Using a scintigraphic technique based on anautologous injection of . 99m. Tc-labelled erythrocytes, we have evaluated the efficiency of different exsanguination procedures in the upper limb of ten healthy male volunteers. The methods were elevation alone, the use of the Esmarch bandage or a gauze bandage, the Pomidor roll-cuff, the squeeze method and the Urias bag. The various procedures gave the following median percentage reductions of blood volumes: elevation for 5 seconds 44%, 15 seconds 45%, 30 seconds 46%, 60 seconds 46% and 4 minutes 42%, the Esmarch bandage 69%, a gauze bandage 63%, the Pomidor roll-cuff 66%, the squeeze method 53%, and the Urias bag 57%. With regard to elevation alone no significant differences were found. All the external methods were significantly more effective than elevation alone. Overall, the squeeze method was found to be the best method of exsanguination before inflation of a tourniquet, because it is effective, fast, practical and inexpensive

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

Introduction & Aims. Mild to moderate CD after TKA is a common side-effect of an otherwise successful procedure. Despite improvement in the majority of the cases within weeks to a few months, this is a source of concern and disappointment. This analysis presents a possible mechanism for post-TKA cognitive changes. Method. We reviewed the literature on the hemodynamic events around limb exsanguination, tourniquet placement and release during TKA. The majority of this literature is in anesthesia journals, with only a few in orthopedic journals (e.g., Berman, JBJS, 1998, 389–96). Once the data was collected, we scrutinized it for validity and in order to identify a plausible etiology that links between the TKA operating procedure and CD. Results. Limb elevation, Esmarch bandage, or Rhys-Davis exsanguinators are used prior to tourniquet inflation. Blond et al, (Acta Orthop Scand. 2002; 73:89–92) showed that at best, 70% of the limb's blood was exsanguinated. Miller et al. (Ann. Surg. 1979; 190:227-230) demonstrated that blood remaining inside the vessels of an occluded limb coagulates. Parmet et al (Lancet. 1993; 341:1057–8) observed a shower of echogenic material in the right atrium approximately 30 seconds after tourniquet release in ALL patients. Berman et al., (JBJS, 1998, 389–96) documented that this echogenic material consisted of fresh thrombi. These thrombi partially occlude the pulmonary circulation, elevating pressure in the right heart. As such, the blood pressure balance across the septum of the right atrium reverses. For patients with patent foramen ovale, blood flows from right to left. This brings echogenic material to the cerebral circulation in over 50% of TKA patients as detected by transcranial Doppler ∼50 seconds after tourniquet release (Sulek, Anesthesiology 1999; 91:672–6). These cerebral emboli were associated with new brain infarcts detected by pre- and post-TKA MRI imaging (Koch, J Neuroimaging. 2007 17:332–5). The last step in this chain-of-evidence analysis is the statistics of CD post-TKA (Rodriguez, J Arthroplasty. 2005 20:763–71). Conclusions. Disproportionate prevalence of CD post-TKA as compared to other surgical procedures performed under similar types of anesthesia and in similar patients is worrisome. This hemodynamic analysis invokes a hypothesis that links incomplete limb exsanguination with cognitive dysfunction. Prospective studies where near-perfect exsanguination is compared with current methods should be performed

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

Bloodless field in limb musculoskeletal tumours’ surgery has great value as it facilitates resection and reconstructions without excessive bleeding.

40 large bone or soft tissue tumors located in upper (n=4) and lower limbs (n=36) were resected and reconstructed in bloodless surgical field achieved by a new device, an elastic silicone ring (S-Mart, OHK Medical Device). Proper size of it is chosen between items of different diameter, length and elasticity depending on their measurements and BP. Our goal was safe and sufficient blood pressure for bloodless operation. In tumours, esh-mark and any pressure on the mass results in microscopic spread. We rolled the ring along the limb, starting from digits and exsanguinated the limb raising it above the tumour to avoid crushing it. If tumours extend too proximally to hip and shoulder we cannot use tourniquet because cuffs are wide enough to allow proximal extension of the incision. The elastic ring we used, is too narrow (Φ< 20cm) and proved of utmost importance in large, bleeding growths helping tumour elimination and limb salvaging. The ring was applied from 18–120 minutes created completely bloodless surgical field thus facilitating and speeding up the operation. The time needed for application was shorter than for pneumatic tourniquet (< 10sec). After removing the elastic ring we noticed neither BP drop nor tumour spread or complications of skin and neurovascular elements pressure.

Thus we conclude that limb ischaemia achieved with special elastic rings have benefits and may be considered as safe in oncological surgery.

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

An interesting case with excellent accompanying images, highlighting the significance of tourniquets in controlling exsanguination, whilst also raising the issue of amputation versus reconstruction in severely injured limbs. A 39 year old male motorcyclist was BIBA to the Midland Regional Hospital in Tullamore, following a head-on collision with a bus at high velocity. On arrival, he was assessed via ATLS guidelines; A- intubated, B- respiratory rate 32, C - heart rate 140bpm, blood-pressure 55/15 and D- GCS 7/15. Injuries included partial traumatic amputation of the right lower limb with clearly visible posterior femoral condyles, a heavily comminuted distal tibial fracture and almost complete avulsion of the skin and fat at the popliteal fossa. Obvious massive blood loss at the scene had been tempered by a passer-by who applied a beach towel as a makeshift tourniquet. CT Brain demonstrated extra-dural and subarachnoid haemorrhages with gross midline shift. Unfortunately, the neurosurgical team in Beaumont concluded that surgical intervention would be inappropriate. However, his kidneys had not sustained ATN and were made available for donation. Two vital surgical issues were featured in this case. Firstly, it highlighted the importance of tourniquets in controlling exsanguination in a trauma situation. 1. Secondly, it raised the critical issue of amputation versus reconstruction in severely injured limbs. 2,3. . Without prompt placement of a make-shift tourniquet by a passer-by, this patient would have almost certainly died at the scene of the accident. Two kidneys were successfully donated as a result. The importance of appropriate tourniquet use cannot be overstated. This case highlights its potential life or limb-saving capabilities in emergency trauma situations. It also raises the critical issue of amputation versus reconstruction in acute emergency situations

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. . This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation. Cite this article: Bone Joint J 2014; 96-B:1143–54

Severe military pelvic trauma has a high mortality rate with previous work identifying an association between pelvic fracture and traumatic amputation (TA) of the lower limb (LL). Research has also identified casualties with this combination of injuries as the potential ‘future unexpected survivors’, however, most casualties die early from exsanguination, often before medical interventions can be performed. Therefore targeting injury prevention or mitigation might be the route to increased survivorship. This study investigates this combination of injury and identifies targets for preventative techniques. A search of the JTTR from 2003 to 2014 identified all patients with TA and all pelvic fractures. Of 989 casualties with LL TAs, 19% had an associated pelvic fracture, and this was associated with a 56% mortality rate compared to 24% without. Both pubic symphysis and sacroiliac separation alike were associated positively with traumatic amputation (p < 0.01). The combination of pelvic instability and TA had a mortality rate of 52%. We hypothesise that pelvic fracture may share a mechanistic link with TA, meaning fracture may occur as a consequence of the force and direction of the TA, and it may be possible to direct mitigation strategies at this injury in order to improve survival rates

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement-bone interface for fixation. The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic: Nerve damage, Altered hemodynamics with limb exsanguinations (15–20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain), Delay in recovery of muscle function, Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes, A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles, Vascular injury with higher risk in atherosclerotic, calcified arteries, Increase in wound healing disturbances, Obese patients TKA with tourniquet show impaired endothelial function and more DVTs. Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last 14 years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, cement penetration/ fixation, less postoperative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Conflict in Afghanistan demonstrated predominantly lower extremity and pelvi-perineal trauma secondary to Improvised Explosive Devices (IEDs). Mortality due to pelvic fracture (PF) is usually due to exsanguination. This study group comprised 169 military patients who sustained a PF and lower limb injury. There were 102 survivors and 67 fatalities (39% mortality). Frequent fracture patterns were a widened symphysis (61%) and widening of the sacroiliac joints (SIJ) (60%). Fatality was 20.7% for undisplaced SIJs, 24% for unilateral SIJ widening and 64% fatality where both SIJs were disrupted, demonstrating an increase in fatality rate with pelvic trauma severity. A closed pubic symphysis was associated with a 19.7% mortality rate versus 46% when widened. Vascular injury was present in 67% of fatalities, versus 45% of survivors. Of PFs, 84% were associated with traumatic amputation (TA) of the lower limb. Pelvic fracture with traumatic lower limb amputation presents a high mortality. It is likely that the mechanism of TA and PF are related, and flail of the lower limb(s) is the current hypothesis. This study prompts further work on the biomechanics of the pelvic-lower limb complex, to ascertain the mechanism of fracture. This could lead to evidence-based preventative techniques to decrease fatalities

Thromboembolic (TE) events and related wound issues are the most common post-operative complications related to lower extremity total joint arthroplasty. They represent not only significant morbidity but also serious economic consequences. Evolution has selected for thrombus formation as a protection against exsanguination. Trauma is by definition a thrombogenic event. As surgery is an elective trauma, it is understandable that an individual undergoing a surgical procedure will be at increased risk to develop a TE event. However, to treat all patients with an identical prophylaxis denies the reality that the population is not homogeneous. Rather it is a normal distribution with wide variability from hemophyllic to thrombophyllic. As a consequence some patients may be over treated with resultant wound complications, i.e. hematomas, drainage, delaying discharge or worse requiring re-admisssion, re-operation or worst of all a secondary infection of the implanted device. For this reason we proposed an inexpensive pre-operative screening protocol to more objectively identify an individual's levelof thrombophyllia. Although not exhaustive, it identifies those patients at ends of the curve with either an increased risk of clot or bleeding. It includes: Factor VIII, Factor V (Leyden), Factor C (APCR), Fibrinogen, D-dimer, Prothrombin Gene Mutation, ESR and CRP. This protocol costs less than $200/patient and was found to be 100% predictive of patient risk. Since instituting this protocol we have eliminated re-admission for complications related to overly aggressive TE prophylaxis. It has become an invaluable and intergral part of our pre-, intra- and post-operative protocol for multimodal TE prophylaxis

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation. The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic: Nerve damage; Altered hemodynamics with limb exsanguinations (15–20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3× greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances. Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-operative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation. The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic - Nerve damage; Altered hemodynamics with limb exsanguinations (15‐20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances. Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less postoperative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation. The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic. . Nerve damage. Altered hemodynamics with limb exsanguinations (15–20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain). Delay in recovery of muscle function. Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes. A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles. Vascular injury with higher risk in atherosclerotic, calcified arteries. Increase in wound healing disturbances. Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-op pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

In a recent publication, 4.6% of 6450 Coalition deaths over ten years were reported to be due to junctional bleeding. The authors suggested that some of these deaths could have been avoided with a junctional hemorrhage control device. Prospectively collected data on all injuries sustained in Afghanistan by UK military personnel over a 2 year period were reviewed. All fatalities with significant pelvic injuries were identified and analysed, and the cause of death established. Significant upper thigh, groin or pelvic injuries were recorded in 124 casualties, of which 92 died. Pelvic injury was the cause of death in 42; only 1 casualty was identified where death was at least in part due to a vascular injury below the inguinal ligament, not controlled by a tourniquet, representing <1% of all deaths. Twenty one deaths were due to vascular injury between the aortic bifurcation and the inguinal ligament, of which 4 survived to a medical facility. Some potentially survivable deaths due to exsanguination may be amenable to more proximal vascular control. We cannot substantiate previous conclusions that this can be achieved through use of a groin junctional tourniquet. There may be a role for more proximal vascular control of pelvic bleeding

Prophylactic antibiotics are important in reducing the risk of periprosthetic joint infection (PJI) following total knee arthroplasty. Their effectiveness depends on the choice of antibiotic and the optimum timing of their administration, to ensure adequate tissue concentrations. Cephalosporins are typically used, but an increasing number of resistant organisms are causing PJI, leading to the additional use of vancomycin. There are difficulties, however, with the systemic administration of vancomycin including its optimal timing, due to the need for prolonged administration, and potential adverse reactions. Intraosseous regional administration distal to a tourniquet is an alternative and attractive mode of delivery due to the ease of obtaining intraosseous access. Many authors have reported the effectiveness of intraosseous prophylaxis in achieving higher concentrations of antibiotic in the tissues compared with intravenous administration, providing equal or enhanced prophylaxis while minimizing adverse effects. This annotation describes the technique of intraosseous administration of antibiotics and summarizes the relevant clinical literature to date.

Cite this article: Bone Joint J 2023;105-B(11):1135–1139.

Aims

Glucose-insulin-potassium (GIK) is protective following cardiac myocyte ischaemia-reperfusion (IR) injury, however the role of GIK in protecting skeletal muscle from IR injury has not been evaluated. Given the similar mechanisms by which cardiac and skeletal muscle sustain an IR injury, we hypothesized that GIK would similarly protect skeletal muscle viability.

Aims

The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes.

Aims

Currently, the effect of drug treatment for osteoporosis is relatively poor, and the side effects are numerous and serious. Melatonin is a potential drug to improve bone mass in postmenopausal women. Unfortunately, the mechanism by which melatonin improves bone metabolism remains unclear. The aim of this study was to further investigate the potential mechanism of melatonin in the treatment of osteoporosis.