Friction burns within the tibia during reaming: Are they affected by the use of a tourniquet

Abstract

We have carried out a prospective, randomised trial to measure the rise of temperature during reaming of the tibia before intramedullary nailing. We studied 34 patients with a mean age of 35.1 years (18 to 63) and mean injury severity score of 10 (9 to 13). The patients were randomised into two groups: group 1 included 18 patients whose procedure was undertaken without a tourniquet and group 2, 16 patients in whom a tourniquet was used. The temperature in the bone was measured directly by two thermocouples inserted into the cortical bone near the isthmus of the tibial diaphysis. Reaming was carried out to at least 1.5 mm above the required diameter of the nail. Blood loss was assessed by recording the preoperative and postoperative haemoglobin (Hb) level. The minimum clinical follow-up was six months. In group 1 (no tourniquet), the mean Hb dropped 2.8 g/dl from 14.3 +/- 1.02 g/dl to 11.5 +/- 1.04 g/dl (p = 0.0001), whereas with the tourniquet, the mean decrease was 1.3 g/dl from 14 +/- 1 g/dl to 12.7 +/- 1.3 g/dl (p = 0.007). This difference was not statistically significant. The mean initial tibial temperature was 35.6 degrees C (SD 0.6) and rose with reaming to levels between 36.3 degrees C and 51.6 degrees C. The highest temperatures were obtained with the largest reamers (11 and 12 mm, p = 0.0001) and the most rapid rise with the smallest diameters of medullary canal (8 or 9 mm). The rise of temperature was transient (20 s). We were unable to identify any effect of the use of a tourniquet on the temperature achieved. Reamed intramedullary tibial nailing induces a transient elevation of temperature which is directly related to the amount of reaming.

Osteocutaneous thermal necrosis of the leg salvaged by TSF/Ilizarov reconstruction. Report of 7 patients

“…Only a few cases [11,13] have been reported in the past, and recently a new one has been reported [15]. Although the heating of cortical bone during reaming has been evaluated in theoretical models [1], animal [4,12] and human cadaveric bone [9], and in vivo in both animals [3,10] and humans [6][7][8], the clinical relevance of these data has been debated. An in vivo assessment [6] of heat production during reaming in humans demonstrated peak temperatures of 36.1-51.6°C, with the highest value lasting no more than 15 seconds, without evidence of clinical manifestation related to excessive heat production.…”

Thermal Necrosis Complicating Reamed Intramedullary Nailing of a Closed Tibial Diaphysis Fracture: A Case Report

“…Additionally, proper reaming technique must always be used to include slow steady reamer advancement, small incremental increase in reamer size, cooling of the reamer when possible, and avoidance of tourniquet when reaming. Transfer to our facility and repeat irrigation and debridement (I&D) April 5, 2006 Removal IMN, placement of antibiotic-impregnated cement rod, soleus flap June 5,2006 Removal cement rod, placement tibial IMN October 18, 2006 Uneventful term delivery of a healthy child January 9,2007 Due to nonunion, removal of intramedullary nail, debridement of necrotic tibia, placement of cement rod March 10, 2007 Removal of cement rod, placement of tibial IMN, proximal tibial corticotomy and placement of Ilizarov external fixator…”

Infection After Reamed Intramedullary Nailing of the Tibia

“…Although there is no evidence that under normal circumstances the small amount of reaming required to insert a 9-mm, 10-mm, or 11-mm nail causes significant damage, it has been shown that reaming smaller canals may induce a significant heating effect. 30 There is evidence that temperatures .56°C denatures alkaline phosphatase and that temperatures .70°C cause cortical necrosis. 30,31 Although neither of the patients in this series had narrow intramedullary canals nor presented with a cutaneous blister, both showed signs of excessive reaming with cortical necrosis proximal to the fracture.…”

“…30 There is evidence that temperatures .56°C denatures alkaline phosphatase and that temperatures .70°C cause cortical necrosis. 30,31 Although neither of the patients in this series had narrow intramedullary canals nor presented with a cutaneous blister, both showed signs of excessive reaming with cortical necrosis proximal to the fracture. There has been a suggestion that thermal necrosis is influenced by the use of a perioperative tourniquet; however, a recent study has shown this belief to be unsubstantiated.…”