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Tourniquet use in lower limb fracture surgery: a systematic review and meta-analysis

  • Martin Præstegaard
  • Elin Beisvåg
  • Julie Ladeby Erichsen
  • Michael Brix
  • Bjarke VibergEmail author
Original Article • LOWER LIMB - FRACTURES
  • 141 Downloads

Abstract

Background

Tourniquets are commonly used in today’s orthopaedic surgical practice, but little evidence is available regarding the links between the use of a tourniquet and the amount of post-operative pain and other complications. The aim of the study was to conduct a systematic review and meta-analysis comparing tourniquet versus non-tourniquet use during fracture surgery of the lower limb in adult patients.

Method

A search was performed using the keyword “tourniquet” in EmBase and as a MeSH term in PubMed, and no limitations (including language) were applied. Available studies were screened using the Covidence software, and demographic as well as outcome data were extracted from the final studies. Critical appraisal was performed according to Cochrane Risk of Bias guidelines. Pooled data were assessed for heterogeneity using Chi-squared and I2 tests.

Results

Five studies were included, and no statistically significant difference was found in the amount of pain and post-operative complications between tourniquet and non-tourniquet groups. Length of in-hospital stay was longer in the tourniquet groups. An overall high risk of bias was found in the included studies.

Conclusion

Although the validity and statistical strength of our results are not strong enough to suggest a change in practice in tourniquet use, the operating surgeon should still carefully consider his or her decision to use a tourniquet in lower limb fracture surgery, as there are indeed complications associated with it and no current evidence to support its continued use.

Level of evidence

Level I, systematic review of randomized controlled trials.

Keywords

Tourniquet Fracture Lower limb Complication Pain 

Notes

Acknowledgements

The authors thank the library search technicians at the library at Odense Universitetshospital for their assistance in gathering material.

Compliance with ethical standards

Conflict of interest

All authors declare that no financial or personal relationships with other people or organisations exist that could inappropriately influence the work in this study.

References

  1. 1.
    Sato J, Ishii Y, Noguchi H, Takeda M (2012) Safety and efficacy of a new tourniquet system. BMC Surg 12:17.  https://doi.org/10.1186/1471-2482-12-17 CrossRefGoogle Scholar
  2. 2.
    Odinsson A, Finsen V (2006) Tourniquet use and its complications in Norway. J Bone Joint Surg Br 88-B:1090–1092.  https://doi.org/10.1302/0301-620x.88b8.17668 CrossRefGoogle Scholar
  3. 3.
    Palmer SH, Graham G (1994) Tourniquet-induced rhabdomyolysis after total knee replacement. Ann R Coll Surg Engl 6:416–417Google Scholar
  4. 4.
    Hirvensalo E, Tuominen H, Lapinsuo M, Helio H (1992) Compartment syndrome of the lower limb caused by a tourniquet: a report of two cases. J Orthop Trauma 6:469–472CrossRefGoogle Scholar
  5. 5.
    Desai K, Dinh TP, Chung S, Pierpont YN, Naidu DK, Payne WG (2015) Upper extremity deep vein thrombosis with tourniquet use. Int J Surg Case Rep 6c:55–57.  https://doi.org/10.1016/j.ijscr.2014.11.055 CrossRefGoogle Scholar
  6. 6.
    Smith TO, Hing CB (2010) The efficacy of the tourniquet in foot and ankle surgery? A systematic review and meta-analysis. Foot Ankle Surg 16:3–8.  https://doi.org/10.1016/j.fas.2009.03.006 CrossRefGoogle Scholar
  7. 7.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Deveraux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700.  https://doi.org/10.1136/bmj.b2700 CrossRefGoogle Scholar
  8. 8.
    Konrad G, Markmiller M, Lenich A, Mayr E, Ruter A (2005) Tourniquets may increase postoperative swelling and pain after internal fixation of ankle fractures. Clin Orthop Relat Res 433:189–194.  https://doi.org/10.1097/01.blo.0000151849.37260.0a CrossRefGoogle Scholar
  9. 9.
    Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928.  https://doi.org/10.1136/bmj.d5928 CrossRefGoogle Scholar
  10. 10.
    Ömeroğlu H, Günel U, Biçimoğlu A, Tabak AY, Uçaner A, Güney O (1997) The relationship between the use of tourniquet and the intensity of postoperative pain in surgically treated malleolar fractures. Foot Ankle Int 18:798–802.  https://doi.org/10.1177/107110079701801208 CrossRefGoogle Scholar
  11. 11.
    Salam AA, Eyres KS, Cleary J, El-Sayed HH (1991) The use of a tourniquet when plating tibial fractures. J Bone Joint Surg Br 73:86–87CrossRefGoogle Scholar
  12. 12.
    Maffulli N, Testa V, Capasso G (1993) Use of a tourniquet in the internal fixation of fractures of the distal part of the fibula. A prospective, randomized trial. J Bone Joint Surg Am 75:700–703CrossRefGoogle Scholar
  13. 13.
    Saied A, Zyaei A (2010) Tourniquet use during plating of acute extra-articular tibial fractures: effects on final results of the operation. J Trauma 69:E94–E97.  https://doi.org/10.1097/TA.0b013e3181dbac93 CrossRefGoogle Scholar
  14. 14.
    Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, Bouter LM, de Vet HC (2007) Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 60:34–42.  https://doi.org/10.1016/j.jclinepi.2006.03.012 CrossRefGoogle Scholar
  15. 15.
    Naylor JM, Hayen A, Davidson E, Hackett D, Harris IA, Kamalasena G, Mittal R (2014) Minimal detectable change for mobility and patient-reported tools in people with osteoarthritis awaiting arthroplasty. BMC Musculoskelet Disord 15:235.  https://doi.org/10.1186/1471-2474-15-235 CrossRefGoogle Scholar
  16. 16.
    Stauffer ME, Taylor SD, Watson DJ, Peloso PM, Morrison A (2011) Definition of nonresponse to analgesic treatment of arthritic pain: an analytical literature review of the smallest detectable difference, the minimal detectable change, and the minimal clinically important difference on the pain visual analog scale. Int J Inflam.  https://doi.org/10.4061/2011/231926 Google Scholar
  17. 17.
    Kruse H, Christensen KP, Møller AM, Gögenur I (2015) Tourniquet use during ankle surgery leads to increased postoperative opioid use. J Clin Anesth 27:380–384.  https://doi.org/10.1016/j.jclinane.2015.03.034 CrossRefGoogle Scholar
  18. 18.
    Zhou K, Ling T, Wang H, Hou Z, Shen B, Yang J, Kang P, Pei F (2017) Influence of tourniquet use in primary total knee arthroplasty with drainage: a prospective randomised controlled trial. J Orthop Surg Res 12:172.  https://doi.org/10.1186/s13018-017-0683-z CrossRefGoogle Scholar
  19. 19.
    Kumar N, Yadav C, Singh S, Kumar A, Vaithlingam A, Yadav S (2015) Evaluation of pain in bilateral total knee replacement and without tourniquet; a prospective randomized control trial. J Clin Orthop Trauma 6:85–88.  https://doi.org/10.1016/j.jcot.2015.01.095 CrossRefGoogle Scholar
  20. 20.
    Su J, Cao X (2017) Risk factors of wound infection after open reduction and internal fixation of calcaneal fractures. Med Baltim 96:e8411.  https://doi.org/10.1097/MD.0000000000008411 CrossRefGoogle Scholar
  21. 21.
    Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L (2014) The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res 9:13.  https://doi.org/10.1097/MD.0000000000008411 CrossRefGoogle Scholar
  22. 22.
    Olivecrona C, Blomfeldt R, Ponzer S, Stanford BR, Nilsson BY (2013) Tourniquet cuff pressure and nerve injury in knee arthroplasty in a bloodless field: a neurophysiological study. Acta Orthop 84:159–164.  https://doi.org/10.3109/17453674.2013.782525 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery and TraumatologyKolding Hospital – Part of Hospital LillebaeltKoldingDenmark
  2. 2.Department of Orthopaedic Surgery and TraumatologyOdense University HospitalOdenseDenmark
  3. 3.Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
  4. 4.Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark

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