Use of Tourniquet During Knee Arthroplasty in Patients With Radiographic Arterial Calcifications

BackgroundUse of tourniquet during total knee arthroplasty (TKA) in patients with radiographic arterial calcifications is controversial. Intimal arterial calcifications are feared to be associated with ischemic complications such as delayed wound healing and arterial thrombosis, whereas medial calcifications stiffen the arterial wall, possibly leading to tourniquet failure and increased blood loss.MethodsWe conducted a prospective cohort study to determine the incidence of tourniquet failure (inflated up to 300 mm Hg), blood transfusions, wound healing, and ischemic complications in thighs with and without arterial calcifications on preoperative radiographs, in 2548 consecutive primary TKAs conducted in our unit over a 5-year period. Eighty-six thighs showed vascular calcifications: 58 medial and 28 intimal.ResultsThighs with vascular calcifications had higher risk of tourniquet failure as compared to those without calcifications (P < .001), but with no significant increase in incidence of blood transfusions. All cases of tourniquet failure in the calcification group occurred in thighs with medial calcifications, whereas all cases of tourniquet failure in the control group occurred in obese patients. There was no difference in wound healing and ischemic complications in limbs with and without arterial calcifications.ConclusionThe presence of arterial calcifications on preoperative radiographs increases the risk of tourniquet failure at 300 mm Hg in patients undergoing TKA, with no significant increase in rate of blood transfusions, wound healing or ischemic complications.     

Initial assessment and management of trauma encountered in the field

This article covers the principles of trauma care relating to specific competencies within the military higher training module. The majority of these principles relate to the pre-hospital assessment and management of patients, introducing some of the nuances of military medicine in comparison to civilian practice.     

Use of a Pneumatic Tourniquet Improves Outcome Following Trans-tibial Amputation

BACKGROUND: It is traditionally taught that a pneumatic tourniquet is contraindicated for trans-tibial amputations in patients with peripheral arterial disease. However, tourniquets are used successfully during total knee arthroplasty in elderly patients. Vascular patients undergoing a trans-tibial amputation have a high perioperative mortality and morbidity-notably the need for wound revision or a higher amputation level. We hypothesised that a tourniquet, used during amputation, would reduce blood loss and subsequent complications without compromising healing. METHODS: This was a prospective non-randomized study of 89 adult patients who underwent a trans-tibial amputation between January 2001 and December 2003. The endpoints were: haemoglobin levels, the need for blood transfusion, perioperative morbidity, revision rate and mortality. Patients were divided into two groups: a group with a pneumatic tourniquet (n=42) and a group without (n=47). RESULTS: The haemoglobin fall was 14.8% in the non-tourniquet group and 5.6% in the tourniquet group, with a higher need for transfusion in the non-tourniquet group. The revision rate was 14.3% in the tourniquet group and significantly higher in the non-tourniquet group (38.3%). Mortality was similar in both groups: 7.1% for the tourniquet and 6.4% for the non-tourniquet group. CONCLUSION: The use of a pneumatic tourniquet is safe and significantly reduces both blood loss and transfusion requirements during trans-tibial amputation. A pneumatic tourniquet reduces revision rates by over 50%, with subsequent cost savings.     

Strangulation of penis by prolonged concealed hair wrapping

Summary Penile strangulation is very infrequent but when delayed it is impressively difficult to treat completely. We report a case of a 12-year-old boy with penile strangulation and a urethral fistula due to long-standing hair wrapping. The reconstruction was achieved by a two-stage technique.     

Prehospital tourniquet use in civilian extremity trauma: an Australian observational study

Background

Prehospital tourniquets (PHTQ) for trauma have been shown to be safe and effective in the military environment and in some civilian settings. However, the supporting civilian data are mostly from North America with a differing case mix and trauma system and may not be applicable to the Australian environment. The aim of this study is to describe our initial experience with PHTQ from safety and efficacy viewpoints.

Method

Retrospective review of all patients with PHTQ from 1 August 2016 to 31 December 2019 was conducted. Data were matched from the RMH Trauma Registry and Ambulance Victoria Registry. Clinical presentation including prehospital observations, PHTQ times, limb outcomes and complications are described.

Results

Thirty-one cases met inclusion criteria, for whom median age was 37 (IQR: 23.9–66.3), median ISS 17 (13–34) and 80.6% were male. The majority (n = 19, 61.3%) were as a result of road traffic crash, and six (19.4%) from penetrating mechanisms, usually glass. Over a quarter (29.0%) suffered a traumatic amputation. The median prehospital SBP was 100 (IQR: 80–110), the median prehospital HR was 101 (IQR: 77.0–122.3) and was the median PHTQ time was 124 min (IQR: 47–243). Complications attributable to the tourniquet were seen in 4/30 cases (13.3%).

Conclusion

This Australian series differs from North American civilian PHTQ series with a lower penetrating trauma rate and longer PHTQ times. Despite this, complication rates are within the published literature's range. Concerns regarding limited transferability of overseas studies to the Australian context suggests that ongoing audit is required.     

气囊止血带在胫腓骨下段骨折手术中的使用

目的:探讨止血带在胫腓骨下段骨折临床应用中存在诸多并发症,术中是否常规应用。方法:回顾性分析2018年6月至2019年9月采用钢板螺钉治疗闭合性胫腓骨下段骨折(AO分型43A型)33例,按是否应用气囊止血带分成两组:观察组16例,男13例,女3例,年龄18～69(38.8±17.0)岁,伤后手术时间(6.9±1.7) d,手术中不应用止血带;对照组17例,男13例,女4例,年龄21～71(43.8±12.4)岁,伤后手术时间(6.5±1.0) d,手术中常规应用自动气压止血带。比较两组患者的手术时间、失血量、术后肿胀、疼痛及并发症情况。结果:33例患者获得随访,时间12～20个月,平均15个月,两组患者的手术时间和失血量比较,差异均无统计学意义(P0.05);观察组患者术后1、3 d,肢体疼痛视觉模拟评分(visual analogue scale,VAS)分别为(5.13±1.70)分、(2.25±1.60)分,明显低于对照组的(7.35±1.30)分、(4.18±1.60)分;肿胀分别为(3.67±0.70) cm、(2.02±0.90) cm,明显低于对照组的(4.54±0.40) cm、(3.54±0.40) cm(P0.05);对照组存在止血带疼痛1例、麻木1例、水泡1例及切口愈合不良1例,观察组无此类并发症,差异有统计学意义(P0.05)。结论:胫腓骨下段骨折位置表浅,术中容易暴露及固定,为避免止血带并发症,术中不建议常规使用气囊止血带或尽量减少止血带应用时间。     

Confidence–Competence Mismatch and Reasons for Failure of Non-Medical Tourniquet Users

Objective: Tourniquet application is a lifesaving skill taught worldwide in first aid bleeding control courses. We observed performance among non-medical users of tourniquets in their confidence, competence, and reasons for failure. Methods: 179 Israeli military recruits without prior medical training underwent their standard first aid course where they learned Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC, USA) use. After course completion, they self-reported confidence in tourniquet use. User performance was assessed 7–14 days later using a HapMed? mannequin that assessed time, pressure, and blood loss. Competent performance required in aggregate: 1) use with pressure of 200 mmHg or more, 2) hemorrhage volume of less than 638 mL, and 3) correct placement of the tourniquet. For failed performance, a reason for failure was reported independently by both the user and an expert observer. Results: 45 of 179 user performances (25%) were competent. Users who reported high confidence had only a slightly higher chance of achieving competence in tourniquet application (r = 0.17, p = 0.022). The most common reason for failure was excess slack in the CAT's strap (experts 55%, users 39%), and too few turns of the windlass (23% and 31%, respectively) was the second most common reason. Expert and user evaluations had poor agreement (κ = 0.44, 95% CI 0.32–0.56). Conclusion: The most common reason for failed use of tourniquets among non-medical users was excess slack in the tourniquet strap. Users self-evaluated their performance inaccurately and demonstrated a confidence-competence mismatch. These pitfalls in performance may help tourniquet instructors improve training of caregivers.     

湿润烧伤膏预防气压止血带致皮肤损伤疗效观察

目的分析探讨湿润烧伤膏预防气压止血带致皮肤损伤的临床疗效。方法按照随机数表法将2016年7月至2017年7月南京医科大学附属南京邦德骨科医院与丹阳市人民医院收治的60例四肢手术后需使用气压止血带治疗的患者随机分为试验组(30例)与对照组(30例),其中试验组患者于常规缚扎止血带前在缚扎止血带部位均匀涂抹湿润烧伤膏,对照组患者仅按常规方法缚扎止血带,对比观察两组患者的手术时间、止血效果及皮肤损伤情况。结果试验组患者的手术时间为(2.5±1.3) h,止血效果为优者28例、良者2例;对照组患者的手术时间为(2.7±1.4) h,止血效果为优者27例、良者3例,两组对比,P均 0.05,差异无统计学意义。解除止血带后即刻,试验组患者的皮肤损伤总发生率为20.0%,对照组患者的皮肤损伤总发生率为86.7%,两组对比,P0.01,差异具有统计学意义。结论缚扎止血带部位均匀涂抹湿润烧伤膏,可在保证止血效果的同时,有效减少气压止血带所致的皮肤损伤。     

Comparison of local pain and tissue reaction between conventional pneumatic tourniquet and disposable silicone ring tourniquet during Total Knee Arthroplasty

BackgroundTo study the comparison of conventional pneumatic and disposable silicone ring tourniquet in Total Knee Arthroplasty.Material and methodsThis is a prospective randomized control trial. We used conventional pneumatic tourniquet on one side of leg and disposable silicone ring tourniquet on the other side in consecutive 50 simultaneous bilateral TKR patients. Patients having peripheral vascular disease of the lower limb were excluded from the study. The patient demographics & characteristics are identical being the same patient with two different legs. We started the study with null hypothesis. An independent observer assessed the local tourniquet site pain (VAS score 1–10) and local tourniquet site skin reaction at 24 h and 48 h after the TKA. P value < 0.05 was considered significant.ResultsThere were no local skin complication with disposable tourniquet (0%). 8 out of 50 patients in whom the conventional tourniquet was applied showed local bruising, and two patients had blister formation making the local skin site complication rate 20% (statistically significant, p value0.0196, chi-squared test). The VAS score at 24 h was 4.3 ± 1.5 for disposable tourniquet group as against 5.6 ± 2.1 for conventional tourniquet group (statistically significant, p value = 0.0152, t statistic test for comparison of means). The VAS score at 48 h was 2.1 ± 1.5 and 3.3 ± 1.2 for disposable tourniquet group and conventional tourniquet group respectively (statistically significant p value = 0.003, student’s t-test).ConclusionUse of disposable tourniquet has better outcome than the conventional tourniquet with minimal or no local complications. The advantages of the disposable tourniquet are: 1 less local pain, 2. no local skin problems, 3. accurate tourniquet pressure at the application site, 4.0% local contamination. Hence, we recommend use of the disposable tourniquet during the Total Knee Arthroplasty.     

血管内止血带的研制及临床应用

目的 研制一种自制的血管内止血带(过去曾用球囊导管代替),探讨血管内止血带的止血的效果及其安全性.方法 将我们设计的血管内止血带置入大白兔右侧颈总动脉充盈球囊以阻断动脉腔内血流,随机将32只大白兔分为A组(阻断1h)和B组(阻断2h),采用测定体外和动脉腔内球囊内压力并通过肉眼及组织学动态观察其对管壁的影响；同顾总结过去临床采用血管内止血带救治邻近颈部及躯干动脉损伤34例.结果 经病理检查,血管内止血带对动脉内膜与中层影响主要表现为炎性水肿与炎性细胞浸润,阻断1h组在14 d内恢复正常；2h组,对管壁影响明显,部分内弹力膜拉直与断裂,21 d才能恢复.阻断时间越长,对管壁影响越大；34例均应用血管内止血带止血成功,止血效果好,无缺血和血栓形成等并发症.结论血管内止血带是抢救邻近颈部及躯干大血管损伤及其晚期并发症假性动脉瘤与动静脉瘘手术的一种安全有效的辅助止血措施.