The risks associated with tourniquet use in lower limb trauma surgery: a systematic review and meta-analysis

Farhan-Alanie, Muhamed M; Dhaif, Fatema; Trompeter, Alex; Underwood, Martin; Yeung, Joyce; Parsons, Nicholas R.; Metcalfe, Andrew; Wall, Peter

doi:10.1007/s00590-021-02957-7

Cited by 20 publications

(11 citation statements)

References 39 publications

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“…In concordance, a recent Cochrane systematic review found tourniquet use to be associated with significantly higher risk of developing wound infection (RR 2.72, 95% CI 1.15 to 6.42); however this study did not employ separate subgroup analyses of superficial and deep infections [ 14 ]. Moreover, an increased incidence of serious adverse events with tourniquet use has also been suggested by other studies in total knee arthroplasty and lower limb trauma surgery [ 44 , 45 ].…”

Section: Discussionmentioning

confidence: 70%

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials

et al. 2022

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Purpose The intra-operative use of tourniquets during Total Knee Arthroplasty (TKA) is common practice. The advantages of tourniquet use include decreased operating time and the creation of a bloodless visualisation field. However, tourniquet use has recently been linked with increased post-operative pain, reduced range of motion, and slower functional recovery. Importantly, there is limited evidence of the effect of tourniquet use on infection risk. The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA. Methods A systematic literature search was performed on Pubmed, Embase, Cochrane and clinicaltrials.gov up to May 2021. Randomized control trials were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes included superficial and deep infection, skin necrosis, skin blistering, DVT rate, and transfusion rate. Results 14 RCTs with 1329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI = 2.7–5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI = 1.1–3.1) with an OR of 1.9 (95% CI = 1.1–3.76, p = 0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12–0.54), P = 0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4–5.3, P = < 0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of inhospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10–0.38, P = < 0.01). The incidence of skin blistering (OR 2.6, 95% CI = 0.7–9.9, p = 0.17), skin necrosis (OR 3.0, 95% CI = 0.50–19.3, p = 0.25), and DVT rates (OR 1.5, 95% CI = 0.60–3.60, p = 0.36) did not differ between the two groups. Conclusion Quantitative synthesis of the data suggested tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this meta-analysis do not support the routine use of tourniquet in TKA and arthroplasty surgeons should consider any potential additional risks associated with its use. Level of evidence meta-analysis, Level II.

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Section: Discussionmentioning

confidence: 70%

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials

et al. 2022

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“…These findings are consistent with recently published meta-analyses on TKA and orthopaedic trauma which have shown significantly reduced operating times when using a tourniquet. 17,18 The shorter operating time is likely to be due to better visualization of the surgical field and less time spent achieving haemostasis. Given the invasive nature and complexity of endoprosthetic reconstructions, the reduction in operating time is proportionately greater in this patient population.…”

Section: Discussionmentioning

confidence: 99%

Tourniquet use in patients undergoing tumour resection and endoprosthetic reconstruction of the knee

Gazendam

Schneider

Vélez

et al. 2022

The Bone & Joint Journal

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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.

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“…The existing evidence on tourniquet use in lower limb fracture fixation surgery in adults suggest that using a tourniquet may cause patients harm with limited benefit ( 34 , 35 ).…”

Section: Introductionmentioning

confidence: 99%

A systematic review of tourniquet use in paediatric orthopaedic surgery: can we extrapolate from adult guidelines?

Pintar,

Brookes,

Trompeter

et al. 2024

EFORT Open Reviews

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Purpose Tourniquets are commonly used intraoperatively in orthopaedic surgery to control bleeding and improve visibility in the surgical field. Recent evidence has thrown into question the routine use of tourniquets in the adult population resulting in a British Orthopaedic Association standard for intraoperative use. This systematic review evaluates the evidence on the practice, benefits, and risks of the intraoperative use of tourniquets for trauma and elective orthopaedic surgery in the paediatric population. Methods A prospectively registered systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO: CRD42022359048). A search of MEDLINE, Embase, the Cochrane Library and a Grey literature search was performed from their earliest record to 23 March 2023. Studies reporting tourniquet data in paediatric patients undergoing orthopaedic surgery were included. Data extracted included demographics, involved limb, trauma versus elective use, tourniquet use as primary or secondary measure, and tourniquet parameters and complications. Results Thirty-nine studies were included. Tourniquet practices and information reporting varied considerably. Tourniquets were used uneventfully in the majority of patients with no specific benefits reported. Several physiological and biochemical changes as well as complications including nerve injury, compartment syndrome, skin burns, thrombosis, post-operative limb swelling, and pain were reported. Conclusions Tourniquets are routinely used in both trauma and elective paediatric orthopaedic surgery with no high-quality research affirming benefits. Severe complications associated with their use are rare but do occur. High-quality studies addressing their benefits, the exact indication in children, and the safest way to use them in this population are necessary.

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The risks associated with tourniquet use in lower limb trauma surgery: a systematic review and meta-analysis

Cited by 20 publications

References 39 publications

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials

Tourniquet use in patients undergoing tumour resection and endoprosthetic reconstruction of the knee

A systematic review of tourniquet use in paediatric orthopaedic surgery: can we extrapolate from adult guidelines?

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