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Finger tourniquets are widely used in hand surgery. However, they do not provide an estimate of the amount of pressure exerted and can potentially be left in situ with grave consequences. We assessed the pneumatic finger tourniquet in 57 adult patients in operations under local anaesthesia distal to the proximal interphalangeal joint. The average tourniquet time was 12 minutes. The tourniquet maintained its pressure for the length of the operation in 96.5% of cases. This airtight flat tubing is made of synthetic polymer, designed and manufactured by Barloworld Scientific Ltd (Staffordshire, UK). The tourniquet was easy to use and easily located after the operation. No complications were reported. This study supports the use of a pneumatic tourniquet in finger injuries requiring use of a finger tourniquet.

Skin complications have been reported to be associated with tourniquet use. The UK Medical Devices Agency (MDA) recommends the use of a limb drape to act as underpadding to reduce these complications. Our hospital had traditionally used Velbands as an underpadding, but changed to limb drapes on the advice of the MDA. The purpose of this study is to establish whether Velbands are still a safe and cost-effective tourniquet underpadding.

A prospective clinical study was performed on consecutive patients undergoing hand surgery over a four-month period. Patients were randomly allocated into one of two treatment groups. Group 1 using Velband as tourniquet underpadding and Group 2 using limb drapes as underpadding. All patients had identical tourniquets, tourniquet pressure and skin preparation agents. After surgery, the tourniquet was removed and the skin beneath the tourniquet was inspected for any skin reaction or damage.

Each group included 50 patients. Skin was normal after tourniquet use in all cases and there was no difference between the two groups.

Velband is still a safe and cost-effective tourniquet underpadding in hand surgery.

Finger tourniquets are used in a variety of operative procedures in both the trauma and elective setting. A wide range of methods are used in clinical practise as there is no standardised method. Many of the methods in use have significant drawbacks such as the inability to exsanguinate the digit or the more concerning problem of inadvertently leaving the tourniquet on the digit on completion of the procedure. We discuss two techniques that are quick, cheap and easy that do not have these drawbacks. There is a brief discussion of the literature assessing the various attributes of published methods. We feel that the adoption of these methods could result in easier and safer finger exsanguination and haemostasis.

Background: “Wide awake hand surgery”, where surgery is performed in local anaesthesia with adrenaline, without sedation or a tourniquet, has become widespread in some countries. It has a number of potential advantages and we wished to evaluate it among our patients.

Methods: All 122 patients treated by this method during one year were evaluated by the surgeons and the patients on a numerical scale from 0 (best/least) to 10 (worst/most). Theatre time was compared to that recorded for a year when regional or general anaesthesia had been used.

Results: The patients’ mean score for the general care they had received was 0.1 (SD 0.6), for pain during lidocaine injection 2.4 (SD 2.2), for pain during surgery 0.9 (SD 1.5), and for other discomfort during surgery 0.5 (SD 1.4). Eight reported that they would want general anaesthesia if they were to be operated again. The surgeons’ mean evaluation of bleeding during surgery was 1.6 (SD 1.8), oedema during surgery 0.4 (SD 1.1), general disadvantages with the method 1.0 (SD 1.6) and general advantages 6.5 (SD 4.3). The estimation of advantages was 9.9 (DS 0.5) for tendon suture. 28 patients needed intra-operative additional anaesthesia. The proportion was lower among trained hand surgeons and fell significantly during the study period. Non-surgical theatre time was 46 (SD 15) minutes during the study period and 55 (SD 22) minutes during the regional/general period (p < 0.001). This gain was cancelled out by a longer surgery time during the wide awake period.

Conclusions: Wide awake surgery is fully acceptable to most patients. It has a number of advantages over general or regional anaesthesia, but we feel it is unlikely to improve the efficiency of the operating theatre.

Introduction: Total Knee Arthroplasty (TKA) is usually performed with a tourniquet. Previous studies investigated the relationship between tourniquet and blood loss. This study evaluated tourniquet usage regarding parameters such as blood loss, drainage, blood administration, knee flexion, and complications. Patients and Methods: A cohort of 77 patients who underwent total knee arthroplasty was reviewed. Results: No difference in 24-hours postoperative hemoglobin levels was observed. Blood collected in drains was slightly higher in the tourniquet group, yet there was more overall administration of blood for non-tourniquet group: a mean of 1.2 units of packed RBC versus a mean of 0.63 units for the tourniquet group. Complication rate was comparable, but a higher rate of local infection in tourniquet group was observed. No thromboembolic events were observed. Conclusion: With regards to direct blood loss parameters, there was no statistical difference between groups, provided that meticulous hemostasis is undertaken. Operating without a tourniquet poses a risk of increased demand for blood products. There is also some concern regarding local complication rate when tourniquets are used.

Background: To compare outcomes of atraumatic hand surgeries using the WALANT technique versus intravenous regional anesthesia or local anesthesia with tourniquet.

Methods: We conducted a comprehensive literature search using PubMed, MEDLINE, Embase, and Cochrane Library from inception to October 2018. All randomized or quasi-randomized trials and cohort studies comparing WALANT procedure versus local anesthesia or intravenous regional anesthesia with tourniquet among atraumatic hand surgeries were included. Methodological quality and risk of bias of eligible studies were assessed by three independent reviewers. The random effects model was used due to both statistical and clinical heterogeneity among studies.

Results: The search yielded 496 records, of which 9 studies were included in the systematic review. We were able to pool findings for operative time, post-operative pain scores, patient satisfaction, and complication rates. On the average, the WALANT group had longer operative times by 2.06 minutes (pooled mean difference, random effects, 95% confidence interval 0.46 to 3.67 minutes, p = 0.01, I² 0%, p = 0.66). The post-operative pain scores were lower in the WALANT group by an average of two VAS points (random effects, pooled mean difference −2.40, 95% confidence interval −3.41 to −1.38, p < 0.00001; I² 0% p = 0.99). We had insufficient evidence to demonstrate a difference in terms of patient satisfaction (random effects, pooled risk ratio 0.98, 95% confidence interval 0.93 to 1.03, p = 0.36, I² 0%, p = 0.64) and complication rates (random effects, pooled risk ratio 0.40, 95% confidence interval 0.07 to 2.18, p = 0.29, I² 60% p = 0.08) between WALANT versus conventional methods.

Conclusions: The WALANT group reported lower post-operative pain scores, but had slightly longer operative times. There are no significant differences between WALANT and conventional methods in terms of patient satisfaction and complication rates.

Background: Pneumatic tourniquet is an effective tool to achieve hemostatic control of the surgical field in upper extremity (UE) operations. Elevated pressures have been associated with adverse effects despite various methods of pressure determination. We aim to demonstrate the usage of reduced tourniquet pressures and examine factors associated with achieving reduced pressures.

Methods: A prospective study was conducted (2016–2018) at a Level 1 Trauma Center and an Outpatient Surgical Center, totaling 226 operations, involving a reduction of cuff pressures over time from a standard baseline of limb occlusion pressure for UE operations.

Results: A gradual reduction of pressures was successfully achieved with a mean pressure of 187 mmHg and average time of tourniquet application being 25 minutes. We found chronological surgical number and patient BMI to be significantly associated with tourniquet pressure (p < 0.05). 4.5% of cases resulted in breakthrough bleeding, but did not reliably occur with any pressure thresholds, patient demographics, or operative factors (p > 0.05, for all).

Conclusions: Reduced tourniquet pressures can mitigate complications associated with tourniquet use. Our research shows reduced pressures are successful in maintaining field visibility and we encourage an adoption of pressures below 200 mm Hg in most procedures that require a tourniquet.

Background: Tourniquet use during upper extremity surgery in patients with a history of axillary lymph node dissection (ALND) remains controversial due to the perceived but unproven risk of lymphoedema. We prospectively evaluated upper extremity swelling in patients with a history of unilateral ALND using a standardised tourniquet model.

Methods: A tourniquet was applied to the upper arm bilaterally, with the unaffected side serving as an internal control. Each arm was subsequently held in an elevated position to reduce swelling. Hand volume was measured using an aqueous volumeter.

Results: The patients’ ALND arms experienced slightly greater increases in volume following tourniquet application compared to their healthy control arms. However, this amount of oedema was temporary and reversible, as both arms experienced spontaneous resolution of swelling with no significant difference in residual hand volume at the conclusion of the study.

Conclusions: Tourniquet use may be safe in patients with a history of ALND. Further investigation is needed to verify this in a surgical setting.

Level of Evidence: Level II (Therapeutic)