Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Jan 18, 2017; 8(1): 62-67
Published online Jan 18, 2017. doi: 10.5312/wjo.v8.i1.62
Tourniquets do not increase the total blood loss or re-amputation risk in transtibial amputations
Christian Wied, Peter T Tengberg, Gitte Holm, Thomas Kallemose, Nicolai B Foss, Anders Troelsen, Morten T Kristensen
Christian Wied, Peter T Tengberg, Gitte Holm, Thomas Kallemose, Anders Troelsen, Morten T Kristensen, Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, 2650 Hvidovre, Denmark
Thomas Kallemose, Clinical Research Centre, Copenhagen University Hospital Hvidovre, 2650 Hvidovre, Denmark
Nicolai B Foss, Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, 2650 Hvidovre, Denmark
Morten T Kristensen, Physical Medicine and Rehabilitation Research-Copenhagen, Department of Physical Therapy, Copenhagen University Hospital Hvidovre, 2650 Hvidovre, Denmark
Author contributions: All the authors contributed to the manuscript.
Institutional review board statement: This retrospective study was undertaken using data from medical records only. The local ethics committee approved the protocol. Protocol: H-6-2014-FSP-026.
Informed consent statement: Our retrospective study contained data from medical records only. The study was registered at the regional data protection agency (04.12.2012) (j. no. 01975 HVH-2012-053).
Conflict-of-interest statement: The authors declare that they have no conflicts of interest. No benefits in any form have been received or will be received from any commercial party related directly or indirectly to the subject of this article.
Data sharing statement: The data from this study will be available on request.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Christian Wied, MD, Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark. chr.wied@gmail.com
Telephone: +45-20-616831 Fax: +45-38-623782
Received: August 11, 2016
Peer-review started: August 11, 2016
First decision: September 28, 2016
Revised: October 28, 2016
Accepted: December 7, 2016
Article in press: December 9, 2016
Published online: January 18, 2017

To investigate the total blood loss (TBL) and the safety with respect to the re-amputation rate after transtibial amputation (TTA) conducted with and without a tourniquet.


The study was a single-centre retrospective cohort study of patients with a primary TTA admitted between January 2013 and April 2015. All patients with a primary TTA were assessed for inclusion if the amputation was performed because of arteriosclerosis or diabetic complications. All patients underwent a standardized TTA procedure that was performed approximately 10 cm below the knee joint and performed with sagittal flaps. The pneumatic tourniquet, when used, was inflated around the femur to a pressure of 100 mmHg above the systolic blood pressure. The number of blood transfusions within the first four postoperative days was recorded. The intraoperative blood loss (OBL), which is defined as the volume of blood lost during surgery, was determined from the suction volume and by the weight difference of the surgical dressings. The trigger for a blood transfusion was set at a decrease in the Hgb level < 9.67 g/dL (6 mmol/L). Transfusions were performed with pooled red blood cells containing 245 mL per portion, which equals 55 g/L of haemoglobin. The TBL during the first four postoperative days was calculated based on the haemoglobin level and the estimated blood volume. The re-amputation rate was evaluated within 30 d.


Seventy-four out of 86 consecutive patients who underwent TTA within the two-year study period were included in the analysis. Of these, 38 were operated on using a tourniquet and 36 were operated on without using a tourniquet. There were no significant preoperative differences between the groups. The patients in both groups had a postoperative decrease in their Hgb level compared with preoperative baseline values. The patients operated on using a tourniquet received approximately three millilitres less blood transfusion per kilogram body weight compared with patients operated on without a tourniquet. The duration of surgery was shorter and the OBL was less for the tourniquet group than the non-tourniquet group, whereas no significant difference was observed for the TBL. The TBL median was 859 mL (IQR: 383-1315) in the non-tourniquet group vs 737 mL (IQR: 331-1218) in the tourniquet group (P = 0.754). Within the 30-d follow-up period, 9 patients in the tourniquet group and 11 in the non-tourniquet group underwent a re-amputation at the trans-femoral level. The use of a tourniquet showed no statistically significant association with the 30-d re-amputation at the femur level in the multiple logistic regression model (P = 0.78). The only variable with a significant association with re-amputation was age (OR = 1.07; P = 0.02).


The results indicate that tourniquets do not cause severe vascular damage with an increased postoperative bleeding or failure rate as the result.

Keywords: Total blood loss, Intraoperative blood loss, Transtibial amputation, Lower extremity amputation, Pneumatic tourniquet, Re-amputation

Core tip: The authors performed a retrospective cohort study on the use of tourniquets during transtibial amputation with the primary aim of comparing various estimates of blood loss and re-operation between the groups with or without a tourniquet. The basis for investigating this subject is the theoretical risk of increased bleeding due to vascular damage in the tourniquet group, which may, in turn, lead to increased risk of re-amputation due to local oedema, among other factors. We found no significant difference in the total blood loss when calculated on day four after surgery or in the 30-d re-amputation rate between the tourniquet and the non-tourniquet group.