Introduction
The use of pneumatic tourniquets in orthopaedic surgery has become essential as they create a bloodless surgical field in lower and upper limb applications and allow the anatomical structures to be better visualized. This facilitates a more accurate and safer surgical intervention. The below-mentioned technological developments have reduced the risks of using pneumatic tourniquets: adjustable pressure settings, safety alarm system, and manufacture of better fitting cuffs for use in lower and upper limbs (Drolet et al., 2014; Knudson, 2013; McMillan & Johnstone, 2017; Vaughan et al., 2017; Wang, 2014).
Although pneumatic tourniquets have well-documented benefits and advantages, their use is not without risks or complications. Deep and superficial tissue damage can be seen in the limb under the cuff. Associated complications include skin burns, abrasions, blisters, swelling, redness, stiffness, delayed muscle recovery, vascular damage, edema, tenderness, deep vein thrombosis, rhabdomyolysis, pulmonary embolism, and even cardiac arrest (Drolet et al., 2014; Ellanti & Hurson, 2015; Knudson, 2013; Lee et al., 2010; Liu et al., 2014; Turkmen et al., 2015). These complications have the potential to cause delays in the healing process and prolong the duration of hospitalization (Khan & Gray, 2014; Knudson, 2013; McMillan & Johnstone, 2017; Sharma & Salhotra, 2012; Wang, 2014).
The most important issue in the use of tourniquets is, undoubtedly, the safety of the patient. Although tourniquets are technologically advanced, it is important for the operating room nurse to confirm that the tourniquet to be used is fully operational and clean, and that it functions according to the manufacturer's recommendations. The nurse has the responsibility to ensure that the tourniquet is attached to the correct surgical intervention side and limb. The tourniquet cuff should be of a length and width suitable for the limb of each individual and remain under constant pressure when inflated. It should be applied in a way that prevents it from slipping during the process. The aim of tourniquet placement is to create minimal ischemia. The anesthesia team is informed when the surgeon requests the inflation process. The tourniquet duration and general condition of the patient should be continuously monitored. The surgeon should be informed at regular intervals about the monitoring status. In procedures exceeding 2 hours, the cuff should be loosened and tissue perfusion allowed for 10-15 minutes. This is performed in cooperation with the anesthesia team. The tourniquet duration must be specified in the surgical note (Brennan et al., 2009; Spruce, 2017; Wong & Irwin, 2014).
Despite the widespread use of pneumatic tourniquets in lower and upper limb surgery, there is still no consensus concerning the starting and end times of tourniquet use, pressure settings, or safety applications (Boya et al., 2016; Drolet et al., 2014; Estebe, 2018; Knudson, 2013; McMillan & Johnstone, 2017; Sharma & Salhotra, 2012; Wang, 2014). Although there are many publications on tourniquet applications in the literature, only a few have addressed the protection of the skin underneath the cuff or investigated the use of padding underneath the cuff to protect the skin (Estebe, 2018; McMillan & Johnstone, 2017). Although some researchers suggest that protecting the skin under the cuff reduces skin complications, others indicate that it has no effect (Estebe, 2018; McMillan & Johnstone, 2017; Wang, 2014).
The current study was conducted on three groups of patients with a pneumatic tourniquet and aimed at determining the effects of two different paddings on the protection of the skin underneath the cuff, as well as making a comparison between two groups with a padding and one without.
Methods
Design
This prospective randomized controlled study was aimed at determining the effect of three different applications on skin protection beneath the pneumatic tourniquet in patients undergoing orthopaedic limb surgery. The research was carried out on 60 patients between September 2017 and February 2018 at the Baltaliman[latin dotless i] Bone Diseases Training and Research Hospital, affiliated with the Turkish Ministry of Health. Inclusion criteria were diagnosis of anterior cruciate ligament rupture and hospitalization for reconstruction surgery. The independent study variable was the pneumatic tourniquet application performed by using two different types of arm padding, and the dependent variable was skin complications resulting from tourniquet application. In the preoperative period, patients meeting the inclusion criteria were briefly informed about the study. The volunteer information form was read to each patient, and verbal as well as written consent was obtained from each. Randomization was made according to the date of hospitalization. The patients were randomly allocated to one of three groups using the randomization program:
* Group 1: Cotton-cast padding folded into two layers and wrapped around the limb under the cuff (see Figure 1a).
* Group 2: Use of the VBM brand long leg protection sleeve (hereafter referred to as "protection sleeve"; see Figure 1b).
* Group 3: No protective padding underneath the cuff (see Figure 1c).
In the preoperative period, just before the tourniquet was applied in the operating room, the image of the skin under the cuff was observed by the researcher and captured by a camera. The same brand (VBM) pneumatic tourniquet was applied to each patient in each group. Pneumatic tourniquet devices used during procedures had previously been tested for calibration by a biomedical technician. The same skin antisepsis method with 10% povidone iodine was applied to all patients. In determining the tourniquet pressure, +100/150 mmHg was added to the systolic blood pressure of each patient, and the tourniquet pressure was applied as recommended in the literature.
After the operation was completed and the cuff removed, the skin was assessed at four points: (1) at the time of tourniquet removal (minute 0), (2) at minutes 30, (3) at minutes 180, and (4) at hours 24. The skin was observed by a circulating nurse and then documented by a researcher as normal, or having ecchymosis, blisters, or abrasions. Both the nurses and the researcher were blind to the application approach.
Participants
The population of interest consisted of patients who were older than 18 years, diagnosed with anterior cruciate ligament rupture, and hospitalized for reconstruction surgery.
Exclusion criteria were systemic disease (e.g., diabetes), peripheral vascular disease, lower extremity nerve damage, skin disease, or skin lesion around the area where the cuff was to be placed. To calculate the sample size, power analysis was conducted using G * Power 3.1 program. The calculation indicated that 20 patients should be included in each group based on the prediction of a difficulty value of 0.80, error level of 0.05, effect level of 0.25, and difference level of 2.0 points.
Data Collection
A questionnaire developed by the researcher, but informed by the literature, included data on the demographic characteristics of the patients (age, gender, etc.), details of the surgery to be performed (operation side, duration, etc.), and cuff application (tourniquet pressure; tourniquet duration; potential complications at minutes 0, 30, and 180, as well as at hours 24 after cuff removal, etc.). A camera was used to record the image of the skin surface and to monitor the changes. The skin was observed by a circulating nurse as soon as the cuff was removed (minute 0) in the operating room. Other evaluations and observations at minutes 30, minutes 180, and hours 24 were performed by the clinical nurse and documented by the researcher. All other patient information was obtained directly from the patients themselves or their medical files.
Data Analysis
SPSS v. 22.0 was used for statistical analyses. The mean, standard deviation, median, lowest and highest, frequency, and ratio values were used in the analysis of the data. The analyses served to determine whether there were any significant differences between groups. The distribution of variables was checked using the Kolmogorov-Smirnov test. In the analysis of quantitative independent data, the Kruskal-Wallis and Mann-Whitney U tests were employed. The [chi]2 test was conducted for the analysis of the qualitative independent data. The [chi]2 test was replaced with Fischer's exact test when the conditions of the former were not met. The employment of these tests made it possible to statistically analyze the below variables between the groups: (1) surgical differences, (2) blood pressure, (3) tourniquet duration (at minute 0, minute 30, minute 180, or hours 24), (4) age and gender, (5) protective material used, (6) tourniquet pressure applied, and (7) occurrence and frequency of complications.
Ethical Considerations
Ethical approval and necessary institutional permission for this study were obtained from the Ethics Committee of the Health Science University Baltaliman[latin dotless i] Bone Diseases Training and Research Hospital (68/2017). All patients provided written consent after being informed about the purpose and duration of the study and how their data would be utilized. Nurses and the members of the anesthesia team were also informed about the research and their support was received.
Results
Demographics: Total and by Group
The age of patients ranged from 18 to 46 years, with a mean age of 27.7 +/- 6.9 years. Of the 60 patients, 96.7% (n = 58) were male, and the surgery was performed on the right limb in 53.3% (n = 32). The systolic blood pressure of the patients ranged from 90 to 150 mmHg, with a mean value of 127.4 +/- 9.8 mmHg, whereas the diastolic blood pressure ranged from 56 to 96 mmHg. The tourniquet pressure values were in the range of 250-350 mmHg. The mean tourniquet duration was 87.8 minutes +/-15.3 (see Table 1).
In the cotton-cast padding group, all patients (n = 20) were male, with a mean age of 28.9 +/- 7.6 years. Fifty-five percent (n = 11) of surgeries were performed on the left limb. The mean systolic, diastolic, and tourniquet pressure values of these patients were 129.7 +/- 9.3, 81.3 +/- 8.9, and 325.0 +/- 25.6 mmHg, respectively, and their mean tourniquet duration was 88.8 +/- 17.9 minutes (see Table 2).
In the protection sleeve group, the mean age was 27.1 +/- 6.8 years, and 90% (n = 18) of the patients were male. Fifty-five percent (n = 11) of surgeries were performed on the right limb. The mean systolic, diastolic, and tourniquet pressure values of the patients in this group were 124.6 +/- 11.2, 80.8 +/- 7.7, and 292.5 +/- 33.5 mmHg, respectively, and mean tourniquet duration was 88.2 +/- 15.1 minutes (see Table 2).
Patients who did not have any protective padding during tourniquet use were all male (n = 20), with a mean age of 27.1 +/- 6.4 years. Sixty percent (n = 12) of surgeries were conducted on the right side. The mean systolic, diastolic, and tourniquet pressure values of the patients in this group were 128.0 +/- 8.5, 81.1 +/- 6.2, and 305.0 +/- 27.6 mmHg, respectively, and mean tourniquet duration was 86.5 +/- 13.2 minutes (see Table 2).
Skin Complications: Total and by Group
Complications were observed in 21.7% (n = 13) of the total sample (all three groups) immediately after removal of the tourniquet, that is, at minute 0. Abrasions were seen in nine patients and bullae in four patients. Rates of complications at three other time intervals were as follows: 15.0% (n = 9) at minutes 30, 11.7% (n = 7) at minutes 180, and 3.3% (n = 2) at hours 24 (see Table 3).
In Group 1 (cotton-cast padding), rate of abrasions observed at minutes 0 and 30 was 15% (n = 3). At minutes 180, there was only one patient left suffering from abrasions, which persisted at hours 24 (see Table 4).
In Group 2 (protection sleeve), rate of abrasions observed at minute 0 was 10% (n = 2). At minutes 30, complications resolved in both patients (see Table 4).
In Group 3 (without any protective padding), rate of abrasions observed at minute 0 was 20% (n = 4) and so was that of bullae. Rates of complications at three other time intervals were as follows: 30% (n = 6) at minutes 30 and 180, and 5% (n = 1) at hours 24 (see Tables 4 and 5).
Discussion
Pneumatic tourniquets are indispensable in orthopaedic surgery thanks to their advantages, such as creating a bloodless surgical intervention area in the limbs and providing shorter surgical time with less technical difficulty and bleeding. However frequently they may be used, they are not flawless and may lead to many complications, such as skin damage, edema, pain, chemical burns, thromboembolism, neurological damage, muscle injuries, and even cardiac arrest (Mittal et al., 2008; Younger et al., 2005).
Although there are a number of publications on tourniquet applications in the literature, there are few that address the protection of the skin under the cuff, and there is limited research on the evaluation of skin-protective padding underneath the cuff (Estebe, 2018; McMillan & Johnstone, 2017). Although some researchers suggest that protecting the skin under the cuff reduces skin complications, others report that this has no such effect. Therefore, the authors conducted this present study on patients undergoing anterior cruciate ligament reconstruction with a view to determining the effect of three different applications for skin protection against complications that are likely to be caused by the use of cuff. Divided into three groups, patients either had one of the two types of padding underneath the cuff or did not have any padding at all. The results obtained in each group were then compared and discussed in terms of descriptive characteristics, tourniquet pressure, tourniquet duration, and related complications.
Descriptive Characteristics
According to the recommendations of the Association of periOperative Registered Nurses (AORN) on pneumatic tourniquet practices, it is necessary to individualize cuff selection by considering the width and shape of the limb to which the tourniquet will be applied, and the cuff should be wider than half the diameter of the limb. However, we found that among the studies published in the literature on complications related to tourniquet applications, data on age, gender, or surgery tended to be limited, if reported. In a study by Drolet et al. (2014), in which 500 patients who underwent upper extremity surgery were examined, the mean age was reported as 40.1 years, covering a wide age range from 3 months to 90 years. The authors reported that in elderly patients, the presence of cardiovascular comorbidities increased and the dermal-epidermal junction became thinner and more susceptible to secondary forces with increasing age, leading to a higher risk of developing skin injuries. However, the authors did not detect any age-related complications associated with tourniquet application.
Din and Geddes (2004) compared skin protection methods applied to 82 patients who underwent total knee prosthesis and 68 others who underwent knee arthroscopy. Their sample consisted of 89 female and 61 male patients with an age range of 23-83 years and a mean age of 51 years. The authors reported no significant difference between the groups with respect to descriptive characteristics. In a similar study carried out by Olivecrona et al. (2006), 92 cases divided into three groups underwent total knee arthroplasty. Skin underneath the cuff was protected with either elastic stockinette or cotton-cast padding, or none. The mean age of the sample was noted as 71 years, but no data were provided with regard to gender. The authors reported no statistically significant relationship between the groups with respect to the descriptive characteristics of the patients. In a study by Bosman and Robinson (2014), the complication rate associated with tourniquet cuff applied directly to the skin was investigated in 97 patients who underwent thigh (n = 47) or ankle (n = 50) surgery. It was reported that 35 of the patients were female and 62 were male, but no data were given regarding age and no statistical result was found related to the descriptive features of the groups.
In the current study, 58 of the patients were men and two were women, and the mean age was 27.7 +/- 6.9 years. Similar to the literature, no statistically significant difference was observed between the groups in terms of descriptive characteristics (p > .05; see Table 2). Thus, it can be stated that the groups were homogenous. In contrast to the results of Din and Geddes (2004) as well as Bosman and Robinson (2014), the number of men in the current study was significantly higher than that of women. This can be attributed to the fact that anterior cruciate ligament injuries are more common in males. Our sample mostly comprised young adult males with anterior cruciate ligament injuries caused by physical activity. This may explain the lower mean age of our patients compared with similar previous studies.
Tourniquet Pressure
Further to a literature review, it appears that the optimal pressure for a safe tourniquet procedure has not yet been determined. There are several methods for the selection of tourniquet pressure, and this decision may vary according to the surgical expertise of the clinician. There are discussions in the literature concerning safe tourniquet pressure, which is believed to reduce associated complications. Recommendations regarding tourniquet pressure favor techniques that obtain a bloodless surgical intervention area that allows for the clear visualization of anatomical structures while avoiding high pressures that may cause nerve damage. Two variables that can easily be measured during surgery are systolic blood pressure and mean arterial pressure. In this method, it is recommended to add 75-100 mmHg and 100-150 mmHg to a patient's systolic pressure for upper and lower limb applications, respectively, or to apply twice the pressure of the systolic value. Another method adopted in clinical practice is the use of standard pressure values, that is, 200-250 mmHg for the upper limb and 250-300 mmHg for the lower limb (Kutty & McElwain, 2002; McMillan & Johnstone, 2017; Wong & Irwin, 2014). Defined as the lowest necessary pressure to stop arterial blood flow, limb occlusion pressure (LOP) has recently been referred to and recommended by AORN (Bogdan & Helfet, 2017; Spruce 2017; Yalc[latin dotless i]nkaya et al., 2014). To illustrate, AORN recommends adding 40 mmHg for LOP levels less than 130 mmHg, and 50 mmHg for pediatric patients (AORN Recommended Practices Committee, 2007; McMillan & Johnstone, 2017; Sharma & Salhotra, 2012).
In the survey conducted by Yalc[latin dotless i]nkaya et al. (2014), 49.3% of the participants stated that they took the patient's blood pressure into consideration, and 5.7% stated that they used a standard cuff pressure. However, none of the participants reported using LOP to determine the appropriate tourniquet pressure. When asked about the most frequently preferred cuff pressure for the lower limb, the response of the orthopaedists was 350.88 +/- 45.748 mmHg and that of the residents was 338.37 +/- 32.416 mmHg, mean: 345.02 +/- 40.457 mmHg.
Din and Geddes (2004) performed a study on 150 patients, 82 of whom underwent total knee arthroplasty and 68 of whom underwent knee arthroscopy. The authors compared the clinical results of skin protection methods and stated that they used the same standard tourniquet pressure (300 mmHg) in all patients. In a similar study undertaken by Olivecrona et al. (2006) with 92 patients who underwent total knee arthroplasty, the recommended pressure was 100-150 mmHg plus systolic blood pressure, but the decision was left to the discretion of the surgeon. The results of that study showed that the mean pressure applied during the process was 259 mmHg, and there was no significant difference between the groups in terms of tourniquet pressure. Bosman and Robinson (2014) carried out a research on 97 patients who underwent foot-ankle surgery and reported that surgeons generally used 300-mmHg tourniquet pressure. According to their results, no complication occurred in relation to skin damage, neurological deficits, or post-traumatic tourniquet syndrome. In another study, Souza Leao et al. (2016) examined pain caused by tourniquet pressure in 60 cases who received total knee prosthesis treatment and stated that 350 mmHg standard tourniquet pressure was applied to one group. The pressure applied to the other group was determined by adding 100 mmHg to the systolic blood pressure. The authors reported that neither pressure value caused pain, blood loss, limited range of motion, or complications. Thus, pressures at these levels were safe and did not alter the results of the surgery. In a meta-analysis study carried out by Smith and Hing (2009) on nine studies on arthroscopic knee surgery with or without the use of tourniquets, the tourniquet pressure applied was reported to range from 100 mmHg to 450 mmHg.
In the current study, we used the method of adding 100-150 mmHg to the systolic blood pressure value to determine the tourniquet pressure for each patient. The mean tourniquet pressure in the cotton-cast padding group was significantly higher (325.0 +/- 25.6 mmHg) than those in the protection sleeve and unprotected groups (p < .05; see Table 2). This difference may be explained by surgeon preference. The mean tourniquet pressure was 305.0 +/- 27.6 mmHg in the group without any protective sleeve. This result suggests that rather than tourniquet pressure, it was the absence of a protective material that caused complications in this group. In this context, our results were similar to those reported by Olivecrona et al. (2006). As to the rate of complications, the difference between the skin protection groups was not statistically significant (p > .05). This may be attributed to the tourniquet duration, which was 90 minutes or shorter.
Tourniquet Duration
It has been reported in the literature that keeping the pneumatic tourniquet in place for the shortest duration possible, yet long enough to be effective in decreasing complications, is important. Excessive tourniquet duration may lead to skin complications and deterioration in venous circulation, as well as other undesirable consequences, such as hyperemia, muscle weakness, ischemic injury, limb paralysis, and pulmonary embolism. Neurological complications are associated with longer tourniquet durations, and every 30-minute increase in the length of tourniquet application results in a threefold increase in nerve damage (AORN Recommended Practices Committee, 2007; Eser et al., 2014; Knudson, 2013; Spruce, 2017). In their review, Oragui et al. (2011) emphasized that careful monitoring of the tourniquet duration and keeping this application as short as possible were the most important factors in preventing negative consequences due to tourniquet use.
The general recommendation for maximum tourniquet duration is between 2 and 2.5 hours. This is based on the idea that adenosine triphosphate is depleted during the ischemia period and this time interval allows tissues to heal. However, despite all recommendations, it is important to know and understand that no tourniquet duration can be completely considered safe, and injury to the limbs can occur at any time during the application. Although the optimal time remains uncertain, it has been reported in most publications that allowing a reperfusion time of 10-15 minutes in tourniquet applications exceeding 2 hours is effective in reducing the risk of complications (Bogdan & Helfet, 2017; Kutty & McElwain, 2002; Spruce, 2017). In a study of Turkish orthopaedic surgeons and residents (Yalc[latin dotless i]nkaya et al., 2014), it was reported that 202 of the 2011 participants preferred a maximum 2-hour tourniquet use on the lower limb. In a meta-analysis by Smith and Hing (2009), it was stated that there was a significant difference among the published studies regarding the length of tourniquet applications, varying from 17.1 to 94 minutes. Observing that no patient developed any skin, soft tissue, or neurological complications, Bosman and Robinson (2014) concluded that pneumatic tourniquets could be safely used in foot and ankle surgery without skin protection. The authors noted that their mean tourniquet duration was 39.8 minutes, which is much lower than the 2-hour duration described in the literature. Din and Geddes (2004) reported the maximum tourniquet duration as 82 minutes. When the authors compared the tourniquet duration between the groups with or without skin protection, they found no statistically significant difference in terms of skin complications. In a similar study, Olivecrona et al. (2006) reported that mean tourniquet duration in patients who developed blisters was longer than those who did not: 112 minutes versus 94 minutes. Therefore, the authors argued that the longer the tourniquet duration is, the higher the risk of blisters is. In the current study, the mean duration of tourniquet application was 87.8 +/- 15.3 minutes in all three groups. There was no significant difference in duration between the three groups (p > .05; see Table 2). The relatively young mean age of our patients (27.7) and their diagnosis (anterior cruciate ligament rupture) may have shortened the mean tourniquet duration. The results of this study were consistent with those of Din and Geddes (2004) in terms of the tourniquet duration.
Complications
Pneumatic tourniquets are advantageous in that they provide a clear operative field view and prevent loss of blood. However, they do so at the risk of causing complications, such as pain, edema, skin damage, muscle injuries, nerve damage in the distal of the cuff, chemical burns, pulmonary embolism, neurological damage, and systemic metabolic effects that occur during and/or after surgery (AORN Recommended Practices Committee, 2007; McMillan & Johnstone, 2017). In a meta-analysis examining the results of patients who underwent arthroscopic knee surgery with or without the use of pneumatic tourniquets, fewer anatomic difficulties were encountered in the former group, but there was no significant difference in terms of other parameters (Smith & Hing, 2009).
Din and Geddes (2004) created three patient groups, in which either the Soffban protector or the Atlantech protector, or none was used. The authors then evaluated skin complications immediately after removing the cuff and divided the complications into four categories as normal skin, abrasions, blisters, and skin cuts. They reported that the complication rates statistically and significantly differed between the unprotected and protected groups. In the Soffban group, four patients out of 50 had skin complications. Atlantech group had even fewer (two out of 50). However, the group without protection had the highest rate of complications (24%). Olivecrona et al. (2006) also had three patient groups comprising patients whose skin was protected with either elastic stockinette or cotton-cast padding, or none. The authors evaluated skin complications based on the presence or absence of blisters and did not take superficial injuries, such as cuts and redness, into consideration. No complication was observed in the elastic stockinette group, whereas three patients in the cotton-cast padding group and seven in the unprotected group had blisters. Elastic stockinette group gave significantly better results than the group in which no protection was used. The results obtained in this group were also better than those obtained in the cotton-cast group, although the difference was not significant. In another study, McEwen et al. (2002) compared five cuff and padding configurations in healthy volunteers and found that elastic stockinette resulted in significantly less wrinkling and folding compared with all other padding types tested, including cotton-cast padding.
In the current study, the skin complication rate in the unprotected group was significantly higher than that in the protection sleeve group (p < .05). On the other hand, there was no statistically significant difference between the cotton-cast padding and protection sleeve groups and the unprotected group (p > .05; see Table 4). Our results parallel those reached by Olivecrona et al. (2006). However, the authors' study was limited in that skin complications were evaluated only upon cuff removal and not at further time intervals. In another study, Bosman and Robinson (2014) stated that they evaluated skin and soft tissues underneath and immediately distal to the cuff at hour 1 and 2 weeks after surgery.
Unlike the patients of the aforementioned authors, ours were in the same diagnostic group and we evaluated the skin underneath the cuff in four categories as having normal appearance, ecchymosis, blisters, and abrasions at four different times (see Table 4). According to the evaluation undertaken immediately after the removal of the cuff (minute 0), there was a significant difference in the complication rate between the cotton-cast padding, protection sleeve, and unprotected groups (p < .05). The complication rate was significantly higher in the unprotected group than in the protection sleeve group at minutes 0 and 30 (p < .05 for both). At minutes 30, the rate of the cotton-cast padding group did not significantly differ from that of the protection sleeve and unprotected groups (p > .05). At minutes 180, it was significantly higher in the unprotected group than in the protection sleeve and cotton-cast padding groups (p < .05). However, no statistically significant difference was observed between the protection sleeve and cotton-cast padding groups (p > .05). The evaluation undertaken at hours 24 revealed no significant difference in terms of the complication rates of the three groups (p > 05; see Table 4).
When the types of complications were evaluated, abrasion was observed in three patients in the cotton-cast padding group, in two patients in the protection sleeve group, and in four patients in the unprotected group (see Figure 2 and Table 5). Blisters were seen in four patients (see Figure 3), all in the unprotected group (see Table 5).
Although the number of complications at minutes 0 was 13, it decreased to nine at minutes 30, to seven at minutes 180, and to two at hours 24 (see Table 3). Abrasion and blister were the two complications seen in the study. In brief, the complication rates observed in the unprotected group at 0, 30 and 180 minutes were significantly higher than those in the two padding groups. This suggests that in tourniquet applications without the use of skin protection, skin complications may occur at any time after surgical intervention.
The surgical procedures were performed by multiple surgeons, which may be considered as a limitation of this study.
Conclusion
This study has two purposes: (1) to determine the effect of two different methods for the protection of skin underneath the pneumatic tourniquet cuff in patients undergoing anterior cruciate ligament reconstruction, and (2) to compare the results with those obtained from the unprotected group.
The results support the following recommendations: (a) skin protectors under the tourniquet cuff should be used to prevent skin complications during anterior cruciate ligament reconstruction; (b) further research should be conducted on other groups of patients undergoing orthopaedic limb surgery, where pneumatic tourniquets are routinely used; (c) pneumatic tourniquet applications, tourniquet pressure, and type of tourniquet cuff should be individualized according to the requirements of patients; (d) as recommended by AORN, tourniquet pressure should be determined on the basis of LOP; (e) addition of a certain amount of pressure to the blood pressure or systolic blood pressure may not be beneficial; (f) using modern tourniquet devices may enhance patient safety; and (g) further studies with well-defined methodologies should be performed on this subject.
References