The Effect of Tourniquet Deflation Timing on Outcomes of Common Upper Extremity Surgeries

Background Historically, upper extremity procedures have relied on tourniquets to achieve hemostasis and provide a bloodless surgical field. However, a shift away from routine tourniquet use occurred in the early 2000s with the popularization of the wide-awake local anesthesia with no tourniquet (WALANT) technique. Despite this trend, many surgeons still prefer pneumatic tourniquets, which may improve visualization and operative efficiency. The purpose of this study was to compare early postoperative pain and function between procedures where the tourniquet was deflated after final wound closure and before final closure in carpal tunnel release (CTR), trigger finger (TF) release, and open reduction and internal fixation (ORIF) for distal radius fracture (DRF) cohorts. Methods A retrospective study of 150 patients undergoing CTR, 150 patients undergoing TF release, and 150 patients undergoing ORIF of a DRF from 2023 to 2025 was performed. Within each procedure category, patients were grouped by whether the tourniquet was deflated before or after final closure. Differences in demographics, comorbidities, perioperative details, and 30-day outcomes were assessed using univariate analysis. Multivariate linear and logistic regression were used to assess tourniquet deflation after closure as a predictor of outcomes. Statistical significance was assessed at p<0.05. Results Overall, demographics and comorbidities were largely similar between groups for the procedures evaluated. In the post-anesthesia care unit (PACU), the deflation after closure group had a longer time in recovery for both CTR and TF (both p < 0.001). CTR patients in the deflation after closure group reported higher average pain scores in the PACU (0.8 ± 2.0 vs. 0.3 ± 1.1; p = 0.026) and were more likely to receive opioids in the PACU (14.4 vs. 1.7%; p = 0.009). These differences in pain during early recovery were not observed in the TF or DRF cohorts. In CTR, after controlling for body mass index, operating room (OR) location, and endoscopic release, the deflation after closure group was significantly more likely to receive opioids in recovery (OR: 9.03; p = 0.043), but no significant differences in other PACU outcomes were observed. In TF, after controlling for race and OR location, the deflation after closure group had increased time in recovery (β: 10.44 min; p < 0.001) and decreased maximum pain score in the PACU (β: -1.11; p = 0.026). Additionally, the TF deflation after closure group was less likely to report a pain score of 5+ in recovery (OR: 0.32; p = 0.028). No significant differences in rates of nerve injury, surgical site infection (SSI), wound issues, pain complaints, or QuickDASH scores at 30-day follow-up were observed between groups for any of the three procedures. Conclusion This study's findings demonstrate that the timing of tourniquet deflation, either before closure or after closure, does not significantly impact the majority of early postoperative clinical outcomes or patient-reported outcome measures following CTR, TF, and DRF. These findings suggest that both deflation timings are safe for patients undergoing these procedures. The choice of when to release the tourniquet can be guided by surgeon preference and the specific context of the procedure. Further study is warranted to identify optimal tourniquet deflation timing protocols in common upper extremity surgeries.