SLR - September 2021 - Hans C. Humrick

Effect of Tourniquet Use During Surgical Treatment of Open Fractures

Reference: Gitajn, Ida Leah MD1,a; Werth, Paul M. PhD1; Sprague, Sheila PhD2; Bzovsky, Sofia MSc2; Petrisor, Brad A. MD2; Jeray, Kyle J. MD3; O’Hara, Nathan N. MHA4; Bhandari, Mohit MD, PhD2; Slobogean, Gerard MD, MPH4; the FLOW Investigators Effect of Tourniquet Use During Surgical Treatment of Open Fractures, The Journal of Bone and Joint Surgery: May 19, 2021 - Volume 103 - Issue 10 - p 860-868 doi: 10.2106/JBJS.20.01458

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Hans C. Humrick, DPM
Residency Program: North Colorado Medical Center – Greeley, CO

Podiatric Relevance: Tourniquets have numerous benefits including clear visualization, decreased blood loss, and potentially less operative time. It has been theorized that in traumatic scenarios, tissues may be more vulnerable to oxidative stress caused by tourniquet induced ischemia. This study sought to correlate open lower extremity trauma and tourniquet use to adverse events. The authors hypothesized increased tourniquet time would leave traumatized tissues more susceptible to adverse effects.

Methods: These data were obtained as unexpected secondary measures from the FLOW trial, which used a standardized treatment protocol regarding open fracture treatment with antibiotics from 2009-2013; however, surgical techniques and tourniquet use were surgeon dependent. In the current study, inclusion criteria were open lower extremity fracture distal to the knee, >18 years old, and follow-up ≥1 year. Fracture locations included the tibial shaft or plafond, ankle, talus, or calcaneus. Correlations between Gustilo-Anderson stage and tourniquet use were compared between various outcome measures including unplanned reoperation rate, DVT risk, infection rate, patient reported outcomes, and fixation type (plates/screws, IM nail, external fixator, etc.).    

Results: One thousand three hundred fifty-one patients were included. A 1:1 match left 352 patients in each group (n=704). The total unplanned reoperation rate was 18.4 percent which positively correlated with increasing age and negatively correlated with negative pressure therapy use. Unplanned reoperation was most commonly due to deep infection (37 percent) and delayed or non-union (26 percent). Overall, no difference in reoperation rate was found between tourniquet versus non-tourniquet use. Operative time was essentially identical (average 121.6 minutes without and 121.2 minutes with). Furthermore, no significant difference for superficial or deep infection risk, wound complications, fixation type, DVT rate, or patient reported outcomes was found. Notably, tourniquet use in Gustilo-IIIA and IIIB was an independent risk factor for unplanned reoperation.

Conclusions: The benefits of tourniquet use are described above, specifically less blood loss and improved visualization. Open fractures pose a unique challenge given the extensive soft tissue damage found especially in Gustilo-III type injury patterns. The present study suggests that tourniquets may cause harm  when used in higher-grade open fractures. This has helped me consider the health of the soft tissue envelope, especially in more severe injury patterns and general poor tissue quality, prior to initiating the use of a tourniquet. 

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