Aims. The aim of this study was to determine the prevalence and impact of tourniquet use in patients undergoing limb salvage surgery with endoprosthetic reconstruction for a tumour around the knee. Methods. We retrieved data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial; specifically, differences in baseline characteristics, surgical details, and postoperative functional outcomes between patients who had undergone surgery under tourniquet and those who had not. A linear regression model was created to evaluate the impact of tourniquet use on postoperative Toronto Extremity Salvage Scores (TESSs) while controlling for confounding variables. A negative-binomial regression model was constructed to explore predictors of postoperative length of stay (LOS). Results. Of the 604 patients enrolled in the PARITY trial, 421 had tumours around the knee joint, of whom 225 (53%) underwent surgery under tourniquet. The tourniquet group was younger (p = 0.014), more likely to undergo surgery for a tumour of the tibia, and had shorter operating times by a mean of 50 minutes (95% confidence interval 30 to 72; p < 0.001). The adjusted linear regression model found that the use of a tourniquet, a shorter operating time, and a higher baseline TESS independently predicted better function at both three- and six-month follow-up. The negative-binomial regression model showed that tourniquet use, shorter operating time, younger age, and intraoperative tranexamic acid administration independently predicted a shorter LOS in hospital. Conclusion. The results of this study show that in patients undergoing resection of a tumour around the knee and endoprosthetic reconstruction, the use of an intraoperative tourniquet is associated with a shorter operating time, a reduced length of stay in hospital, and a better early functional outcome. Cite this article: Bone Joint J 2022;104-B(10):1168–1173

Aims. Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets. Methods. This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling. Results. A total of 4,050 ankle fractures treated with open reduction and internal fixation between 15 March 2012 and 31 December 2016 were included, with 669 (16.5%) undergoing surgery with a tourniquet and 3,381 (83.5%) without a tourniquet. The overall reoperation risk was 28.2% with an adjusted relative risk of 1.46 (95% CI 0.91 to 2.32) for group comparison. The reoperation risk due to major complications was 3.1% with a tourniquet and 4.4% without a tourniquet, resulting in an adjusted relative risk of 1.45 (95% CI 0.91 to 2.32). For minor complications, there were 24.7% and 23.9% reoperations, resulting in an adjusted relative risk of 0.99 (95% CI 0.84 to 1.17). Conclusion. We found no significant difference in the reoperation rate when comparing ankle fractures treated surgically with and without the use of pneumatic tourniquets. Cite this article: Bone Joint J 2024;106-B(9):994–999

Abstract. Background. The use of tourniquet in knee arthroplasty is common but in recent times, it has initiated a debate on its use. Complications from use of tourniquet are well documented in literature but there is less evidence on thigh pain, blood loss and length of stay post arthroplasty. Methods. We included 62 patients undergoing knee arthroplasty either Unicondylar knee arthroplasty or total knee arthroplasty. Patients were allocated randomly in tourniquet and without tourniquet groups. Half of the patients had UKA and other half TKA. Thigh pain was recorded using Visual analogue scale on day 1, 2 and on discharge. A drop in pre-operative and post operative haemoglobin level was recorded too. Independent sample t-test was done to compare the difference between the 2 groups mainly, drop in haemoglobin, thigh pain, knee pain and length of stay. Results. The mean drop in haemoglobin was comparable and was not statistically significant. Thigh pain on day 1 in no tourniquet group had a mean value of 0 and statistically significant difference in thigh pain at day 1,2 and discharge. In subgroup analysis between TKA and UKA the latter had improved results. Conclusions. Knee arthroplasty surgery without the use of tourniquet provides less thigh pain in the post-operative period and there isn't any significant difference in post op haemoglobin drop. None of the patient required any blood transfusion. A trend of early discharge was noted too but probably due to sample size, it wasn't statistically significant

We report the effect of padding on the efficiency of the pneumatic tourniquet for the upper limb. Varying thicknesses of two commercially-available types of orthopaedic padding (Cellona and Velband) were applied to the arms of 20 volunteers, with three pressure transducers placed directly beneath the padding. A tourniquet was positioned over the padding and inflated to 220 mmHg. Significant reductions in the transmitted pressure were recorded from the transducers with both padding materials. With eight layers of padding, reductions in pressure of 13% (1% to 26%) and 18% (7% to 35%) were seen with Cellona and Velband, respectively. The reduction in pressure with Velband padding correlated with increasing arm circumference (Pearson’s correlation coefficient 0.711, p < 0.001). Studies to date have examined how arm circumference affects the required tourniquet inflation pressure. Our study is the first to investigate the effect of the padding and the findings suggest that using more than two layers results in a significant reduction in the transmitted pressure

Aims. Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery. Methods. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay. Results. We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87). Conclusion. TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery. Cite this article: Bone Joint J 2021;103-B(5):830–839

During total knee arthroplasty (TKA), a tourniquet is often used intraoperatively. There are proposed benefits of tourniquet use including shorter duration of surgery, improved surgical field visualization and increased cement penetration which may improve implant longevity. However, there are also cited side effects that include increased post-operative pain, slowed recovery, skin bruising, neurovascular injury and quadriceps weakness. Randomized controlled trials have demonstrated no differences in implant longevity, however they are limited by short follow-up and small sample sizes. The objective of the current study was to evaluate the rates of revision surgery among patients undergoing cemented TKA with or without an intraoperative tourniquet and to understand the causes and risk factors for failure. A retrospective cohort study was undertaken of all patients who received a primary, cemented TKA at a high-volume arthroplasty centre from January 1999 to December 2010. Patients who underwent surgery without the use of a tourniquet and those who had a tourniquet inflated for the entirety of the case were included. The causes and timing of revision surgery were recorded and cross referenced with the Canadian Institute of Health Information Discharge Abstract Database to reduce the loss to follow-up. Survivorship analysis was performed with the use of Kaplan-Meier curves to determine overall survival rates at final follow-up. A Cox proportional hazards model was utilized to evaluate independent predictors of revision surgery. Data from 3939 cases of primary cemented TKA were available for analysis. There were 2276 (58%) cases in which a tourniquet was used for the duration of the surgery and 1663 (42%) cases in which a tourniquet was not utilized. Mean time from the primary TKA was 14.7 years (range 0 days - 22.8 years) when censored by death or revision surgery. There were 150 recorded revisions in the entire cohort, with periprosthetic joint infection (n=50) and aseptic loosening (n=41) being the most common causes for revision. The cumulative survival at final follow-up for the tourniquetless group was 93.8% at final follow-up while the cumulative survival at final follow-up for the tourniquet group was 96.9% at final follow-up. Tourniquetless surgery was an independent predictor for all-cause revision with an HR of 1.53 (95% CI 1.1, 2.1, p=0.011). Younger age and male sex were also independent factors for all cause revision. The results of the current study demonstrate higher all-cause revision rates with tourniquetless surgery in a large cohort of patients undergoing primary cemented TKA. The available literature consists of short-term trials and registry data, which have inherent limitations. Potential causes for increased revision rates in the tourniquetless group include reduced cement penetration, increased intraoperative blood loss and longer surgical. The results of the current study should be taken into consideration, alongside the known risks and benefits of tourniquet use, when considering intraoperative tourniquet use in cemented TKA

Aims. Tourniquets have potential adverse effects including postoperative thigh pain, likely caused by their ischaemic and possible compressive effects. The aims of this preliminary study were to determine if it is possible to directly measure intramuscular pH in human subjects over time, and to measure the intramuscular pH changes resulting from tourniquet ischaemia in patients undergoing knee arthroscopy. Methods. For patients undergoing short knee arthroscopic procedures, a sterile calibrated pH probe was inserted into the anterior fascial compartment of the leg after skin preparation, but before tourniquet inflation. The limb was elevated for three minutes prior to tourniquet inflation to 250 mmHg or 300 mmHg. Intramuscular pH was recorded at one-second intervals throughout the procedure and for 20 minutes following tourniquet deflation. Probe-related adverse events were recorded. Results. A total of 27 patients were recruited to the study. Mean tourniquet time was 21 minutes (10 to 56). Tourniquet pressure was 300 mmHg for 21 patients and 250 mmHg for six patients. Mean muscle pH prior to tourniquet inflation was 6.80. Muscle pH decreased upon tourniquet inflation, with a steeper fall in the first ten minutes than for the rest of the procedure. Change in muscle pH was significant after five minutes of tourniquet ischaemia (p < 0.001). Mean muscle pH prior to tourniquet release was 6.58 and recovered to 6.75 within 20 minutes following release. No probe related adverse events were recorded. Conclusion. It is possible to directly measure skeletal muscle pH in human subjects over time. Tourniquet ischaemia results in a decrease in human skeletal muscle pH over time during short procedures. Cite this article: Bone Joint Res 2021;10(6):363–369

The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK

Tourniquet use in total knee arthroplasty (TKA) remains a subject of considerable debate. A recent study questioned the need for tourniquets based on associated risks. However, the study omitted analysis of crucial tourniquet-related parameters which have been demonstrated in numerous studies to be associated with safe tourniquet use and reduction of adverse events. The current utilization and preferences of tourniquet use in Canada remain unknown. Our primary aim was to determine the current practices, patterns of use, and opinions of tourniquet use in TKA among members of the Canadian Arthroplasty Society (CAS). Additionally, we sought to determine the need for updated best practice guidelines to inform optimal tourniquet use and to identify areas requiring further research. A self-administered survey was emailed to members of the CAS in October 2021(six-week period). The response rate was 57% (91/161). Skip logic branching was used to administer a maximum of 59 questions related to tourniquet use, beliefs, and practices. All respondents were staff surgeons and 88% were arthroplasty fellowship trained. Sixty-five percent have been in practice for ≥11 years and only 16% for 50 TKA/year, 59% have an academic practice, and >67% prefer cemented TKA. Sixty-six percent currently use tourniquets, 25% no longer do but previously did, and 9% never used tourniquets. For those not using tourniquets, the most common reasons are potential harm/risks and publications/conferences. Among current users, 48% use in all cases and an additional 37% use in 76-99% of cases. The top reason for use was improved visualization/bloodless field (88%), followed by performing a cemented TKA, used in training, and faster operative times. The main patient factor influencing selective tourniquet use was peripheral vascular disease and main surgical factors were operative duration and cementless TKA. The most frequent adverse events reported were bruising/pinching under the tourniquet and short-term pain, which majority believed were related to improper tourniquet use (prolonged time, high-pressures, poor cuff fit), yet only 8% use contoured tourniquets and 32% don't use limb protection. Despite substantial evidence in literature that tourniquet safety and probability of harm are affected by tourniquet time and pressure, only 83% and 72% of respondents believe reducing tourniquet time and pressure respectively reduce the probability of harm. In addition, no surgeon utilizes personalized limb occlusion pressure which has been demonstrated to substantially reduce tourniquet pressure while being safe and effective. Furthermore, 62% always use fixed pressure and 37% will modify the pressure based on patient parameters, most often systolic blood pressure and limb size. Almost all (88%) were interested in new evidence-based guidelines regarding these parameters. Tourniquet use in TKA remains prevalent among arthroplasty surgeons in the CAS; however tremendous practice variability regarding several key parameters required for optimal use exists. Current best practices of tourniquet use regarding personalized pressures, time, and type are not being utilized across Canada. There is considerable interest and need for further research and updated guidelines regarding key parameters of safe tourniquet usage to optimize tourniquet use in TKA

Aim. Tourniquet is widely used in extremity surgery. In order to prevent surgical site infection, correct timing of antimicrobial prophylaxis and tourniquet inflation is important. We aimed to evaluate the time for which the free drug concentration of cefuroxime is maintained above the minimal inhibitory concentration (T>MIC) in subcutaneous tissue and calcaneal cancellous bone during three clinically relevant tourniquet application scenarios. Method. Twenty-four female pigs were included. Microdialysis catheters were placed for sampling of cefuroxime concentrations bilaterally in calcaneal cancellous bone and subcutaneous tissue, and a tourniquet cuff was applied on a randomly picked leg of each pig. Subsequently, the pigs were randomized into three groups to receive 1.5 g of cefuroxime by intravenous injection 15 min prior to tourniquet inflation (Group A), 45 min prior to tourniquet inflation (Group B), and at the tourniquet release (Group C). The tourniquet duration was 90 min in all groups. Dialysates and venous blood samples were collected eight-hours postcefuroxime administration. Results. Cefuroxime concentrations were maintained above the clinical breakpoint MIC for Staphylococcus aureus (4 µg/mL) in calcaneal cancellous bone and subcutaneous tissue throughout the 90 min tourniquet duration in Group A and B. Cefuroxime administration at tourniquet release (Group C) resulted in concentrations above 4 µg/mL for a minimum of 3.5 hours in the tissues on the tourniquet side. There were no significant differences in the T>MIC (4 µg/mL) in subcutaneous tissue or calcaneal cancellous bone between the three groups. However, Group A tended toward shorter T>MIC in tourniquet calcaneal cancellous bone compared to Group C (p=0.08). Conclusions. Administration of cefuroxime (1.5 g) in the 15–45 min window prior to tourniquet inflation resulted in sufficient calcaneal cancellous bone and subcutaneous tissue concentrations throughout the 90 min tourniquet application. If the target is to maintain postoperative cefuroxime concentrations above relevant MIC values, our results suggest that a second dose of cefuroxime should be administered at tourniquet release

In modern orthopaedics surgery, the pneumatic tourniquet has become an essential tool that paved the way to many of the advances in trauma and orthopaedic surgery. Tourniquet slippage is one of the challenging disadvantages of it use. This study examines the possibility of reducing tourniquet slippage by comparing two different tourniquet application techniques. Twenty two patients were included in the study. Thirteen were males and eight were females. The average age was fifty five years. The patients were randomized into two groups, a controlled, and a modified tourniquet application technique groups. There were eleven patients in the control group and ten in the modified group. A standard tourniquet application technique was used as a control by applying Softband (Orthoband) alone to skin prior to application of tourniquet; this was compared to a modified version where a drape (Steridrape) was used as an interval layer. There was a strong statistical significant difference in tourniquet slippage between the two groups, p< 0.0001 the control group being the better performer. We concluded that steridrape interval makes tourniquet slippage more likely to occur

Aims. The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid. Methods. This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events. Results. The mean total blood loss was lowest in the no-tourniquet group at 867.32 ml (SD 201.11), increased in the limited-tourniquet group at 1024.35 ml (SD 176.35), and was highest in the tourniquet group at 1,213.00 ml (SD 211.48). The hidden blood loss was lowest in the no-tourniquet group (both p < 0.001). There was less mean intraoperative blood loss in the tourniquet group (77.48 ml (SD 24.82)) than in the limited-tourniquet group (137.04 ml (SD 26.96)) and the no-tourniquet group (212.99 ml (SD 56.35); both p < 0.001). Patients in the tourniquet group showed significantly higher levels of muscle damage and inflammation biomarkers such as CK, CRP, and IL-6 than the other two groups (p < 0.05). Outcomes for VAS pain scores, limb swelling ratio, quadriceps strength, straight leg raising, ROM, and KSS were significantly better in the no-tourniquet group at three weeks postoperatively (p < 0.05), but there were no significant differences at three months. No significant differences were observed among the three groups with respect to transfusion rate, thrombotic events, or the length of hospital stay. Conclusion. Patients who underwent TKA with multiple doses of intravenous tranexamic acid but without a tourniquet presented lower total blood loss and hidden blood loss, and they showed less postoperative inflammation reaction, less muscle damage, lower VAS pain score, and better early knee function. Our results argue for not using a tourniquet during TKA. Cite this article: Bone Joint Res 2020;9(6):322–332

Tourniquet is widely used in extremity surgery. In order to prevent surgical site infection, correct timing of antimicrobial prophylaxis and tourniquet inflation is important. We aimed to evaluate the time for which the free drug concentration of cefuroxime is maintained above the minimal inhibitory concentration (T>MIC) in subcutaneous tissue and calcaneal cancellous bone during three clinically relevant tourniquet application scenarios. Twenty-four female pigs were included. Microdialysis catheters were placed for sampling of cefuroxime concentrations bilaterally in calcaneal cancellous bone and subcutaneous tissue, and a tourniquet cuff was applied on a randomly picked leg of each pig. Subsequently, the pigs were randomized into three groups to receive 1.5 g of cefuroxime by intravenous injection 15 min prior to tourniquet inflation (Group A), 45 min prior to tourniquet inflation (Group B), and at the tourniquet release (Group C). The tourniquet duration was 90 min in all groups. Dialysates and venous blood samples were collected eight-hours postcefuroxime administration. Cefuroxime concentrations were maintained above the clinical breakpoint MIC for Staphylococcus aureus (4 μg/mL) in calcaneal cancellous bone and subcutaneous tissue throughout the 90 min tourniquet duration in Group A and B. Cefuroxime administration at tourniquet release (Group C) resulted in concentrations above 4 μg/mL for a minimum of 3.5 hours in the tissues on the tourniquet side. There were no significant differences in the T>MIC (4 μg/mL) in subcutaneous tissue or calcaneal cancellous bone between the three groups. However, Group A tended toward shorter T>MIC in tourniquet calcaneal cancellous bone compared to Group C (p=0.08). We conclude that administration of cefuroxime (1.5 g) in the 15–45 min window prior to tourniquet inflation resulted in sufficient calcaneal cancellous bone and subcutaneous tissue concentrations throughout the 90 min tourniquet application. If the target is to maintain postoperative cefuroxime concentrations above relevant MIC values, our results suggest that a second dose of cefuroxime should be administered at tourniquet release

Blood management protocols attempt to reduce blood loss by strategies including autologous blood donation, red cell salvage, normovolaemic haemodilution and haemostatic agents such as tranexamic acid (TXA). TXA usage in particular has become increasingly commonplace with numerous studies demonstrating a significant reduction in peri-operative blood loss and proportion of patients requiring transfusion, without increasing the risk of venous thromboembolism. Tourniquet usage has now become ubiquitous in TKA operations with reported benefits of improved visualization, shorter operative time and decreased intra-operative bleeding. However, its use is not without considerable complications including wounding dehiscence, increased venous thromboembolism, superficial wound infection and skin blistering. It is therefore imperative that we review tourniquet usage in light of ever evolving blood management strategies. The aim of this study was to evaluate the effect of stopping tourniquet usage in primary TKRs, performed by an experienced surgeon, in light of new blood reduction measures, such as a TXA. A retrospective analysis identified a total of 31 patients who underwent primary TKR without the use of a tourniquet from January 2018 to March 2019. This was compared to an earlier group of patients from the same surgeon undergoing TKR with the use of a tourniquet; dating from July 2016 to November 2017. All surgeries were performed within the same hospital (CXH). Peri-operative factors and outcome measures were collected for analysis. There was no significant difference in post-operative haemoglobin drop (Tourniquet, 23.1 g/L; No Tourniquet, 24.4 g/: p=0.604) and fall in haematocrit (Tourniquet, 0.082; No Tourniquet, 0.087: p=0.604). Allogenic blood transfusion rates were the same in both groups at 12.9% (2 patients) and blood loss was not found to be significantly different (Tourniquet, 1067ml; No tourniquet, 1058mls). No significant difference was found in operative time (Tourniquet, 103 minutes; No Tourniquet, 111.7 minutes: p=0.152) or length of stay (Tourniquet, 5.5 days; No Tourniquet, 5.2 days: p=0.516). Tranexamic acid usage was not found to be significant (p=1.000). ROM of motion and analgesia requirement was significantly better in the no tourniquet group on one post-operative day out of five analysed (p=0.025, p=00.011). No post-operative thromboembolic events were reported in either group. There was no significant difference in readmission rates (p=0.492) or complications (p=0.238). The increase in minor complications and potential increased VTE risk with tourniquet usage must be balanced against an improved visual field and reduced blood loss in TKR patients. Our study found no difference in post-operative blood loss and transfusion rates between tourniquet and no tourniquet groups. With ever evolving and improving blood loss management strategies, including the use of TXA, the application of tourniquet may not be needed. Further prospective RCTs are needed to assess the impact of tourniquet usage in light of this

Patients were randomized between surgeon chosen pressure (control) and an automatically determined tourniquet pressure(study) group. Of the study group 94/106 (88.7%) had good to excellent fields compared to the control group where 100/132 (75.8%) had good to excellent fields (p< 0.05). In the study group, 5% failed to obtain an automatic pressure. Of the remainder, the average tourniquet pressure was 198 +/− 20.2 mHg compared to 259.6 +/− 4.4 mmHg for the control group (p< 0.0001). The automatic measurement of limb occlusion pressure resulted in better operative fields at a lower pressure. To compare the quality of the operative field that results from using an automatic limb occlusion pressure measurement (study group) versus the tourniquet cuff pressure chosen by the surgeon (control group). A module allowing rapid determination of tourniquet pressure from limb occlusion pressure was attached to a Zimmer ATS tourniquet machine. Using a coin toss, patients were randomized to the study or control groups. All patients underwent elective foot and ankle operations using a wide contoured tourniquet cuff. Of two hundred and forty-three patients, one hundred and twelve were assigned to the study (automatic) group and one hundred and thirty-two to the control (surgeon selected) group. Six patients (5.4%) failed to obtain a limb occlusion pressure measurement due to anatomical constraints (toe or thigh shape) or equipment problems, leaving one hundred and six in the study group. The average measurement time to determine limb occlusion pressure was 20 +/− 6 seconds. The mean tourniquet pressure for the study group was 198.5 +/−20.2 mmHg, and 259.6 +/−4.4 mmHg for the control group (p< 0.0001). Of the study group 94 (88.7%) had good to excellent fields compared to the control group where one hundred (75.8%) had good to excellent fields (p< 0.05). An automatically determined tourniquet pressure reduced the tourniquet pressure and improved the incidence of good to excellent operative fields compared to surgeon chosen pressures. The distribution curve of automatically determined tourniquet pressure indicates that 16% of patients will have a failed field if a standard pre-selected pressure of 250 mmHg is always chosen, in part explaining why pre-selected pressure may cause a poorer operative field

Tourniquet is a commonly used tool in orthopaedic practice. Incidence of complications is low but if any develops, it is devastating. Transient nerve damage, ischemia or skin burns are the possible tourniquet related complications. There is big variation in practice regarding the limb occlusion pressure. 51 procedures in 50 patients were reviewed retrospectively in our district general hospital. We looked at quality of documentation guided by the BOAST standard (The Safe Use of Intraoperative Tourniquets, published in October 2021). Limb occlusion pressure and ischemic time were analysed. Intra-operative and post-operative notes were reviewed to assess quality of documentation and post-operative complications. Although limb occlusion pressure was above the recommended range in more than 75% of cases, there were no significant complications observed. Two cases only developed transient neuropraxia in common peroneal nerve and median nerve following tibial plateau ORIF and trapeziectomy simultaneously. Tibial ORIF fixation case had prolonged ischemic time (more than 120 minutes) and the limb occlusion pressure for the hand case was above the recommended range. Both have recovered within few days with no long-term consequences. Minimum documentation threshold was not met with regarding tourniquet site condition, method of skin isolation and padding, and exsanguination method. This relatively new standard with no previous similar guidance needs time until it is followed by the health care professionals especially when there is no high incidence of complications related to the use of the tourniquet. However, it is crucial to increase the theatre staff awareness of such standards. This will prevent devastating complications specifically in vulnerable patients. Adjustments to theatre checklist have been suggested to improved documentation. Additionally, local teaching sessions will be delivered to theatre personnel aiming at improving our compliance to this standard

A tourniquet is usually used during ankle arthroscopy to allow for improved visibility and reduced operation time. However, clinical studies on knee arthroscopy have not demonstrated this to be true. In addition, Zengerink and van Dijk emphasized a limited tourniquet time in ankle arthroscopy as a possible factor to lower the complication rate even more. The purpose of this prospective randomized controlled trial was to examine the effect of tourniquet use on arthroscopic visualization, operative time, postoperative intra-articular bleeding, postoperative pain scores and outcome of anterior ankle arthroscopy. A consecutive series of 50 patients who were scheduled for anterior ankle arthroscopy were randomized to have the surgery done either without the tourniquet inflated (25 patients) or with the tourniquet inflated (25 patients). The patients were evaluated by the course of the surgery, postoperative intra-articular bleeding, pain during the early postoperative period and by using the subjective and objective functional scores to evaluate the condition of the ankle before and 3 and 6 months after the surgery. The statistical analysis was performed with the normality of distribution tested by both Kolmogorov-Smirnov and Shapiro-Wilk tests. Appropriate parametric or non-parametric methods were then used to test statistical hypotheses, while the statistical significance (alpha, Type I error) was set at .05. Fourty-nine patients were present at the final follow-up, 6 months after the surgery. The results between the groups were comparable regarding the duration of the operative procedure, consumption of sterile saline, visualisation and functional scores. Notable difference between the groups in favour of the non-tourniquet group was present regarding postoperative bleeding, but was not statistically significant. Statistically significant difference in favour of the non-tourniquet group was found regarding postoperative pain during several days in the early postoperative period. Our study has shown that anterior ankle arthroscopy may be performed adequately without the use of a tourniquet and that it has the same operative course as in cases in which the tourniquet is used and functional outcomes which are not worse than in cases in which the tourniquet is used

Total knee replacement (TKR) is an operation that can be performed with or without the use of a tourniquet. Meta-analyses of the available Level-1 studies have demonstrated that the use of a tourniquet leads to a significant reduction in blood loss. The opponents for use of a tourniquet cite development of complications such as skin bruising, neurovascular injury, and metabolic disturbance as drawbacks. Although there may certainly be reason for concern in arteriopathic patients, there is little evidence that routine use of a tourniquet during TKR results in any of the above complications. The use of a tourniquet, on the other hand, provides a bloodless field that allows the surgeon to perform the procedure with expediency and optimal visualisation. Blood conservation has gained great importance in recent years due to increased understanding of the problems associated with blood transfusion, such as increased surgical site infection (due to immunomodulation effect), increased length of hospital stay and increased cost. Based on the authors’ understanding of the available evidence, the routine use of a tourniquet during TKR is justified as good surgical practice. . Cite this article: Bone Joint J 2013;95-B, Supple A:133–4

Tourniquet is widely used in orthopedic surgery to reduce intraoperative bleeding and improve visualization. We evaluated the effect of tourniquet application on both peri- and postoperative cefuroxime concentrations in subcutaneous tissue, skeletal muscle, calcaneal cancellous bone, and plasma. The primary endpoint was the time for which the free drug concentration of cefuroxime was maintained above the clinical breakpoint minimal inhibitory concentration (T>MIC) forStaphylococcus aureus (4 µg/mL). Ten patients scheduled for hallux valgus or hallux rigidus surgery were included. Microdialysis catheters were placed for sampling of cefuroxime concentrations bilaterally in subcutaneous tissue, skeletal muscle, and calcaneal cancellous bone. A tourniquet was applied on the thigh of the leg scheduled for surgery. Cefuroxime (1.5 g) was administered intravenously as a bolus 15 minutes prior to tourniquet inflation, followed by a second dose 6 hours later. The mean tourniquet duration (range) was 65 (58; 77) minutes. Dialysates and venous blood samples were collected for 12 hours. For cefuroxime the T>MIC (4 μg/mL) ranged between 4.8–5.4 hours across compartments, with similar results for the tourniquet and non-tourniquet leg. Comparable T>MIC and penetration ratios were found for the first and second dosing intervals. We concluded that administration of cefuroxime (1.5 g) 15 minutes prior to tourniquet inflation is safe in order to achieve tissue concentrations above 4 µg/mL throughout surgery. A tourniquet application time of approximately 1 hour did not affect the cefuroxime tissue penetration in the following dosing interval

Tourniquet use in total knee arthroplasty (TKA) is convenient for the surgeon and provides a bloodless field for expeditious surgery and a dry field for cementation, but can best be described as an orthopaedic tradition. It is logical for complex anatomy of ligament, nerve, and vessel surgery but it may not be necessary for TKA. In one recent randomised trial, the absence of the tourniquet was not found to affect the quality of cement fixation. There are numerous potential downsides to the use of a tourniquet including decrease range of motion, delayed recovery, increased pain, wound complications, micro-emboli, neuropathy, and increased VTE. There are also a number of complications associated with the use of a tourniquet including arterial thrombosis, skin irritation below the tourniquet, post-operative hyperemia, blood loss, less accurate intra-operative assessment, and it complicates intravenous drug administration. Studies of range of motion have shown that when there is a difference noted, the range of motion is consistently better without tourniquet use. When a tourniquet is utilised it has been found to be advantageous to only use the tourniquet for a minimal amount of the case, typically when cementing is performed. Functional strength has also been found to be improved without the use of a tourniquet. In a recent randomised trial, tourniquet use was associated with decreased quad strength at 3 weeks that persisted at 3 months. This was attributed to muscle damage, tourniquet-induced ischemia, and compressive injury. Increased peri-operative pain has also been reported in randomised trials associated with the use of a tourniquet. Edema, swelling, and limb girth issues have also been noted to be associated with tourniquet use. Exsanguinating a limb will result in swelling approximately 10% of the original volume half due to a return of blood, and half due to reactive hyperemia. Longer tourniquet times are also associated with increased wound drainage and more wound hypoxia as measured by transcutaneous oxygen levels. Tourniquet use has also been associated with embolic phenomenon with several times greater risk of large emboli. In one study where quantitative MRI was utilised on both thighs after unilateral total knee replacement with and without a tourniquet, the tourniquet group showed more atrophy with a loss of 20% of the volume compared to the normal side in total knees performed with a tourniquet which also performed clinically worse. There is a small but substantial risk of arterial thrombosis particularly in patients that have atherosclerotic plaque. Ironically there is a risk of increased post-operative blood loss due to the post-tourniquet “blush” as the blood pressure and pain increase hours after a surgical procedure is completed. There is also difficulty in identifying and coagulating posterior and lateral geniculate vessels with the components in place. Utilizing a tourniquet also interferes with intra-operative assessment of patella tracking, range of motion, ligament stability, and gap balancing. Randomised clinical trials have concluded that there is less pain and quicker recovery without the use of a tourniquet. There have also been reports of less swelling, increased range of motion, less analgesic use and better clinical outcome when a tourniquet is not utilised. A meta-analysis of systematic reviews favored not utilizing a tourniquet due to the decrease in complication rate and the improvement in clinical results. While it is standard practice in the US to utilise a tourniquet, the strong consensus of the literature on the subject favors either not using a tourniquet or minimizing the use of a tourniquet for the period of time necessary for a very dry field for cement fixation

The December 2023 Knee Roundup. 360. looks at: Obesity is associated with greater improvement in patient-reported outcomes following primary total knee arthroplasty; Does mild flexion of the femoral prosthesis in total knee arthroplasty result in better early postoperative outcomes?; Robotic or manual total knee arthroplasty: a randomized controlled trial; Patient-relevant outcomes following first revision total knee arthroplasty, by diagnosis: an analysis of implant survivorship, mortality, serious medical complications, and patient-reported outcome measures using the National Joint Registry data set; Sagittal alignment in total knee arthroplasty: are there any discrepancies between robotic-assisted and manual axis orientation?; Tourniquet use does not impact recovery trajectory in total knee arthroplasty; Impact of proximal tibial varus anatomy on survivorship after medial unicondylar knee arthroplasty; Bone cement directly to the implant in primary total knee arthroplasty?; Maintaining joint line obliquity optimizes outcomes in patients with constitutionally varus knees

Over a two-year period, 265 Norwegian orthopaedic surgeons working at 71 institutions performed 63 484 operations under a tourniquet. Their replies to a questionnaire revealed that they mostly followed modern guidelines in their use of the tourniquet. Most felt that the tourniquet could be left on for two hours, and that it could be re-applied after 15 minutes. A total of 26 complications (one in 2442 operations) that might have been due to the tourniquet were reported, of which 15 were neurological. Three were in the upper limb (one in 6155 operations) and 12 in the lower limb (one in 3752 operations). Two were permanent (one in 31742 operations), but the remainder resolved within six months. One permanent and one transient complication occurred after tourniquet times of three hours. The incidence of tourniquet complications is still at least as high as that estimated in the 1970s

Tourniquets have been used for many years during total knee arthroplasty (TKA). With a growing demand for TKA in recent years, tourniquet use has been surrounded by ongoing controversy due to many conflicting advantages and disadvantages of tourniquet use. Quantifying the case for or against tourniquet use in TKA, in terms of patient focused outcomes, is a priority. This meta-analysis analysed, the never before assessed, impact of tourniquet use during TKA on post-operative pain. We completed a systematic review and meta-analysis using PRISMA reporting guidelines to assess the impact of tourniquet use on patients post-TKA. Post-operative pain was the primary outcome. Secondary outcomes were post-operative range of motion (ROM) and length of stay (LOS). The initial search yielded 230 studies, of which 14 met the inclusion criteria. A post-operative increase in pain and reduction in ROM when using a tourniquet appeared significantly more likely when compared to no tourniquet use during TKA, yet with no overall difference in post-operative LOS. Subgroup meta-analysis demonstrated a trend that favoured the half-course tourniquet for reduced post-operative pain in patients when compared to full tourniquet use during TKA. This systematic review and meta-analysis concluded that the after-effects of tourniquet use in TKA patients and its impact on post-operative pain and ROM are indeed significant. We recommend further randomized controlled trials (RCTs) focusing on TKA patient outcomes of post-operative pain and ROM. Conflict of interest: The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript

In this study patients were randomized between surgeon chosen pressure (control) and an automatically determined tourniquet pressure(study group). Of 112 patients in the study group, 5% failed to obtain an automatic pressure. Of the remainder, the average tourniquet pressure was 198 +/− 20.2 mm Hg compared to 259.6 +/− 4.4 mmHg for the control group (p<0.0001). Of the study group 94 (88.6%) had good to excellent fields compared to the control group where 100 (77.5%) had good to excellent fields (p<0.05). The automatic measurement of limb occlusion pressure results in better operative fields at a lower pressure

Background. Tourniquets are routinely used in total knee arthroplasty (TKA) with an estimated use by up to 93% of surgeons. Advantages include the ability to provide a bloodless field of view to facilitate cement application and increase the success of the procedure. Overall reduction in blood loss is another perceived advantage, however recent research has demonstrated no measurable reduction and conversely a substantial increase in complications such as deep vein thrombosis and systemic emboli. Given the significant complications of tourniquet use we aim to identify patients’ views on tourniquets and of emphasis their awareness of the possible risks involved prior to the procedure. Method. A questionnaire-based study was carried out on 35 patients attending an elective orthopaedic centre for TKA surgery. Ethical approval was granted by NRES committee – East of England (REC Ref: 14/EE/1265). Patients were provided with an information sheet detailing the reasons for the tourniquet use and the associated risks and benefits. They were then provided with a questionnaire to ascertain their views and previous understanding of the subject. Simple statistical measures were implemented to analyse the data. Results. Only 32% of patients were aware of the use of tourniquets during the operation. 19% were aware of the benefits prior to reading the information sheet provided with 29% understanding the risks involved prior to their procedure. Finally we found 97% of patients would like more information on the use of tourniquets preoperatively. Conclusion. Tourniquets are widely used in TKA surgery, however, they carry significant risks which are not clearly relayed preoperatively to all patients. Given that 91,000 TKA operations are performed per year we believe it is of paramount importance that all patients are appropriately counselled on the risks and benefits of its use and fully informed consent, including risks of tourniquet use, should be obtained prior to the procedure. Level of Evidence. Level 3

Background. Tourniquets are routinely used in total knee arthroplasty (TKA) with an estimated use by up to 93% of surgeons. Advantages include the ability to provide a bloodless field of view to facilitate cement application and increase the success of the procedure. Overall reduction in blood loss is another perceived advantage, however recent research has demonstrated no measurable reduction and conversely a substantial increase in complications such as deep vein thrombosis and systemic emboli. Given the significant complications of tourniquet use we aim to identify patients' views on tourniquets and of emphasis their awareness of the possible risks involved prior to the procedure. Method. A questionnaire-based study was carried out on 35 patients attending an elective orthopaedic centre for TKA surgery. Ethical approval was granted by NRES committee – East of England (REC Ref: 14/EE/1265). Patients were provided with an information sheet detailing the reasons for the tourniquet use and the associated risks and benefits. They were then provided with a questionnaire to ascertain their views and previous understanding of the subject. Simple statistical measures were implemented to analyse the data. Results. Only 32% of patients were aware of the use of tourniquets during the operation. 19% were aware of the benefits prior to reading the information sheet provided with 29% understanding the risks involved prior to their procedure. Finally we found 97% of patients would like more information on the use of tourniquets preoperatively. Conclusion. Tourniquets are widely used in TKA surgery, however, they carry significant risks which are not clearly relayed preoperatively to all patients. Given that 91,000 TKA operations are performed per year we believe it is of paramount importance that all patients are appropriately counselled on the risks and benefits of its use and fully informed consent, including risks of tourniquet use, should be obtained prior to the procedure. Level of Evidence. Level 3

Objectives. The length of the tourniquet time during total knee arthroplasty (TKA) is related to the incidence of post-operative deep vein thrombosis (DVT). Our aim in this study was to investigate the effect of the early release of the tourniquet on the incidence of DVT in patients undergoing TKA. Methods. A total of 200 patients who underwent TKA between November 2015 and November 2016 were prospectively enrolled. The tourniquet was inflated before surgery and released immediately after the introduction of the components (early release group). This group was compared with a retrospective cohort of 200 primary TKAs, in which the tourniquet was released after the dressings had been applied (late release group). The presence of a DVT was detected using bilateral lower limb ultrasonography. Peri-operative clinical and follow-up data were collected for analysis. Results. The incidence of DVT in the early release group (9 of 196, 4.6%) was significantly lower compared with the late release group (24 of 200, 12%; odds ratio (OR) 0.35, 95% confidence interval (CI) 0.16 to 0.78, p = 0.008). The incidence of proximal DVT in the early release group (1 of 196 (0.5%)) was significantly lower than in the late release group (8 of 196, 4%; OR 0.12, 95% CI 0.02 to 0.99, p = 0.020). Although the mean intra-operative blood loss was higher in the early release group, the mean post-operative drainage, total blood loss, transfusion requirements and complications were not significantly different in the two groups. Conclusion. In patients who undergo TKA, releasing the tourniquet early is associated with a decreased incidence of DVT, without increasing the rate of complications. Cite this article: Bone Joint Res 2017;6:535–541

Background. Tourniquets and tranexamic acid (TXA) are commonly used in total knee arthroplasty (TKA), but there is not consensus on how these interventions affect blood transfusion rates and total blood loss. Few studies examine the combined use of both interventions. We compared outcome measures and transfusion rates following TKA, with and without the use of tourniquet and TXA. Methods. Retrospective cohort study of 477 consecutive patients undergoing primary TKA at a single center between 2008 and 2013. There were 243 in the tourniquet-assisted (TA) and 234 in the tourniquet-unassisted (TU) group. Subanalysis was performed on those patients receiving TXA. Results. Mean operative duration was 66.4 minutes (30–135) in the TA group and 87.5 minutes (43–162) in the TU group (p<0.0001). Mean post-operative drop in hemoglobin was significantly greater in TU group (3.1g/dl vs. 2.8g/dl, p=0.002). The transfusion rate was 9.5% in TA compared to 11.5% in TU patients (p=0.46) with comparable mean units transfused (2.6 vs. 2.2, p=0.30). There was no significant difference in rate of wound infection (2% vs. 1.7%, p = 0.82) and total complication rate (4.1% vs. 2.5%, p=0.19) between groups. Mean length of stay was 5.8 days in TA and 7 days in the TU group (p=0.07). Those patients given TXA had a lower hemoglobin drop (2.6g/dl vs. 3.3g/dl, p=0.04) with similar transfusion (10.9% vs. 13.3%, p=0.61) and complication (3.3% vs. 5.2%, p=0.95) rates. Discussion. Tourniquet-unassisted TKA had a greater operative duration and post-operative drop in hemoglobin than tourniquet-assisted TKA. However, transfusion rates were similar between groups. TXA use reduced the operative decrease in hemoglobin with no effect on complication or transfusion rates. Key words. TKA, tourniquet, tranexamic acid, transfusion rates, outcomes. For any figures or tables, please contact authors directly

INTRODUCTION. The efficacy and safety of the tourniquet are discussed, in particular with regard to the blood saving and tissue damage induced by ischemia. The quality of exsanguination and tissue necrosis in the compression zone are significant prognostic factors. The objective of this study was to evaluate the efficacy and safety of a new tourniquet system combining efficient and controlled exsanguination (figure 1) and ischemia maintained by pressure on a minimal surface (figure 2). The hypothesis tested was that the new system allowed tourniquet to reduce blood loss compared to conventional withers without increasing the risk of complications. MATERIAL. Two groups of 30 patients undergoing total knee arthroplasty (TKA) were compared. There were 39 women and 21 men with a mean age of 67 years and a mean BMI of 34. The study group was operated with the innovative tourniquet and followed prospectively. The control group was operated with the traditional tourniquet and analyzed retrospectively. METHODS. Operating time was measured between skin incision and dressing application. Blood loss was calculated with the Gross formula. Blood transfusion requirements were collected. Rehabilitation course was appreciated by the time to discharge. Complications, whether related or not to the tourniquet used, were recorded. Data were compared in both groups with the appropriate statistical tests at a 0.05 level of significance. The sample size was calculated to allow detecting a 300 ml decrease in mean blood loss with a power of 0.80. RESULTS. Both groups were comparable for all pre-operative data (age, gender, BMI, severity of the pre-operative deformation, pre-operative hematocrit level). Calculated blood loss was not significant different in the two groups (968 ml in the study group versus 1,022 ml in the control group, p<0.05). Operating time was not significantly decreased in the study group. Blood transfusion requirements were not significant different in the two groups (4 units versus 6 units). The complication rate was significantly decreased in the study group (no case versus 4 cases), especially for skin complications (3 cases of persistent bleeding or skin ischemia in the study group). The mean discharge time was significantly shorter in the study group (3rd post-operative day versus 5th post-operative day, p<0.05). DISCUSSION. The tested hypothesis was not confirmed. This preliminary study did not show any advantage of the new technology of tourniquet when analyzing blood loss. However, the decreased rate of local skin complications may be in relationship with a decreased intra-operative skin ischemia. This might lead to an earlier discharge. CONCLUSION. A prospective, randomized study is necessary to confirm these preliminary results

Recent emphasis in total knee arthroplasty has been on accelerated rehabilitation and recovery. Minimally invasive and quadriceps sparing techniques have been developed to expediate return to normal function. The aim of this study was to evaluate the effect of the tourniquet on post-operative pain and quadriceps function in total knee arthroplasty. This study involved a randomised, blinded, prospective trial of 20 patients undergoing total knee arthroplasty by a single surgeon. All patients received a general anaesthetic, identical prosthesis and post-operative protocol. Patients were randomly allocated to one of two group: (a) tourniquet group or (b) no tourniquet group. A standard surgical tourniquet was applied to all patients but only inflated in the tourniquet group. Outcomes included Oxford knee scores, post-operative pain scores, post-operative drainage and transfusion requirements, thigh and knee circumference measurements, range of motion, and surface EMG measurements at intervals of two weeks, six weeks, six months and twelve months. The study included 16 male and four female patients with 11 right and nine left knees. There was no significant difference pre-operatively between groups in age, degree of deformity or range of motion. There was no significant difference detected between Oxford knee scores up to twelve months, days to discharge, post-operative drainage and range of motion. However, the pain scores were significantly higher in the tourniquet group. Surface EMG as a measurement of quadriceps activation showed a significant difference between the groups and between time points. The no tourniquet group can support more energy in their quads muscle than the tourniquet group. The use of a tourniquet in total knee arthroplasty has no effect on overall knee function at twelve months as measured by the Oxford knee score and range of motion; however tourniquet use results in higher initial pain scores and reduction in quadriceps function as measured by surface EMG

Introduction. Tourniquets have been used for many years during total knee arthroplasty as a means of achieving a bloodless field for better visualization and cement-bond inter-digitation. Controversy has surrounded the necessity for a tourniquet in past years. There are many advantages and disadvantages to using a tourniquet, and one prominent disadvantage is a purported increase in post-operative pain and limitations in range of motion. Objective. This study examined the literature for assessment of pain and analgesia usage in post-operative patient who have either received no tourniquet during surgery or received variations in both timing and pressure. Secondary outcomes included were functional in nature, namely range of motion and post-operative hospital stay. Methods. Three hundred and nineteen articles were searched and narrowed to 6 using the QUORUM approach. All were randomized, controlled trials with specific exclusion criteria. Results. When analyzing each trial, pain did not seem to be significantly lower in those with no tourniquet. Instead, patients who received lower pressures for only a portion of the surgery had lower pain levels. Range of motion was consistently higher in the non-tourniquet groups compared to the tourniquet patients in all studies that included this measure. There was no difference in hospital stay within the groups for each trial. Conclusion. Our conclusion is that this question is not as straightforward as originally perceived. Patients who receive tourniquet compression up until cementation at lower cuff pressures using a wider cuff may be at an advantage in their post-operatively outcomes

It has stated that the application of a pre-hospital tourniquet could prevent 7% of combat deaths, but their widespread use has been questioned due to the potential risk from prolonged ischaemia, or local pressure. The debate centres on their ability to improve survival after major haemorrhage, versus the potential risk of limb loss. A recent US military prospective study on their use demonstrated improved survival when a tourniquet was applied, and reported that no limb was lost solely from tourniquet use. However, this study focused on early limb loss, with a median follow-up of only 7 days, and so could not consider later morbidity. The aim of this study was to investigate if the pre-hospital application of a tourniquet resulted in an increase in morbidity following significant ballistic limb injury. We reviewed members of the UK armed forces who sustained severe limb-threatening injuries in Iraq and Afghanistan, and based on the presence or absence of a pre-hospital tourniquet a cohort study was then performed. Of the 23 lower limbs that definitely had a pre-hospital tourniquet applied it was possible to match 22 limbs with 22 that did not have a pre-hospital tourniquet. The injuries were matched for anatomical location, severity of the bony injury, initial surgical management, Injury Severity Score and Mangled Extremity Severity Score as much as possible. Of the 22 limbs with a pre-hospital tourniquet applied, 19 limbs had a least 1 complication. Of the 22 with no tourniquet applied, 15 had at least 1 complication (p=0.13). There were 10 limbs with at least 1 major complication in the pre-hospital tourniquet group but only 4 in the group with no tourniquet (p=0.045). There was no difference in the amputation rate. The significant difference in the incidence of major complications is a concern, particularly as the difference was mainly due to a deep infection rate of 32% vs. 4.5%. Although there are a number of variables which could have influenced these small groups, such as choice of implant, method and timing of wound closure, the use of a cohort and a p < 0.05, does suggest the use of a pre-hospital tourniquet was a factor. Although the use of pre-hospital tourniquets cannot be decried as a result of this study, there does remain the need to continually review their use, prospectively, to determine their risk/benefit ratio

Background: Tourniquet provides a blood less field for surgery, but it has few complications and contraindications. There are several studies identifying the tourniquet as a factor for increased risk of complications in knee arthroscopy, we reviewed 200 consecutive knee arthroscopies done in our hospital with out tourniquet to analyse the outcome. Aim: To analyse the out come of 200 knee arthroscopies with out use of tourniquet; with respect to visualisation, time of surgery, bleeding, analgesia and post operative complications. Materials and methods: We retrospectively analysed 200 consecutive knee arthroscopies with out tourniquet done in our institute. Average age of these patients was 39 (21–81). All patients underwent soft tissue procedures under general anaesthesia, supine, with sole support, no antibiotics and was done by same surgeon as day case. Same arthroscopic kit with pump was used for all patients, using 2 litre saline bag and pump set at 65 mm Hg pressure. First few cases had tourniquet applied but not inflated, but later even this was avoided. Procedures included were diagnostic arthroscopies, arthroscopic debridements, meniscal repairs and partial or complete meniscal resections. Procedures like arthroscopic ACL reconstruction and other bony procedures were excluded. We looked at any visualisation problems, time of surgery, bleeding, analgesia and post operative complications. We also looked weather any of these patients visited the consultant or GP for any wound related problem or pain before the usual review at 2 weeks. Results: There was no problem with visualisation noted in any of the cases, or any incidence where arthroscopy was unduly prolonged. There was no incidence of bleeding, stiffness or increased need for analgesia in any of these patients. None of the patients had any wound problem or haemathrosis requiring intervention. There was no record of any patients reattending the clinic or their GP for pain or bleeding. Conclusions: Many orthopaedic units continue to use a tourniquet routinely for soft tissue procedures in knee arthroscopy, probably in the belief that a clear operative view can only be achieved with one. However, the findings in our study indicate that knee arthroscopy for soft tissue procedures may be performed adequately without the use of a tourniquet provided a pump system is used and the pressure maintained above venous pressure. Therefore we recommend that its use for routine soft tissue arthroscopic procedures be discontinued

Our aim was to determine if a tourniquet placed on the ankle has any advantage in forefoot surgery over the position on the midcalf. We randomised 30 patients who were undergoing forefoot surgery under under local anaesthesia into two groups. One had a tourniquet on the ankle and the other on the mid calf. All calf and ankle tourniquets were inflated to 100 mm Hg above the systolic pressure, just before the surgical procedure. The blood pressure, pulse and level of pain were recorded at intervals of five minutes during the operation. The surgeon evaluated the quality of the anaesthesia, the bloodless field, and the site of the tourniquet. The patients tolerated the tourniquet on the ankle much more. Both the tourniquet positions gave good operative fields, however the use of the ankle tourniquet was less painful at 5,10,20 and 30 minutes after the operation had started (p< 0.01). Physiological parameters were better in the ankle group. We conclude that the ankle tourniquet gives a good bloodless field and provides improved pain tolerance for forefoot surgery carried out under local anaesthesia

Background: Tourniquet provides a blood less field for surgery, but it has few complications and contraindications. There are several studies identifying the tourniquet as a factor for increased risk of complications in knee arthroscopy, we reviewed 200 consecutive knee arthroscopies done in our hospital with out tourniquet to analyse the outcome. Aim: To analyse the out come of 200 knee arthroscopies done with out use of tourniquet; with respect to visualisation, time of surgery, bleeding, analgesia and post operative complications. Materials and methods: We retrospectively analysed 200 consecutive knee arthroscopies with out tourniquet done in our institute. Average age of these patients was 39 (21–81). All patients underwent soft tissue procedures under general anaesthesia, supine, with sole support, no antibiotics and were done by same surgeon as day case. Same arthroscopic kit (Dyonics) with pump was used for all patients, using 2 litre saline bag and pump set at 65 mm Hg pressure. First few cases had tourniquet applied but not inflated, but later even this was avoided. Procedures included were diagnostic arthroscopies, arthroscopic debridements, meniscal repairs and partial or complete meniscal resections. Procedures like arthroscopic ACL reconstruction and other bony procedures were excluded. We looked at any visualisation problems, time of surgery, bleeding, analgesia and post operative complications. We also looked weather any of these patients visited the consultant or GP for any wound related problem or pain before the usual review at 2 weeks. Results: There was no problem with visualisation noted in any of the cases, or any incidence where arthroscopy was unduly prolonged. There was no incidence of bleeding, stiffness or increased need for analgesia in any of these patients. None of the patients had any wound problem or haemathrosis requiring intervention. There was no record of any patients reattending the clinic or their GP for pain or bleeding. Conclusions: Many orthopaedic units continue to use a tourniquet routinely for soft tissue procedures in knee arthroscopy, probably in the belief that a clear operative view can only be achieved with one. However, the findings in our study indicate that knee arthroscopy for soft tissue procedures may be performed adequately without the use of a tourniquet provided a pump system is used and the pressure maintained above venous pressure. Therefore we recommend that its use for routine soft tissue arthroscopic procedures be discontinued

Our aim was to determine if a tourniquet placed on the forearm has any advantage in clinical practice over the usual position on the upper arm. We randomised 50 patients who were undergoing an open operation for carpal tunnel syndrome under local anaesthesia into two groups. One had a tourniquet on the upper arm and the other on the forearm. The blood pressure, pulse, and level of pain were recorded at intervals of five minutes during the operation. The surgeons were also asked to evaluate the quality of the anaesthesia, the bloodless field, and the site of the tourniquet. The patients tolerated the tourniquet on the upper arm and forearm equally well. The surgeons had some difficulties when it was placed on the forearm. We therefore recommend placement of a tourniquet on the upper arm for operations on the hand and wrist which are carried out under local anaesthesia

We assessed the influence of the use of a tourniquet in total knee arthroplasty in a prospective, randomised study. After satisfying exclusion criteria, we divided 77 patients into two groups, one to undergo surgery with a tourniquet and one without. Both groups were well matched. The mean change in knee flexion in the group that had surgery without a tourniquet was significantly better at one week (p = 0.03) than in the other group, but movement was similar at six weeks and at four months. There was no significant difference in the surgical time, postoperative pain, need for analgesia, the volume collected in the drains, postoperative swelling, and the incidence of wound complications or of deep-venous thrombosis. We conclude that the use of a tourniquet is safe and that current practice can be continued

Introduction and Aims: Patellar subluxation is most troublesome and accounts for a number of complications in total knee arthroplasty. The purpose of this study is to report the incidence of need for lateral release before and after tourniquet deflation, and the effect of the tourniquet on proper patellar tracking. Method: A total of 171 knees in 133 patients were prospectively evaluated for the need for a lateral retinacular release before and after tourniquet deflation. All knees were implanted using the same knee system. An initial group of 99 knees were evaluated with tourniquet inflation while the knee was in flexion. Tourniquet inflation with the knee in flexion versus extension was subsequently assessed in a subset group of 72 knees. The need for lateral release was determined using the rule of ‘no-thumbs’ and rule of ‘full contact’. Results: A total of 77 knees appeared to need a lateral release before tourniquet deflation. After tourniquet deflation 27 knees required lateral release representing a 65 percent reduction in lateral release. There was no statistically significant difference (p equals 0.5506: Pearson’s chi square) when comparing the flexion/extension groups. Conclusion: Often, the surgeon evaluates patellar tracking with the tourniquet inflated, not taking into account the effect of tourniquet pressure on the quadriceps muscle. Our findings support the hypothesis that the resulting pressure from the tourniquet impacts patellar tracking. We conclude that if patellar tracking is questionable with the tourniquet inflated, tracking should be re-assessed with the tourniquet deflated before considering a lateral release

Introduction. Total knee arthroplasty (TKA) is associated with significant blood loss, for which blood transfusion might be necessary. The role of the tourniquet is controversial, though it is widely used by orthopedic surgeons. Its use was believed to be effective in decreasing intraoperative blood loss and creating a bloodless surgical field, which theoretically would facilitate the cementing technique and other surgical procedures. However, reactive blood flow reached its peak within five minutes after the tourniquet had been released. The tourniquet controls intraoperative blood loss, but cannot stop postoperative blood loss. Patients who were managed with a tourniquet during the operation often complained of thigh pain. This was possibly caused by the direct pressure of an inflated tourniquet on the nerves and local soft tissues. Limb swelling and increased soft tissue tension caused by reactive hyperperfusion after tourniquet deflation may also contribute to the wound pain. The aim of our study is to investigate the effect of tourniquet on blood loss and soft tissue damage in TKA. Materials & Methods. In this prospective, randomized study, 72 patients with primary cemented knee arthroplasty were randomly allocated to two groups (with and without tourniquet). The operation time, blood loss, post-operative hemoglobin, hematocrit, markers of soft tissue damage (myoglobin, Cretine Posphokinase(CK), LDH, GOT, Creatinine), status of rehabilitation, knee pain and thigh pain were monitored until discharge. Results. The intra-operative and total blood loss is more in non-tourniquet. The post-operative levels of hemoglobin and hematocrit were significant higher in tourniquet group until postoperative day 4. Using tourniquet also shortened the operation time. Patients managed without tourniquet showed higher CK level in postoperative day 2. The severity of knee pain was similar in both group. Mild thigh pain was noted in tourniquet group. Conclusions. Our randomized controlled trial revealed that the usage od tourniquet in TKA may save blood and save time with minor adverse effect. Without using tourniquet, the prolonged surgical time and excessive hemostasis may cause more soft tissue damage

Aims. The aim of this study was to compare the pain caused by the application of a tourniquet after exsanguination of the upper limb with that occurring after simple elevation. . Patients and Methods. We used 26 healthy volunteers (52 arms), each of whom acted as their own matched control. The primary outcome measure was the total pain experienced by each volunteer while the tourniquet was inflated for 20 minutes. This was calculated as the area under the pain curve for each individual subject. Secondary outcomes were pain at each time point; the total pain experienced during the recovery phase; the ability to tolerate the tourniquet and the time for full recovery after deflation of the tourniquet. . Results. There was a significant difference in the area under the pain curves in favour of exsanguination (mean difference 8.4; 95% confidence interval (CI) 3.0 to 13.7, p = 0.004). There was no difference between the dominant and non-dominant arms (mean difference -0.2; 95% CI -23.2 to 22.8, p = 0.99). The area under both recovery curves were similar (mean difference 0.7; 95% CI -6.0 to 4.6, p = 0.78). There was no statistical difference in recovery time, the actual mean difference being 30 seconds longer in the elevation group (p = 0.06). Conclusion. Many orthopaedic and plastic surgery procedures are done under local anaesthetic or regional block where a bloodless field and a motionless patient are essential. Optimising patient comfort during surgery with the tourniquet inflated is thus a priority. This study is useful in that it compares two common methods of preparation of the upper limb prior to tourniquet inflation and which have not previously been compared in this context. Following on the results of this study, we can confidently conclude that exsanguinating the upper limb before inflating a tourniquet is more comfortable than simply elevating the arm for patients undergoing a procedure under local or regional block, both during the procedure and in the recovery phase. . Take home message: Exsanguination rather than elevation is recommended in order to minimise patient discomfort and optimise the surgical field. Cite this article: Bone Joint J 2016;98-B:519–25

The use of a tourniquet during total knee arthroplasty (TKA) is controversial. Return to function and pain are believed to be affected by the use of a tourniquet. The hypothesis of this study was that use of a tourniquet (T) would delay postoperative functional recovery and increase pain as compared to no tourniquet use (NT). 200 patients were recruited for this prospective, double-blinded, randomized controlled trial. All surgeries were performed by one of two fellowship trained arthroplasty surgeons at our institution. Patients were randomized to either undergo TKA with T or NT and blinded to group allocation. An otherwise standardized perioperative protocol was followed. The primary outcome measures were functional assessment testing using the timed up-and-go (TUG) and stair-climb (SC) tests and visual analog scale pain (VAS-P) scores. Secondary outcome measures included blood loss and range-of-motion (ROM). Patients completed outcomes measures preoperatively, in hospital, and postoperatively at 4–6 weeks and 6–8 months. Minimal detectable change (MDC) and Student's T-test, alpha of p < 0.05, were used to determine significance. No significant differences were seen in postoperative TUG, SC, VAS-P, or ROM at any time point. NT patients were seen to have significantly more calculated blood loss (means: T 1,370.04mL, NT 1,743.85mL; p < 0.001), without a significant increase in transfusion events. Tourniquet use during TKA significantly decreases blood loss and does not adversely affect early postoperative outcomes. Tourniquet use during routine TKA is safe and effective and concerns over deleterious effects on function and pain may not be justified

Pain produced by the tourniquet is a common source of complaint for patients undergoing carpal tunnel decompression. Practice varies as to tourniquet position. There is little evidence to suggest benefit of one position over another. Our aim was to compare the experience of both the patient and the surgeon with the tourniquet placed either on the arm or the forearm. Ethical approval was granted. Following power calculation and a significance level set at 0.05, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomised to arm or forearm group. Visual Analogue Scores (VAS) (0–100) for pain, blood pressure and heart rate were taken at 2 minute intervals. The operating surgeon provided a VAS for bloodless field achieved and obstruction caused by the tourniquet. The demographics of the groups was similar. There were no statistically significant differences in any measure between the groups. Average tourniquet times were 8.8 minutes (forearm) and 8.2 minutes (arm). The average VAS score for forearm and arm was 13 and 11 respectively for bloodless field, 9 and 2 for obstruction. Average overall VAS for pain was 27 in each group, however interval VAS scores for pain were higher in the arm group. The average change Mean Arterial Pressure was −5 mmHg (forearm) −2 mmHg (arm) pulse rate was −1 bpm (forearm) and −2 bpm (arm). Tourniquet placement on the arm does not result in significant difference in patient pain, physiological response or length of operation. Surgeons reported less obstruction and better bloodless fields with an arm tourniquet, however there was a trend for forearm tourniquet to result in less pain for the patient

Aims. We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue. Methods. This was a randomized control trial of 169 patients who required surgery for closed isolated distal radius fractures. The study was performed between March 2016 and April 2019 at a public sector level 1 trauma centre. General anaesthesia was used in 56 patients, Bier’s block in 58 patients, and WALANT in 55 patients. Data were collected on pre-, peri-, and postoperative parameters, clinical outcome, hospital costs, and patient satisfaction. One-way analysis of variance (ANOVA) was used with a p-value of 0.05 being significant. Results. Operations with WALANT proceeded sooner, and patients recovered faster, resulting in mean fewer missed working days (7.8 (SD 1.67)) compared with general anaesthesia (20.1 (SD 7.37)) or Bier’s block (14.1 (SD 7.65)) (p < 0.001). The WALANT patients did not develop complications, while the other patients did (p < 0.04). Clinical outcomes did not differ, nor did surgeon qualification affect clinical outcomes. Mean hospital costs were lower for WALANT ($428.50 (SD 77.71)) than for general anaesthesia ($630.63 (SD 114.77)) or Bier’s block ($734.00 (SD 37.54)) (p < 0.001). Patient satisfaction was also higher (p < 0.001). Conclusion. WALANT for distal radius fractures results in a faster recovery, is more cost-effective, has similar clinical outcomes, and has fewer complications than general anaesthesia or Bier's block. This makes WALANT an attractive technique in any setting, but especially in middle- and low-income countries. Cite this article: Bone Joint Res 2020;9(7):429–439

Introduction. Intraosseous administration of low dose vancomycin has been proven to produce 6 to 20 times higher tissue concentrations compared to intravenous administration in both primary and revision knee replacement. However, these superior levels are achieved when the antibiotic given intraosseously is administered distal to a tourniquet that is inflated for the majority of the case. With increasing interest in limited, or no, tourniquet use during TKA we sought to study the tissue concentrations achieved with limited tourniquet use and intraosseously administered vancomycin compared to weight-based, time optimized intravenous administration. Methods. Twenty-four patients undergoing primary TKA were randomized to two groups. The Intravenous (IV) Group received weight based (15mg/kg) vancomycin timed to finish before incision. The Intraosseous (IO) Group received 500 mg of vancomycin injected as a bolus through a needle into the proximal tibia distal to an inflated tourniquet prior to skin incision. In the IO group, the tourniquet was deflated 10 minutes following the injection and re-inflated only for cementation. In the IV group, the tourniquet was only inflated for cementation. During the procedure, fat and bone samples were taken at regular intervals. Tissue antibiotic concentrations were measured using a validated technique involving high performance liquid chromatography. Results. Mean tissue concentrations of vancomycin in fat and bone samples from all time points were 3–10 times greater in the IO group (all results, p<0.01). At closure, mean vancomycin levels in fat were 6.0ug/g in the IV group vs 40.5ug/g in the IO group (p<0.001). Final bone levels were 8.3ug/g in the IV group vs 26.9ug/g in the IO group (p=0.009). Conclusion. In total knee replacement, IO administration of prophylactic vancomycin achieves significantly higher tissue concentrations versus IV administration given under ideal conditions despite limited tourniquet use. For figures, tables, or references, please contact authors directly

About 81,000 total knee replacements are implanted in the United Kingdom annually. Conventionally pneumatic tourniquet and surgical drains have been used in total knee arthroplasty. However, no definite evidence or guidelines exist to support their use. The present study aims to look for any difference in perioperative recovery and complications following use of pneumatic tourniquet and surgical drains in knee replacement surgery. We retrospectively analysed 60 total knee arthroplasties performed by 3 different surgeons at our hospital during January 2007 to June 2010. A sample size of 20 patients in each group was evaluated. Group 1: used tourniquet and drain; Group 2: used tourniquet but no drain; Group 3: didn't use tourniquet but used drain. Data was collected and analysed using statistical means, t-test & analysis of variance. Parameters compared were surgical (anaesthetic) time, mean postoperative haemoglobin at 24 hrs, blood transfusion rate, haematoma formation, wound infection, pain, deep vein thrombosis and infection at discharge. At 6 weeks clinical follow up letters were analysed. Our results reveal that there is no significant difference in duration of surgery in either group. Use of tourniquets didn't improve on surgical time (123–133 minutes). Our Local Hospital Pain Score was used (1 no pain, 2 mild, 3 moderate, 4 severe and 5 worst imaginable pain). No difference at discharge was seen in either group. Similarly no difference was seen in either group with postoperative haematoma formation with one case (5%) in Group 1 and 3 respectively. Although the immediate postoperative haemoglobin (Hb%) was comparable in all 3 groups, Group 3 patients received more blood transfusion compared to other groups based on clinical grounds. About 50 % of Group 3 needed blood transfusion compared to 10% in Group 1 and 5% in Group 2. There was only one proven case of superficial infection at 6 weeks (Group 2) which responded well to antibiotics. There were 4 cases of cellulitis noted at 6 weeks (3 in Group 2 and 1 in Group 3) which responded to oral antibiotics. No deep infection was noted. The mean hospital stay in hospital was 6.5 days in Group 1, 5.5 days in Group 2 and 8 days in Group 3. There was no difference in rate of post-operative deep vein thrombosis (5% in Group 1 and 3). The present study with the use of tourniquet and surgical drain in total knee arthroplasty showed no significant difference in surgical time and incidence of postoperative haematoma, deep vein thrombosis. Pain score at discharge was comparable and so was the infection rate. Patients in Group 2 (used tourniquet but no surgical drain) had least hospital stay (mean 5.5 days) and least blood transfusion rate (5%). Decision to use pneumatic tourniquet & drain still lies with the operating surgeon. We recommend a randomised control study for further evidence

Background. There are multiple documented advantages of undertaking total knee arthroplasty (TKA) without tourniquet, however, increased rates of blood loss and transfusion are often cited as contraindications to this approach. The aim of this study was to examine the effect of intra-operative TA administration on blood loss and transfusion rates in TKA without pneumatic tourniquet, using Rivaroxaban as thrombo-embolic prophylaxis. Method. 120 patients split into two continuous data sets, (A+B), underwent TKA without application of above knee tourniquet, receiving a post operative dose of oral Rivaroxaban within 8 hours. Group B patients received an intra-operative dose of 1 gram of Tranexamic Acid intravenously before the first cut, whilst those in group A did not. Haemoglobin and haematocrit levels were recorded peri-operatively. A revised Gross formula was used to calculate blood loss. Four patients were excluded from the study for incomplete data. Results. 58 patients (M34F24) in Group A, average age 6, had a mean haemoglobin drop of 33gram/litre, haematocrit drop of 0.097litre/litre (9.7%), with an average calculated blood loss of 1393ml. 58 (M34, F24) patients in group B, average age 67, had a haemoglobin drop of 25.2gram/litre, haemotocrit drop of 0.076litre/litre (7.6%) with an average calculated blood loss of1079ml. Thus Group A patients were seen to sustain significantly more blood loss without TA administration, with a 29.1% larger calculated blood loss, a 25.5% larger drop in haemoglobin and a 27.6% larger fall in haematocrit. Transfusion rate was 5.2% (3 patients) per group. Conclusion. TA was shown to be effective in reducing blood loss in TKA without tourniquet using Rivaroxaban. Transfusion rates of 5.2% across both groups is close to 1/10th of the transfusion rate reported for some major studies of TKA using Rivaroxaban with tourniquet application, and 1/8th of the transfusion rate in studies of TKA with administration of TA and use of tourniquet. Level of Evidence. Level-III. The authors report there are no relevant disclosures to make. Ethical approval was granted for the study

Today the use of pneumatic tourniquet is commonly accepted in total knee arthroplasty (TKA) to reduce perioperative blood loss. There are a few prospective randomised and nonrandomised studies that compare the effect of tourniquet release timing in cementless or cemented unilateral TKA. However, many of these studies show an inadequate reporting and methodology. This randomized prospective study was designed to investigate the efficiency of tourniquet release timing in preventing perioperative blood loss in a simultaneous bilateral TKA study design. To our knowledge, this is the first study of its kind, in which the effect of tourniquet release timing on perioperative blood loss was investigated in simultaneous bilateral cemented TKA. In 20 patients (40 knees) one knee was operated with tourniquet release and hemostasis before wound closure, and the other knee with tourniquet release after wound closure and pressure dressing. To determine the order of tourniquet release technique for simultaneous bilateral TKA, patients were randomized in two groups: ‘Group A’ first knee with tourniquet release and hemostasis before wound closure, and ‘Group B’ second knee with tourniquet release and hemostasis before wound closure. The blood loss was recorded 48 hours postoperative for each technique. We found no significant difference in total blood loss between both techniques (p =.930), but a significant difference in operating time (p =.035). There were no postoperative complications at a follow-up of 6 month. Other studies report an increase the blood loss in early tourniquet release and an increase the risk of early postoperative complications in deflation of tourniquet after wound closure. In this study we found no significant difference in perioperative blood loss and no increase of postoperative complications. Therefore, we recommend a tourniquet release after wound closure to reduce the duration of TKA procedure and to avoid possible risks of extended anaesthesia

Free radicals, such as reactive oxygen species (ROS) which are released abruptly after deflation of an ischaemic tourniquet, cause reperfusion injuries. Ischaemic precondition (IPC), however, can reduce the injury. In clinical practice, the sequential application and release of tourniquets is often used in bilateral total knee replacement (TKR) to obtain a clearer operative field, but the effects on the production of free radicals and lipid peroxidation have not been studied. In this study, we have observed the production of free radicals and the subsequent lipid peroxidation in bilateral TKR with sequential application of a tourniquet to examine the effect of IPC. Patients undergoing elective TKR under intrathecal anaesthesia were studied. Blood samples were obtained after spinal anaesthesia, one minute before and five and 20 minutes after release of each tourniquet. We used the lucigenin chemiluminescence analysis and the phosphatidylcholine hydroperoxide (PCOOH) assay to measure the production of ROS and lipid peroxidation. Our results showed that production of ROS significantly increased at five and 20 minutes after release of the first tourniquet and at five minutes after release of the second tourniquet, but returned to normal at 20 minutes after the second reperfusion. The peak production of ROS was at 20 minutes after the first reperfusion; lipid peroxidation did not change significantly. We conclude that in spite of significant production of ROS after the release of tourniquet, the IPC phenomenon occurs during bilateral TKR with sequential application of a tourniquet

Background. Forefoot surgery is often performed under regional anaesthesia (ankle block) in awake patients, using tourniquet or esmarch bandage to obtain bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under regional anaesthesia. We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive subcutaneous local anaesthetic mixture under the tourniquet. We checked for local tourniquet pain score (VAS 0–100) and skin condition during and after the procedure. Results. Tourniquet was quite tolerable in both groups, with an average VAS score of 7–21. No difference was observed between groups throughout most of the procedure. No correlation between VAS scores and procedure length or patient's age or gender. Conclusion. Ankle tourniquet is well tolerated by patients without need for local anaesthetics

Introduction: The use of lower limb tourniquets is routine in lower limb surgery. Several methods have been used often based on surgical preference. Aim: To establish the pain quality in patients undergoing forefoot surgery with the tourniquet placed at the ankle and the calf. Method: A prospective randomised trial was undertaken. Assessment of peri-operative and postoperative pain in 30 patients undergoing forefoot surgery under local anaesthetic was undertaken. All calf and ankle tourniquets were inßated just before surgery. Patients were concealed randomised to either midcalf or ankle tourniquet. Cuffs were inßated to 100 mm Hg above the systolic pressure. Pain and pulse were measured pre-operatively and at 5 minutes, 10 minutes and at 10-minute intervals. We also assessed the quality of the þeld. Results: Both the tourniquet positions gave very good þelds however the use of the ankle tourniquet was far less painful at 5,10,20 and 30 minutes after the operation started p< 0.0001. Conclusion: We conclude that the ankle tourniquet gives an excellent bloodless þeld whilst providing a far less discomfort