. CONCLUSION: The current literature suggests that there are no significant differences in mean surgical time and complication rate between the tourniquet and non-tourniquet groups.

Silicone ring tourniquet could be a substitute for a conventional tourniquet in total knee arthroplasty with a longer surgical field: a prospective comparative study in simultaneous total knee arthroplasty.

INTRODUCTION: This study aimed to compare the clinical outcomes of silicon ring tourniquets and conventional pneumatic tourniquets in total knee arthroplasty (TKA). The study compared the operation time, total bleeding amount, length from the tourniquet distal end to the patella superior pole (L_TP), and complications related to the two tourniquet application methods and attempted to determine whether the silicon ring tourniquet has advantages over conventional pneumatic tourniquets. MATERIALS AND METHODS: This prospective comparative study included 30 patients who underwent bilateral simultaneous TKA for degenerative osteoarthritis in August to December 2021. All patients underwent TKA on one side with a conventional pneumatic tourniquet, while TKA on the other side with a silicon ring tourniquet. The primary outcomes were the L_TP, operation time, tourniquet time, total bleeding amount, total drainage amount, and postoperative visual analog scale (VAS) score of the tourniquet applied site at 6, 24, and 48 h postoperatively. The secondary outcome was tourniquet-related complications in both groups. RESULTS: L_TP was significantly longer in the silicon ring tourniquet group compared with that in the pneumatic tourniquet group (20.22 ± 2.74 cm versus 15.12 ± 2.40, p < 0.001). No significant difference was found in other results. The tourniquet applied site pain was less in the silicon ring tourniquet group (p = 0.037). CONCLUSIONS: Silicon ring tourniquet application resulted in better clinical outcomes than conventional pneumatic tourniquets in TKA. Because we can obtain a wider surgical field using silicon ring tourniquets without complications, silicon ring tourniquets could be a substitute for conventional pneumatic tourniquets in total knee arthroplasty or distal femoral surgeries.

The effects of tourniquet use on blood loss and perioperative complications in total knee arthroplasty.

BACKGROUND: There has been ongoing debate about the use of tourniquets in total knee arthroplasty, and their application is widely studied. A comprehensive understanding of the advantages and disadvantages of tourniquet use during the procedure is crucial for optimizing surgical outcomes. This study aimed to investigate the effectiveness of tourniquet application, with a particular focus on blood loss and perioperative complications, providing valuable insights for clinical practice. METHODS: Fifty patients who underwent total knee arthroplasty were randomized into tourniquet (n = 25) and nontourniquet (n = 25) groups. The same surgeon performed all surgical procedures. The follow-up time was 14 days after surgery. Primary outcomes were hemoglobin level changes, blood loss, operation time, and perioperative plasma D-dimer levels. Secondary outcomes were postoperative complications, including thrombotic and nonthrombotic events. RESULTS: No significant differences were found in drainage, calculated blood loss, total blood loss, postoperative hemoglobin levels, or blood transfusion between the two groups (P > 0.05). No differences in D-dimer levels were observed on postoperative Days 1, 3, and 14 between the two groups, except on postoperative Day 7, when the D-dimer level in the tourniquet group was lower than that in the nontourniquet group (P = 0.03). The incidence of local complications (thigh bruising, blisters, pain, fat liquefaction, and superficial infections) in the tourniquet group was significantly higher than that in the nontourniquet group (P = 0.03), but no significant differences were found in thromboembolic and nonthromboembolic events or overall complications (P > 0.05). CONCLUSION: We conclude that tourniquet use does not reduce the length of surgery or blood loss but does increase local complications in total knee arthroplasty.

Hair tourniquet syndrome: A retrospective study.

OBJECTIVE: Hair thread tourniquet syndrome (HTS) is a pediatric condition in which human hair or synthetic fiber encircles and strangulates a body appendage causing tissue necrosis. Few epidemiologic studies have been done. Our objective was to better define the demographics, clinical features, and predisposing factors for this condition. MATERIALS AND METHODS: Medical records of all infants up to 1 year old seen in the orthopedic emergency department of Galilee Medical Center were searched for the diagnosis of HTS or its ICD equivalent. RESULTS: Forty-one cases of hair tourniquet syndrome (HTS) were reviewed. Most cases (68%) occurred during the winter months (December to February). There were no reports between June to August (summer). The median age was 4 months and the male-to-female ratio was approximately 2:5. Toes were significantly more involved than fingers (97.5%) and the 3rd toe was the most affected (58%). Nine patients (21.9%) had more than one toe affected and only one case reported finger involvement. CONCLUSIONS: HTS in our population is a phenomenon that seems to occur mostly in winter. Infants between 3 and 5 months are at greater risk. Toes are more affected than fingers. The most involved toes are the 3rd and 4th.

Blood-conserving and therapeutic efficacy of intravenous tranexamic acid at different time points after primary total knee arthroplasty with tourniquet application: a randomised controlled trial.

BACKGROUND: The use of a tourniquet in combination with tranexamic acid (TXA) not only ensures clear vision, reduces intraoperative blood loss and shortens operative time but also improves cement-bone inter-digitation in total knee arthroplasty (TKA). However, there is no proof whether the blood flow blocking effect of tourniquet affects the antifibrinolytic effect of TXA, and the optimal timing of TXA administration is still unclear. Therefore, this study aims to investigate the effect of the first dose of TXA administered intravenously before tourniquet compression and release in TKA on perioperative blood loss and therapeutic efficacy in patients. METHODS: In this double-blind trial, 90 patients undergoing primary TKA were randomised into 2 groups: Group A, patients received intravenous TXA 10 min before tourniquet compression (20 mg/kg) and 3, 6 and 24 h later (10 mg/kg), and Group B, patients were treated the same as those in Group A but received intravenous TXA before tourniquet release. The primary outcomes were changes in blood loss, haemoglobin and haematocrit. Secondary outcomes included operation and tourniquet times, blood transfusion rate, subcutaneous petechiae and circumferential changes in the operated limb, visual analogue scale (VAS) score, hospital for special surgery (HSS) score, length of stay (LOS) postoperatively, complications and patient satisfaction. RESULTS: No statistically significant difference was found between the 2 groups with regard to age, sex, weight, body mass index (BMI), Kellgren-Lawrence class, preoperative blood volume, preoperative laboratory values, operation and tourniquet times, transfusion rate, knee circumference, preoperative HSS, or VAS score (P:n.s.). There was no significant difference in intraoperative blood loss (IBL) (52.7 ml vs. 63.4 ml, P = 0.07), hidden blood loss (HBL) (91.4 ml vs. 119.9, P = 0.4) or total blood loss (TBL) (144.1 ml vs. 183.3 ml, P = 0.72) between Groups A and B. Haemoglobin, haematocrit and red blood cell count (RBC) dropped to a low point on postoperative day 3 and then rebounded, returning to normal levels on day 21, and the trend of change between the 2 groups was not statistically significant (P:n.s.). There was no significant difference in subcutaneous ecchymosis incidence, knee swelling rate, HSS score, VAS score, LOS postoperatively, complication rate or patient satisfaction (P:n.s.). CONCLUSION: TXA was administered intravenously prior to tourniquet compression could effectively reduce blood loss in patients who had undergone total knee arthroplasty. However, there was no significant difference in knee swelling rate, subcutaneous bruising and petechiae incidence, knee function, complication rate or satisfaction between patients who TXA was given intravenously before tourniquet compression and release in primary TKA.