Evaluation of a novel tourniquet device for bloodless surgery of the hand

This study evaluates a new device (S-MART ) for exsanguination and occlusion of the blood flow to the arm for hand surgery. The device consists of a silicone ring wrapped within a sterile stockinette and pull straps. It is applied by placing it on the patient's fingers and rolling it up the limb to the desired occlusion site by pulling on the straps. The time for placement and removal of the device was measured during trigger release and carpal tunnel surgery and the quality of exsanguination was evaluated. The device could be placed and removed quickly and provided an excellent bloodless field. At follow-up examination no signs or symptoms were seen at the site of the S-MART occlusion and no complications were observed in any patient.     

Distal forearm tourniquet for hand surgery

To evaluate the usefulness of the tourniquet placed at the distal forearm, 30 patients were operated with the tourniquet set at the distal forearm using nerve-block anaesthesia. Pain during surgery, flexion of the fingers, bloodless field, and general complications during surgery and 18 months thereafter were recorded. The mean time of ischemia was 19.6±7.5 (10–50) min. A bloodless field was achieved in all cases, and pain during operation was low. Flexion of the fingers were found in most cases but was reducible and not annoying for the surgeon. There were no serious complications during surgery or at follow-up. The tourniquet placed at the distal forearm is painless, safe, and useful in hand surgery.

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Résumé Pour évaluer lutilité du garrot placé à la partie distale de lavant-bras, 30 malades ont été opérés avec le garrot dans cette position et une anesthésie par bloc nerveux. La douleur pendant la chirurgie, la flexion des doigts, l exsanguinité du champ opératoire et les complications générales pendant la chirurgie et 18 mois ensuite ont été enregistrées. Le temps moyen dischémie était de 19,6±7,5 min (10–50). Un champ exsangue a été obtenu dans tous les cas. La douleur pendant lopération était faible. La flexion des doigts a été notée dans la plupart des cas, mais était réductible et ne gênait pas le chirurgien. Il ny avait pas de complication sérieuse. Seulement une blessure nerveuse a été suspectée. Le garrot placé à la partie distale de lavant-bras est indolore, sûr et utile dans chirurgie de la main.

     

The wrist tourniquet: an alternative technique in hand surgery

This study investigated the efficacy and safety of the use of a size 8 1/2 surgical glove as a wrist tourniquet in hand surgery. A neonatal blood pressure cuff was placed under the wrist tourniquet to measure the presssures generated with use of this technique. The wrist tourniquet was applied in 25 consecutive procedures. Pressures generated with this technique ranged from 110 mm Hg to 260 mm Hg, with a mean pressure of 158 mm Hg. The average tourniquet time was 29 minutes, with the longest time being 135 minutes. The tourniquet achieved a bloodless surgical field in 24 (96%) of the 25 patients, and was well tolerated in all but two patients. Aside from tourniquet pain in these two (8%) patients, and tourniquet failure in one (4%) patient, there were no other complications associated with the wrist tourniquet. The size 8 1/2 surgical glove can be adopted as an effective and safe tourniquet in hand surgery.     

Wrist arthrodesis as part of composite surgery of the hand

A simple, quick and reliable method of arthrodesis of the wrist joint enables other surgical procedures to be carried out at the same time under the same tourniquet, thus reducing strain upon the patient and the hospital services.     

Sensory changes with prolonged double-cuff tourniquet time in hand surgery

This study evaluates the sensory changes that occur in the operated hand after the use of the double-cuff tourniquet technique for up to 4 hours. Thirty patients whose hand operations lasted more than 2 hours were evaluated. Tourniquet time ranged between 2 hours and 4 hours, 17 minutes. Light touch, von Frey's aesthesiometry, vibratory sensation, and two-point discrimination were examined. Subjective overall sensation and postoperative edema were also assessed. Patients were evaluated the evening before operation, on the second postoperative day, and at every out-patient follow-up visit, until all examined parameters returned to normal. Of the patients 73% demonstrated clinically normal sensibility test results within 23 days after operation. In 80% of all patients, subjective sensibility of the operated hand was equal to the nonoperated hand within 1 week of operation. Ultimately, all patients (96%) but one, demonstrated normal sensibility test results and normal subjective sensibility. Postoperative edema developed in 53% of the patients; it subsided in less than 4 weeks. The double-cuff technique can prolong tourniquet time safely for up to 4 hours.     

Efficacy of forearm versus upper arm tourniquet for local anaesthetic surgery of the hand

A prospective study was undertaken to compare the use of forearm and upper arm tourniquets for local anaesthetic procedures on the hand. One hundred consecutive patients with an upper arm tourniquet were compared with a further consecutive 100 patients in whom a forearm tourniquet was used. The tourniquet time was always less than 20 minutes and the scoring of perceived pain was not significantly different in the two groups. Use of a forearm tourniquet was well tolerated and was not associated with an increase in complications.     

Clinical outcomes in cardiac surgery: conventional surgery versus bloodless surgery

Bleeding during and after cardiac operations and the effects of cardiopulmonary bypass hemodilution commonly result in blood transfusions. Excessive microvascular bleeding can result in re-exploration and prolonged hospitalization. Nearly 20% of all blood transfusions in the United States are associated with cardiac surgery. The risks associated with the use of allogeneic blood product transfusion include mistransfusion, immunologic complications, and transmission of infectious diseases. The large demand for blood products places significant pressure on the national blood supply, resulting in frequent shortages. The variability in transfusion practice of cardiac surgery patients suggests that sound blood management and a conservative approach to this population can result in reduced transfusions without increasing morbidity or mortality and avoiding complications associated with allogeneic blood transfusion.     

Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet

Background

In our experience, for all surgeries in the hand, the optimal epinephrine effect from local anesthesia—producing maximal vasoconstriction and visualization—is achieved by waiting significantly longer than the traditionally quoted 7 min from the time of injection.

Methods

In this prospective comparative study, healthy patients undergoing unilateral carpal tunnel surgery waited either 7 min or roughly 30 min, between the time of injection of 1 % lidocaine with 1:100,000 epinephrine and the time of incision. A standardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60 s of measuring the quantity of blood loss using sterile micropipettes.

Results

There was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30 min after injection and before incision compared to the group that waited only 7 min (95 % confidence intervals of 0.06 + −0.03 ml/cm of incision, compared to 0.17 + −0.08 ml/cm, respectively) (P = 0.03).

Conclusions

Waiting roughly 30 min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min, achieves an optimal epinephrine effect and vasoconstriction. In the hand, this will result in roughly a threefold reduction in bleeding—making wide awake local anesthesia without tourniquet (WALANT) possible. This knowledge has allowed our team to expand the hand procedures that we can offer using WALANT. The benefits of WALANT hand surgery include reduced cost and waste, improved patient safety, and the ability to perform active intraoperative movement examinations.     

Oedema of the hand after fasciectomy with or without tourniquet

Two groups of patients with Dupuytren's disease were treated by limited fasciectomy. A tourniquet was used for one group, and an elevated hand table without tourniquet for the other. Taking into account other factors controlling oedema it was discovered over a post-operative period of twenty-eight days that “Tourniquet” hands remained significantly increased in volume compared to “Non-Tourniquet” hands. Other facts of clinical interest also emerge from the trial and are discussed. It is concluded that the use of the elevated hand table without tourniquet, not only allows an unlimited and uninterrupted period for hand surgery, but also reduces the subsequent oedema.     

Sternal preservation: a better way to treat most sternal wound complications after cardiac surgery

Background

Postcardiotomy sternal wound complications remain challenging. The prevailing approach for deep sternal wound infection of débridement and flap coverage without osseous closure makes subsequent reoperation difficult.

Methods

An analysis of all patients undergoing cardiac surgery at a single institution between 1986 and 2001 was conducted. Prospective data collection and chart review were used to compare different treatment strategies for sternal complications.

Results

Of 5337 patients, 122 had sternal wound complications (2.2%) comprising 15 (0.3%) uninfected dehiscences (El Oakley class 1), 45 (0.8%) superficial infections (El Oakley class 2A), and 62 (1.1%) deep sternal wound infections (El Oakley class 2B). Thirty-two patients with deep sternal infection were treated by débridement, rewiring, and delayed primary closure. There were initial treatment failures in 6 patients (18.8%) and ultimate failures in 2 patients (6.3%), both of whom died. One of these patients had previously received external beam radiation after a radical mastectomy for breast cancer. Median length of stay was 32 days and median time to wound healing was 85 days. Twenty-five patients were managed by muscle flap coverage without sternal reclosure. There were 6 initial treatment failures (24%) but no ultimate failures or deaths (p = NS). Median length of stay was 31 days and median infection time was 161 days.

Conclusions

In patients with postcardiotomy deep sternal wound infection without previous chest radiation, débridement, rewiring, and delayed skin closure is effective. It offers a shorter healing time and probably makes late cardiac reoperation safer. We propose an algorithm for the management of poststernotomy complications.     

气囊止血带在四肢手术中应用的研究进展

为有效减少术中出血量、获得更为清晰的手术野,使得义肢固定更为简便,气囊止血带被广泛应用于各类外科手术,尤其是四肢手术。本研究就气囊止血带的最适充气压力、最佳捆绑部位、使用时间、释放时间点、止血带并发症及其对出血量、手术时间、术后康复等的影响进行分析讨论,系统地介绍止血带在外科手术中的应用现状。     

Development of hand surgery: education of hand surgeons

An organized experience in the care of hand injuries and infections was not available until World War II, when military hand centers were established. Dr Sterling Bunnell was designated as a special civilian consultant to the Secretary of War. The surgeons in the military services during World War II became the nucleus of the American Society for Surgery of the Hand (ASSH). Following World War II and the Korean War there was a major shift toward medical subspecialization, and the growth of surgery of the hand as a subspecialty parallels that trend. The ASSH initiated a coordinated effort to improve the educational experience, and in 1967 the ASSH Resident Training Committee was evaluating hand training programs. The ASSH developed a comprehensive program in continuing medical education, and received full accreditation from the American Medical Association Council on Medical Education. The American Medical Association has included hand surgery on its list of designated specialties since 1975. In 1973, the bylaws of the American Board of Medical Specialties were revised to provide special certification. The ASSH developed a proposal for a certificate of added qualification in surgery of the hand that was presented to the three primary boards (orthopaedic, plastic, surgery) and the ad hoc joint Committee on Surgery of the Hand was organized in 1982. An application for a certificate of added qualification in surgery was developed by the Joint Committee on Surgery of the Hand and approved by all three boards in 1985 and the ABMS in 1986. The first examination for the certificate of added qualification in surgery was held in 1989.     

The pneumatic tourniquet in arthroscopic surgery of the knee

In a randomized study 56 patients undergoing arthroscopic surgery of the knee were randomly allocated to one of 2 groups: surgery with a tourniquet and surgery without a tourniquet. No significant difference was found between the 2 groups with regard to operating times, technical intraoperative difficulties, identification of intraarticular structures, postoperative pain or postoperative complications. In neither group was the procedure abandoned due to technical difficulties. The pain scores in the non-tourniquet group were lower than those in the group of patients operated on with the use of a pneumatic tourniquet. The study suggests that the use of a tourniquet in arthroscopic surgery of the knee is unnecessary.