The sterile silicone ring tourniquet is a single-use device that enables the exposure of a larger proximal area compared to conventional pneumatic compression tourniquets. The volume of the sterile silicone ring tourniquet is small and does not restrict joint movement during surgery. Postoperative evaluation showed no evidence of surgical site infections, skin problems, or ischemic changes when tourniquet application was completed within 2 hours. This study found that sterile silicone ring tourniquets were effective in pediatric patients with varying limb sizes and circumferences.
Sterile silicone ring tourniquets for pediatric patients
Limb circumference increases as children grow until they reach skeletal maturity [8, 9]. Therefore, it is essential to select appropriate tourniquet cuffs and pressure based on the circumference of individual limbs in pediatric patients undergoing orthopedic surgery. Because pneumatic tourniquet cuffs must be sterilized for intraoperative use, the cuff size must be determined at least several hours before surgery. In contrast, cuff sizes for silicone ring tourniquets can be determined based on limb circumference after surgical draping. The present study included patients aged 1–17 years with limb circumferences ranging from 15 to 65 cm. In addition, the nature of pediatric fractures, such as supracondylar and lateral condylar fractures, can lead to intraoperative changes from pre-planned surgical methods, including conversion from closed reduction to open reduction [10, 11]. This conversion is difficult in the absence of a sterilized pneumatic tourniquet. In contrast, silicone ring tourniquets can always be applied, even during unplanned alterations of the surgical methods; moreover, both application and removal can be completed within 15 seconds.
Intraoperative outcomes of sterile silicone ring tourniquet
Sufficient operative fields were secured in all 30 limbs analyzed in this study. The proximal limb length exposed by ring-type tourniquets is longer than that exposed by conventional pneumatic tourniquets [12, 13]. This is because pneumatic cuffs are 8–14 cm wide when added to surgical drapes, making it difficult to expose the proximal surgical site in young children with short limb lengths. In contrast, silicone ring tourniquets provide better limb exposure because their final cuff width is approximately 2 cm. This has been a great advantage in operations that require maximal exposure of the upper thigh or arm, such as soft tissue tumor removal or proximal limb fixation surgery [14]. In addition, the application of silicone ring tourniquets did not decrease joint ROM. In obese patients, the thickness of inflated pneumatic cuffs makes it difficult to obtain full ROM during surgery. In contrast, because they are narrower, silicone ring tourniquets do not alter joint ROM. These tourniquets are not restricted by changes in posture, thus allowing for an easier surgical approach. Moreover, bleeding control with silicone ring tourniquets was similar to that of conventional tourniquets in adults undergoing orthopedic surgery [15]. In this study, most operations were bloodless and gauze was generally not required. Therefore, this type of tourniquet minimizes blood loss in pediatric orthopedic surgery.
Postoperative outcomes of sterile silicone ring tourniquet
None of the patients in the present study experienced skin problems such as bullae, necrosis, hematoma, contusion, or burn wounds at the tourniquet application site. Because children have softer and more fragile soft tissue than adults, tourniquets may be harmful postoperatively [3]. However, proper application of skin protection can protect the soft tissue from damage caused by tourniquet usage [4, 16]. None of the patients in this study experienced skin or soft tissue problems even 24 hours postoperatively. In addition, none of the patients experienced surgical site infection. Although the reuse of pneumatic tourniquets is economical, they can be a source of infection even after sterilization [17, 18]. One study showed significant bacterial contamination in 68% of orthopedic surgical tourniquets, suggesting that bacteria may be transferred between operated patients [19]. In contrast, silicone ring tourniquets are both sterile and disposable, thereby reducing the risk of surgical site infections [19]. Tourniquet use has also been associated with ischemic complications and deep vein thrombosis. High pressure and prolonged obstruction of arterial blood flow induce ischemic changes in the limbs. Moreover, ischemic tissue perfusion after blood circulation resumes can lead to secondary injury, including compartment syndrome and distal neurovascular problems, with the remaining blood possibly causing deep vein thrombosis [5, 20]. Ischemic soft tissue damage did not differ between silicone rings and pneumatic tourniquets [21, 22]. In addition, silicone ring tourniquets effectively minimize residual blood in the extremities by compressing the limb while unrolling it from the distal end to the proximal site. This procedure provides effective exsanguination and may significantly reduce deep vein thrombosis. None of the patients in the present study experienced pain or sensory problems at the tourniquet site within 24 hours postoperatively. According to previous studies, the incidence of pain and paresthesia among patients who underwent silicone ring tourniquet application was comparable or lower than the incidence of these complications among patients who underwent pneumatic tourniquet application [23, 24].
The present study has several limitations. First, it was a prospective clinical trial and not a comparative study. Moreover, the target patient population was heterogeneous, with patients of different ages and limb sizes undergoing different types of surgery. Second, this study reported the short-term results of sterile silicone ring tourniquet application. Most complications associated with tourniquet application appear within a short period of time, suggesting that a short follow-up period may provide significant results; however, long-term follow-up is warranted. Finally, the study had a limited sample size, with only 30 cases among 27 patients being included. Because silicone ring tourniquets were developed for use in adults, few studies have evaluated these tourniquets in pediatric patients. Comparative trials with a larger number of patients are warranted.