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Impact of Tourniquet Use in Major Lower Limb Amputation: A Systematic Review and Meta-analysis
Jessie Shea1, Elisabeth Smith2, Megan Lyons3
1Department of Trauma and Orthopaedics, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, UK.
Objective:
Intra-operative blood loss is a significant complication of major lower limb amputation (MLLA). This systematic review and meta-analysis assessed the effect of tourniquet use on patients undergoing amputation.
Data Sources:
Embase, MEDLINE, and Cochrane databases were searched from inception to April 2024.
Review Methods:
Inclusion criteria were any study design assessing MLLA with and without tourniquet use. Primary outcomes were peri-operative blood loss and transfusion requirements. Secondary outcomes were operative duration, surgical site infection, stump revision, and mortality. Articles were screened and data extracted independently by two reviewers, then pooled using random effects meta-analysis, and presented with their GRADE certainty. Risk of bias was assessed using ROBINS-I and Cochrane RoB 2 tools.
Results:
Seven studies (one randomised controlled trial [RCT] and six cohort studies) were included, totalling 1 018 limbs (412 tourniquet, 606 non-tourniquet). Intra-operative blood loss was lower with tourniquet use (mean difference [MD] -192.09 mL; 95% confidence interval [CI] -291.67 - -92.52; p < .001); however, there was no significant difference in total blood loss measured over the first three to four post-operative days (MD -254.66 mL; 95% CI -568.12 - 58.80; p = .11). Post-operative haemoglobin drop was lower for tourniquet patients (MD -0.55 g/dL; 95% CI -0.80 - -0.31; p < .001). The odds ratio (OR) for requiring blood transfusion was 0.65 (95% CI 0.38 - 1.11; p = .11) for tourniquet vs. non-tourniquet patients, with no significant difference in the number of units transfused per patient (MD -0.35, 95% CI -0.72 - 0.03; p = .070). Operation duration was shorter with tourniquet use (MD -8.69 minutes, 95% CI -15.95 - -1.42; p = .020). There was no significant difference in rates of surgical site infection (OR 1.07, 95% CI 0.60 - 1.90; p = .82), stump revision (OR 0.71, 95% CI 0.43 - 1.16; p = .17), or death (OR 0.80, 95% CI 0.49 - 1.30; p = .36). GRADE certainty was low or very low for all outcomes.
Conclusion:
Tourniquet use may be associated with reduced post-operative haemoglobin drop and operative duration, without negative consequences on stump infection, revision, and mortality. However, most data are observational. Further RCTs are needed to generate higher quality evidence.
