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CC BY 4.0 · Rev Bras Ortop (Sao Paulo) 2025; 60(03): s00451809689
DOI: 10.1055/s-0045-1809689
Update Article

Recommendations and Protocols for the Safe Use of Tourniquets in Upper- and Lower-Extremity Surgeries

Recomendações e protocolos para o uso seguro de torniquetes em cirurgias de extremidades superiores e inferiores

Authors

  • Antonio Tufi Neder Filho 

    1   Locomotor System Department, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
    2   Rede Mater Dei de Saúde, Belo Horizonte, MG, Brasil

  • Túlio Vinícius de Oliveira Campos 

    1   Locomotor System Department, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil

Financial Support The authors declare that they did not receive financial support from agencies in the public, private, or non-profit sectors to conduct the present study.
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Abstract

The tourniquet (TNQ) interrupts blood flow to a given anatomical segment and has critical applications in orthopedic surgeries by providing a blood-free operating field. The risks and complications attributed to its use are increased pain, reperfusion injury, edema, deep venous thrombosis, and peripheral nerve injury. The main recommendations for TNQ use and to reduce the occurrence of complications include adequate limb padding; TNQ inflation to pressures of 50 mmHg and 100 mmHg above the perfusion pressure for the upper and lower limbs respectively; avoid TNQ use in children and patients with cachexia, lupus, and coagulopathy; avoid keeping the device inflated for more than 2 hours; and have a trained team alert to deflation, which is characterized by the possibility of bleeding, pulmonary embolism, and myonephropathic metabolic syndrome. The present update article summarizes the best evidence on TNQ use in orthopedic surgeries and proposes a protocol for its safe use.

Resumo

O torniquete (TNQ) interrompe o fluxo sanguíneo para um determinado segmento anatômico e tem aplicação importante nas cirurgias ortopédicas ao proporcionar um campo operatório limpo de sangue. Os riscos e complicações atribuídos ao seu uso são aumento da dor, lesão por reperfusão, edema, trombose venosa profunda e lesão de nervos periféricos. As principais recomendações para se utilizar o TNQ e diminuir a ocorrência de complicações são: acolchoar adequadamente o membro; insuflar o torniquete até pressão 50 mmHg acima da pressão de perfusão para os membros superiores e 100 mmHg para os membros inferiores; evitar o uso em pacientes com caquexia, crianças, portadores de lúpus e coagulopatia; evitar manter o dispositivo insuflado por período superior a 2 horas; e ter equipe treinada e atenta para a desinsuflação, caracterizada pela possibilidade de sangramento, embolia pulmonar e síndrome metabólica mionefropática. Este artigo de atualização resume a melhor evidência acerca do emprego do TNQ nas cirurgias ortopédicas e propõe um protocolo para sua utilização segura.

Keywords

complications - lower extremity - protocols - tourniquets - upper extremity

Palavras-chave

complicações - extremidade inferior - extremidade superior - protocolo - torniquetes

Authors' Contributions

Each author contributed individually and significantly to the development of this article.


* Study developed at the Locomotor System Department, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.




Publication History

Received: 07 November 2024

Accepted: 13 March 2025

Article published online:
29 July 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

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Bibliographical Record
Antonio Tufi Neder Filho, Túlio Vinícius de Oliveira Campos. Recommendations and Protocols for the Safe Use of Tourniquets in Upper- and Lower-Extremity Surgeries. Rev Bras Ortop (Sao Paulo) 2025; 60: s00451809689.
DOI: 10.1055/s-0045-1809689
 

  • References

  • 1 Saied A, Mousavi AA, Arabnejad F, Heshmati AA. Tourniquet in surgery of the limbs: a review of history, types and complications. Iran Red Crescent Med J 2015; 17 (02) e9588
    Search in Google Scholar
  • 2 Bogdan Y, Helfet DL. Use of tourniquets in limb trauma surgery. Orthop Clin North Am 2018; 49 (02) 157-165
    Search in Google Scholar
  • 3 Han J, Zhang XY, Mu SY, Liu S-L, Cui Q-T, Zhang C, Liu A-F. Tourniquet application in primary total knee arthroplasty for osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Front Surg 2023; 9: 994795
    Search in Google Scholar
  • 4 Sadri A, Braithwaite IJ, Abdul-Jabar HB, Sarraf KM. Understanding of intra-operative tourniquets amongst orthopaedic surgeons and theatre staff–a questionnaire study. Ann R Coll Surg Engl 2010; 92 (03) 243-245 , quiz 1p, 245
    Search in Google Scholar
  • 5 Fitzgibbons PG, Digiovanni C, Hares S, Akelman E. Safe tourniquet use: a review of the evidence. J Am Acad Orthop Surg 2012; 20 (05) 310-319
    Search in Google Scholar
  • 6 Zhang Y, Li L, Wang J, Li ZH, Shi ZJ. Do patients benefit from tourniquet in arthroscopic surgeries of the knee?. Knee Surg Sports Traumatol Arthrosc 2013; 21 (05) 1125-1130
    Search in Google Scholar
  • 7 Wang J, Xu W, Lv J. Is it better to routinely use tourniquet for knee arthroscopic surgery: A systematic review and meta-analysis. J Knee Surg 2020; 33 (09) 866-874
    Search in Google Scholar
  • 8 Arciero RA, Scoville CR, Hayda RA, Snyder RJ. The effect of tourniquet use in anterior cruciate ligament reconstruction. A prospective, randomized study. Am J Sports Med 1996; 24 (06) 758-764
    Search in Google Scholar
  • 9 Daniel DM, Lumkong G, Stone ML, Pedowitz RA. Effects of tourniquet use in anterior cruciate ligament reconstruction. Arthroscopy 1995; 11 (03) 307-311
    Search in Google Scholar
  • 10 Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J. Timing of tourniquet release in total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2017; 96 (17) e6786
    Search in Google Scholar
  • 11 Lu C, Song M, Chen J, Li C, Lin W, Ye G. et al. Does tourniquet use affect the periprosthetic bone cement penetration in total knee arthroplasty? A meta-analysis. J Orthop Surg Res 2020; 15 (01) 602
    Search in Google Scholar
  • 12 Sun C, Zhang X, Ma Q, Tu Y, Cai X, Zhou Y. Impact of tourniquet during total knee arthroplasty when tranexamic acid was used: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2022; 17 (01) 18
    Search in Google Scholar
  • 13 He YX, Qiao WJ, Zhao YH, Gao Z, Wang WJ. Effectiveness and safety of tourniquet application strategies in total knee arthroplasty: A meta-analysis. Indian J Orthop 2021; 55 (05) 1087-1095
    Search in Google Scholar
  • 14 Ahmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson C. et al. Tourniquet use for knee replacement surgery. Cochrane Database Syst Rev 2020; 12 (12) CD012874
    Search in Google Scholar
  • 15 Horlocker TT, Hebl JR, Gali B, Jankowski CJ, Burkle CM, Berry DJ. et al. Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesth Analg 2006; 102 (03) 950-955
    Search in Google Scholar
  • 16 Præstegaard M, Beisvåg E, Erichsen JL, Brix M, Viberg B. Tourniquet use in lower limb fracture surgery: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol 2019; 29 (01) 175-181
    Search in Google Scholar
  • 17 Noordin S, McEwen JA, Kragh Jr JF, Eisen A, Masri BA. Surgical tourniquets in orthopaedics. J Bone Joint Surg Am 2009; 91 (12) 2958-2967
    Search in Google Scholar
  • 18 Reilly CW, McEwen JA, Leveille L, Perdios A, Mulpuri K. Minimizing tourniquet pressure in pediatric anterior cruciate ligament reconstructive surgery: a blinded, prospective randomized controlled trial. J Pediatr Orthop 2009; 29 (03) 275-280
    Search in Google Scholar
  • 19 Pintar V, Brookes C, Trompeter A, Bridgens A, Hing C, Gelfer Y. A systematic review of tourniquet use in paediatric orthopaedic surgery: can we extrapolate from adult guidelines?. EFORT Open Rev 2024; 9 (01) 80-91
    Search in Google Scholar
  • 20 Halladin NL, Zahle FV, Rosenberg J, Gögenur I. Interventions to reduce tourniquet-related ischaemic damage in orthopaedic surgery: a qualitative systematic review of randomised trials. Anaesthesia 2014; 69 (09) 1033-1050
    Search in Google Scholar
  • 21 Graham B, Breault MJ, McEwen JA, McGraw RW. Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs. Clin Orthop Relat Res 1993; (286) 257-261
    Search in Google Scholar
  • 22 Ding L, Ding CY, Wang YL, Wang M-L, Qian X-H, Huang L. et al. Application effect of pneumatic tourniquet with individualized pressure setting in orthopaedic surgery of extremities: A meta-analysis. J Adv Nurs 2019; 75 (12) 3424-3433
    Search in Google Scholar
  • 23 Ochoa J, Fowler TJ, Gilliatt RW. Anatomical changes in peripheral nerves compressed by a pneumatic tourniquet. J Anat 1972; 113 (Pt 3): 433-455
    Search in Google Scholar