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Arch Orthop Trauma Surg (2008) 128:297300 DOI 10.

1007/s00402-007-0446-0

ORTHOPAEDIC SURGERY

A new tourniquet system that determines pressures in synchrony with systolic blood pressure
Yoshinori Ishii Hideo Noguchi Yoshikazu Matsuda Mitsuhiro Takeda To-ichi Higashihara

Received: 24 January 2007 / Published online: 15 September 2007 Springer-Verlag 2007

Abstract Introduction This study reports the results of the clinical use of a new tourniquet system for surgery of the lower extremity that can determine tourniquet pressure in synchrony with systolic blood pressure. Materials and methods We prospectively applied additional pressure of 100 mmHg during 100 surgical procedures (54 knees, 2 legs, 44 feet and ankles). Results A bloodless surgical Weld was obtained in almost all patients. The average durations of surgery and tourniquet time were 50 and 51 min, respectively. The average initial blood pressures were 112 mmHg systolic and 60 mmHg diastolic. The average maximum pressure changes during surgery were 33 mmHg systolic and 21 mmHg diastolic. No complications associated with this system arose either during or after surgery. Conclusion The conventional tourniquet pressure in the lower extremity is 300 or 350 mmHg, whereas this synchronized system required less pressure, making it a safe, useful device for controlling a bloodless surgical Weld in lower extremity surgery. Keywords Tourniquet Systolic blood pressure Lower extremity surgery

Objective Minimal tourniquet inXation pressures are recommended for limb surgery in order to eliminate complications attributable to the high inXation pressures associated with pneumatic tourniquets. Great eVort has been invested in reducing the required tourniquet pressure [4, 1215, 18, 24, 25]. Some reports have outlined the advances in tourniquet design [4, 1215, 18], which include increased width and number of cuVs [24, 25], to increase tourniquet pressure until the arterial pulsations in the Wnger or toe of the operated limb disappears on an oscilloscope or plethysmographic system. However, blood pressure is not always constant and can vary with conditions, and these tourniquets could not respond to blood pressure changes [25]; any necessary adjustments had to be made manually. This study reports the results of the clinical use of a new tourniquet system for lower extremity surgery that can determine tourniquet pressure in synchrony with systolic blood pressure to maintain a bloodless surgical Weld.

Materials and methods We used a new tourniquet system, in which the pressure is synchronized to 0300 mmHg above systolic blood pressure (SBP), using a vital information monitor. In clinical practice, the level of additional pressure is determined as deemed appropriate by the surgeon. In our study, we applied 100 mmHg as the additional pressure. We routinely used an MT-920 tourniquet system (Mizuho-Ika, Tokyo, Japan) (Fig. 1). The actual pressure produced with this system is within 10 mmHg of the displayed pressure. The interval of the measurement of blood pressure was every 2.5 min. The tourniquet cuV was 86 cm long and 10.5 cm wide. A single

Y. Ishii (&) H. Noguchi Y. Matsuda M. Takeda Ishii Orthopaedic and Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama 361-0037, Japan e-mail: ishii@sakitama.or.jp T.-i. Higashihara Mizuho-Ika, Tokyo, Japan

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298 Fig. 1 a The MT-920 tourniquet system (Mizuho-Ika, Tokyo, Japan) (right), CRB (a connector broadcast box) (center), and the vital information monitor (left). b Scheme in MT-920 tourniquet system (Mizuho-Ika, Tokyo, Japan) Blood pressure of a patient is monitored by living body information monitor BP-88. The method of the monitor adopts a simple arm cuV since this system is a cuV sphygmomanometer. The information is recorded by the anesthesia notation record device AR-600 since it can be output as a digital (RS232C) signal. In MT-920 system, the monitored systolic blood pressure is used. MT-920 system gain the information diverged with CRB (a connector broadcast box). The timing and frequency of the measurement are controlled by the BP-88. The data are always updated when the every measurement is Wnished. Since MT-920 system always read data, it operates in real-time for a change of the blood pressure

Arch Orthop Trauma Surg (2008) 128:297300

(a)

(b)
Vital information monitor
D-sub15S D-sub15P D-sub15P

Connector relay box


D-sub15S D-sub15S

Anesthesia table recorder

AR-600 BP-88 Straight cable


D-sub9P D-sub9S

Usual cable

Cross cable
D-sub9S D-sub9P

Tourniquet MT-920

layer of cast padding was applied between the skin and cuV. The same surgical team performed all of the surgeries, in a laminar-Xow operating room. The limb was prepared and exsanguinated by elevation and a Esmarch bandage. The tourniquet was inXated to the desired pressure based on the SBP recorded before the skin incision. After surgery began, the tourniquet pressure was automatically synchronized with the SBP (Fig. 1a, b). The actual pressure produced with this system is within 10 mmHg of the displayed pressure. The interval of the measurement of blood pressure was every 2.5 min in both groups. For this study, 100 patients, aged from 13 to 86 years (average age 49 years), were recruited. None had any neurovascular disease. The patients were scheduled to have knee (54), leg (2), or foot and ankle (44) procedures performed by the three senior authors of this study, using a thigh tourniquet and either general (80) or spinal (20) anaesthesia (Table 1). All of the patients signed a consent form that included a description of the protocol and the potential tourniquet-related complications.

Table 1 Patient demographics Parameter Age Gender Operation site Weight Height BMI Value 49 23 years 38 men, 62 women 54 knees, 2 legs, 44 feet and ankles 60 12 kg 159 10 cm 23 3

Results The surgeon rated the quality of the bloodless Weld as poor, fair, good, or excellent, and noted any changes in the

quality of the bloodless Weld throughout the procedure. A poor Weld was one, in which blood obscured the Weld; a fair Weld had blood present but not signiWcantly interfering with surgery; a good Weld had some blood with no interference with the procedure; and an excellent Weld had no blood present. An excellent bloodless surgical Weld was obtained in almost all patients (Table 2). The average durations of the operation and tourniquet use were 50 (range 15132) and 51 (range 15125) min, respectively. The average initial blood pressures were 112 mmHg (range 78202) systolic and 60 mmHg (range 33110) diastolic. The average maximum pressure changes during surgery were 33 mmHg (range 5101) systolic and 21 mmHg (range 359) diastolic (Table 3).

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Arch Orthop Trauma Surg (2008) 128:297300 Table 2 Evaluation of the surgical Weld in 100 patients

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Evaluation Excellent Good Fair Poor

Numbers 100 0 0 0

Table 3 Tourniquet conditions in this study (N = 100) Initial TP Maximum change in systolic BP Maximum change in diastolic BP Maximum TP through surgery Tourniquet time TP Tourniquet pressure, SD standard deviation Average SD 212 22 mmHg 33 20 mmHg 21 12 mmHg 235 27 mmHg 51 21 min

Complications No complications associated with this system, such as compartment syndrome, deep vein complications, skin troubles, paresis, or nerve complications, arose either during or after surgery.

Discussion Pneumatic tourniquets are commonly used in orthopaedics and provide a clean, dry surgical Weld; improve surgical visualization of the anatomic structures; and reduce the operating time. Fortunately, complications of tourniquet use are very rare, although this inevitably makes an exact estimate of their incidence diYcult. In a recent report from Norway [16], the incidence was 1 in 6,155 operations on the limbs, with 1 complication in 3,752 operations on the lower limb. The incidence of tourniquet complications are still at least as high as that estimated in the 1970s. Clinical and experimental studies have revealed positive correlations between the degree of neuromuscular injury and the amount of tourniquet pressure or the duration of tourniquet application [3, 5, 9, 11, 17, 19, 2123]. Serious complications have arisen from prolonged tourniquet-induced ischemia and the mechanical damage caused by excessively long application times, extreme pressure, or a combination of these two factors. Considering the possible complications, the goal of tourniquet use is to apply the minimal tourniquet pressure [3, 19, 22] for the shortest compression time [2, 3, 8, 9, 17, 19, 21, 23] necessary to maintain satisfactory haemostasis control. Ishii and Matsuda recently recommended the application of tourniquet pressure at 100 mmHg above SBP in cement-

less total knee arthroplasty, rather than the conventional 350 mmHg [6]. This pressure matches that of the most common method in Norway [16]. In our study, the mean initial tourniquet pressure was 100 mmHg above SBP, or 212 mmHg (range 178302). This pressure is very close to the 231.0 26.5 mmHg used by Reid et al. [20], who reported that this pressure provided adequate control of haemostasis in the lower extremities in 97.5% of cases using a Doppler stethoscope. Based on these studies, we recommend the application tourniquet pressure at 100 mmHg above SBP, rather than the conventional 350 mmHg, to provide a suYciently bloodless operative Weld and minimize potential complications in surgery of the lower extremity. The inXation of the tourniquet to a pressure based on the SBP recorded before the skin incision might allow blood to ooze into the operative Weld as the SBP gradually or sharply rises. For example, Younger et al. [25] reported a poor bloodless Weld after a sharp rise (44 and 56 mmHg) in blood pressure during surgery using a new automated plethysmographic limb occlusion pressure measurement technique. They stressed the necessity of good anaesthetic technique rather than the eYcacy of this system. In our study, we overcame both problems with the application of tourniquet pressure at 100 mmHg above SBP, despite average and maximum SBP changes of 33 and 101 mmHg, respectively. Our system responded automatically to changes in blood pressure. This lower tourniquet pressure can maintain a suYciently bloodless operative Weld while minimizing potential complications. This is particularly valuable given that a patients blood pressure does not remain constant but varies with the conditions. The tourniquets used in a previous study were not able to respond to blood pressure changes. As stated by Younger et al. [25], SBP is only one of the variables aVecting limb occlusion pressure; tourniquet cuV design, application method, limb circumference and shape, and tissue characteristics at the cuV site also have eVects. However, given the bloodless surgical Weld that resulted with SBP plus 100 mmHg, SBP seems to be the most reliable index. Thus, the new tourniquet system that maintains synchrony with SBP appears to be reasonable and safe for use in lower extremity procedures. This study has some limitations. Although we adopted a tourniquet pressure of 100 mmHg above SBP in all cases, we should consider the thigh girth to determine the optimal minimal pressure for each patient. For example, patients with thick fat or muscle layers may need an additional pressure greater than 100 mmHg, whereas slender patients may require lower pressures. In addition, we used a standard 10.5 mm-wide cylinder cuV and not a wide contoured (curved) cuV. If the latter cuV design were adopted, we may need less additional pressure to maintain a bloodless surgical Weld.

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Arch Orthop Trauma Surg (2008) 128:297300 internal Wxation of ankle fractures. Clin Orthop Relat Res 433:189194 McLaren AC, Rorabeck CH (1985) The pressure distribution under tourniquets. J Bone Joint Surg Am 67:433438 Moore MR, GraWn SR, Hargens AR (1987) Wide tourniquets eliminate blood Xow at low inXation pressures. J Hand Surg Am 12:10061011 Muirhead A, Newman RJ (1986) A low-pressure tourniquet system for the lower limb. Injury 17:5354 Neimkin RJ, Smith RJ (1983) Double tourniquet with linked mercury manometers for hand surgery. J Hand Surg Am 8:938941 Newman RJ, Muirhead A (1986) A safe and eVective low-pressure tourniquet: a prospective evaluation. J Bone Joint Surg Br 68:625 628 Odinsson A, Finsen V (2006) Tourniquet use and its complications in Norway. J Bone Joint Surg Br 88:10901092 Patterson S, Klenerman L (1979) The eVect of pneumatic tourniquets on the ultrastructure of skeletal muscle. J Bone Joint Surg Br 61:178183 Pauers RS, Carocci MA (1994) Low pressure pneumatic tourniquets: eVectiveness at minimum recommended inXation pressures. J Foot Ankle Surg 33:605609 Pedowitz RA, Gershuni DH, Schmidt AH et al (1991) Muscle injury induced beneath and distal to a pneumatic tourniquet: a quantitative animal study of eVects tourniquet pressure and duration. J Hand Surg Am 16:610621 Reid HS, Camp RA, Jacob WH (1983) Tourniquet hemostasis. A clinical study. Clin Orthop Relat Res 177:230234 Saunders KC, Louis DL, Weingarden SI, Waylonis GW (1979) EVect of tourniquet time on postoperative quadriceps function. Clin Orthop Relat Res 143:194199 Shaw JA, Murray DG (1982) The relationship between tourniquet pressure and underlying soft-tissue pressure in the thigh. J Bone Joint Surg Am 64:11481152 Sherman OH, Fox JM, Snyder SJ et al (1986) Arthroscopy: no problem surgery: analysis of complications in two thousand six hundred and forty cases. J Bone Joint Surg Am 68:256265 Tuncali B, Karci A, Bacakoglu AK, Tuncali BE, Ekin A (2003) Controlled hypotension and minimal inXation pressure: a new approach for pneumatic tourniquet application in upper limb surgery. Anesth Analg 97:15291532 Younger AS, McEwen JA, Inkpen K (2004) Wide countered thigh cuVs and automated limb occlusion measurement allow lower tourniquet pressures. Clin Orthop Relat Res 428:286293

In conclusion, this new tourniquet system that synchronizes with SBP is a safe, useful devise for maintaining a bloodless surgical Weld in lower extremity operations. Although some studies have shown advantages to not using a tourniquet in total knee arthroplasty surgery [1, 7] and osteosynthesis ankle surgery [10], it seems likely that, for reasons of convenience and long-established practice, the general use of tourniquets will continue.

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13. 14. 15.

References
16. 1. Abdel-Salam A, Eyres KS (1995) EVects of tourniquet during total knee arthroplasty. A prospective randomized study. J Bone Joint Surg Br 77:250253 2. Bruner JM (1951) Safety factors in the use of the pneumatic tourniquet for hemostasis in surgery of the hand. J Bone Joint Surg Am 33:221224 3. GersoV WK, Ruwe P, Jokl P, Panjabi M (1989) The eVect of tourniquet pressure on muscle function. Am J Sports Med 17:123127 4. Graham B, Breault MJ, McEwen JA, McGraw RW (1993) Occlusion of arterial Xow in the extremities at subsystolic pressures through the use of wide tourniquet cuVs. Clin Orthop Relat Res 286:257261 5. Heppenstall RB, Scott R, Sapega A (1986) A comparative study of the tolerance of skeletal muscle to ischemia. Tourniquet application compared with acute compartment syndrome. J Bone Joint Surg Am 68:820828 6. Ishii Y, Matsuda Y (2005) EVect of tourniquet pressure on perioperative blood loss associated with cementless total knee arthroplasty: a prospective, randomized study. J Arthroplasty 20:325330 7. Jarolem KL, Scott DF, JaVe WL et al (1995) A comparison of blood loss and transfusion requirements in total knee arthroplasty with and without arterial tourniquet. Am J Orthop 24:906909 8. Klenerman L (1980) Tourniquet time: how long? Hand 12:231 234 9. Klenerman L, Biswas M, Hulands GH, Rhodes AM (1980) Systemic and local eVects of the application of a tourniquet. J Bone Joint Surg Br 62:385388 10. Konrad G, Markmiller M, Lenich A, Mayr E, Rter A (2005) Tourniquets may increase postoperative swelling and pain after 17.

18.

19.

20. 21.

22.

23.

24.

25.

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