Is Tourniquet Pain the Result of Increased Compartment Pressure in the Forearm?

ABSTRACT: The pneumatic tourniquet has been a mainstay in upper extremity surgery by allowing the surgeon to operate in a blood-free field. Many upper extremity surgical procedures are done under local anesthesia or minimal sedation, and the problem of tourniquet pain is a vexing one. The question is posed: Is tourniquet pain the result of increased compartment pressure in the forearm? This study measured compartment pressures of the volar forearm in 10 healthy normotensive volunteers before inflation of a pneumatic tourniquet and compared it with pressure measurements taken while the tourniquet was still inflated after 15 minutes. Compartment pressures were measured using a Stryker needle manometer; all measurements were taken in the volar forearm by the senior author (C.H.M.). There was no increase in the volar/flexor compartment pressure of the forearm after 15 minutes of tourniquet inflation. All subjects complained of pain of the forearm, characteristically what is commonly called "tourniquet pain." We therefore conclude that in the upper extremity, at least for relatively short operating times, appropriate inflation of a tourniquet does not induce the early onset of increased compartment pressure in the forearm.

Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis.

BACKGROUND: Tourniquets (TQ) have been increasingly adopted in pre-hospital settings recently. This study examined the effectiveness and safety of applying TQ in the pre-hospital settings for civilian patients with traumatic vascular injuries to the extremities. MATERIALS AND METHODS: We systematically searched the Ovid Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from their inception to June 2023. We compared pre-hospital TQ (PH-TQ) use to no PH-TQ, defined as a TQ applied after hospital arrival or no TQ use at all, for civilian vascular extremity trauma patients. The primary outcome was overall mortality rate, and the secondary outcomes were blood product use and hospital stay. We analyzed TQ-related complications as safety outcomes. We tried to include randomized controlled trials (RCTs) and non-randomized studies (including non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies, and case-control studies), if available. Pooled odds ratios (ORs) were calculated and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. RESULTS: Seven studies involving 4,095 patients were included. In the primary outcome, pre-hospital TQ (PH-TQ) use significantly decrease mortality rate in patients with extremity trauma (odds ratio [OR], 0.48, 95% confidence interval [CI] 0.27-0.86, I2 = 47%). Moreover, the use of PH-TQ showed the decreasing trend of utilization of blood products, such as packed red blood cells (mean difference [MD]: -2.1 [unit], 95% CI: -5.0 to 0.8, I2 = 99%) or fresh frozen plasma (MD: -1.0 [unit], 95% CI: -4.0 to 2.0, I2 = 98%); however, both are not statistically significant. No significant differences were observed in the lengths of hospital and intensive care unit stays. For the safety outcomes, PH-TQ use did not significantly increase risk of amputation (OR: 0.85, 95% CI: 0.43 to 1.68, I2 = 60%) or compartment syndrome (OR: 0.94, 95% CI: 0.37 to 2.35, I2 = 0%). The certainty of the evidence was very low across all outcomes. CONCLUSION: The current data suggest that, in the pre-hospital settings, PH-TQ use for civilian patients with vascular traumatic injury of the extremities decreased mortality and tended to decrease blood transfusions. This did not increase the risk of amputation or compartment syndrome significantly.

Prospective Analysis of Simulated Pneumatic Tourniquet Use and Oedema Following Axillary Lymph Node Dissection.

Background: Tourniquet use during upper extremity surgery in patients with a history of axillary lymph node dissection (ALND) remains controversial due to the perceived but unproven risk of lymphoedema. We prospectively evaluated upper extremity swelling in patients with a history of unilateral ALND using a standardised tourniquet model. Methods: A tourniquet was applied to the upper arm bilaterally, with the unaffected side serving as an internal control. Each arm was subsequently held in an elevated position to reduce swelling. Hand volume was measured using an aqueous volumeter. Results: The patients' ALND arms experienced slightly greater increases in volume following tourniquet application compared to their healthy control arms. However, this amount of oedema was temporary and reversible, as both arms experienced spontaneous resolution of swelling with no significant difference in residual hand volume at the conclusion of the study. Conclusions: Tourniquet use may be safe in patients with a history of ALND. Further investigation is needed to verify this in a surgical setting. Level of Evidence: Level II (Therapeutic).

Tourniquet-free minimally invasive total knee arthroplasty is associated with early aseptic loosening.

BACKGROUND: While tourniquet-free (T-) total knee arthroplasty (TKA) has gained popularity, tourniquet-use during minimally-invasive (MIS)-TKA has not been adequately studied. Traditional techniques employ knee hyper-flexion, compressing vasculature and reducing impact of bleeding, while MIS-TKA embraces the semi-extended knee position, which does not restrict the effects of bleeding on cementation and visualization. We compared the risk of aseptic loosening between patients undergoing T- MIS-TKA compared to T + MIS-TKA. METHODS: This single-surgeon cohort study included 329 consecutive MIS-TKA (226 T+,103 T-) patients with minimum 3-year follow-up. Aseptic loosening, radiolucent lines (RLL), health related quality of life scores, and complications were recorded. T-test and chi-square test were used to compare continuous and categorical variables, and logistic regression included BMI, age, ASA, patellar-resurfacing, and tourniquet-use. RESULTS: There were no differences in baseline demographics. One (0.4 %) aseptic loosening occurred with T+, versus 7 (6.8 %) with T- (p = 0.002). No T + and 3 T- patients (2.9 %, p = 0.01) had revision for aseptic loosening. The incidence of RLLs was 16.8 % in T + and 30.1 % in T- (p = 0.008). Logistic regression revealed T + was significantly associated with decreased aseptic loosening and risk of RLL (odds ratio = 16.4, odds ratio = 2.8). CONCLUSION: In this consecutive series, T- MIS-TKA was associated with increased rates of revision for aseptic loosening as compared to the T + MIS-TKA, even controlling for BMI, age, ASA level, and patellar resurfacing. Radiolucent lines were increased with T- MIS-TKA compared to T + MIS-TKA. Complications, all-cause revision, ROM, and HRQoL scores were similar between tourniquet-use and tourniquet-free cohorts.

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.

Tourniquet Use in Extremity-Based Microsurgery.

BACKGROUND: The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. The authors hypothesize that tourniquets enhance visualization, bloodless approaches to vessel harvest, flap elevation, and anastomosis without added complications. METHODS: A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between January 2018 and February 2022 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet use during three operative segments: (1) flap elevation, (2) vessel harvest, and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. RESULTS: A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was trauma (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). A total of 70, 61, and 32% of procedures used a tourniquet for flap elevation, vessel harvest, and for anastomosis, respectively. Statistical analyses identified no difference in complication rates for procedures for which a tourniquet was or was not used for interventions. CONCLUSION: Based on these results, the authors state that tourniquets can be utilized for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk.

BACKGROUND: Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. MATERIALS AND METHODS: We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. RESULTS: 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. CONCLUSIONS: Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

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.

The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery - a retrospective cohort study.

OBJECTIVES: A pneumatic tourniquet is often used during ankle fracture surgery to reduce bleeding and enhance the visibility of the surgical field. Tourniquet use causes both mechanical and ischemic pain. The main purpose of this study was to evaluate the effect of tourniquet time on postoperative opioid consumption after ankle fracture surgery. METHODS: We retrospectively reviewed the files of 586 adult patients with surgically treated ankle fractures during the years 2014-2016. We evaluated post hoc the effect of tourniquet time on postoperative opioid consumption during the first 24 h after surgery. The patients were divided into quartiles by the tourniquet time (4-43 min; 44-58 min; 59-82 min; and ≥83 min). Multivariable linear regression analysis was used to evaluate the results. RESULTS: Tourniquets were used in 486 patients. The use of a tourniquet was associated with an increase in the total postoperative opioid consumption by 5.1 mg (95 % CI 1.6-8.5; p=0.004) during the first 24 postoperative hours. The tourniquet time over 83 min was associated with an increase in the mean postoperative oxycodone consumption by 5.4 mg (95 % CI 1.2 to 9.7; p=0.012) compared to patients with tourniquet time of 4-43 min. CONCLUSIONS: The use of a tourniquet and prolonged tourniquet time were associated with higher postoperative opioid consumption during the 24 h postoperative follow-up after surgical ankle fracture fixation. The need for ethical approval and informed consent was waived by the Institutional Review Board of Northern Ostrobothnia Health District because of the retrospective nature of the study.

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.

An investigation into the cellular-level adverse effects of tourniquet use on the infrapatellar fat pad in primary total knee arthroplasty: A prospective randomized study.

OBJECTIVE: This study aimed to examine the cellular-level adverse effects of tourniquet use on the infrapatellar fat pad (IPFP) in patients undergoing primary total knee arthroplasty (TKA). METHODS: Infrapatellar fat pad samples were collected in a prospective, randomized design to compare 2 groups of primary TKA patients with a tourniquet (T) and without a tourniquet (NT). The study included 80 knees of 58 patients with a mean age of 65.91 ± 9.04 years. The authors collected 3 samples from the T group (after exposure to the fat pad "t1," just before deflating the tourniquet "t2," just before fascia closure "t3") and 2 samples from the NT group (t1 and t3) for each patient. BAX, Bcl-2, and HIF-1α staining showed the extent of cellular hypoxia and apoptosis in IPFP cells, whereas the oxidative stress index (OSI) was determined using a biochemical method. The Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), and Kujala score were used as clinical outcome measures. RESULTS: The mean HIF-1α, BAX/Bcl-2, and OSI scores across all time points were significantly higher in the T group than in the NT group (p<0.001) (d=1.16, 2.9, and 0.9, respectively). The mean BAX/Bcl-2 (P=.030) and HIF-1α (P < .001) scores significantly peaked at t2 in the T group (d=-1.2 and -3.9, respectively). The OSI had higher levels at t1 (P=.011) and t3 (P=.073) (d=0.2 and 0.1, respectively) than at t2 in the T group. The third-month postoperative follow-up revealed that the mean KOOS, KSS, and Kujala score improved significantly compared to the baseline preoperative values (P < .001); however, there was no difference between the T and NT groups regarding the maximum and total knee range of motion or clinical outcome scores. CONCLUSION: Evidence from this study has shown that tourniquet use during primary TKA may be associated with significantly increased cellular hypoxia, oxidative stress, and apoptosis in the IPFP. LEVEL OF EVIDENCE: Level I, Therapeutic study.

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.

The use of tourniquet is useful in terms of blood loss and soft tissue damage in arthroscopic anterior cruciate ligament reconstruction: a retrospective study.

Whether a tourniquet should be used for anterior cruciate ligament reconstruction (ACLR) when the operative field is secured remains controversial. Little is known about the influence of not using a tourniquet on total perioperative blood loss and soft tissue damage. The aim of this study was to compare total perioperative blood loss and soft tissue damage with and without tourniquet use during ACLR. Seventy-seven consecutive ACLRs in 76 patients were performed without tourniquet use at our hospital and enrolled in this study (T- group) between November 2018 and September 2021. The control group (T + group) comprised 55 historical ACLRs in 55 patients performed with tourniquet use at our hospital between April 2017 and September 2018. Total perioperative blood loss, calculated from the change in hemoglobin between that preoperatively and on postoperative day (POD) 1, and indicators of soft tissue damage including serum white blood cell (WBC) counts, creatine phosphokinase (CPK), and C-reactive protein (CRP) values measured on POD 1 and POD 7 were compared between groups. Total blood loss was significantly higher in the T- group (339 ± 216 mL) than in the T + group (258 ± 199 mL; P = 0.030). On POD 1, WBC counts were significantly higher in the T- group (9.7 ± 2.4 × 103 cells/µL) than in the T + group (9.1 ± 2.5 × 103 cells/µL; P = 0.043), CPK levels were significantly higher in the T- group (294 ± 417 U/L) than in the T + group (255 ± 88 U/L; P = 0.046), and CRP levels were also significantly higher in the T- group (1.40 ± 1.12 mg/dL) than in the T + group (0.91 ± 0.76 mg/dL; P = 0.016). No significant differences in WBC counts or CPK or CRP levels were seen between groups on POD 7. Total blood loss and soft tissue damage were significantly increased without tourniquet use during ACLR. No advantage was found for not using a tourniquet in terms of blood loss or soft tissue damage.

Tourniquet-Related Nerve Injury Following Reconstructive Surgery for Wassel Type IV Preaxial Polydactyly of 13-Year-Old Boy: A Case Report.

BACKGROUND Congenital thumb duplication comes under the Wassel type IV classification is the hypoplastic variety, with the extra digit growing from the dominant thumb's soft tissue alone. Excising the hypoplastic finger while reconstructing for the retained one has been the most adopted approach. Tourniquets are commonly utilized tools in orthopedic surgeries to reduce the amount of blood, thus enhancing the visibility. Unfortunately, tourniquet-related nerve injury (TNRI) is gaining more attention as a serious complication of tourniquet use in surgery. CASE REPORT A 13-year-old Asian boy with preaxial polydactyly Wassel type IV of the right hand underwent reconstruction surgery. A pneumatic tourniquet was applied at 200 mmHg on the right mid-upper arm and maintained for 90 min. After the surgery, the patient had total weakness with numbness, tingling, and burning sensation from his right upper arm to his fingertips. The neurological examination and nerve conduction studies (NCS) results were consistent with axonotmesis lesions. Pharmacological and physical rehabilitation therapy had successfully restored full motoric and sensory function after 6 months. CONCLUSIONS Nerve injury should be acknowledged as a possible complication from routinely-utilized tourniquets in orthopedic surgeries. Our cases may expand the need for further studies to establish a guideline for tourniquet use and TRNI management.

Prehospital tourniquet application in extremity vascular trauma: Improved functional outcomes.

BACKGROUND: Support for prehospital tourniquet use has increased, with recent data suggesting that tourniquet usage decreases shock without increasing limb complications. We hypothesized that prehospital tourniquet application in extremity vascular trauma, compared with no prehospital tourniquet application, is associated with lower rates of delayed amputation and better functional mobility. METHODS: We retrospectively studied adult patients with extremity vascular trauma at an urban civilian Level 1 trauma center (June 2016-May 2021). Outcomes of interest included delayed amputation and mobility at hospital discharge, measured by the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Score. The "6 Clicks" Basic Mobility Score was documented by physical therapy; higher scores indicate more independent mobility. Injury mechanism, initial lactate, 24-hour transfusions, mortality, and acute kidney injury were also collected. Comparisons were performed using χ2 analysis and Fisher Exact and Wilcoxon rank-sum tests. RESULTS: Of 232 patients, prehospital tourniquet application was not associated with mortality or lactate level (both P > .05). The prehospital tourniquet application group had more transfusions, lower rates of acute kidney injury, and fewer delayed amputations (all P < .05). Ninety-one patients (45 prehospital tourniquet application and 46 without prehospital tourniquet application) were evaluated for "Moving between Bed and Chair" in the "6 Clicks" Basic Mobility Score, with patients in the prehospital tourniquet application group demonstrating higher levels of independence (P = .034). CONCLUSION: Prehospital tourniquet application was associated with favorable outcomes, including higher functional mobility and decreased delayed amputation. This suggests that tourniquet use should be encouraged in the civilian setting to improve outcomes and reduce the risk of limb loss.

The tourniquet syndrome of the thumb due to dressing with a rubber band in a pediatric patient.

Ischemia of an appendage caused by dressing, tourniquet or hair is a rare, but devastating clinical entity. A six-year-old girl presented to the emergency department with necrosis of her right thumb caused by compressive dressing for four days. The patient was treated with an immediate surgical decompression and the thumb was saved. The patient had a full range of the thumb at 10 months of follow-up. In conclusion, instead of waiting for full demarcation, timely surgical interventions may protect the fingers from being amputated.

Tourniquet use benefits to reduce intraoperative blood loss in patients receiving total knee arthroplasty for osteoarthritis: An updated meta-analysis with trial sequential analysis.

PURPOSE: The efficacy and safety of tourniquets use during total knee arthroplasty (TKA) in patients with osteoarthritis remain debated. This updated systematic review and meta-analysis aimed to further evaluate the role of tourniquets use in patients undergoing TKA for knee osteoarthritis by introducing trial sequential analysis. METHODS: PubMed, Embase, and the Cochrane Library were searched. We used the Cochrane risk of bias tool for quality assessment. Statistical heterogeneity across studies was evaluated using Cochran's Q and I2 statistic. Meta-analysis was performed using Stata/SE 14.0, and trail sequential analysis was performed using TSA software version 0.9.5.10 Beta. In addition, qualitative summary was also used to describe results. RESULTS: 15 randomized controlled trials (RCTs) involving 1202 patients were included in the meta-analysis. The pooled results showed that tourniquet use during TKA significantly reduced intraoperative blood loss (mean difference (MD)= -123.84, 95% confidence interval (CI): -163.37 to -84.32, p < .001)and shortened operation time (MD = -4.71, 95% CI: -7.6 to -1.82, p = .001), but there were no significant differences in postoperative blood loss, calculated blood loss, total blood loss, transfusion rate (p = .939), and deep venous thrombosis (DVT) rate between the tourniquet and no-tourniquet groups. TSA confirmed that the result of operation time was false positive, but the results of other outcomes were conclusive. The results of qualitative summary showed conflicting findings in terms of pain, range of motion (RoM) and swelling ratio between the two groups. CONCLUSIONS: Tourniquet use in patients receiving TKA for osteoarthritis benefits to reduce intraoperative blood loss but has no effect on postoperative blood loss, calculated blood loss, total blood loss, operation time, transfusion rate, and DVT rate. In addition, it remains unclear the difference between the tourniquet and non-tourniquet groups in terms of pain, RoM and swelling ratio.

[The application of a new type of sterile elastic exsanguination tourniquet in aspiration surgery for upper limb lymphedema].

Objective: To evaluate the effect of a new type of sterile elastic exsanguination tourniquet (SEET) in aspiration surgery for upper limb lymphedema. Methods: The clinical data of 159 patients who underwent aspiration surgery for upper limb lymphedema from January 2017 to June 2022 in the Beijing Shijitan Hospital, Capital Medical University were retrospectively analyzed. Among them, 54 patients were treated with SEET (SEET group), while 105 patients were not treated with SEET (No-SEET group). The propensity score matching method was used, and the surgical indicators and complications were compared between the two groups. The factors affecting intraoperative bleeding volume were analyzed through multiple linear regression analysis. Results: A total of 49 pairs of patients were successfully matched by the propensity score method. The age of patients in the SEET and No-SEET groups was (57.7±8.9) years and (56.8±9.1) years, respectively. Compared with the Non-SEET group, the SEET group had less bleeding volume [(311±164) ml vs (437±173) ml, P<0.001]. The results of multiple linear regression analysis showed that the factors affecting intraoperative bleeding volume included age (ß=-0.142, P=0.041), using the SEET (ß=-0.249, P=0.002), surgical time (ß=0.195, P=0.010) and the amount of fat mixture sucked out (ß=0.464, P<0.001). Conclusions: The clinical application of the SEET in aspiration surgery for upper limb lymphedema is safe, and can significantly reduce the bleeding volume and alleviate blood shortage.

Prehospital tourniquet placement in extremity trauma.

BACKGROUND: Extremity tourniquets (ET) use has increased in trauma systems to manage traumatic hemorrhage. This study aims to evaluate prehospital ET placement. METHODS: This is a retrospective review of a prospectively collected cohort of 211 adult patients who underwent prehospital ET placement over 3 ½ years. Data regarding ET placement was analyzed regarding ET applier, reported indications, extremity appearance at arrival and outcomes. RESULTS: A total of 211 patients had completed data sheets. Of these patients, 63.2% had no other intervention prior to ET placement. On arrival, nearly 1/3 of the patients had palpable pulses with ET in place and less than ½ had arterial bleeding upon ET release. DISCUSSION/CONCLUSIONS: This study shows that ET are frequently used as the initial intervention in the field. It is of paramount importance that we adapt our first responders training to teach wound assessment and appropriate steps in management of extremity hemorrhagic trauma.