Abnormal Thigh Swelling after Anterior Cruciate Ligament Reconstruction with Tourniquet
,
Abstract
Background: Anterior cruciate ligament (ACL) reconstruction surgery is a common orthopedic procedure. Minimally invasive surgeries and arthroscopy are becoming more common, and tourniquets are utilized in these procedures to reduce bleeding and allow for improved tissue visualization.
Case Report: In this paper, we report a 32-year-old man who underwent the right knee ACL reconstruction using a tourniquet following trauma. He developed thigh swelling at the tourniquet site after surgery. Right thigh ultrasound and magnetic resonance imaging (MRI) indicated extensive interstitial edema in all compartments without collection, hematoma, or hemorrhage. The patient was treated with dexamethasone and Lasix for four days. Rehabilitation activities included exercises to improve range of motion (ROM), strength exercises, and a home workout routine. Two weeks after discharge, the swelling decreased by about 80%.
Conclusion: We believe that using a tourniquet during the reconstruction surgery may be responsible for the extensive edema in the limb. However, despite several diagnostic methods, we could not explain the reason for the edema in the limb following surgery.
1. Daniel DM, Lumkong G, Stone ML, Pedowitz RA. Effects of tourniquet use in anterior cruciate ligament reconstruction. Arthroscopy. 1995;11(3):307-11. doi: 10.1016/0749-8063(95)90008-x. [PubMed: 7632307].
2. Arciero RA, Scoville CR, Hayda RA, Snyder RJ. The effect of tourniquet use in anterior cruciate ligament reconstruction. A prospective, randomized study. Am J Sports Med. 1996;24(6): 758-64. doi: 10.1177/036354659602400610. [PubMed: 8947397].
3. Reda W, ElGuindy AMF, Zahry G, Faggal MS, Karim MA. Anterior cruciate ligament reconstruction; is a tourniquet necessary? A randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2948-52. doi: 10.1007/s00167-015-3582-z. [PubMed: 25786826].
4. Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. J Am Acad Orthop Surg. 2001;9(5):345-51. doi: 10.5435/00124635-200109000-00008. [PubMed: 11575914].
5. Kam PC, Kavanagh R, Yoong FF. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia. 2001;56(6):534-45. doi: 10.1046/j.1365-2044.2001.01982.x. [PubMed: 11412159].
6. Nagashima M, Takeshima K, Origuchi N, Sasaki R, Okada Y, Otani T, et al. Not using a tourniquet may reduce the incidence of asymptomatic deep venous thrombosis after ACL reconstruction: An observational study. Orthop J Sports Med. 2021;9(12):23259671211056677. doi: 10.1177/23259671211056677.
[PubMed: 34901291]. [PubMed Central: PMC8655454].
7. Liu D, Graham D, Gillies K, Gillies RM. Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty. Knee Surg Relat Res. 2014;26(4):207-13. doi: 10.5792/ksrr.2014.26.4.207. [PubMed: 25505702]. [PubMed Central: PMC4258487].
8. Wong S, Irwin MG. Procedures under tourniquet. Anaesthesia and Intensive Care Medicine. 2018;19(4):155-8. doi: 10.1016/j.mpaic.2018.01.007.
9. Purcell A, Buckner S, Brindley G, Grimes J. A unique case of extra-articular extravasation of metal into the lower leg resulting from oxidized zirconium wear particles from total knee arthroplasty. Arthroplast Today. 2020;6(4):988-92. doi: 10.1016/j.artd.2020.09.008. [PubMed: 33385039]. [PubMed Central: PMC7772447].
10. Marberry KM, Ginsburg Z. Extra-articular synovial fluid extravasation following operative fixation of an osteochondral fracture of the patella. Orthopedics. 2012;35(8):e1267-e1271. doi: 10.3928/01477447-20120725-32. [PubMed: 22868618].
11. Cavaignac E, Pailhe R, Reina N, Chiron P, Laffosse JM. Massive proximal extravasation as a complication during arthroscopic anterior cruciate ligament reconstruction. Knee Surg Relat Res. 2013;25(2):84-7. doi: 10.5792/ksrr.2013.25.2.84. [PubMed: 23741704]. [PubMed Central: PMC3671121].
12. Pedowitz RA, Gershuni DH, Schmidt AH, Friden J, Rydevik BL, Hargens AR. Muscle injury induced beneath and distal to a pneumatic tourniquet: a quantitative animal study of effects of tourniquet pressure and duration. J Hand Surg Am. 1991;16(4):610-21. doi: 10.1016/0363-5023(91)90183-c. [PubMed: 1652605].
13. Mingo-Robinet J, Castaneda-Cabrero C, Alvarez V, Leon Alonso- Cortes JM, Monge-Casares E. Tourniquet-related iatrogenic femoral nerve palsy after knee surgery: Case report and review of the literature. Case Rep Orthop. 2013;2013:368290. doi: 10.1155/2013/368290. [PubMed: 24371536]. [PubMed Central: PMC3858884].
14. Choudhary A, Kanodia N, Agrawal S, Bhasin VB, Singh A. Tourniquet use in arthroscopic acl reconstruction: A blinded randomized trial. Indian J Orthop. 2021;55(2):384-91. doi: 10.1007/s43465-020-00250-z. [PubMed: 33927817]. [PubMed Central: PMC8046876].
15. Wang J, Xu W, Lv J. Is it better to routinely use tourniquet for knee arthroscopic surgery: A systematic review and meta- analysis. J Knee Surg. 2020;33(9):866-74. doi: 10.1055/s-0039- 1688555. [PubMed: 31064020].
16. Atisuksma ID, Rhatomy S, Dewo P. A tourniquet-less technique using saline epinephrine irrigation system in an arthroscopic ACL reconstruction in patient with history of popliteal artery ligation. Int J Surg Case Rep. 2018;53:157-62. doi: 10.1016/j.ijscr.2018.10.040. [PubMed: 30396128]. [PubMed Central: PMC6216074].
17. Soares ROS, Losada DM, Jordani MC, Evora P, Castro-E-Silva O. Ischemia/reperfusion injury revisited: an overview of the latest pharmacological strategies. Int J Mol Sci. 2019;20(20). doi: 10.3390/ijms20205034. [PubMed: 31614478]. [PubMed Central: PMC6834141].
18. Cearra I, Herrero de la Parte B, Moreno-Franco DI, Garcia- Alonso I. A reproducible method for biochemical, histological and functional assessment of the effects of ischaemia- reperfusion syndrome in the lower limbs. Sci Rep. 2021;11(1):19325. doi: 10.1038/s41598-021-98887-9. [PubMed: 34588582]. [PubMed Central: PMC8481548].
19. Lee YG, Park W, Kim SH, Yun SP, Jeong H, Kim HJ, et al. A case of rhabdomyolysis associated with use of a pneumatic tourniquet during arthroscopic knee surgery. Korean J Intern Med. 2010;25(1):105-9. doi: 10.3904/kjim.2010.25.1.105. [PubMed: 20195412]. [PubMed Central: PMC2829407].
20. Marti CB, Jakob RP. Accumulation of irrigation fluid in the calf as a complication during high tibial osteotomy combined with simultaneous arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 1999;15(8):864-6. doi: 10.1053/ar.1999.v15.0150861. [PubMed: 10564866].
21. Karim A, Baghbani S, Pendar E, Fallah Y, Shafiei SH, Golbakhsh M. Compartment syndrome in tibial plateau fractures: educational corner. J Orthop Spine Trauma. 2022;7(4):146-50. doi: 10.18502/jost.v7i4.8862.
22. Kaper BP, Carr CF, Shirreffs TG. Compartment syndrome after arthroscopic surgery of knee. A report of two cases managed nonoperatively. Am J Sports Med. 1997;25(1):123-5. doi: 10.1177/036354659702500124. [PubMed: 9006706].
23. Gillani S, Cao J, Suzuki T, Hak DJ. The effect of ischemia reperfusion injury on skeletal muscle. Injury. 2012;43(6):670-5. doi : 10.1016/j.injury.2011.03.008. [PubMed: 21481870].
24. Moazen Jamshidi MM, Moharrami A, Nezhad Tabrizi B. Time from injury of anterior cruciate ligament (ACL) to reconstruction has an important role in saving meniscus. J Orthop Spine Trauma. 2022;8(3):95-6. doi: 10.18502/jost.v8i3.9909.
25. Gonzalez D. Crush syndrome. Crit Care Med. 2005; 33(1 Suppl):S34-S41. doi: 10.1097/01.ccm.0000151065.13564.6f. [PubMed: 15640677].
26. Coupens SD, Yates CK. The effect of tourniquet use and hemovac drainage on postoperative hemarthrosis. Arthroscopy. 1991;7(3):278-82. doi: 10.1016/0749-8063(91)90127-j. [PubMed: 1750936].
27. Bogdan Y, Helfet DL. Use of tourniquets in limb trauma surgery. Orthop Clin North Am. 2018;49(2):157-65. doi: 10.1016/j.ocl.2017.11.004. [PubMed: 29499817].
2. Arciero RA, Scoville CR, Hayda RA, Snyder RJ. The effect of tourniquet use in anterior cruciate ligament reconstruction. A prospective, randomized study. Am J Sports Med. 1996;24(6): 758-64. doi: 10.1177/036354659602400610. [PubMed: 8947397].
3. Reda W, ElGuindy AMF, Zahry G, Faggal MS, Karim MA. Anterior cruciate ligament reconstruction; is a tourniquet necessary? A randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2948-52. doi: 10.1007/s00167-015-3582-z. [PubMed: 25786826].
4. Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. J Am Acad Orthop Surg. 2001;9(5):345-51. doi: 10.5435/00124635-200109000-00008. [PubMed: 11575914].
5. Kam PC, Kavanagh R, Yoong FF. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia. 2001;56(6):534-45. doi: 10.1046/j.1365-2044.2001.01982.x. [PubMed: 11412159].
6. Nagashima M, Takeshima K, Origuchi N, Sasaki R, Okada Y, Otani T, et al. Not using a tourniquet may reduce the incidence of asymptomatic deep venous thrombosis after ACL reconstruction: An observational study. Orthop J Sports Med. 2021;9(12):23259671211056677. doi: 10.1177/23259671211056677.
[PubMed: 34901291]. [PubMed Central: PMC8655454].
7. Liu D, Graham D, Gillies K, Gillies RM. Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty. Knee Surg Relat Res. 2014;26(4):207-13. doi: 10.5792/ksrr.2014.26.4.207. [PubMed: 25505702]. [PubMed Central: PMC4258487].
8. Wong S, Irwin MG. Procedures under tourniquet. Anaesthesia and Intensive Care Medicine. 2018;19(4):155-8. doi: 10.1016/j.mpaic.2018.01.007.
9. Purcell A, Buckner S, Brindley G, Grimes J. A unique case of extra-articular extravasation of metal into the lower leg resulting from oxidized zirconium wear particles from total knee arthroplasty. Arthroplast Today. 2020;6(4):988-92. doi: 10.1016/j.artd.2020.09.008. [PubMed: 33385039]. [PubMed Central: PMC7772447].
10. Marberry KM, Ginsburg Z. Extra-articular synovial fluid extravasation following operative fixation of an osteochondral fracture of the patella. Orthopedics. 2012;35(8):e1267-e1271. doi: 10.3928/01477447-20120725-32. [PubMed: 22868618].
11. Cavaignac E, Pailhe R, Reina N, Chiron P, Laffosse JM. Massive proximal extravasation as a complication during arthroscopic anterior cruciate ligament reconstruction. Knee Surg Relat Res. 2013;25(2):84-7. doi: 10.5792/ksrr.2013.25.2.84. [PubMed: 23741704]. [PubMed Central: PMC3671121].
12. Pedowitz RA, Gershuni DH, Schmidt AH, Friden J, Rydevik BL, Hargens AR. Muscle injury induced beneath and distal to a pneumatic tourniquet: a quantitative animal study of effects of tourniquet pressure and duration. J Hand Surg Am. 1991;16(4):610-21. doi: 10.1016/0363-5023(91)90183-c. [PubMed: 1652605].
13. Mingo-Robinet J, Castaneda-Cabrero C, Alvarez V, Leon Alonso- Cortes JM, Monge-Casares E. Tourniquet-related iatrogenic femoral nerve palsy after knee surgery: Case report and review of the literature. Case Rep Orthop. 2013;2013:368290. doi: 10.1155/2013/368290. [PubMed: 24371536]. [PubMed Central: PMC3858884].
14. Choudhary A, Kanodia N, Agrawal S, Bhasin VB, Singh A. Tourniquet use in arthroscopic acl reconstruction: A blinded randomized trial. Indian J Orthop. 2021;55(2):384-91. doi: 10.1007/s43465-020-00250-z. [PubMed: 33927817]. [PubMed Central: PMC8046876].
15. Wang J, Xu W, Lv J. Is it better to routinely use tourniquet for knee arthroscopic surgery: A systematic review and meta- analysis. J Knee Surg. 2020;33(9):866-74. doi: 10.1055/s-0039- 1688555. [PubMed: 31064020].
16. Atisuksma ID, Rhatomy S, Dewo P. A tourniquet-less technique using saline epinephrine irrigation system in an arthroscopic ACL reconstruction in patient with history of popliteal artery ligation. Int J Surg Case Rep. 2018;53:157-62. doi: 10.1016/j.ijscr.2018.10.040. [PubMed: 30396128]. [PubMed Central: PMC6216074].
17. Soares ROS, Losada DM, Jordani MC, Evora P, Castro-E-Silva O. Ischemia/reperfusion injury revisited: an overview of the latest pharmacological strategies. Int J Mol Sci. 2019;20(20). doi: 10.3390/ijms20205034. [PubMed: 31614478]. [PubMed Central: PMC6834141].
18. Cearra I, Herrero de la Parte B, Moreno-Franco DI, Garcia- Alonso I. A reproducible method for biochemical, histological and functional assessment of the effects of ischaemia- reperfusion syndrome in the lower limbs. Sci Rep. 2021;11(1):19325. doi: 10.1038/s41598-021-98887-9. [PubMed: 34588582]. [PubMed Central: PMC8481548].
19. Lee YG, Park W, Kim SH, Yun SP, Jeong H, Kim HJ, et al. A case of rhabdomyolysis associated with use of a pneumatic tourniquet during arthroscopic knee surgery. Korean J Intern Med. 2010;25(1):105-9. doi: 10.3904/kjim.2010.25.1.105. [PubMed: 20195412]. [PubMed Central: PMC2829407].
20. Marti CB, Jakob RP. Accumulation of irrigation fluid in the calf as a complication during high tibial osteotomy combined with simultaneous arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 1999;15(8):864-6. doi: 10.1053/ar.1999.v15.0150861. [PubMed: 10564866].
21. Karim A, Baghbani S, Pendar E, Fallah Y, Shafiei SH, Golbakhsh M. Compartment syndrome in tibial plateau fractures: educational corner. J Orthop Spine Trauma. 2022;7(4):146-50. doi: 10.18502/jost.v7i4.8862.
22. Kaper BP, Carr CF, Shirreffs TG. Compartment syndrome after arthroscopic surgery of knee. A report of two cases managed nonoperatively. Am J Sports Med. 1997;25(1):123-5. doi: 10.1177/036354659702500124. [PubMed: 9006706].
23. Gillani S, Cao J, Suzuki T, Hak DJ. The effect of ischemia reperfusion injury on skeletal muscle. Injury. 2012;43(6):670-5. doi : 10.1016/j.injury.2011.03.008. [PubMed: 21481870].
24. Moazen Jamshidi MM, Moharrami A, Nezhad Tabrizi B. Time from injury of anterior cruciate ligament (ACL) to reconstruction has an important role in saving meniscus. J Orthop Spine Trauma. 2022;8(3):95-6. doi: 10.18502/jost.v8i3.9909.
25. Gonzalez D. Crush syndrome. Crit Care Med. 2005; 33(1 Suppl):S34-S41. doi: 10.1097/01.ccm.0000151065.13564.6f. [PubMed: 15640677].
26. Coupens SD, Yates CK. The effect of tourniquet use and hemovac drainage on postoperative hemarthrosis. Arthroscopy. 1991;7(3):278-82. doi: 10.1016/0749-8063(91)90127-j. [PubMed: 1750936].
27. Bogdan Y, Helfet DL. Use of tourniquets in limb trauma surgery. Orthop Clin North Am. 2018;49(2):157-65. doi: 10.1016/j.ocl.2017.11.004. [PubMed: 29499817].
| Files | ||
| Issue | Vol 9 No 3 (2023) | |
| Section | Case Report | |
| DOI | https://doi.org/10.18502/jost.v9i3.13036 | |
| Keywords | ||
| Anterior Cruciate Ligament Case Report Anterior Cruciate Ligament Reconstruction Edema | ||
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How to Cite
1.
Aslani H, Hosseini SM, Kouhestani E, Bisadi A. Abnormal Thigh Swelling after Anterior Cruciate Ligament Reconstruction with Tourniquet. J Orthop Spine Trauma. 2024;9(3):141-5.
