A systematic review of tourniquet use in paediatric orthopaedic surgery

Key points

• Tourniquets are routinely used in both trauma and elective paediatric orthopaedic surgery, but no high-quality research confirms their benefits.
• The review included 39 studies; 9 were at low, 13 at moderate and 17 at high risk of bias.
• Most children had tourniquets used without problems, but physiological changes and complications were reported, including nerve injury, compartment syndrome, chemical skin burns, thrombosis, limb swelling and pain.
• Tourniquet time was reported in 88% of studies, but inflation pressure in only 41%.
• The authors recommend deciding on tourniquet use case by case, recording its parameters, and using a correctly sized cuff over padding with a shut-off against antiseptic pooling.

Overview

Evidence on tourniquets in children is scarce compared with adults, and the review found no high-quality study showing that their routine use in paediatric orthopaedics is beneficial, although severe complications, while rare, do occur. The British Orthopaedic Association standard (BOAST) of 2021 states that tourniquets should be used only when clinically justified; for patients younger than 16 years it advises a pressure of 50 mm Hg above limb occlusion pressure (LOP) or 50–100 mm Hg above systolic blood pressure.

How the review was done

This prospectively registered systematic review (PROSPERO CRD42022359048) followed PRISMA. MEDLINE, Embase and the Cochrane Library were searched from their earliest records to 23 March 2023, together with grey literature and conference proceedings. Studies reporting tourniquet data in patients under 18 years undergoing orthopaedic surgery were eligible. Of 297 articles found, 39 were included; 22 concerned the lower limb, 22 elective and 8 trauma surgery.

Physiological effects

Tourniquet use raised core body temperature until deflation, more so with bilateral lower limb tourniquets, so aggressive intraoperative warming should be avoided. Deflation was followed by a mixed respiratory and metabolic acidosis, with rises in lactate, potassium and carbon dioxide; similar changes occurred at pressures of 75 mm Hg above systolic pressure, in line with BOAST. Longer tourniquet time was associated with higher pulse rate, serum lactate and end-tidal carbon dioxide. In two children, heart rate and blood pressure rose within 30 minutes of inflation and returned to baseline when the pressure was lowered.

Complications

Seven studies reported nerve injury, for example peroneal nerve palsy in 5 of 42 children after tibial derotation osteotomy and 11 peroneal injuries in 255 tibial osteotomies, all recovered by six months. Other reports included one case of compartment syndrome, a 10% increase in limb volume after tourniquet release, partial-thickness chemical burns from antiseptic pooling under the cuff, symptomatic deep vein thrombosis in 7 of 2,783 adolescents after knee arthroscopy and one case of fat embolism after deflation. In 204 children having lower limb surgery, tourniquet use was linked to more pain and analgesia, but also to shorter operating time, less blood loss and no rise in infection. In 1,002 children having knee arthroscopy, tourniquet times above 114 minutes were associated with more major complications. A survey described a child who needed an amputation after a tourniquet was inadvertently left inflated during bilateral surgery. No iatrogenic fractures were reported in children with osteogenesis imperfecta.

Pressure and technique

Using LOP as the reference allowed lower pressures than the standard 250–300 mm Hg with adequate visibility. In a randomised trial of paediatric anterior cruciate ligament surgery, the mean pressure was 151 mm Hg with individualised LOP versus 300 mm Hg with a standard setting, with equivalent operating time and adequate haemostasis in both groups. No study directly compared the quality of the surgical field with and without a tourniquet.

Recommendations

The authors recommend assessing the need for a tourniquet case by case and documenting its parameters in the operation notes. Tourniquets should be correctly sized, applied over padding and shut off to prevent antiseptic pooling. In bilateral surgery, removing the tourniquet once one side is finished avoids leaving it inflated by mistake. Anaesthetists should watch for hyperthermia and acidosis, and pain, swelling and signs of compartment syndrome should be monitored after surgery. A large high-quality study is needed.

Frequently asked questions

Are tourniquets proven to help in children's orthopaedic surgery?

No. The review found no high-quality evidence of benefit; only one study compared blood loss, and the difference was not clinically significant.

Which complications were reported?

Nerve injury, compartment syndrome, chemical skin burns, deep vein thrombosis, fat embolism, limb swelling, increased pain and physiological changes such as hyperthermia and acidosis. Severe complications were rare.

Is this a formal guideline?

No. It is a systematic review with the authors' practical recommendations; most included studies were small and many were at high risk of bias.

Source

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(1):80-91. DOI: 10.1530/EOR-23-0091. Open access under CC BY-NC 4.0. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.