The authors concluded that available limited data suggested that tourniquets may reduce the incidence of technical difficulties during upper limb surgery. Effects on pain perception and operative duration remained unclear. The authors' conclusions should be interpreted with caution given the small number of studies and participants reviewed.

To assess the effectiveness of tourniquet use on intra-and post-operative outcomes in upper limb orthopaedic surgery.

MEDLINE, CINAHL, AMED, EMBASE (from 1950 to December 2008), The Cochrane Library and Current Controlled Trials database (for on-going studies) were searched for publications in any language. Search terms were reported. A number of grey literature sites (for example, System for Information on Grey Literature in Europe) were searched for unpublished studies. Reference lists of identified systematic reviews and articles were handsearched and expert authors were contacted to identify additional articles.

Randomised controlled trials (RCTs) and controlled clinical trials that compared clinical outcomes of upper limb surgery with or without a tourniquet in patients aged 16 years and above were eligible for inclusion. Outcomes considered included pain and visualisation operative time.

The included studies evaluated elbow, forearm, wrist and hand surgeries. Exsanguination techniques were varied and included elevation and manual compression and use of Esmarch bandaging. Outcomes assessed included visualisation, visual analogue scale pain scores, present pain intensity scores and operative time.

Two reviewers independently assessed studies for eligibility. Disagreements were resolved through discussion.

The quality of included studies was assessed according to the following criteria: adequacy of random allocation concealment; balance of baseline measures; identical additional care; blinding (participants, outcome assessors, investigators); follow-up duration and intention-to-treat analysis.

Two reviewers independently assessed study quality. Disagreements were resolved by discussion.

Data on mean visual analogue scale pain scores and standard deviations in the tourniquet and non-tourniquet surgery groups were extracted and used to calculate mean differences (MDs) with 95% confidence intervals (CIs). Data on mean differences and 95% confidence intervals (CIs) and operative durations were extracted where reported.

Two reviewers (blinded to author details such as name and institution) independently extracted data.

The pooled mean difference and 95% CIs for visual analogue pain scores was calculated using a random-effects model. The effects of tourniquet and non-tourniquet surgeries on visualisation, present pain intensity scores and operative times were summarised narratively. Statistical heterogeneity was assessed using X² and I² statistics.

Two studies (n=55 patients) were included in the review. Baseline characteristics were comparable in one study. Outcome assessors were blinded in one study. Allocation concealment, duration of follow-up, intention-to-treat analysis and sample sizes were inadequate in both studies.

There was no statistically significant difference in visual analogue scale pain scores between tourniquet and non-tourniquet surgeries (MD 8.72, 95% CI -23.06 to 5.63; n=39 patients, two studies).

Present pain intensity scores were significantly lower in the non-tourniquet surgery groups during the first two postoperative days (MD 1.30, 95% CI 0.34 to 2.26; n=32 patients, one study).

Mixed results were reported for the effects of tourniquet and non-tourniquet surgeries on operative duration.

The surgeons’ perception of operative difficulty was significantly lower in tourniquet surgeries (p<0.01, one study).

Available limited data suggested that tourniquets may reduce the incidence of technical difficulties during upper limb surgery. Effects on pain perception and operative duration remained unclear.

The review question was clearly stated. The search strategy was comprehensive. The risk of reviewer bias and errors was minimised throughout the review processes. Study quality was assessed with appropriate criteria and found to be poor. Statistical and narrative methods used to summarise study results were justified. Only two studies with small sample sizes were included. The conclusions appeared appropriate given the evidence presented. Given the potential for publication bias and the small number of studies and patients reviewed, the authors' conclusions should be interpreted with caution.

Practice: The authors did not state any implications for practice.

Research: The authors stated that further studies of the effectiveness tourniquet for elbow, forearm, wrist and hand surgeries on clinical outcomes (visualisation, pain, operative times) were needed.

None.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.