Startseite The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery – a retrospective cohort study
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The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery – a retrospective cohort study

  • Pasi M. Lehto EMAIL logo , Tero Kortekangas , Merja Vakkala , Pasi Ohtonen , Emma-Sofia Nyman , Kaisu Karvonen , Janne Liisanantti und Timo I. Kaakinen
Veröffentlicht/Copyright: 16. November 2023
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Scandinavian Journal of Pain
Aus der Zeitschrift Scandinavian Journal of Pain Band 24 Heft 1

Abstract

Objectives

A pneumatic tourniquet is often used during ankle fracture surgery to reduce bleeding and enhance the visibility of the surgical field. Tourniquet use causes both mechanical and ischemic pain. The main purpose of this study was to evaluate the effect of tourniquet time on postoperative opioid consumption after ankle fracture surgery.

Methods

We retrospectively reviewed the files of 586 adult patients with surgically treated ankle fractures during the years 2014–2016. We evaluated post hoc the effect of tourniquet time on postoperative opioid consumption during the first 24 h after surgery. The patients were divided into quartiles by the tourniquet time (4–43 min; 44–58 min; 59–82 min; and ≥83 min). Multivariable linear regression analysis was used to evaluate the results.

Results

Tourniquets were used in 486 patients. The use of a tourniquet was associated with an increase in the total postoperative opioid consumption by 5.1 mg (95 % CI 1.6–8.5; p=0.004) during the first 24 postoperative hours. The tourniquet time over 83 min was associated with an increase in the mean postoperative oxycodone consumption by 5.4 mg (95 % CI 1.2 to 9.7; p=0.012) compared to patients with tourniquet time of 4–43 min

Conclusions

The use of a tourniquet and prolonged tourniquet time were associated with higher postoperative opioid consumption during the 24 h postoperative follow-up after surgical ankle fracture fixation.

The need for ethical approval and informed consent was waived by the Institutional Review Board of Northern Ostrobothnia Health District because of the retrospective nature of the study.

Keywords: ankle fracture; tourniquet; postoperative pain; opioid consumption

Introduction

A pneumatic tourniquet is often used in extremity surgery to reduce bleeding and to improve visualisation of the surgical field. Its use is considered safe in foot and ankle surgical procedures [1]. However, the use of a tourniquet carries a risk of increased postoperative pain and other complications, such as skin, muscle, nerves and blood vessel damage due to mechanical pressure [2], [3], [4]. A tourniquet can also cause peripheral and compression-related ischemia and cell damage [5]. A tourniquet constriction is noticed to exacerbate the painful stimulus around the site of induced secondary hyperalgesia [6]. In addition, more complications are associated with long tourniquet times than with short tourniquet times [7, 8]. Thus, the use of a tourniquet may increase postoperative pain sensation.

The effects of thigh tourniquet use on postoperative pain and opioid consumption have been debated in previous studies that used heterogeneous study designs and achieved conflicting results. Most of these studies were conducted on patients undergoing elective total knee arthroplasty [9], [10], [11], [12], thereby raising the question of whether the results from studies performed in an elective setting can be compared with surgical procedures after traumatic injury, such as ankle fracture. Pain from an ankle fracture is caused by immediate mechanic nociception due to the bone fracture, combined with pain caused by tissue swelling and inflammation. A patient with an ankle fracture experiences significant pain both pre- and postoperatively [13], whereas patients scheduled for elective surgery do not suffer from pain caused by acute tissue trauma occurring prior to surgery.

Only a few studies have evaluated the use of a tourniquet on pain sensation or opioid consumption following ankle fracture surgery [14], [15], [16], and good-quality randomised controlled trials (RCT) are lacking [17]. One RCT comparing postoperative pain in patients with open reduction and internal fixation (ORIF) of an ankle fracture operated with or without tourniquet use found that patients with a tourniquet reported significantly higher pain scores during the first 24 to 48 postoperative hours [14]. Another RCT evaluating tourniquet use in patients with ORIF of an ankle fracture noted that patients operated without a tourniquet described less postoperative pain on the fifth postoperative day and in the sixth postoperative week [15]. These two previous RCTs did not report the mean tourniquet times or opioid consumption. To our knowledge, only one previous retrospective study evaluated the effect of tourniquet insufflation time on postoperative opioid consumption during the first 24 h postoperatively in 358 patients with surgical ankle fracture fixation. An increase in opioid consumption in relation to a longer duration of tourniquet insufflation was noted [16].

The main purpose of the present study was to evaluate whether tourniquet insufflation time influences postoperative opioid consumption in patients with surgical ankle fracture fixation during the first 24 postoperative hours. Our hypothesis was that, because prolonged tourniquet insufflation time can have harmful effects, the use of a tourniquet may cause more postoperative pain, which might be accompanied by a rise in postoperative opioid consumption.

Methods

The present retrospective cohort study was a post hoc analysis of the data used in our previous study comparing postoperative opioid consumption between spinal anaesthesia (SA) and general anaesthesia (GA) in patients with surgical ankle fracture fixation [18]. The study was approved by the hospital administration. According to local policy concerning retrospective database studies, no approval was needed from the local ethics committee.

We reviewed the files of all patients who had undergone surgical ankle fracture fixation at Oulu University Hospital between January 2014 and December 2016. The data were collected from the digital medical records, surgery booking system and anaesthesia charts. We included all adult patients with an isolated surgically treated ankle fracture. The exclusion criteria were fractures of both ankles, multiple fractures and/or major trauma, other surgical procedure performed at the same time, re-operation of the ankle and patients with inadequate recording of tourniquet time.

Anaesthesia management and pain treatment

Due to the retrospective design of the study, the anaesthesia method was not pre-planned. The anaesthesia was given according to the hospital’s anaesthesia guidelines for lower limb surgical procedures, which recommend GA or SA for ankle fracture patients. Fentanyl boluses were used for pain management during GA. No intrathecal or epidural analgesia or peripheral nerve blocks (PNB) were used during GA. Bupivacaine was used for SA and intrathecal fentanyl was used to enhance the analgesic effect.

In the PACU, pain was treated individually, mainly with oxycodone, acetaminophen and ketoprofen. PNBs were used only if conservative pain management was insufficient. Opioids were given (intravenously and orally) whenever needed so that the Numeric Rating Scale (NRS) score was ≤4 (scale 0–10) and the pain was under control. Acetaminophen was ordered for almost every patient. NSAIDs (oral ibuprofen or intravenous ketoprofen) were not ordered routinely for every patient but were given to alleviate more severe pain. In the ward, acetaminophen was given routinely around the clock if no contraindications were noted. Short-acting oxycodone was administered perorally when needed. Long-acting oxycodone was combined with the medication if the pain was moderate to severe and/or persistent in the ward. Intramuscular opioids were not administered in this patient cohort.

The doses of any opioid administered postoperatively were converted into an intravenous equivalent dose of oxycodone in milligrams. A conversion ratio of 1:2 was applied between intravenous and oral oxycodone based on the product characteristics of intravenous oxycodone [19]. Also, this ratio can be considered safer in clinical practice when compared to the observed variations in peroral bioavailability of oxycodone in previous studies [20, 21]. The amount of oral codeine in milligrams was converted into intravenous equianalgesic oxycodone in milligrams in a relation of 20:1. Intravenous fentanyl was converted into intravenous equivalent oxycodone in milligrams in a ratio of 1:75 [21, 22]. Opioid consumption during the surgical procedure, including intrathecal administration of fentanyl, was recorded, but was not included in the analysis of postoperative opioid consumption. The anaesthesia management and pain treatment have been described in detail in our previous study [18].

Primary outcome

The primary outcome was the total opioid consumption in milligrams within 24 h postoperatively in relation to tourniquet time. The duration of tourniquet insufflation in minutes was collected from the digital anaesthesia charts. A thigh tourniquet was used during surgical ankle fracture fixation. During the insufflation, a standard cuff pressure of 250 mmHg was used. The study population was divided into quartiles in relation to tourniquet time (Q1 4–43 min; Q2 44–58 min; Q3 59–82 min; Q4 ≥83 min).

Statistical analysis

Statistical analyses were performed using SPSS for Windows software (IBM SPSS Statistics for Windows, version 25.0; IBM Corp., Armonk, New York). Categorical data are expressed as numbers (n) and percentages (%). Continuous variables are presented as medians with 25th and 75th percentiles. Categorical data were analysed using Pearson’s chi-square and continuous variables were analysed using the non-parametric Mann–Whitney U-test.

Post hoc power analysis and sample size calculation was made with alfa=0.05, mean difference of 5 mg, SD 16.4 and superiority margin of 2.5, resulting in a post hoc power of 100 % in our study, and with estimated 90 % power a sufficient sample size would be 352 patients.

Multivariable adjusted linear regression models were calculated to assess the impact of tourniquet use and the impact of tourniquet time on total opioid consumption. The constant in the linear regression modes was the mean opioid consumption for patients who had a tourniquet time within 4–43 min, an operation in SA and an unimalleolar fracture.

Multivariable adjusted logistic regression models were calculated to assess the impact of tourniquet time on the administration of postoperative NSAID and/or acetaminophen. Regression coefficients are presented as the result of the linear regression model, and odds ratios (OR’s) are presented for the logistic regression model. Regression models were adjusted by the severity of trauma and anaesthesia method (SA and GA), and 95 % confidence intervals are presented with regression coefficients and ORs. Two-sided p-values <0.05 were considered as significant. DAGitty software [23] was used to identify the minimum set of variables requiring adjustment to estimate the effect of tourniquet time on opioid consumption (Figure S2, Supplementary Material).

A matched pairs dataset was created to assess opioid consumption between patients treated with and without tourniquet. The pairs were matched by operation time (±10 min), anaesthesia method (general anaesthesia vs. spinal anaesthesia), age (±10 years) and sex (male vs. female). A paired samples t-test was used to compare the impact of tourniquet use. The mean difference with 95 % confidence interval is presented as the result for the paired samples t-test. The p-values should be treated with caution since several comparisons were made, and p-value correction coefficient methods has not been used.

Results

A total of 586 patients were included in the analysis. Of those, 486 had a tourniquet applied during ankle fracture fixation. Of those, 141 (29 %) were operated in SA, and the same distribution between SA and GA remained regardless of fracture type or operation technique. Patients with a tourniquet were divided into four groups by the tourniquet time, and each group had nearly equal numbers of patients (Q1 4–43 min, n=132; Q2 44–58 min, n=112; Q3 59–82 min, n=123; Q4>83 min, n=119). The median tourniquet time was 58 min (25th to 75th percentiles; 43–82). Patients who did not have a tourniquet (n=100) were older, had a higher ASA (American Society of Anesthesiologists) classification score and were more often operated in SA (38 vs. 29 %) compared to patients with a tourniquet. The characteristics of patients operated with and without a tourniquet are shown in Table 1.

Table 1:

Patient characteristics and results.

Parameters All patients n=586 Tourniquet n=486 (82.9 %) No tourniquet n=100 (17.1 %) p-Value
Gender male 49.3 % (289) 48.1 % (234) 55.0 % (55) 0.23
Age 53 [36–64] 51 [35–52] 60 [45–74] <0.001
BMI 27.9 [24.9–31.2] 28.0 [24.9–31.3] 27.7 [24.8–30.1] 0.49
ASA 2 [1–2] 2 [1–2] 2 [1–3] 0.012
1–2 77.4 % (452) 79.8 % (387) 65.7 % (65)
3–4 22.6 % (132) 20.2 % (98) 34.3 % (34)
Smoking 36.3 % (213) 38.2 % (185) 28 % (28) 0.08
Diabetes 12.8 % (75) 11.6 % (56) 19 % (19) 0.048
Fracture type % (n) 0.023
 –Unimalleolar 29.5 % (173) 31.7 % (154) 19.0 % (19)
 –Bimalleolar 27.8 % (163) 27.8 % (135) 28 % (28)
 –Luxation and/or trimalleolar 42.7 % (250) 40.5 % (197) 53.0 % (53)
Operation technique <0.001
 –Unimalleolar fixation 46.3 % (271) 47.5 % (231) 40.0 % (40)
 –Bimalleolar and/or trimalleolar fixation 49.3 % (289) 50.8 % (247) 42.0 % (42)
 –Fibular rod only 4.4 % (26) 1.6 % (8) 18 % (18)
Operation time in minutes 56 [38–78] 58 [39–80] 49 [33–68] 0.003
Length of PACU stays in minutes 146 [112–193] 145 [112–190] 149 [116–200] 0.41
NRS during the PACU stay 4 [2–7] 5 [2–7] 4 [2–6] 0.048
NRS ≥5 during the PACU stay 37.7 % (221) 39.7 % (193) 28 % (28) 0.12
Spinal anaesthesia 30.5 % (179) 29.0 % (141) 38.0 % (38) 0.095

  1. The values are shown as medians and 25th–75th percentiles [], or percentiles (%) and number of patients (n). (BMI, body mass index; ASA, American Society of Anesthesiologists classification score; NRS, numeric rating scale; PACU, post-anaesthesia care unit).

The total opioid consumption during the first 24 postoperative hours was 25 mg (16–38.5) of equianalgesic intravenous oxycodone in the whole study population and 26 mg (17–39) in the tourniquet group vs. 20.5 mg (12.5–40) in the no-tourniquet group (p<0.001). The multivariable adjusted analysis suggested that tourniquet use was associated with an increase in total postoperative opioid consumption of 5.1 mg during the first 24 postoperative hours (95 % CI 1.6–8.5; p=0.004).

The primary outcome is shown in Table 2. The result suggested that the increase in total postoperative opioid consumption was associated with the duration of tourniquet insufflation time. The multivariable-adjusted analysis, statistically correcting for all confounders considered (Figure S2, Supplementary Material), shows that a tourniquet time over 83 min was associated with a 5.4 mg increase in total postoperative opioid consumption (95 % CI 1.2–9.7; p=0.012). A similar increase in total postoperative opioid consumption was noticed when patients operated with and without a tourniquet were compared (Table 3). The mean total opioid consumption was associated with a 5.8 mg (95 % CI −1.7 to 13.2; p=0.12) increase in the patients operated with a tourniquet and with the surgical operation time over 68 min compared to the patients treated without a tourniquet. The characteristics of the patients with a tourniquet time over 83 min were: tourniquet time median 96 min [89–109]; ASA 1 [1–2]; age median 54 [36–64]; GA 70.6 % (n=84); female 55.5 % (N=66), diabetes 13.4 % (n=16); BMI 28 [25–31], smoking 37.8 % (n=45). An increase in the surgical procedure time was associated with the severity of trauma. The tourniquet insufflation time was comparable with the surgical procedure time (Figure 1), and the total postoperative opioid consumption was not associated with the severity of trauma in the patients operated with a tourniquet (Table S4, Supplementary Material).

Table 2:

The total postoperative opioid consumption associated with tourniquet insufflation time in each quartile and the effect of tourniquet time on the total postoperative opioid consumption in 24 h of follow-up compared to the first quartile (4–43 min, constant). The results are adjusted by the severity of trauma and the type of anaesthesia.

Mean (std. deviation) [median] Effect on opioid consumption 95 % CI p-Value
Tourniquet time 4–43 min (n=132) 26.9 mg (15.1) [24.75] 0 mg/reference
Tourniquet time 44–58 min (n=112) 28.9 mg (15.8) [25.25] 2.3 mg −1.7–6.3 0.26
Tourniquet time 59–82 min (n=123) 30.9 mg (17.8) [28] 3.7 mg −0.4–7.7 0.075
Tourniquet time >83 min (n=119) 32.1 mg (16.4) [30] 5.4 mg 1.2–9.7 0.012

  1. Constant=19.7 mg. The constant is the mean opioid consumption for patients with tourniquet insufflation time within 4–43 min, operated in SA and who had an unimalleolar ankle fracture. Pct, percentiles. CI, confidence interval. p-value for the effect size compared to a tourniquet time of 4–43 min.

Table 3:

Total opioid consumption associated with surgical procedure time and the mean difference with 95 % confidence interval between patients operated with and without tourniquet: matched pairsa data. The opioid consumption is the total opioid consumption during the 24 h of follow-up.

Surgical procedure time in minutes No tourniquet (n=90) Tourniquet (n=90)
Mean Mean Mean difference (95 % CI) p-Value
0–33 min (n=23+23) 28.1 mg 26.0 mg −2.1 mg (6.9 to −11.1) 0.64
34–48 min (n=23+23) 23.5 mg 23.2 mg −0.3 mg (9.4 to −10.1) 0.94
49–67 min (n=22+22) 20.9 mg 27.8 mg 6.9 mg (14.7 to −0.9) 0.08
>68 min (n=22+22) 24.7 mg 30.4 mg 5.8 mg (13.2 to −1.7) 0.12

  1. n=number of patients. Two-sided p-value for the paired samples t-test. CI, confidence interval. aThe pairs were matched by operation time (±10 min), anaesthesia method (general anaesthesia vs. spinal anaesthesia), age (±10 years) and sex (male vs. female).

Figure 1: The tourniquet insufflation time compared to the operation time.
Figure 1:

The tourniquet insufflation time compared to the operation time.

NSAIDs were given to 38 % (n=221) and acetaminophen to 71 % (n=414) of all patients during the PACU stay. Neither the use of a tourniquet nor the tourniquet time increased the rate of NSAID [OR 0.87 (95 % CI 0.49–1.56); p=0.64] or acetaminophen [OR 1.56 (95 % CI 0.86–2.84); p=0.15] administration in the PACU. The use of a tourniquet did not increase the need for postoperative PNBs (no-tourniquet 4.0 % vs. tourniquet 2.7 %), and only 13/486 patients were administered a postoperative nerve blockade.

Discussion

The findings of the present retrospective cohort study in patients with ORIF of an ankle fracture suggest that the prolonged use of a tourniquet is associated with a higher postoperative opioid consumption during the first 24 postoperative hours. To our knowledge, this is the largest cohort to be evaluated for the effect of tourniquet time on opioid consumption in patients with surgically treated ankle fracture.

In the present study, the increase in opioid consumption in relation to tourniquet insufflation time 24 h postoperative was higher compared to previous study which reported an average rise of 0.43 mg of intravenous morphine equivalent per every 10 min of insufflated tourniquet use in postoperative opioid consumption 24 h after surgery [16]. In that study, a linear rise in opioid consumption in relation to tourniquet insufflation time was assumed; therefore, a tourniquet time over 125 min would have been needed to reach the results of the present study. However, the opioid equivalents between studies were not directly proportional, nor was the postoperative pain management. In our study, the cohort was divided into quartiles by tourniquet insufflation time, because a linear rise between tourniquet time and opioid consumption was not assumed.

An argument can be made that the results of the present study may simply reflect the pain caused by tissue damage due to the severity of the trauma and surgical procedures. This hypothesis was ultimately rejected following a comparison of the postoperative opioid consumption between the patients operated with and without tourniquet and with similar surgical procedure times. The difference in opioid consumption between the groups was associated only with the longer tourniquet insufflation time. The total opioid consumption during the first 24 h postoperatively in the patients with a tourniquet and a procedure time over 68 min was associated with an almost 20 percent rise in opioid consumption. Although the number of patients in this comparison was too small to draw any definitive conclusions, the results support the hypothesis that the tourniquet itself and a longer tourniquet insufflation time may be associated with more postoperative pain.

The minimum clinically important difference in the visual analogue scale and NRS is often used to evaluate adequate pain relief [24]. However, no consensus is evident in the literature regarding a clinically significant difference in opioid consumption because it is influenced by a variety of factors. Some studies have shown that patients with acute postoperative pain can require approximately five mg of intravenous morphine equivalent to obtain the desired pain relief and NRS reduction [25, 26]. Also, 10 mg of intravenous morphine have been suggested as clinically meaningful difference for 24 h opioid consumption [27]. An equivalence ratio of 1:1 between intravenous oxycodone and morphine is often used in the literature but consumption of intravenous oxycodone has also noticed to be less compared to intravenous morphine with consumption ratio close to 2:3 between intravenous oxycodone and intravenous morphine [28]. In reference to these studies, a cautious interpretation can be made that a 5.4 mg increase in intravenous equianalgesic oxycodone consumption during the first 24 postoperative hours in patients with a tourniquet time over 83 min could be a clinically significant finding. Furthermore, had we chosen an oral to intravenous oxycodone coefficient derived from the observed variations in peroral bioavailability across different studies [20, 21], such as a coefficient of 0.6 or 0.7 rather than 0.5, it would have resulted in a notable increase in the equivalent intravenous oxycodone consumption, especially in patients with the longest tourniquet times. This would reinforce our suggestion about a clinically significant finding.

A general recommendation for the longest allowable continuous tourniquet cuff insufflation time is 2–2½ h [29, 30]. Standard thigh tourniquet pressures vary, and some centres use levels of 300–350 mmHg [1, 29]. The recommended pressure for lower extremity tourniquets is less than 300 mmHg or the use of the limb occlusion pressure plus 50–100 mmHg, depending on the underlying systolic blood pressure [29], [30], [31], [32]. The tourniquet pressures used in previous ankle studies were 250 mmHg [14] and 350 mmHg [15]. In our study, a standard cuff pressure of 250 mmHg was used. Prolonged tourniquet insufflation and higher tourniquet cuff pressures can lead to more tissue damage, overall postoperative complications, and pain [2, 3]. An increased rate of complications has been noted in patients with total knee arthroplasty and tourniquet times over 100 min, but the pain sensation and opioid consumption were not recorded [8]. A study on patients with diabetes and Charcot foot who underwent ankle and foot reconstruction surgery documented more complications with longer tourniquet times (119±9 min) than with shorter tourniquet times (74±56 min) [7].

Clinical impact

The advantages of a tourniquet include providing a bloodless field and better visibility for surgical area, and is thought to reduce intraoperative blood loss, and shortening the operation time. However, tourniquet use is associated with thrombotic events, hematomas, infections, nerve palsy, skin bruising and blisters, and longer hospital stays and increase in pain sensation [4]. Although our study was not designed to evaluate overall postoperative complications, the clinical impact of a prolonged tourniquet insufflation time suggests a higher postoperative opioid consumption, which can be interpreted as a surrogate for a higher postoperative pain sensation. The tourniquet may exacerbate pain sensations at the site of inflammation [6], such as the inflammation caused by ankle fracture. Moreover, prolonged tourniquet insufflation times and higher cuff pressures may cause increased pain due to tissue damage by mechanical compression and ischaemia, and prolonged tourniquet time is associated with post-tourniquet syndrome [2], [3], [4], [5]; therefore, attention should be paid to both tourniquet cuff pressures and insufflation times. Additionally, tourniquet insufflation and deflation may cause significant variations in cardiac output and systemic vascular resistance. After deflation, elevated blood lactate levels and oxygen consumption are associated with tourniquet-induced ischemia time [33]. These cardiovascular changes can be clinically significant for patients with related diseases and in the elderly.

Limitations and strengths

This study has some limitations. It was not a randomised prospective study, and no controlled protocols were used. Although a standard tourniquet cuff pressure is used in our hospital for ankle fracture patients, the tourniquet time was not predetermined, and the decision to use a tourniquet was left to the attending surgeon. Patients treated without tourniquet had more often SA, were older and had higher ASA score, all factors which could have confounded effect on opioid consumption and administration. NSAIDs have a clear and acknowledged analgesic and opioid sparing effect. In the present study the use of NSAIDs was heterogenous. NSAIDs were administered to patients with more severe pain and more often to patients treated with GA. In addition, postoperative opioid consumption can be confounded by several unmeasured factors, such as pain catastrophising, anxiety and preoperative opioid consumption. The postoperative pain treatment was also not standardised and was heterogeneous, especially on the ward during the first 24 postoperative hours. However, this heterogeneity most likely influenced the cohort somewhat randomly. Pain scores were not routinely documented in the ward, which made it more difficult to evaluate the indications for on-demand opioid administration. However, postoperative opioids are prescribed and administered to patients with more severe acute pain. Therefore, opioids can be used as a surrogate for patient-reported pain assessment. A more severe type of fracture, together with the operation technique, could also have influenced postoperative pain [16], although a previous study in patients with ankle fracture indicated that the type of fracture or procedure technique did not predict more severe pain [34].

Several confounding factors could affect the association between tourniquet insufflation time and opioid consumption. For this reason, variables such as diabetes, smoking, alcohol consumption, type of fracture, pain perception, age and gender were evaluated with the DAGitty software [23] to estimate the effect of tourniquet time on opioid consumption. The type of ankle fracture and the anaesthesia method were used to adjust the regression model, as these were predicted to be factors with the greatest influence. The type of ankle fracture was correlated with the operation technique and the duration of surgery, which in turn was related to the tourniquet time. The tourniquet time was affected by the abovementioned factors in the present study. The method of anaesthesia had been determined as the most influencing confounder for total opioid consumption in our previous study, which is why it was used to adjust the regression model [18]. SA lowers total postoperative opioid consumption significantly because of the ongoing anaesthetic effect during PACU stays, but also because of the use of intrathecal fentanyl. The effect of intrathecal fentanyl on postoperative opioid consumption was indirectly considered when the regression model was adjusted with the anaesthesia method in the present study. However, even if a multivariable model was created with adjustments for known confounders, the residual confounding by unmeasured confounders could still influence the results. The characteristics of the patients with the longest tourniquet times were comparable with the rest of the patients with tourniquet. Habitual opioid users or patients with chronic pain were included in the analysis and were not registered separately, since they were few and did not demonstrate any real difference in their postoperative opioid use compared to the other patients. This could have been a source of significant bias had there been many habitual opioid users. Approximately every tenth patient treated with tourniquet had diabetes, most of them type II diabetes mellitus. Diabetes could cause neuropathy and neuropathic pain which could have impact on post operative pain and lead to higher opioid consumption. Severe neuropathy and neuropathic pain are often considered a contraindications for tourniquet use. In the present study, neuropathy or neuropathic pain was not recognised as a confounding factor for postoperative opioid consumption.

A strength of the present study was its relatively large patient cohort with a broad scale of tourniquet insufflation times and a sufficient number of patients in each quartile for statistical analysis [35]. Also, post hoc power analysis and sample size calculation support that our cohort size was adequate.

The study population consisted of a normal clinical patient population. Also, as a retrospective study, it does not have presumptions about study outcomes, such as how much opioid should be given or how the study patients should be treated postoperatively. Therefore, the risk of observer bias is low [36]. Moreover, the cohort consisted of patients treated only with either GA or SA, and their pain was treated conservatively, mainly with opioids. PNBs were used only on a few occasions, and more frequent use could have caused significant bias when evaluating the effect of tourniquet-related postoperative pain.

Conclusions

The results of the present study suggest that the use of a tourniquet and longer tourniquet insufflation times are associated with increased postoperative opioid consumption. This finding was most pronounced in patients with tourniquet times longer than 83 min. The association between tourniquet time and opioid use may be caused by confounding factors. A randomised controlled trial is required to explore any causal relationships.

Corresponding author: Pasi M. Lehto, MD, PhD student, Department of Anesthesiology and Intensive Care, Oulu University Hospital, P.O. Box 21, 90029 OYS, Kajaanintie 50, 90220, Oulu, Finland, Phone: +358 8 315 5578, +358 41 434 1480, E-mail:

  1. Research ethics: Procedures were followed in accordance with the ethical standards of the responsible institutional committee on human experimentation and with the Helsinki Declaration of 1975.

  2. Informed consent: The study was approved by the hospital administration. The need for ethical approval and informed consent was waived by the Institutional Review Board of Northern Ostrobothnia Health District, because of the retrospective nature of the study.

  3. Author contributions: All authors have contributed to the conception and design of the work, and to the interpretation and analysis of the data, and drafting or revising it. All authors have approved the final version to be published.

  4. Competing interests: The authors declare that they have no competing interests.

  5. Research funding: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  6. Data availability: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/sjpain-2023-0051).

Received: 2023-04-22
Accepted: 2023-10-30
Published Online: 2023-11-16

© 2023 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

Artikel in diesem Heft

  1. Editorial Comment
  2. From pain to relief: Exploring the consistency of exercise-induced hypoalgesia
  3. Christmas greetings 2024 from the Editor-in-Chief
  4. Original Articles
  5. The Scandinavian Society for the Study of Pain 2022 Postgraduate Course and Annual Scientific (SASP 2022) Meeting 12th to 14th October at Rigshospitalet, Copenhagen
  6. Comparison of ultrasound-guided continuous erector spinae plane block versus continuous paravertebral block for postoperative analgesia in patients undergoing proximal femur surgeries
  7. Clinical Pain Researches
  8. The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery – a retrospective cohort study
  9. Changes in pain, daily occupations, lifestyle, and health following an occupational therapy lifestyle intervention: a secondary analysis from a feasibility study in patients with chronic high-impact pain
  10. Tonic cuff pressure pain sensitivity in chronic pain patients and its relation to self-reported physical activity
  11. Reliability, construct validity, and factorial structure of a Swedish version of the medical outcomes study social support survey (MOS-SSS) in patients with chronic pain
  12. Hurdles and potentials when implementing internet-delivered Acceptance and commitment therapy for chronic pain: a retrospective appraisal using the Quality implementation framework
  13. Exploring the outcome “days with bothersome pain” and its association with pain intensity, disability, and quality of life
  14. Fatigue and cognitive fatigability in patients with chronic pain
  15. The Swedish version of the pain self-efficacy questionnaire short form, PSEQ-2SV: Cultural adaptation and psychometric evaluation in a population of patients with musculoskeletal disorders
  16. Pain coping and catastrophizing in youth with and without cerebral palsy
  17. Neuropathic pain after surgery – A clinical validation study and assessment of accuracy measures of the 5-item NeuPPS scale
  18. Translation, contextual adaptation, and reliability of the Danish Concept of Pain Inventory (COPI-Adult (DK)) – A self-reported outcome measure
  19. Cosmetic surgery and associated chronic postsurgical pain: A cross-sectional study from Norway
  20. The association of hemodynamic parameters and clinical demographic variables with acute postoperative pain in female oncological breast surgery patients: A retrospective cohort study
  21. Healthcare professionals’ experiences of interdisciplinary collaboration in pain centres – A qualitative study
  22. Effects of deep brain stimulation and verbal suggestions on pain in Parkinson’s disease
  23. Painful differences between different pain scale assessments: The outcome of assessed pain is a matter of the choices of scale and statistics
  24. Prevalence and characteristics of fibromyalgia according to three fibromyalgia diagnostic criteria: A secondary analysis study
  25. Sex moderates the association between quantitative sensory testing and acute and chronic pain after total knee/hip arthroplasty
  26. Tramadol-paracetamol for postoperative pain after spine surgery – A randomized, double-blind, placebo-controlled study
  27. Cancer-related pain experienced in daily life is difficult to communicate and to manage – for patients and for professionals
  28. Making sense of pain in inflammatory bowel disease (IBD): A qualitative study
  29. Patient-reported pain, satisfaction, adverse effects, and deviations from ambulatory surgery pain medication
  30. Does pain influence cognitive performance in patients with mild traumatic brain injury?
  31. Hypocapnia in women with fibromyalgia
  32. Application of ultrasound-guided thoracic paravertebral block or intercostal nerve block for acute herpes zoster and prevention of post-herpetic neuralgia: A case–control retrospective trial
  33. Translation and examination of construct validity of the Danish version of the Tampa Scale for Kinesiophobia
  34. A positive scratch collapse test in anterior cutaneous nerve entrapment syndrome indicates its neuropathic character
  35. ADHD-pain: Characteristics of chronic pain and association with muscular dysregulation in adults with ADHD
  36. The relationship between changes in pain intensity and functional disability in persistent disabling low back pain during a course of cognitive functional therapy
  37. Intrathecal pain treatment for severe pain in patients with terminal cancer: A retrospective analysis of treatment-related complications and side effects
  38. Psychometric evaluation of the Danish version of the Pain Self-Efficacy Questionnaire in patients with subacute and chronic low back pain
  39. Dimensionality, reliability, and validity of the Finnish version of the pain catastrophizing scale in chronic low back pain
  40. To speak or not to speak? A secondary data analysis to further explore the context-insensitive avoidance scale
  41. Pain catastrophizing levels differentiate between common diseases with pain: HIV, fibromyalgia, complex regional pain syndrome, and breast cancer survivors
  42. Prevalence of substance use disorder diagnoses in patients with chronic pain receiving reimbursed opioids: An epidemiological study of four Norwegian health registries
  43. Pain perception while listening to thrash heavy metal vs relaxing music at a heavy metal festival – the CoPainHell study – a factorial randomized non-blinded crossover trial
  44. Observational Studies
  45. Cutaneous nerve biopsy in patients with symptoms of small fiber neuropathy: a retrospective study
  46. The incidence of post cholecystectomy pain (PCP) syndrome at 12 months following laparoscopic cholecystectomy: a prospective evaluation in 200 patients
  47. Associations between psychological flexibility and daily functioning in endometriosis-related pain
  48. Relationship between perfectionism, overactivity, pain severity, and pain interference in individuals with chronic pain: A cross-lagged panel model analysis
  49. Access to psychological treatment for chronic cancer-related pain in Sweden
  50. Validation of the Danish version of the knowledge and attitudes survey regarding pain
  51. Associations between cognitive test scores and pain tolerance: The Tromsø study
  52. Healthcare experiences of fibromyalgia patients and their associations with satisfaction and pain relief. A patient survey
  53. Video interpretation in a medical spine clinic: A descriptive study of a diverse population and intervention
  54. Role of history of traumatic life experiences in current psychosomatic manifestations
  55. Social determinants of health in adults with whiplash associated disorders
  56. Which patients with chronic low back pain respond favorably to multidisciplinary rehabilitation? A secondary analysis of a randomized controlled trial
  57. A preliminary examination of the effects of childhood abuse and resilience on pain and physical functioning in patients with knee osteoarthritis
  58. Differences in risk factors for flare-ups in patients with lumbar radicular pain may depend on the definition of flare
  59. Real-world evidence evaluation on consumer experience and prescription journey of diclofenac gel in Sweden
  60. Patient characteristics in relation to opioid exposure in a chronic non-cancer pain population
  61. Topical Reviews
  62. Bridging the translational gap: adenosine as a modulator of neuropathic pain in preclinical models and humans
  63. What do we know about Indigenous Peoples with low back pain around the world? A topical review
  64. The “future” pain clinician: Competencies needed to provide psychologically informed care
  65. Systematic Reviews
  66. Pain management for persistent pain post radiotherapy in head and neck cancers: systematic review
  67. High-frequency, high-intensity transcutaneous electrical nerve stimulation compared with opioids for pain relief after gynecological surgery: a systematic review and meta-analysis
  68. Reliability and measurement error of exercise-induced hypoalgesia in pain-free adults and adults with musculoskeletal pain: A systematic review
  69. Noninvasive transcranial brain stimulation in central post-stroke pain: A systematic review
  70. Short Communications
  71. Are we missing the opioid consumption in low- and middle-income countries?
  72. Association between self-reported pain severity and characteristics of United States adults (age ≥50 years) who used opioids
  73. Could generative artificial intelligence replace fieldwork in pain research?
  74. Skin conductance algesimeter is unreliable during sudden perioperative temperature increases
  75. Original Experimental
  76. Confirmatory study of the usefulness of quantum molecular resonance and microdissectomy for the treatment of lumbar radiculopathy in a prospective cohort at 6 months follow-up
  77. Pain catastrophizing in the elderly: An experimental pain study
  78. Improving general practice management of patients with chronic musculoskeletal pain: Interdisciplinarity, coherence, and concerns
  79. Concurrent validity of dynamic bedside quantitative sensory testing paradigms in breast cancer survivors with persistent pain
  80. Transcranial direct current stimulation is more effective than pregabalin in controlling nociceptive and anxiety-like behaviors in a rat fibromyalgia-like model
  81. Paradox pain sensitivity using cuff pressure or algometer testing in patients with hemophilia
  82. Physical activity with person-centered guidance supported by a digital platform or with telephone follow-up for persons with chronic widespread pain: Health economic considerations along a randomized controlled trial
  83. Measuring pain intensity through physical interaction in an experimental model of cold-induced pain: A method comparison study
  84. Pharmacological treatment of pain in Swedish nursing homes: Prevalence and associations with cognitive impairment and depressive mood
  85. Neck and shoulder pain and inflammatory biomarkers in plasma among forklift truck operators – A case–control study
  86. The effect of social exclusion on pain perception and heart rate variability in healthy controls and somatoform pain patients
  87. Revisiting opioid toxicity: Cellular effects of six commonly used opioids
  88. Letter to the Editor
  89. Post cholecystectomy pain syndrome: Letter to Editor
  90. Response to the Letter by Prof Bordoni
  91. Response – Reliability and measurement error of exercise-induced hypoalgesia
  92. Is the skin conductance algesimeter index influenced by temperature?
  93. Skin conductance algesimeter is unreliable during sudden perioperative temperature increase
  94. Corrigendum
  95. Corrigendum to “Chronic post-thoracotomy pain after lung cancer surgery: a prospective study of preoperative risk factors”
  96. Obituary
  97. A Significant Voice in Pain Research Björn Gerdle in Memoriam (1953–2024)
https://doi.org/10.1515/sjpain-2023-0051
Schlagwörter für diesen Artikel
ankle fracture; tourniquet; postoperative pain; opioid consumption
Creative Commons
BY 4.0

Artikel in diesem Heft

  1. Editorial Comment
  2. From pain to relief: Exploring the consistency of exercise-induced hypoalgesia
  3. Christmas greetings 2024 from the Editor-in-Chief
  4. Original Articles
  5. The Scandinavian Society for the Study of Pain 2022 Postgraduate Course and Annual Scientific (SASP 2022) Meeting 12th to 14th October at Rigshospitalet, Copenhagen
  6. Comparison of ultrasound-guided continuous erector spinae plane block versus continuous paravertebral block for postoperative analgesia in patients undergoing proximal femur surgeries
  7. Clinical Pain Researches
  8. The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery – a retrospective cohort study
  9. Changes in pain, daily occupations, lifestyle, and health following an occupational therapy lifestyle intervention: a secondary analysis from a feasibility study in patients with chronic high-impact pain
  10. Tonic cuff pressure pain sensitivity in chronic pain patients and its relation to self-reported physical activity
  11. Reliability, construct validity, and factorial structure of a Swedish version of the medical outcomes study social support survey (MOS-SSS) in patients with chronic pain
  12. Hurdles and potentials when implementing internet-delivered Acceptance and commitment therapy for chronic pain: a retrospective appraisal using the Quality implementation framework
  13. Exploring the outcome “days with bothersome pain” and its association with pain intensity, disability, and quality of life
  14. Fatigue and cognitive fatigability in patients with chronic pain
  15. The Swedish version of the pain self-efficacy questionnaire short form, PSEQ-2SV: Cultural adaptation and psychometric evaluation in a population of patients with musculoskeletal disorders
  16. Pain coping and catastrophizing in youth with and without cerebral palsy
  17. Neuropathic pain after surgery – A clinical validation study and assessment of accuracy measures of the 5-item NeuPPS scale
  18. Translation, contextual adaptation, and reliability of the Danish Concept of Pain Inventory (COPI-Adult (DK)) – A self-reported outcome measure
  19. Cosmetic surgery and associated chronic postsurgical pain: A cross-sectional study from Norway
  20. The association of hemodynamic parameters and clinical demographic variables with acute postoperative pain in female oncological breast surgery patients: A retrospective cohort study
  21. Healthcare professionals’ experiences of interdisciplinary collaboration in pain centres – A qualitative study
  22. Effects of deep brain stimulation and verbal suggestions on pain in Parkinson’s disease
  23. Painful differences between different pain scale assessments: The outcome of assessed pain is a matter of the choices of scale and statistics
  24. Prevalence and characteristics of fibromyalgia according to three fibromyalgia diagnostic criteria: A secondary analysis study
  25. Sex moderates the association between quantitative sensory testing and acute and chronic pain after total knee/hip arthroplasty
  26. Tramadol-paracetamol for postoperative pain after spine surgery – A randomized, double-blind, placebo-controlled study
  27. Cancer-related pain experienced in daily life is difficult to communicate and to manage – for patients and for professionals
  28. Making sense of pain in inflammatory bowel disease (IBD): A qualitative study
  29. Patient-reported pain, satisfaction, adverse effects, and deviations from ambulatory surgery pain medication
  30. Does pain influence cognitive performance in patients with mild traumatic brain injury?
  31. Hypocapnia in women with fibromyalgia
  32. Application of ultrasound-guided thoracic paravertebral block or intercostal nerve block for acute herpes zoster and prevention of post-herpetic neuralgia: A case–control retrospective trial
  33. Translation and examination of construct validity of the Danish version of the Tampa Scale for Kinesiophobia
  34. A positive scratch collapse test in anterior cutaneous nerve entrapment syndrome indicates its neuropathic character
  35. ADHD-pain: Characteristics of chronic pain and association with muscular dysregulation in adults with ADHD
  36. The relationship between changes in pain intensity and functional disability in persistent disabling low back pain during a course of cognitive functional therapy
  37. Intrathecal pain treatment for severe pain in patients with terminal cancer: A retrospective analysis of treatment-related complications and side effects
  38. Psychometric evaluation of the Danish version of the Pain Self-Efficacy Questionnaire in patients with subacute and chronic low back pain
  39. Dimensionality, reliability, and validity of the Finnish version of the pain catastrophizing scale in chronic low back pain
  40. To speak or not to speak? A secondary data analysis to further explore the context-insensitive avoidance scale
  41. Pain catastrophizing levels differentiate between common diseases with pain: HIV, fibromyalgia, complex regional pain syndrome, and breast cancer survivors
  42. Prevalence of substance use disorder diagnoses in patients with chronic pain receiving reimbursed opioids: An epidemiological study of four Norwegian health registries
  43. Pain perception while listening to thrash heavy metal vs relaxing music at a heavy metal festival – the CoPainHell study – a factorial randomized non-blinded crossover trial
  44. Observational Studies
  45. Cutaneous nerve biopsy in patients with symptoms of small fiber neuropathy: a retrospective study
  46. The incidence of post cholecystectomy pain (PCP) syndrome at 12 months following laparoscopic cholecystectomy: a prospective evaluation in 200 patients
  47. Associations between psychological flexibility and daily functioning in endometriosis-related pain
  48. Relationship between perfectionism, overactivity, pain severity, and pain interference in individuals with chronic pain: A cross-lagged panel model analysis
  49. Access to psychological treatment for chronic cancer-related pain in Sweden
  50. Validation of the Danish version of the knowledge and attitudes survey regarding pain
  51. Associations between cognitive test scores and pain tolerance: The Tromsø study
  52. Healthcare experiences of fibromyalgia patients and their associations with satisfaction and pain relief. A patient survey
  53. Video interpretation in a medical spine clinic: A descriptive study of a diverse population and intervention
  54. Role of history of traumatic life experiences in current psychosomatic manifestations
  55. Social determinants of health in adults with whiplash associated disorders
  56. Which patients with chronic low back pain respond favorably to multidisciplinary rehabilitation? A secondary analysis of a randomized controlled trial
  57. A preliminary examination of the effects of childhood abuse and resilience on pain and physical functioning in patients with knee osteoarthritis
  58. Differences in risk factors for flare-ups in patients with lumbar radicular pain may depend on the definition of flare
  59. Real-world evidence evaluation on consumer experience and prescription journey of diclofenac gel in Sweden
  60. Patient characteristics in relation to opioid exposure in a chronic non-cancer pain population
  61. Topical Reviews
  62. Bridging the translational gap: adenosine as a modulator of neuropathic pain in preclinical models and humans
  63. What do we know about Indigenous Peoples with low back pain around the world? A topical review
  64. The “future” pain clinician: Competencies needed to provide psychologically informed care
  65. Systematic Reviews
  66. Pain management for persistent pain post radiotherapy in head and neck cancers: systematic review
  67. High-frequency, high-intensity transcutaneous electrical nerve stimulation compared with opioids for pain relief after gynecological surgery: a systematic review and meta-analysis
  68. Reliability and measurement error of exercise-induced hypoalgesia in pain-free adults and adults with musculoskeletal pain: A systematic review
  69. Noninvasive transcranial brain stimulation in central post-stroke pain: A systematic review
  70. Short Communications
  71. Are we missing the opioid consumption in low- and middle-income countries?
  72. Association between self-reported pain severity and characteristics of United States adults (age ≥50 years) who used opioids
  73. Could generative artificial intelligence replace fieldwork in pain research?
  74. Skin conductance algesimeter is unreliable during sudden perioperative temperature increases
  75. Original Experimental
  76. Confirmatory study of the usefulness of quantum molecular resonance and microdissectomy for the treatment of lumbar radiculopathy in a prospective cohort at 6 months follow-up
  77. Pain catastrophizing in the elderly: An experimental pain study
  78. Improving general practice management of patients with chronic musculoskeletal pain: Interdisciplinarity, coherence, and concerns
  79. Concurrent validity of dynamic bedside quantitative sensory testing paradigms in breast cancer survivors with persistent pain
  80. Transcranial direct current stimulation is more effective than pregabalin in controlling nociceptive and anxiety-like behaviors in a rat fibromyalgia-like model
  81. Paradox pain sensitivity using cuff pressure or algometer testing in patients with hemophilia
  82. Physical activity with person-centered guidance supported by a digital platform or with telephone follow-up for persons with chronic widespread pain: Health economic considerations along a randomized controlled trial
  83. Measuring pain intensity through physical interaction in an experimental model of cold-induced pain: A method comparison study
  84. Pharmacological treatment of pain in Swedish nursing homes: Prevalence and associations with cognitive impairment and depressive mood
  85. Neck and shoulder pain and inflammatory biomarkers in plasma among forklift truck operators – A case–control study
  86. The effect of social exclusion on pain perception and heart rate variability in healthy controls and somatoform pain patients
  87. Revisiting opioid toxicity: Cellular effects of six commonly used opioids
  88. Letter to the Editor
  89. Post cholecystectomy pain syndrome: Letter to Editor
  90. Response to the Letter by Prof Bordoni
  91. Response – Reliability and measurement error of exercise-induced hypoalgesia
  92. Is the skin conductance algesimeter index influenced by temperature?
  93. Skin conductance algesimeter is unreliable during sudden perioperative temperature increase
  94. Corrigendum
  95. Corrigendum to “Chronic post-thoracotomy pain after lung cancer surgery: a prospective study of preoperative risk factors”
  96. Obituary
  97. A Significant Voice in Pain Research Björn Gerdle in Memoriam (1953–2024)
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