OBJECTIVE: To evaluate the analgesic efficacy of ultrasound-guided high fascia iliaca compartment block (HFICB) in managing tourniquet-related pain following total knee arthroplasty (TKA). METHODS: A prospective randomized controlled trial was conducted involving 84 patients with severe knee osteoarthritis or rheumatoid arthritis who underwent unilateral TKA between March 2024 and December 2024. Patients were randomly assigned to two groups ( n=42) using a random number table. In the trial group, ultrasound-guided HFICB was performed preoperatively, with 0.2% ropivacaine injected into the fascia iliaca compartment. No intervention was administered in the control group. Baseline characteristics, including gender, age, surgical side, body mass index, and preoperative visual analogue scale (VAS) scores at rest and during movement, showed no significant difference between the two groups ( P>0.05). In both groups, a tourniquet was applied after osteotomy and before pulsed lavage, and removed after the closure of the first layer of the joint capsule. Postoperative assessments were conducted at 6, 12, 24, and 48 hours, including VAS scores at the tourniquet site (at rest and during movement), Bromage motor block scores, Ramsay sedation scores, and Bruggrmann comfort scale (BCS) scores to evaluate patient comfort. Additionally, the average tramadol consumption and incidence of nausea and vomiting within 48 hours postoperatively were recorded and compared. RESULTS: In the trial group and control group, VAS scores during movement at the tourniquet site significantly improved at all postoperative time points compared to preoperative levels ( P<0.05). VAS scores at rest increased transiently at 6 hours after operation in both groups, and then gradually decreased to the preoperative level. Except that there was no significant difference at 48 hours after operation in the trial group ( P>0.05), there were significant differences at other time points of two groups compared to preoperative score ( P<0.05). Except for VAS score at rest at 6 hours, VAS score during movement at 48 hours, and BCS comfort score at 48 hours ( P>0.05), the trial group showed significantly better outcomes than the control group in terms of VAS score at rest, VAS score during movement, Ramsay sedation scores, and BCS comfort scores at all other time points ( P<0.05). No significant difference was found in Bromage motor block scores between the groups ( P>0.05). Tramadol was used in 3 patients in the trial group and 7 patients in the control group within 48 hours after operation, the dosage was (133.30±14.19) mg and (172.40±22.29) mg, showing significant difference ( P<0.05). Nausea and vomiting occurred in 4 patients (9.5%) in the trial group and 3 patients (7.1%) in the control group, with no significant difference in incidence between groups ( P>0.05). CONCLUSION Ultrasound-guided HFICB provides effective analgesia for tourniquet-related pain following TKA, facilitates early postoperative functional recovery of the knee joint, and may serve as a valuable clinical option for postoperative pain management in TKA patients.
Humans ; Arthroplasty, Replacement, Knee/adverse effects* ; Nerve Block/methods* ; Male ; Female ; Pain, Postoperative/etiology* ; Tourniquets/adverse effects* ; Prospective Studies ; Middle Aged ; Ropivacaine/administration & dosage* ; Aged ; Ultrasonography, Interventional ; Anesthetics, Local/administration & dosage* ; Pain Measurement ; Fascia ; Osteoarthritis, Knee/surgery* ; Treatment Outcome ; Arthritis, Rheumatoid/surgery*

Against the backdrop of the Russia-Ukraine Conflict in 2022, this article reviews the characteristics of traumatic hemorrhage in modern warfare spanning the past century. It investigates several types of tourniquets used by the Russian and Ukrainian armed forces, including limb tourniquets and junctional tourniquets recommended by the Committee on Tactical Combat Casualty Care, tourniquets employed by the Armed Forces of the Russian Federation, and those used by the Armed Forces of Ukraine in the Russia-Ukraine Conflict. The analysis is conducted from perspectives, including the structure, usage methods, and limitations of different tourniquets. Additionally, the article synthesizes the research progress on tourniquets from 3 angles: battlefield adaptability, the impact of tourniquet application methods on patient outcomes, and training in tourniquet usage, offering insights from our team's perspective.
Tourniquets ; Humans ; Russia ; Hemorrhage/therapy* ; Ukraine ; Military Medicine/methods* ; Warfare ; Armed Conflicts

PURPOSE: SAM junctional tourniquet (SJT) has been applied to control junctional hemorrhage. However, there is limited information about its safety and efficacy when applied in the axilla. This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model. METHODS: Eighteen male Yorkshire swines, aged 6-month-old and weighing 55 - 72 kg, were randomized into 3 groups, with 6 in each. An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery. Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume. Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied. In Group I, the swine spontaneously breathed, while SJT was applied for 2 h with a pressure of 210 mmHg. In Group II, the swine were mechanically ventilated, and SJT was applied for the same duration and pressure as Group I. In Group III, the swine spontaneously breathed, but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression. The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands. After then, a temporary vascular shunt was performed in the 3 groups to achieve resuscitation. Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution. T_b and T₀ represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock, respectively. T₃₀, T₆₀, T₉₀ and T₁₂₀, denote 30, 60, 90, and 120 min after T₀ (hemostasis period), while T₁₅₀, and T₁₈₀ denote 150 and 180 min after T₀ (resuscitation period). The mean arterial pressure and heart rate were monitored through the right carotid artery catheter. Blood samples were collected at each time point for the analysis of blood gas, complete cell count, serum chemistry, standard coagulation tests, etc., and thromboelastography was conducted subsequently. Movement of the left hemidiaphragm was measured by ultrasonography at T_b and T₀ to assess respiration. Data were presented as mean ± standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method. All statistical analyses were processed using GraphPad Prism software. RESULTS: Compared to T_b, a statistically significant increase in the left hemidiaphragm movement at T₀ was observed in Groups I and II (both p < 0.001). In Group III, the left hemidiaphragm movement remained unchanged (p = 0.660). Compared to Group I, mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement (p < 0.001). Blood pressure and heart rate rapidly increased at T₀ in all three groups. Respiratory arrest suddenly occurred in Group I after T₁₂₀, which required immediate manual respiratory assistance. PaO₂ in Group I decreased significantly at T₁₂₀, accompanied by an increase in PaCO₂ (both p < 0.001 vs. Groups II and III). Other biochemical metabolic changes were similar among groups. However, in all 3 groups, lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH. The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis. The coagulation function test did not show statistically significant differences among three groups at any time point. However, D-dimer levels showed a more than 16-fold increase from T₁₂₀ to T₁₈₀ in all groups. CONCLUSION In the swine model, SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation. Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency. Therefore, mechanical ventilation could be necessary before SJT removal.
Male ; Animals ; Swine ; Shock, Hemorrhagic/therapy* ; Tourniquets ; Axilla ; Hemorrhage/therapy* ; Vascular Diseases ; Respiration

OBJECTIVE: To investigate the complications of tourniquet in the clinical application of lower tibiofibular fracture. METHODS: From June 2018 to September 2019, 33 cases of closed lower tibiofibular fractures (AO type 43A) were treated with plates and screws and were divided into two groups according to whether pueumatic tourniquet was used:16 cases in the observation group, 13 males and 3 females, aged 18 to 69 (38.8±17.0) years, the operation time after injury was (6.9±1.7) days, and tourniquet was not used during operation. There were 17 cases in the control group, 13 males and 4 females, aged from 21 to 71 (43.8±12.4) years, the operation time after injury was (6.5±1.0) days, automatic pneumatic tourniquetwas routinely used in the operation. The operation time, blood loss, postoperative swelling, pain and other complications were compared between two groups. RESULTS: Total of 33 patients were followed up for an average of 15 months. There was no significant difference in operation time and blood loss between two groups ( CONCLUSION The fracture of lower tibiofibular segment is superficial and easy to be exposed and fixed during operation. In order to avoid tourniquet complications, it is not recommended to use air bag tourniquet routinely or minimize the application time of tourniquet.
Adolescent ; Adult ; Aged ; Female ; Fracture Fixation, Internal ; Fractures, Bone/surgery* ; Humans ; Male ; Middle Aged ; Operative Time ; Retrospective Studies ; Tourniquets ; Treatment Outcome ; Young Adult

A 70-year-old man complained imbalance while walking, inability to perform ankle flexion, and could not stand on tip-toe 3 months after injury. The ankle looked swollen with loss of Achilles contour and obvious gait disturbance. Magnetic resonance imaging shows a 5-cm Achilles tendon gap. Subsequently, surgery was performed to solve the neglected Achilles tendon rupture. Patient was put under general anesthesia with a regional block. Using a non-tourniquet technique, a reconstructive procedure was performed using a half-width autologous Achilles tendon graft, which was attached to the calcaneal prominence with wire in a double strand Bunnell fashion. As for the proximal stump, double core Bunnell/modified Kessler suturing was carried out to suture the graft to Achilles stump. To increase the vascularization, an ipsilateral gastrocnemius fascial flap with a distally based-pedicle was harvested to wrap around the tendon graft. At a 6-month follow-up, the patient was able to stand on tip-toe and had also regained a normal gait.
Achilles Tendon ; Aged ; Anesthesia, General ; Ankle ; Follow-Up Studies ; Gait ; Humans ; Magnetic Resonance Imaging ; Reconstructive Surgical Procedures ; Rupture ; Sutures ; Tendons ; Tourniquets ; Transplants ; Walking

Sciatic nerve palsy after total knee arthroplasty, accompanied by motor power weakness and electromyographic evidence, is a rare occurrence. In a 78-year-old female, pneumatic tourniquet was used for 72 minutes, with a pressure of 300 mmHg. The time and pressure are generally accepted values. We noticed sciatic nerve palsy showing motor power weakness and electromyographic evidence. One year after the operation, she recovered full motor power, but complained about a tingling sensation below the knee. Given that the nerve injury after using tourniquet was due to neural ischemia, and since our patient had vascular circulation problems such as atrial fibrillation and clip insertion due to internal carotid artery aneurysm, our patient can be considered as a high-risk patient with weakness to neural ischemic damage, even with the use of conventional tourniquet. Therefore, surgeons should be cautious when using tourniquet in patients with vascular circulation problems.
Aged ; Aneurysm ; Arthroplasty, Replacement, Knee* ; Atrial Fibrillation ; Carotid Artery, Internal ; Female ; Humans ; Ischemia ; Knee ; Sciatic Nerve* ; Sciatic Neuropathy ; Sensation ; Surgeons ; Tourniquets

PURPOSE: Body mass index (BMI) is often used to predict surgical difficulty in patients receiving total knee arthroplasty (TKA); however, BMI neglects variation in the central versus peripheral distribution of adipose tissue. We sought to examine whether anthropometric factors, rather than BMI alone, may serve as a more effective indication of surgical difficulty in TKA. MATERIALS AND METHODS: We prospectively enrolled 67 patients undergoing primary TKA. Correlation coefficients were used to evaluate the associations of tourniquet time, a surrogate of surgical difficulty, with BMI, pre- and intraoperative anthropometric measurements, and radiographic knee alignment. Similarly, Knee Injury and Osteoarthritis Outcome Score (KOOS) was compared to BMI. RESULTS: Tourniquet time was significantly associated with preoperative inferior knee circumference (p=0.025) and ankle circumference (p=0.003) as well as the intraoperative depth of incision at the quadriceps (p=0.014). BMI was not significantly associated with tourniquet time or any of the radiographic parameters or KOOS scores. CONCLUSIONS: Inferior knee circumference, ankle circumference, and depth of incision at the quadriceps (measures of peripheral obesity) are likely better predictors of surgical difficulty than BMI. Further study of alternative surgical indicators should investigate patients that may be deterred from TKA for high BMI, despite relatively low peripheral obesity.
Adipose Tissue ; Ankle ; Anthropometry ; Arthroplasty ; Arthroplasty, Replacement, Knee ; Body Mass Index ; Humans ; Knee ; Knee Injuries ; Obesity ; Osteoarthritis ; Prospective Studies ; Tourniquets

BACKGROUND: The aim of this study was to investigate the effects of remote ischemic conditioning on ischemia-reperfusion injury in rat muscle flaps histopathologically and biochemically. METHODS: Thirty albino rats were divided into 5 groups. No procedure was performed in the rats in group 1, and only blood samples were taken. A gracilis muscle flap was elevated in all the other groups. Microclamps were applied to the vascular pedicle for 4 hours in order to achieve tissue ischemia. In group 2, no additional procedure was performed. In groups 3, 4, and 5, the right hind limb was used and 3 cycles of ischemia-reperfusion for 5 minutes each (total, 30 minutes) was applied with a latex tourniquet (remote ischemic conditioning). In group 3, this procedure was performed before flap elevation (remote ischemic preconditoning). In group 4, the procedure was performed 4 hours after flap ischemia (remote ischemic postconditioning). In group 5, the procedure was performed after the flap was elevated, during the muscle flap ischemia episode (remote ischemic perconditioning). RESULTS: The histopathological damage score in all remote conditioning ischemia groups was lower than in the ischemic-reperfusion group. The lowest histopathological damage score was observed in group 5 (remote ischemic perconditioning). CONCLUSIONS: The nitric oxide levels were higher in the blood samples obtained from the remote ischemic perconditioning group. This study showed the effectiveness of remote ischemic conditioning procedures and compared their usefulness for preventing ischemia-reperfusion injury in muscle flaps.
Animals ; Extremities ; Ischemia ; Ischemic Preconditioning ; Latex ; Methods* ; Nitric Oxide ; Rats* ; Reperfusion Injury* ; Tourniquets

BACKGROUND: The aim of this study was to investigate the effects of remote ischemic conditioning on ischemia-reperfusion injury in rat muscle flaps histopathologically and biochemically. METHODS: Thirty albino rats were divided into 5 groups. No procedure was performed in the rats in group 1, and only blood samples were taken. A gracilis muscle flap was elevated in all the other groups. Microclamps were applied to the vascular pedicle for 4 hours in order to achieve tissue ischemia. In group 2, no additional procedure was performed. In groups 3, 4, and 5, the right hind limb was used and 3 cycles of ischemia-reperfusion for 5 minutes each (total, 30 minutes) was applied with a latex tourniquet (remote ischemic conditioning). In group 3, this procedure was performed before flap elevation (remote ischemic preconditoning). In group 4, the procedure was performed 4 hours after flap ischemia (remote ischemic postconditioning). In group 5, the procedure was performed after the flap was elevated, during the muscle flap ischemia episode (remote ischemic perconditioning). RESULTS: The histopathological damage score in all remote conditioning ischemia groups was lower than in the ischemic-reperfusion group. The lowest histopathological damage score was observed in group 5 (remote ischemic perconditioning). CONCLUSIONS: The nitric oxide levels were higher in the blood samples obtained from the remote ischemic perconditioning group. This study showed the effectiveness of remote ischemic conditioning procedures and compared their usefulness for preventing ischemia-reperfusion injury in muscle flaps.
Animals ; Extremities ; Ischemia ; Ischemic Preconditioning ; Latex ; Methods* ; Nitric Oxide ; Rats* ; Reperfusion Injury* ; Tourniquets

OBJECTIVETo compare the effect between nebulized and intravenous administration of Shenmai Injection () on pulmonary gas exchange function of patients following tourniquet-induced lower limb ischemia-reperfusion.

METHODSThirty-eight patients scheduled for lower extremity surgery were randomized into three groups using the closed envelop method: Shenmai Injection was administered 30 min before tourniquet inflflation by nebulization [0.6 mL/kg in 10 mL normal saline (NS)] in the nebulization group or by intravenous drip (0.6 mL/kg dissolved in 250 mL of 10% glucose) in the intravenous drip group, and equal volume of NS was given intravenously in the NS group; 15 in each group. Arterial blood gases were analyzed, serum levels of malonaldehyde (MDA) and interleukine-6 (IL-6) and interleukine-8 (IL-8) were determined using the method of thiobarbituric acid reaction and enzyme-linked immuno sorbent assay respectively just before tourniquet inflflation (T0), and at 0.5 h (T1), 2 h (T2), 6 h (T3) after tourniquet deflflation.

RESULTSCompared with baselines at T0, MDA levels signifificantly increased at T2, T3 in the NS group and at T3 in the nebulization group, and IL-6 and IL-8 levels were signifificantly increased at T2, T3 in NS, the intravenous drip and the nebulization groups (P <0.05). Arterial pressure of oxygen (PaO) at T3 was decreased, while alveolararterial oxygen tension showed difference (PA-aDO) at T3 in the NS group; RI at T3 in both intravenous drip and the nebulization groups were enhanced (P <0.05). Compared with the NS group, MDA and IL-8 levels at T2, T3, IL-6 at T3 in the intravenous drip group, and IL-8 at T3 in the nebulization group were all remarkably increased (P <0.05). Additionally, MDA level at T3 in the nebulization group was higher than that in the intravenous drip group (P <0.05).

CONCLUSIONSIntravenous administration of Shenmai Injection provided a better protective effect than nebulization in mitigating pulmonary gas exchange dysfunction in patients following tourniquet-induced limb ischemia-reperfusion.

Adult ; Blood Gas Analysis ; Drug Administration Routes ; Drug Combinations ; Drugs, Chinese Herbal ; administration & dosage ; pharmacology ; therapeutic use ; Female ; Humans ; Injections ; Interleukin-6 ; blood ; Interleukin-8 ; blood ; Male ; Malondialdehyde ; blood ; Pulmonary Gas Exchange ; drug effects ; Reperfusion Injury ; blood ; drug therapy ; physiopathology ; Tourniquets ; adverse effects