Impact of a Special Waterproof Layer Under Tourniquet Cuffs on Postoperative Burn Incidence, Pain Intensity, and Operating Room Staff Satisfaction in Knee Arthroscopic Surgeries

Impact of a Special Waterproof Layer Under Tourniquet Cuffs on Postoperative Burn Incidence, Pain Intensity, and Operating Room Staff Satisfaction in Knee Arthroscopic Surgeries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of a Special Waterproof Layer Under Tourniquet Cuffs on Postoperative Burn Incidence, Pain Intensity, and Operating Room Staff Satisfaction in Knee Arthroscopic Surgeries Soheila Bakhtiari, Mehdi Teimouri, Nafise Rahimi, Mohammad Hassan Bagheri, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6050937/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 May, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 3 You are reading this latest preprint version Abstract Introduction: The use of multiple layers of Vibril under tourniquet cuffs is common. However, these layers can lead to complications. We designed a special waterproof curtain for use under tourniquet cuffs. Its effects on burns, postoperative pain, and operating room staff satisfaction were evaluated. Materials & Methods: In this randomized clinical trial study, 34 patients underwent arthroscopic surgery of the knee joint in the operating rooms of selected hospitals of Isfahan University of Medical Sciences in 2022, using a simple random method based on the day. Even and odd days were divided into two groups: Group A (even days: special tourniquet drape: 17 people) and Group B (odd days: usual layers under the tourniquet cuff: 17 people). The degree of pain was evaluated with a visual analogue scale (VAS), the severity of burns was evaluated based on a rating from one to four, and the satisfaction of the operating room personnel was evaluated using a standardized questionnaire with 10 questions. Results: Pain intensity in the Group A, compared to the Group B, at all times was lower: immediately after entering recovery (2.29 ± 0.47 vs. 5.00 ± 0.71, P < 0.001), during the first eight hours (1.71 ± 0.47 vs. 3.94 ± 0.56, P < 0.001), the second eight hours (2.82 ± 0.73 vs. 5.12 ± 0.45, P < 0.001), and the third eight hours (1.65 ± 0.61 vs. 3.59 ± 0.62, P < 0.001). None of the participants in the Group A and only one participant (5.9%) in the Group B suffered burns, a difference that was not significant (P = 0.500). All operating room personnel (100%) reported a "high" level of satisfaction. Conclusion: It seems that the use of a special tourniquet in arthroscopic surgeries of the knee joint has a positive effect, considering the reduction of postoperative pain and the increase in the satisfaction of the operating room personnel. Arthroscopy knee tourniquet Figures Figure 1 Figure 2 Introduction Knee arthroscopy is one of the most common orthopedic surgeries, used both for diagnosing and treating intra-articular pathologies ( 1 ). The results of several studies have shown that, theoretically and clinically, the use of a tourniquet can reduce the amount of blood loss in this surgery ( 2 , 3 ), and by improving the surgeon's vision, it leads to a reduction in operation time ( 4 – 10 ). The most common complication of using a tourniquet is pain, which causes discomfort to the patient during the operation and affects the results of the operation ( 4 , 11 ). Therefore, it can be said that tourniquet-related complications remain a clinical concern, as the literature shows that postoperative pain is reported in 35.8–60% of lower extremity surgeries and 51.8–60% of upper extremity surgeries when swelling lasts longer than 60 minutes ( 12 ). In addition, post-tourniquet syndrome is a common reaction to prolonged limb ischemia in which the patient experiences stiffness and decreased muscle strength, pallor, dry joints, and a tingling sensation. Although this condition interferes with the postoperative physiotherapy program, it usually resolves itself about 24 hours after the surgery ( 3 , 13 ). In some studies, researchers considered the cause of such problems in the usual tourniquets to be related to the layers beneath them and advocated for replacing these layers with better materials ( 14 – 16 ). Despite potential benefits in blood loss reduction particularly observed in total knee arthroplasty (TKA), where tourniquets decrease intraoperative blood loss by 138–544 mL ( 17 , 18 ), the materials used under tourniquet cuffs may exacerbate complications. The use of conventional cotton padding, including 100% bleached pure cotton Vibril and similar layers under the tourniquet cuff, can lead to leg pain and limb swelling ( 19 ), stiffness, delayed recovery of muscle strength, resentment and discomfort ( 20 ), necrosis after orthopedic surgeries ( 10 ), peeling skin, wound hematoma leading to permanent wound drainage, and an increased risk of subcutaneous infection ( 6 , 7 , 12 ). Complaints of thigh pain in patients for whom the usual layers of 100% bleached pure cotton Vibril were used under the tourniquet cuff are probably due to blood congestion and fluid accumulation in the fabric or Vibril tissue under the tourniquet cuff, and as a result, the direct pressure of the tourniquet. This pressure is localized on nerves and soft tissue; the swelling of the limb and the increase in the internal pressure of the soft tissue caused by the reperfusion reaction after releasing the tourniquet may lead to pain in the operative field ( 10 ). The absence of a specialized protective covering beneath tourniquet cuffs, such as nano products, can result in various complications, increasing patient and hospital treatment costs. Therefore, there is a need to adopt newer, more accessible, and cheaper methods with fewer side effects. As such, there is a pressing need for a protective layer with the following attributes: waterproof and liquid-penetration resistance to prevent fluid accumulation; absorbent properties to manage minimal fluid leakage and prevent burns; and the ability to reduce pain and mitigate back syndrome ( 21 ). Another issue is the satisfaction of personnel in cases involving the use of a tourniquet and its different types. The satisfaction of personnel with the tools and materials used in the work environment facilitates the improvement of the existing situation and enhances the efficiency of personnel in providing better medical care. In the meantime, the satisfaction of operating room personnel with the tools used in surgery is of great importance, as by facilitating the surgical process, it forms the basis for improving surgical outcomes and, as a result, reducing potential complications caused by surgery ( 21 – 24 ). Considering the fact that the leakage of liquids, especially blood, under the tourniquet in orthopedic surgery is very dangerous and in some cases causes various complications ( 15 ), and considering the role of operating room technicians in maintaining hemodynamics during surgery and providing solutions to prevent bleeding or its aggravation ( 3 , 19 ), it seems necessary to design and replace a protective covering under the tourniquet. First of all, it should have waterproof and liquid-penetration properties, which, in the first place, will prevent water penetration and accumulation under the cuff. Secondly, it should have the property of absorbing liquids, which, in case of possible and minimal passage of liquids, will quickly absorb them and prevent the accumulation of liquids and burns in this area. Thirdly, it should prevent the complications caused by the tourniquet, especially pain and back syndrome. High availability, reasonable price, ease of use, and high effectiveness should be other features of this tool. The absence of such a cover can harm the patient by causing the various complications mentioned, and therefore, increase the costs of treating the patient and the hospital. For the mentioned reasons, we decided to use a special waterproof drape under the tourniquet in orthopedic surgeries to more accurately measure its possible side effects on the patient. This study addresses two underexplored aspects of tourniquet use: 1- the role of interface materials in preventing cutaneous complications and improving patient outcomes, and 2- the impact of equipment design on operating room workflow. We hypothesize that a waterproof absorbent layer beneath the tourniquet cuff will reduce postoperative burn incidence by 40%, decrease pain scores on the visual analog scale by ≥ 2 points, and increase staff satisfaction ratings by 30% compared to conventional cotton padding. By systematically evaluating both clinical outcomes and ergonomic factors, this investigation aims to provide evidence-based recommendations for optimizing tourniquet use in ambulatory orthopedic procedures. It should be noted that this waterproof cover was designed and approved by the researcher of this project in another study. Methods This randomized clinical trial study was conducted in the form of a randomized clinical trial with a blind statistical analyzer. The statistical population of this study included all patients undergoing arthroscopic surgery of the knee joint in the operating rooms of selected hospitals of Isfahan University of Medical Sciences in 2022, who met the inclusion criteria. Inclusion criteria included: 18 years of age or older, informed consent, arthroscopic knee surgery requiring the use of a tourniquet, non-emergency surgery, no fractures in other body parts, and no history of illness. Cardiovascular conditions such as congestive heart failure, cardiac arrhythmias, high blood pressure, diabetes, non-drug use or continuous alcohol or cigarette consumption of more than 5 packs per year, no chest, head, or abdominal trauma, no need for other surgeries, and not suffering from coagulation diseases or requiring anticoagulant drugs. After obtaining the approval of the ethics committee and registering the proposal in the Iranian Clinical Trial Center (IRCT), sampling was done by random allocation. In this way, patients operated on even days were in the Group A (17 people), and patients operated on odd days were in the Group B (17 people). At a coordinated time and place, and in person, the demographic information checklist (age, gender, and body mass index) was completed using clinical records. In the Group A, the tourniquet used was an inflatable tourniquet, beneath which four layers of Vibril made of 100% pure cotton were used to protect the skin. The construction of the waterproof cover for the tourniquet under the cuff was completed according to the functional plan below. According to Figure 1, the waterproof cover for the tourniquet included two main parts, as follows: Part 1: Inner layer This part is made of liquid-absorbing foam, which, in addition to being highly impermeable compared to the usual materials used in tourniquets (Vibril), has high absorption power for fluids. This layer effectively absorbed the small amounts of fluid that passed through and prevented their excessive accumulation under the tourniquet, thereby avoiding complications caused by these accumulations. This part was used in a rectangular shape with dimensions of 70 × 17 cm and was marked with the number "1" in the plan shown below (Figure 1). Part 2: Outer layer In this part, two layers of adhesive were used as follows to create maximum adhesion to the patient's body, prevent liquids from penetrating, and avoid excessive sensitivity to the patient's skin: A: Waterproof glue This glue is resistant and does not lose its effectiveness when wet by fluids at the surgical site. Additionally, it largely prevents the penetration of these fluids beneath the tourniquet. This part was placed in rectangles with dimensions of 80 × 2 cm and 21 × 10 cm around the inner layer (Part 1). In this way, two rectangular layers with dimensions of 80 × 2 cm surrounded the lengths of the inner layer (Part 1), and two rectangular layers with dimensions of 21 × 10 cm surrounded the widths of the inner layer. This arrangement is marked with the number "2" in the plan shown below (Figure 1). A: Wicker glue This glue was used to strengthen the existing connections and reinforce the inner layer on the patient's skin and under the tourniquet. Furthermore, due to its hypoallergenic properties, it prevented complications in cases of prolonged connections, ensuring no long-term damage to the patient's skin. This part was also arranged as rectangles with dimensions of 80 × 2 cm and 21 × 10 cm around the inner layer (Part 1). Two rectangular layers with dimensions of 80 × 2 cm surrounded the lengths of the inner layer (Part 1), and two rectangular layers with dimensions of 21 × 10 cm surrounded the widths of the inner layer. This arrangement is marked with the number "2" in the plan shown below (Figure 1), surrounding the waterproof adhesive. After creating the waterproof cover for the tourniquet, its effectiveness and resistance were tested on the moulage with an outer layer of natural leather. To test and examine the product, after using the specially designed waterproof cover under the tourniquet, the final product was placed in close proximity to drinking water for 30 minutes. Finally, through observation and assessment of the amount of water penetration and accumulation under the tourniquet, its efficiency was verified and confirmed. It should be noted that this waterproof drape was produced and approved during another independent study at the research center of the Faculty of Nursing and Midwifery of Isfahan University of Medical Sciences, with the ethics code IR.ARI.MUI.REC.1400.080. The tourniquet pressure in all patients was set at 150 mm Hg above the systolic pressure (270 to 300 mm Hg) (1). Immediately after the surgery, the duration of the operation was recorded. Then, in the first 24 hours after entering recovery, the patients were examined by the researcher in terms of the amount of pain (using the VAS scale, immediately, and every 8 hours after entering recovery). In this scale, the patient scored the intensity of their pain from 0 (no pain) to 10 (highest pain intensity) (1, 25). The severity of the burn, in the first 24 hours after entering recovery, was assessed by the researcher based on the following grading system, through observation and registration in the relevant checklist: First degree : Involvement of the epidermis; red skin without blisters. Second degree : Superficial involvement of the dermis : Red skin without blisters, which turns white when pressed. Deep involvement of the dermis : Red skin with blisters. Third degree : Involvement of the entire skin; hard and white skin. Fourth degree : Involvement of the entire skin and underlying muscle and bone layers; black and dry skin. To measure the satisfaction of the operating room personnel, the standard personnel satisfaction questionnaire containing 10 items was used. The scoring of these items was done using a 5-point Likert scale (very low: 1 point, low: 2 points, medium: 3 points, high: 4 points, very high: 5 points). Scores between 10 and 15 were considered as low satisfaction, scores between 16 and 34 as medium satisfaction, and scores between 35 and 50 as high satisfaction. The validity and reliability of this questionnaire were confirmed using similar studies, the opinions of professors and experts, and a previously confirmed correlation coefficient close to 0.1 (21). This questionnaire was completed by the researcher in the operating room after the surgery. It should be noted that all measurements and data recording were conducted by one researcher, and all surgical procedures were performed by one orthopedic surgeon and a single team using anesthesia. Finally, the data were analyzed using the Kolmogorov-Smirnov, t, Mann-Whitney, and chi-square tests, with Statistical Package for the Social Sciences (SPSS) version 25.0 software and Stata software version 2.9 (Stata Corp., College Station, TX, USA). In all tests, the confidence level was 95%, and the significance level was set at less than 0.05. Results In the Group A compared to the Group B, age (32.94 ± 4.37 vs. 33.71 ± 4.67 years; P = 0.605) and BMI (28.59 ± 2.21 vs. 28.94 ± 2.73 kg/m²; P = 0.399) showed no significant differences. Most of the participants in the Group A (70.6%) and the Group B (64.7%) were men. There was no significant difference between genders (P = 0.714) (Table 1). The mean and standard deviation of the duration of surgery for patients in the Group A was 135.59 ± 12.73 minutes, and in the Group B, it was 135.59 ± 12.73 minutes; this difference was not significant (P = 0.476). According to Table 2, the intensity of pain in the Group A compared to the Group B at all times—immediately after entering recovery, the first eight hours after entering recovery, the second eight hours after entering recovery, and the third eight hours after entering recovery—was lower. In Table 2, the distribution of the severity of burns caused by the use of tourniquets in the studied groups is presented. Based on this data, none of the participants in the Group A suffered burns. Only one participant (5.9%) in the Group B suffered burns, which was a first-degree burn. There was no statistically significant difference in the severity of burns between the studied groups (P = 0.5). The mean and standard deviation of operating room personnel satisfaction with the special drape under the tourniquet used in this study was 41.71 ± 1.61 (out of 50 points). All operating room personnel (100%) reported a "high" level of satisfaction with the special drape under the tourniquet used in this study. Table 1: Demographic characteristics Variables Group A Group B P -value * n % N % Age (year) 18 - 29 4 23.5 4 23.5 0.999 30 - 59 13 76.5 13 76.5 Sex male 12 70.6 11 64.7 0.714 female 5 29.4 6 35.3 BMI (Kg/m 2 ) 18.5-24.9 9 52.9 6 35.3 0.581 25-29.9 6 35.3 8 47.1 30 ≤ 2 11.8 3 17.6 Notes: BMI, body mass index; *Chi-Square test Table 2: Dependent variables Variables Group A Group B P -value mean SD mean SD Duration of surgery (min) ≤ 135 7 41.2 10 58.8 0.303 * 135 0.001 ** first 8 hours 1.71 0.47 3.94 0.56 > 0.001 ** second 8 hours 2.82 0.73 5.12 0.45 > 0.001 ** third 8 hours 1.65 0.61 3.59 0.62 > 0.001 ** Burn severity Grade 1 - - 1 5.9 0.5 *** Grade 2 17 100 16 94.1 Notes: BMI, body mass index; SD, standard deviation; *Chi-Square test; **Mann-Whitney test; **Fisher's exact test Discussion Since the use of a tourniquet and the usual layers beneath it in arthroscopic surgeries of the knee joint can be associated with complications such as burns and pain intensity after the operation, and, as a result, dissatisfaction among the operating room personnel, we decided to take a step toward increasing the effectiveness of tourniquets and reducing the human and financial costs caused by the complications of using tourniquets by designing a special tourniquet drape. Therefore, the aim of the present study was to investigate the effect of using a special tourniquet on the incidence of burns, the intensity of pain after the operation, and the satisfaction level of operating room personnel in arthroscopic surgeries of the knee joint in selected hospitals of Isfahan University of Medical Sciences in 2022. As mentioned before, one of the side effects of using a tourniquet in surgery, especially arthroscopic surgery of the knee joint, is pain. In this context, the results of the present study showed that the intensity of pain in the Group A with a special tourniquet at all times—immediately after entering recovery, the first eight hours after entering recovery, the second eight hours after entering recovery, and the third eight hours after entering recovery—was less than the Group B. Therefore, the use of a special tourniquet (designed by the researcher in a separate study) may be effective in controlling the pain caused by its use. A tourniquet was used in arthroscopic surgery of the knee joint. Considering the number of reported cases of pain caused by tourniquets in surgical operations, the use of a special tourniquet drape could be a new step in solving this common complication in surgical operations. In the same context, Lai et al. (2022) in China investigated the effect of tourniquet use on postoperative pain, blood loss, recovery, and tourniquet burns in knee arthroscopy. In this study, patients who were candidates for knee arthroscopy were randomly divided into two groups of 14 people, with and without tourniquet use. The results showed that the intensity of pain after surgery was significantly higher in the tourniquet group ( 13 ). Ahmed et al. (2020) observed that the application of tourniquets in knee surgical procedures is frequently associated with an increase in postoperative pain. However, their findings also highlighted that adjustments aimed at minimizing ischemia or reducing pressure may alleviate such adverse effects ( 26 ). Similarly, Wang et al. (2020) reported decreased analgesic use in arthroscopic procedures conducted without tourniquets, providing indirect support for the conclusion that enhanced tourniquet designs can contribute to pain reduction ( 27 ). In another study, Tai et al. (2012) in Taiwan investigated the effect of tourniquet use on blood loss and soft tissue damage in total knee arthroplasty surgery. In this randomized controlled clinical trial study, 72 patients undergoing total knee arthroplasty surgery were randomly divided into groups with and without tourniquet use, and the results showed that back pain and postoperative pain were more severe in the tourniquet group. In other words, the use of a tourniquet increased postoperative pain ( 28 ). In addition to arthroscopic surgeries of the knee joint, this finding has also been observed in other surgeries. For example, in a study, Wang et al. (2021) in China investigated the effect of tourniquets on the short-term outcomes of osteotomy. All patients were divided into two groups based on whether or not a tourniquet was used during the procedure. The results of this study showed that, in terms of early recovery after surgery, the use of a tourniquet significantly increased the pain score and decreased the range of motion of the knee on the first and second days after surgery ( 23 ). Of course, in a number of studies, the effect of using a tourniquet and its various types on pain caused by surgery has not been fully confirmed. For example, Zhang et al. (2022) in China investigated the use of tourniquets in primary total knee arthroplasty. In this study, patients who underwent total knee arthroplasty were randomly assigned to one of three groups: Group A used a tourniquet from the time of skin incision until the hardening of the cement; Group B used a tourniquet only at the time of cement hardening; and Group C used a tourniquet from the time of skin incision until the skin was closed. The results of this study showed that there was no statistically significant difference in pain intensity among any of the studied groups ( 29 , 30 ). Also, in another study, Andrade et al. (2022) in Brazil addressed whether the quality of primary total knee arthroplasty surgery and the resulting clinical outcomes are affected by the use of tourniquets. In this randomized clinical trial, 50 patients were randomly divided into two groups: ( 1 ) a tourniquet was used during all surgical procedures, and ( 2 ) a tourniquet was used only during skin incision and cement application. The results of this study did not show any significant difference in pain intensity between the two groups ( 31 ). The reason for these contradictory results could be related to differences in how research units were investigated and the statistical sample sizes of the different studies. Another reported complication related to the use of tourniquets in arthroscopic surgeries of the knee joint is the local burn caused by the tourniquet. Regarding this issue, the results of the present study showed that although none of the participants in the Group A with a special tourniquet drape suffered burns caused by the use of tourniquets, there was no statistically significant difference in the severity of burns between the both groups. This lack of significance could, of course, be related to the small sample size of our study. It is possible that by increasing the sample size and conducting the study on a wider scale, a significant statistical difference could be reported in this regard. However, the low prevalence of burns caused by tourniquets in this study is an important finding and a strong point for using a special tourniquet drape. This is because, in other studies, burns have been identified as an important and common complication of tourniquet use during surgery. The results of other studies have also shown that the layer beneath the tourniquet is important for preventing the leakage of washing liquid under the tourniquet, as such leakage may cause severe skin reactions, local burns, and even the loss of part or all of the skin. This risk is much higher in children and elderly individuals, and it occurs more commonly with solutions containing alcohol ( 32 ). Other authors have suggested using a sterile towel, a piece of plastic, or even a surgical glove or pre-made devices pushed under the tourniquet to prevent burns caused by the tourniquet. However, these methods are incomplete and require more modern solutions ( 32 , 33 ). This is a topic that has been well addressed in the present study. With the design and use of a special tourniquet drape, none of the participants in the Group A experienced burns caused by the tourniquet. This highlights the importance and high efficiency of the special tourniquet drape. Lai et al. (2022) in China investigated the effect of tourniquet use on post-surgery pain, blood loss, recovery, and burns at the tourniquet site in knee arthroscopy and concluded that burns at the site where the tourniquet was applied are an important and common complication ( 13 ). Of course, in a contradictory study, Li et al. (2021) in China investigated the effect of using tourniquets in orthopedic surgeries. In this randomized controlled trial, patients were randomly divided into two groups: using a tourniquet and not using a tourniquet. The results showed that there was no difference in the occurrence of complications such as burns between the two investigated groups ( 22 ). These differences could be due to variations in the tools and methods of measuring burn severity, as well as the demographic differences of the patients investigated in different studies. In addition to the reduction of side effects (pain and burns), another important parameter that can indicate the efficiency of the tool used is the satisfaction of personnel with using that tool. In this regard, the findings of the upcoming study showed that all operating room personnel (100%) reported a "high" level of satisfaction with the special drape under the tourniquet used in this study. Another positive aspect of using this drape in arthroscopic knee surgeries is that, in other studies; most operating room personnel were not satisfied due to issues such as the difficulty of applying the usual layers under the tourniquet or the occurrence of numerous complications related to it, especially pain and burns. For example, in the study of Lai et al. (2022) in China, by examining the effect of tourniquet use on post-surgery pain, blood loss, recovery, and tourniquet burns in knee arthroscopy, they concluded that the use of tourniquets during knee arthroscopy increased postoperative pain and prolonged postoperative recovery, thus causing dissatisfaction among the surgeon, operating room personnel, and patients ( 13 ). Of course, some studies have also stated that the use of tourniquets has no effect on the satisfaction of operating room personnel. For example, Jawhar et al. (2020) in Germany investigated the effect of tourniquet use in knee arthroplasty on the satisfaction of operating room personnel, muscle strength, and joint function of the patient after surgery. The results showed no difference in any of these parameters, especially the satisfaction of the operating room personnel, between the two groups ( 21 ). These contradictions could be due to the demographic differences of the research units in different studies, as well as differences in the statistical sample sizes of various studies ( 33 – 35 ). Along with the strengths of this research, this study, like any other study, also had some limitations. One of these limitations is the relatively small volume of statistical samples, which is due to the limited cases of knee arthroscopy or the use of tourniquets in selected hospitals in Isfahan. Due to the limitations of our center, we were unable to include more participants than the number specified in our article. Despite this constraint, we ensured that the study was conducted with meticulous attention to detail, and we believe the findings obtained are both robust and valuable. In future studies, we will strive to include a larger sample size to further strengthen the validity and generalizability of our results. Additionally, there are certainly many known and unknown factors that may have influenced the results of this study. Future studies on wider statistical populations will help clarify these factors further. Conclusion In conclusion, the findings of this study demonstrate that utilizing a specially designed waterproof drape under tourniquet cuffs during knee arthroscopic surgeries significantly reduces postoperative pain intensity and enhances operating room staff satisfaction. Additionally, the incidence of local burns associated with tourniquet use was notably limited in the Group A. Compared to conventional Vibril layers, using a special drape or waterproof cover presents several advantages. Its cost-effectiveness, accessibility, and ease of production make it a practical alternative. Conventional Vibril layers, often used under the tourniquet, can be both costly and potentially unsafe. From an economic perspective, the special cover used in this study offers a more affordable option. Additionally, the simplicity of its production makes it widely accessible, aligning with the high demand and promising outcomes observed. Its potential to mitigate complications, enhance efficiency, and simplify surgical procedures supports broader adoption in clinical settings. Considering its high market demand and demonstrated benefits, further large-scale studies are encouraged to confirm these results and explore the full scope of its advantages. Abbreviations Visual Analogue Scale (VAS), Iranian Clinical Trial Center (IRCT) Declarations Acknowledgments This study was supported by the Isfahan University of Medical Sciences, Isfahan, Iran. Conflict of Interests None; The authors declare no conflict of interest. Consent for publication All authors are aware of and have provided their consent for the publication of this manuscript. Patients entered our study with full awareness and informed consent. Ethical issues This waterproof drape was developed and validated as part of a separate independent study conducted at the research center of the Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences. Furthermore, this approval is reinforced by the issuance of the ethical code IR.ARI.MUI.REC.1400.080 and the formal registration of the study with the Iranian Registry of Clinical Trials, under the registration number IRCT20220718055487N1. Funding None. Availability of data and materials Datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Authors' contributions S.B. and M.T. designed the study and conducted the experiments. N.R. analyzed the data and contributed to the methodology. M.H.B. provided additional insights and contributed to the manuscript's writing. S.Y.A. is the corresponding author and oversaw the entire project. All authors reviewed and approved the final manuscript. References Pinsornsak P, Pinitchanon P, Boontanapibul K. Effect of Different Tourniquet Pressure on Postoperative Pain and Complications After Total Knee Arthroplasty: A Prospective, Randomized Controlled Trial. The Journal of arthroplasty. 2021;36(5):1638-44. Cirocchi R, Prigorschi D, Properzi L, Matteucci M, Duro F, Tebala GD, et al. Is the Use of Tourniquets More Advantageous than Other Bleeding Control Techniques in Patients with Limb Hemorrhage? A Systematic Review and Meta-Analysis. Medicina (Kaunas, Lithuania). 2025;61(1). Sobhan MR, Saeed Banadaky, Seyed Hossein, Shafiee M, Gheisari M. Evaluation of the Results of Arthroscopic Release in Limits of Movement in Knees %J The Journal of Shahid Sadoughi University of Medical Sciences. 2020;27(9):1886-92. Farhan-Alanie MM, Dhaif F, Trompeter A, Underwood M, Yeung J, Parsons N, et al. The risks associated with tourniquet use in lower limb trauma surgery: a systematic review and meta-analysis. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2021;31(5):967-79. Neufeld ME, McEwen JA, Kerr J, Sidhu A, Howard LC, Masri BA. Optimization of surgical tourniquet usage to improve patient outcomes: Translational cross-disciplinary implications of a surgical practice survey. Frontiers in surgery. 2023;10:1104603. Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. Journal of orthopaedic surgery and research. 2014;9(1):13. Rosenstein AD, Michelov YA, Thompson S, Kaye AD. Benefits of Limited Use of a Tourniquet Combined With Intravenous Tranexamic Acid During Total Knee Arthroplasty. Ochsner journal. 2016;16(4):443-9. Yavarikia A, Amjad GG, Davoudpour K. The influence of tourniquet use and timing of its release on blood loss in total knee arthroplasty. Pakistan journal of biological sciences : PJBS. 2010;13(5):249-52. Hernandez AJ, Almeida AM, Fávaro E, Sguizzato GT. The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty. Clinics (Sao Paulo, Brazil). 2012;67(9):1053-7. Tai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2011;19(7):1121-30. Smith TO, Hing CB. Should tourniquets be used in upper limb surgery? A systematic review and meta-analysis. Acta orthopaedica Belgica. 2009;75(3):289-96. Kamath K, Kamath SU, Tejaswi P. Incidence and factors influencing tourniquet pain. Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2021;24(5):291-4. Lai YH, Xu H, Su Q, Wan XF, Yuan MC, Zhou ZK. Effect of tourniquet use on blood loss, pain, functional recovery, and complications in robot-assisted total knee arthroplasty: a prospective, double-blinded, randomized controlled trial. Journal of orthopaedic surgery and research. 2022;17(1):118. Guo S. Is Velband still a safe and cost effective skin protection beneath the tourniquet in hand surgery? Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand. 2011;16(1):5-8. Din R, Geddes T. Skin protection beneath the tourniquet. A prospective randomized trial. ANZ journal of surgery. 2004;74(9):721-2. Ahmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson CE, et al. Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. The bone & joint journal. 2021;103-b(5):830-9. Arafah OM, Alotaibi AM, Alsalloum AM, Alotaibi HM. Safety and Blood Loss Associated With Tourniquets in Total Knee Arthroplasty. Cureus. 2021;13(8):e16875. Han J, Zhang XY, Mu SY, Liu SL, Cui QT, Zhang C, et al. Tourniquet application in primary total knee arthroplasty for osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Frontiers in surgery. 2022;9:994795. Zhou K, Ling T, Wang H, Zhou Z, Shen B, Yang J, et al. Influence of tourniquet use in primary total knee arthroplasty with drainage: a prospective randomised controlled trial. Journal of orthopaedic surgery and research. 2017;12(1):172. Ledin H, Aspenberg P, Good L. Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta orthopaedica. 2012;83(5):499-503. Jawhar A, Skeirek D, Stetzelberger V, Kollowa K, Obertacke U. No effect of tourniquet in primary total knee arthroplasty on muscle strength, functional outcome, patient satisfaction and health status: a randomized clinical trial. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2020;28(4):1045-54. Li S, Zhang X, Liu M, Lu Q, Yu Y, Miao Z, et al. Not using a tourniquet is superior to tourniquet use for high tibial osteotomy: a prospective, randomised controlled trial. Int Orthop. 2022;46(4):823-9. Wang L, Zhang Z, Xiong W, Fang Q, Tang Y, Wang G. Impact of tourniquet on short-term outcomes in opening wedge high tibial osteotomy with modern tranexamic acid protocols: a retrospective cohort study. BMC musculoskeletal disorders. 2021;22(1):931. Tang JB, Xing SG, Ayhan E, Hediger S, Huang S. Impact of Wide-Awake Local Anesthesia No Tourniquet on Departmental Settings, Cost, Patient and Surgeon Satisfaction, and Beyond. Hand clinics. 2019;35(1):29-34. Bullens PH, van Loon CJ, de Waal Malefijt MC, Laan RF, Veth RP. Patient satisfaction after total knee arthroplasty: a comparison between subjective and objective outcome assessments. The Journal of arthroplasty. 2001;16(6):740-7. Ahmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson C, et al. Tourniquet use for knee replacement surgery. The Cochrane database of systematic reviews. 2020;12(12):Cd012874. Wang J, Xu W, Lv J. Is It Better to Routinely Use Tourniquet for Knee Arthroscopic Surgery: A Systematic Review and Meta-analysis. The journal of knee surgery. 2020;33(9):866-74. Tai TW, Chang CW, Lai KA, Lin CJ, Yang CY. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial. The Journal of bone and joint surgery American volume. 2012;94(24):2209-15. Zhang C, Yan CH, Chan PK, Fu H, Chiu KY. A Randomized Controlled Study on the Use of Tourniquet in Primary Total Knee Arthroplasty. The journal of knee surgery. 2022;35(6):698-706. Andrade MAP, Monte LFR, Lacerda GC, Dourado TR, Lei P, Abreu ESGM. Are cementation quality and clinical outcomes affected by the use of tourniquet in primary total knee arthroplasty? Archives of orthopaedic and trauma surgery. 2022;142(5):845-50. Nahlieli O, Baruchin AM, Levi D, Shapira Y, Yoffe B. Povidone-iodine related burns. Burns : journal of the International Society for Burn Injuries. 2001;27(2):185-8. Sarkhel T, Stride V. The TourniquAid: prevention of chemical burns. Injury. 2002;33(1):73-4. Tetro AM, Rudan JF. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Canadian journal of surgery Journal canadien de chirurgie. 2001;44(1):33-8. Younger AS, McEwen JA, Inkpen K. Wide contoured thigh cuffs and automated limb occlusion measurement allow lower tourniquet pressures. Clinical orthopaedics and related research. 2004(428):286-93. Hoogeslag RA, Brouwer RW, van Raay JJ. The value of tourniquet use for visibility during arthroscopy of the knee: a double-blind, randomized controlled trial. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2010;26(9 Suppl):S67-72. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 May, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 15 Apr, 2025 Submission checks completed at journal 14 Apr, 2025 First submitted to journal 12 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6050937","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":443122949,"identity":"798899e9-b57d-4934-a856-b0bf4ed6683a","order_by":0,"name":"Soheila Bakhtiari","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Soheila","middleName":"","lastName":"Bakhtiari","suffix":""},{"id":443122951,"identity":"b14c3d86-9c95-4b03-8381-53d4bbe75003","order_by":1,"name":"Mehdi Teimouri","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehdi","middleName":"","lastName":"Teimouri","suffix":""},{"id":443122952,"identity":"a7c6995e-935b-4154-8539-c79b80efe0b8","order_by":2,"name":"Nafise Rahimi","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nafise","middleName":"","lastName":"Rahimi","suffix":""},{"id":443122953,"identity":"ee0b781f-8475-4f76-8cde-5c5508938446","order_by":3,"name":"Mohammad Hassan Bagheri","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Hassan","lastName":"Bagheri","suffix":""},{"id":443122955,"identity":"32cf29d2-2651-4392-8e4d-daef093ba61e","order_by":4,"name":"Sayyed Yazdan Asadi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYJACCShtcOADkGRjJ0XLwRkgLcykaGHmAVGEtBgcP/7wxs8dDPLy7Yc3HrZt2ybPx8zA+OFjDh4tZxKSLXvPMBhuOJNWcDi37bZhGzMDs+TMbXi0HEg4JsHbxsC4gSHHAKSFEaiFjZkXn5bzD9sk/7Yx2M/vf2Nw2LLttj1hLTeS2aSBtiQ23ADawth2O5GgFskbz5itZdskkjfceFZwsOfc7eQ2ZsZmvH7hO5/+8ObbNhvb+f3Jmz/8KLttO7+9+eCHj3i0KBwAU9CoYWQDkw241QOBPKr0H7yKR8EoGAWjYIQCAKuwVA5zaJ5AAAAAAElFTkSuQmCC","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Sayyed","middleName":"Yazdan","lastName":"Asadi","suffix":""}],"badges":[],"createdAt":"2025-02-17 21:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6050937/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6050937/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-025-05903-z","type":"published","date":"2025-05-17T15:58:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81003709,"identity":"68e16843-05d8-4ef2-b698-662df57d541f","added_by":"auto","created_at":"2025-04-21 06:40:27","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68828,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6050937/v1/7a9b6d8f3ce13b4f4cebcb5b.jpeg"},{"id":81004287,"identity":"23aca847-eb5b-4546-be7c-4dda7bb22039","added_by":"auto","created_at":"2025-04-21 06:48:27","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1164902,"visible":true,"origin":"","legend":"\u003cp\u003eThe final product (special waterproof cover under the tourniquet cuff)\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6050937/v1/7378d86bc7195ac33b02ed0a.jpeg"},{"id":83067900,"identity":"82049e8b-3bdd-4e3a-b686-233bfdf0b042","added_by":"auto","created_at":"2025-05-19 16:07:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1872907,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6050937/v1/58b93205-4e74-4e2e-a802-4ed06fec04e2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of a Special Waterproof Layer Under Tourniquet Cuffs on Postoperative Burn Incidence, Pain Intensity, and Operating Room Staff Satisfaction in Knee Arthroscopic Surgeries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKnee arthroscopy is one of the most common orthopedic surgeries, used both for diagnosing and treating intra-articular pathologies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The results of several studies have shown that, theoretically and clinically, the use of a tourniquet can reduce the amount of blood loss in this surgery (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and by improving the surgeon's vision, it leads to a reduction in operation time (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The most common complication of using a tourniquet is pain, which causes discomfort to the patient during the operation and affects the results of the operation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Therefore, it can be said that tourniquet-related complications remain a clinical concern, as the literature shows that postoperative pain is reported in 35.8\u0026ndash;60% of lower extremity surgeries and 51.8\u0026ndash;60% of upper extremity surgeries when swelling lasts longer than 60 minutes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In addition, post-tourniquet syndrome is a common reaction to prolonged limb ischemia in which the patient experiences stiffness and decreased muscle strength, pallor, dry joints, and a tingling sensation. Although this condition interferes with the postoperative physiotherapy program, it usually resolves itself about 24 hours after the surgery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn some studies, researchers considered the cause of such problems in the usual tourniquets to be related to the layers beneath them and advocated for replacing these layers with better materials (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Despite potential benefits in blood loss reduction particularly observed in total knee arthroplasty (TKA), where tourniquets decrease intraoperative blood loss by 138\u0026ndash;544 mL (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), the materials used under tourniquet cuffs may exacerbate complications. The use of conventional cotton padding, including 100% bleached pure cotton Vibril and similar layers under the tourniquet cuff, can lead to leg pain and limb swelling (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), stiffness, delayed recovery of muscle strength, resentment and discomfort (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), necrosis after orthopedic surgeries (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), peeling skin, wound hematoma leading to permanent wound drainage, and an increased risk of subcutaneous infection (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Complaints of thigh pain in patients for whom the usual layers of 100% bleached pure cotton Vibril were used under the tourniquet cuff are probably due to blood congestion and fluid accumulation in the fabric or Vibril tissue under the tourniquet cuff, and as a result, the direct pressure of the tourniquet. This pressure is localized on nerves and soft tissue; the swelling of the limb and the increase in the internal pressure of the soft tissue caused by the reperfusion reaction after releasing the tourniquet may lead to pain in the operative field (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe absence of a specialized protective covering beneath tourniquet cuffs, such as nano products, can result in various complications, increasing patient and hospital treatment costs. Therefore, there is a need to adopt newer, more accessible, and cheaper methods with fewer side effects. As such, there is a pressing need for a protective layer with the following attributes: waterproof and liquid-penetration resistance to prevent fluid accumulation; absorbent properties to manage minimal fluid leakage and prevent burns; and the ability to reduce pain and mitigate back syndrome (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother issue is the satisfaction of personnel in cases involving the use of a tourniquet and its different types. The satisfaction of personnel with the tools and materials used in the work environment facilitates the improvement of the existing situation and enhances the efficiency of personnel in providing better medical care. In the meantime, the satisfaction of operating room personnel with the tools used in surgery is of great importance, as by facilitating the surgical process, it forms the basis for improving surgical outcomes and, as a result, reducing potential complications caused by surgery (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsidering the fact that the leakage of liquids, especially blood, under the tourniquet in orthopedic surgery is very dangerous and in some cases causes various complications (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), and considering the role of operating room technicians in maintaining hemodynamics during surgery and providing solutions to prevent bleeding or its aggravation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), it seems necessary to design and replace a protective covering under the tourniquet. First of all, it should have waterproof and liquid-penetration properties, which, in the first place, will prevent water penetration and accumulation under the cuff. Secondly, it should have the property of absorbing liquids, which, in case of possible and minimal passage of liquids, will quickly absorb them and prevent the accumulation of liquids and burns in this area. Thirdly, it should prevent the complications caused by the tourniquet, especially pain and back syndrome. High availability, reasonable price, ease of use, and high effectiveness should be other features of this tool. The absence of such a cover can harm the patient by causing the various complications mentioned, and therefore, increase the costs of treating the patient and the hospital.\u003c/p\u003e \u003cp\u003eFor the mentioned reasons, we decided to use a special waterproof drape under the tourniquet in orthopedic surgeries to more accurately measure its possible side effects on the patient. This study addresses two underexplored aspects of tourniquet use: 1- the role of interface materials in preventing cutaneous complications and improving patient outcomes, and 2- the impact of equipment design on operating room workflow. We hypothesize that a waterproof absorbent layer beneath the tourniquet cuff will reduce postoperative burn incidence by 40%, decrease pain scores on the visual analog scale by \u0026ge;\u0026thinsp;2 points, and increase staff satisfaction ratings by 30% compared to conventional cotton padding. By systematically evaluating both clinical outcomes and ergonomic factors, this investigation aims to provide evidence-based recommendations for optimizing tourniquet use in ambulatory orthopedic procedures. It should be noted that this waterproof cover was designed and approved by the researcher of this project in another study.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis randomized clinical trial study was conducted in the form of a randomized clinical trial with a blind statistical analyzer. The statistical population of this study included all patients undergoing arthroscopic surgery of the knee joint in the operating rooms of selected hospitals of Isfahan University of Medical Sciences in 2022, who met the inclusion criteria. Inclusion criteria included: 18 years of age or older, informed consent, arthroscopic knee surgery requiring the use of a tourniquet, non-emergency surgery, no fractures in other body parts, and no history of illness. Cardiovascular conditions such as congestive heart failure, cardiac arrhythmias, high blood pressure, diabetes, non-drug use or continuous alcohol or cigarette consumption of more than 5 packs per year, no chest, head, or abdominal trauma, no need for other surgeries, and not suffering from coagulation diseases or requiring anticoagulant drugs.\u003c/p\u003e\n\u003cp\u003eAfter obtaining the approval of the ethics committee and registering the proposal in the Iranian Clinical Trial Center (IRCT), sampling was done by random allocation. In this way, patients operated on even days were in the Group A (17 people), and patients operated on odd days were in the Group B (17 people). At a coordinated time and place, and in person, the demographic information checklist (age, gender, and body mass index) was completed using clinical records. In the Group A, the tourniquet used was an inflatable tourniquet, beneath which four layers of Vibril made of 100% pure cotton were used to protect the skin. The construction of the waterproof cover for the tourniquet under the cuff was completed according to the functional plan below.\u003c/p\u003e\n\u003cp\u003eAccording to Figure 1, the waterproof cover for the tourniquet included two main parts, as follows:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePart 1: Inner layer\u003c/strong\u003e This part is made of liquid-absorbing foam, which, in addition to being highly impermeable compared to the usual materials used in tourniquets (Vibril), has high absorption power for fluids. This layer effectively absorbed the small amounts of fluid that passed through and prevented their excessive accumulation under the tourniquet, thereby avoiding complications caused by these accumulations. This part was used in a rectangular shape with dimensions of 70 \u0026times; 17 cm and was marked with the number \u0026quot;1\u0026quot; in the plan shown below (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePart 2: Outer layer\u003c/strong\u003e In this part, two layers of adhesive were used as follows to create maximum adhesion to the patient\u0026apos;s body, prevent liquids from penetrating, and avoid excessive sensitivity to the patient\u0026apos;s skin:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eA: Waterproof glue\u003c/strong\u003e This glue is resistant and does not lose its effectiveness when wet by fluids at the surgical site. Additionally, it largely prevents the penetration of these fluids beneath the tourniquet. This part was placed in rectangles with dimensions of 80 \u0026times; 2 cm and 21 \u0026times; 10 cm around the inner layer (Part 1). In this way, two rectangular layers with dimensions of 80 \u0026times; 2 cm surrounded the lengths of the inner layer (Part 1), and two rectangular layers with dimensions of 21 \u0026times; 10 cm surrounded the widths of the inner layer. This arrangement is marked with the number \u0026quot;2\u0026quot; in the plan shown below (Figure 1).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eA: Wicker glue\u003c/strong\u003e This glue was used to strengthen the existing connections and reinforce the inner layer on the patient\u0026apos;s skin and under the tourniquet. Furthermore, due to its hypoallergenic properties, it prevented complications in cases of prolonged connections, ensuring no long-term damage to the patient\u0026apos;s skin. This part was also arranged as rectangles with dimensions of 80 \u0026times; 2 cm and 21 \u0026times; 10 cm around the inner layer (Part 1). Two rectangular layers with dimensions of 80 \u0026times; 2 cm surrounded the lengths of the inner layer (Part 1), and two rectangular layers with dimensions of 21 \u0026times; 10 cm surrounded the widths of the inner layer. This arrangement is marked with the number \u0026quot;2\u0026quot; in the plan shown below (Figure 1), surrounding the waterproof adhesive.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAfter creating the waterproof cover for the tourniquet, its effectiveness and resistance were tested on the moulage with an outer layer of natural leather. To test and examine the product, after using the specially designed waterproof cover under the tourniquet, the final product was placed in close proximity to drinking water for 30 minutes. Finally, through observation and assessment of the amount of water penetration and accumulation under the tourniquet, its efficiency was verified and confirmed.\u003c/p\u003e\n\u003cp\u003eIt should be noted that this waterproof drape was produced and approved during another independent study at the research center of the Faculty of Nursing and Midwifery of Isfahan University of Medical Sciences, with the ethics code IR.ARI.MUI.REC.1400.080.\u003c/p\u003e\n\u003cp\u003eThe tourniquet pressure in all patients was set at 150 mm Hg above the systolic pressure (270 to 300 mm Hg) (1). Immediately after the surgery, the duration of the operation was recorded. Then, in the first 24 hours after entering recovery, the patients were examined by the researcher in terms of the amount of pain (using the VAS scale, immediately, and every 8 hours after entering recovery). In this scale, the patient scored the intensity of their pain from 0 (no pain) to 10 (highest pain intensity) (1, 25).\u003c/p\u003e\n\u003cp\u003eThe severity of the burn, in the first 24 hours after entering recovery, was assessed by the researcher based on the following grading system, through observation and registration in the relevant checklist:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFirst degree\u003c/strong\u003e: Involvement of the epidermis; red skin without blisters.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSecond degree\u003c/strong\u003e:\u003cul type=\"circle\"\u003e\n \u003cli\u003e\u003cem\u003eSuperficial involvement of the dermis\u003c/em\u003e: Red skin without blisters, which turns white when pressed.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eDeep involvement of the dermis\u003c/em\u003e: Red skin with blisters.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eThird degree\u003c/strong\u003e: Involvement of the entire skin; hard and white skin.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFourth degree\u003c/strong\u003e: Involvement of the entire skin and underlying muscle and bone layers; black and dry skin.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTo measure the satisfaction of the operating room personnel, the standard personnel satisfaction questionnaire containing 10 items was used. The scoring of these items was done using a 5-point Likert scale (very low: 1 point, low: 2 points, medium: 3 points, high: 4 points, very high: 5 points). Scores between 10 and 15 were considered as low satisfaction, scores between 16 and 34 as medium satisfaction, and scores between 35 and 50 as high satisfaction. The validity and reliability of this questionnaire were confirmed using similar studies, the opinions of professors and experts, and a previously confirmed correlation coefficient close to 0.1 (21). This questionnaire was completed by the researcher in the operating room after the surgery.\u003c/p\u003e\n\u003cp\u003eIt should be noted that all measurements and data recording were conducted by one researcher, and all surgical procedures were performed by one orthopedic surgeon and a single team using anesthesia.\u003c/p\u003e\n\u003cp\u003eFinally, the data were analyzed using the Kolmogorov-Smirnov, t, Mann-Whitney, and chi-square tests, with Statistical Package for the Social Sciences (SPSS) version 25.0 software and Stata software version 2.9 (Stata Corp., College Station, TX, USA). In all tests, the confidence level was 95%, and the significance level was set at less than 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the Group A compared to the Group B, age (32.94 \u0026plusmn; 4.37 vs. 33.71 \u0026plusmn; 4.67 years; P = 0.605) and BMI (28.59 \u0026plusmn; 2.21 vs. 28.94 \u0026plusmn; 2.73 kg/m\u0026sup2;; P = 0.399) showed no significant differences. Most of the participants in the Group A (70.6%) and the Group B (64.7%) were men. There was no significant difference between genders (P = 0.714) (Table 1).\u003c/p\u003e\n\u003cp\u003eThe mean and standard deviation of the duration of surgery for patients in the Group A was 135.59 \u0026plusmn; 12.73 minutes, and in the Group B, it was 135.59 \u0026plusmn; 12.73 minutes; this difference was not significant (P = 0.476). According to Table 2, the intensity of pain in the Group A compared to the Group B at all times\u0026mdash;immediately after entering recovery, the first eight hours after entering recovery, the second eight hours after entering recovery, and the third eight hours after entering recovery\u0026mdash;was lower.\u003c/p\u003e\n\u003cp\u003eIn Table 2, the distribution of the severity of burns caused by the use of tourniquets in the studied groups is presented. Based on this data, none of the participants in the Group A suffered burns. Only one participant (5.9%) in the Group B suffered burns, which was a first-degree burn. There was no statistically significant difference in the severity of burns between the studied groups (P = 0.5).\u003c/p\u003e\n\u003cp\u003eThe mean and standard deviation of operating room personnel satisfaction with the special drape under the tourniquet used in this study was 41.71 \u0026plusmn; 1.61 (out of 50 points). All operating room personnel (100%) reported a \u0026quot;high\u0026quot; level of satisfaction with the special drape under the tourniquet used in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Demographic characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e \u003cstrong\u003eA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e \u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eAge (year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e18 - 29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e30 - 59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e76.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e76.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e70.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e64.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eBMI (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e18.5-24.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e52.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.581\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e25-29.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e47.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e30\u0026nbsp;\u0026le;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e17.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNotes: BMI, body mass index; *Chi-Square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Dependent variables\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"668\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003emean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003emean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eDuration of surgery (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026le; 135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e58.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e0.303\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e135 \u0026lt;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e58.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePain (VAS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eImmediately\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026gt;\u003c/span\u003e 0.001\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003efirst 8 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026gt;\u003c/span\u003e 0.001\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003esecond 8 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e5.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026gt;\u003c/span\u003e 0.001\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ethird 8 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026gt;\u003c/span\u003e 0.001\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eBurn severity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eGrade 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e0.5\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eGrade 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e94.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNotes: BMI, body mass index; SD, standard deviation; *Chi-Square test; **Mann-Whitney test; **Fisher\u0026apos;s exact test\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSince the use of a tourniquet and the usual layers beneath it in arthroscopic surgeries of the knee joint can be associated with complications such as burns and pain intensity after the operation, and, as a result, dissatisfaction among the operating room personnel, we decided to take a step toward increasing the effectiveness of tourniquets and reducing the human and financial costs caused by the complications of using tourniquets by designing a special tourniquet drape. Therefore, the aim of the present study was to investigate the effect of using a special tourniquet on the incidence of burns, the intensity of pain after the operation, and the satisfaction level of operating room personnel in arthroscopic surgeries of the knee joint in selected hospitals of Isfahan University of Medical Sciences in 2022.\u003c/p\u003e \u003cp\u003eAs mentioned before, one of the side effects of using a tourniquet in surgery, especially arthroscopic surgery of the knee joint, is pain. In this context, the results of the present study showed that the intensity of pain in the Group A with a special tourniquet at all times\u0026mdash;immediately after entering recovery, the first eight hours after entering recovery, the second eight hours after entering recovery, and the third eight hours after entering recovery\u0026mdash;was less than the Group B. Therefore, the use of a special tourniquet (designed by the researcher in a separate study) may be effective in controlling the pain caused by its use.\u003c/p\u003e \u003cp\u003eA tourniquet was used in arthroscopic surgery of the knee joint. Considering the number of reported cases of pain caused by tourniquets in surgical operations, the use of a special tourniquet drape could be a new step in solving this common complication in surgical operations. In the same context, Lai et al. (2022) in China investigated the effect of tourniquet use on postoperative pain, blood loss, recovery, and tourniquet burns in knee arthroscopy. In this study, patients who were candidates for knee arthroscopy were randomly divided into two groups of 14 people, with and without tourniquet use. The results showed that the intensity of pain after surgery was significantly higher in the tourniquet group (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Ahmed et al. (2020) observed that the application of tourniquets in knee surgical procedures is frequently associated with an increase in postoperative pain. However, their findings also highlighted that adjustments aimed at minimizing ischemia or reducing pressure may alleviate such adverse effects (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Similarly, Wang et al. (2020) reported decreased analgesic use in arthroscopic procedures conducted without tourniquets, providing indirect support for the conclusion that enhanced tourniquet designs can contribute to pain reduction (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn another study, Tai et al. (2012) in Taiwan investigated the effect of tourniquet use on blood loss and soft tissue damage in total knee arthroplasty surgery. In this randomized controlled clinical trial study, 72 patients undergoing total knee arthroplasty surgery were randomly divided into groups with and without tourniquet use, and the results showed that back pain and postoperative pain were more severe in the tourniquet group. In other words, the use of a tourniquet increased postoperative pain (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to arthroscopic surgeries of the knee joint, this finding has also been observed in other surgeries. For example, in a study, Wang et al. (2021) in China investigated the effect of tourniquets on the short-term outcomes of osteotomy. All patients were divided into two groups based on whether or not a tourniquet was used during the procedure. The results of this study showed that, in terms of early recovery after surgery, the use of a tourniquet significantly increased the pain score and decreased the range of motion of the knee on the first and second days after surgery (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf course, in a number of studies, the effect of using a tourniquet and its various types on pain caused by surgery has not been fully confirmed. For example, Zhang et al. (2022) in China investigated the use of tourniquets in primary total knee arthroplasty. In this study, patients who underwent total knee arthroplasty were randomly assigned to one of three groups: Group A used a tourniquet from the time of skin incision until the hardening of the cement; Group B used a tourniquet only at the time of cement hardening; and Group C used a tourniquet from the time of skin incision until the skin was closed. The results of this study showed that there was no statistically significant difference in pain intensity among any of the studied groups (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlso, in another study, Andrade et al. (2022) in Brazil addressed whether the quality of primary total knee arthroplasty surgery and the resulting clinical outcomes are affected by the use of tourniquets. In this randomized clinical trial, 50 patients were randomly divided into two groups: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) a tourniquet was used during all surgical procedures, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) a tourniquet was used only during skin incision and cement application. The results of this study did not show any significant difference in pain intensity between the two groups (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The reason for these contradictory results could be related to differences in how research units were investigated and the statistical sample sizes of the different studies.\u003c/p\u003e \u003cp\u003eAnother reported complication related to the use of tourniquets in arthroscopic surgeries of the knee joint is the local burn caused by the tourniquet. Regarding this issue, the results of the present study showed that although none of the participants in the Group A with a special tourniquet drape suffered burns caused by the use of tourniquets, there was no statistically significant difference in the severity of burns between the both groups. This lack of significance could, of course, be related to the small sample size of our study. It is possible that by increasing the sample size and conducting the study on a wider scale, a significant statistical difference could be reported in this regard.\u003c/p\u003e \u003cp\u003eHowever, the low prevalence of burns caused by tourniquets in this study is an important finding and a strong point for using a special tourniquet drape. This is because, in other studies, burns have been identified as an important and common complication of tourniquet use during surgery. The results of other studies have also shown that the layer beneath the tourniquet is important for preventing the leakage of washing liquid under the tourniquet, as such leakage may cause severe skin reactions, local burns, and even the loss of part or all of the skin. This risk is much higher in children and elderly individuals, and it occurs more commonly with solutions containing alcohol (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOther authors have suggested using a sterile towel, a piece of plastic, or even a surgical glove or pre-made devices pushed under the tourniquet to prevent burns caused by the tourniquet. However, these methods are incomplete and require more modern solutions (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). This is a topic that has been well addressed in the present study. With the design and use of a special tourniquet drape, none of the participants in the Group A experienced burns caused by the tourniquet. This highlights the importance and high efficiency of the special tourniquet drape. Lai et al. (2022) in China investigated the effect of tourniquet use on post-surgery pain, blood loss, recovery, and burns at the tourniquet site in knee arthroscopy and concluded that burns at the site where the tourniquet was applied are an important and common complication (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf course, in a contradictory study, Li et al. (2021) in China investigated the effect of using tourniquets in orthopedic surgeries. In this randomized controlled trial, patients were randomly divided into two groups: using a tourniquet and not using a tourniquet. The results showed that there was no difference in the occurrence of complications such as burns between the two investigated groups (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These differences could be due to variations in the tools and methods of measuring burn severity, as well as the demographic differences of the patients investigated in different studies.\u003c/p\u003e \u003cp\u003eIn addition to the reduction of side effects (pain and burns), another important parameter that can indicate the efficiency of the tool used is the satisfaction of personnel with using that tool. In this regard, the findings of the upcoming study showed that all operating room personnel (100%) reported a \"high\" level of satisfaction with the special drape under the tourniquet used in this study. Another positive aspect of using this drape in arthroscopic knee surgeries is that, in other studies; most operating room personnel were not satisfied due to issues such as the difficulty of applying the usual layers under the tourniquet or the occurrence of numerous complications related to it, especially pain and burns. For example, in the study of Lai et al. (2022) in China, by examining the effect of tourniquet use on post-surgery pain, blood loss, recovery, and tourniquet burns in knee arthroscopy, they concluded that the use of tourniquets during knee arthroscopy increased postoperative pain and prolonged postoperative recovery, thus causing dissatisfaction among the surgeon, operating room personnel, and patients (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf course, some studies have also stated that the use of tourniquets has no effect on the satisfaction of operating room personnel. For example, Jawhar et al. (2020) in Germany investigated the effect of tourniquet use in knee arthroplasty on the satisfaction of operating room personnel, muscle strength, and joint function of the patient after surgery. The results showed no difference in any of these parameters, especially the satisfaction of the operating room personnel, between the two groups (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). These contradictions could be due to the demographic differences of the research units in different studies, as well as differences in the statistical sample sizes of various studies (\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlong with the strengths of this research, this study, like any other study, also had some limitations. One of these limitations is the relatively small volume of statistical samples, which is due to the limited cases of knee arthroscopy or the use of tourniquets in selected hospitals in Isfahan. Due to the limitations of our center, we were unable to include more participants than the number specified in our article. Despite this constraint, we ensured that the study was conducted with meticulous attention to detail, and we believe the findings obtained are both robust and valuable. In future studies, we will strive to include a larger sample size to further strengthen the validity and generalizability of our results. Additionally, there are certainly many known and unknown factors that may have influenced the results of this study. Future studies on wider statistical populations will help clarify these factors further.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the findings of this study demonstrate that utilizing a specially designed waterproof drape under tourniquet cuffs during knee arthroscopic surgeries significantly reduces postoperative pain intensity and enhances operating room staff satisfaction. Additionally, the incidence of local burns associated with tourniquet use was notably limited in the Group A. Compared to conventional Vibril layers, using a special drape or waterproof cover presents several advantages. Its cost-effectiveness, accessibility, and ease of production make it a practical alternative. Conventional Vibril layers, often used under the tourniquet, can be both costly and potentially unsafe. From an economic perspective, the special cover used in this study offers a more affordable option. Additionally, the simplicity of its production makes it widely accessible, aligning with the high demand and promising outcomes observed. Its potential to mitigate complications, enhance efficiency, and simplify surgical procedures supports broader adoption in clinical settings. Considering its high market demand and demonstrated benefits, further large-scale studies are encouraged to confirm these results and explore the full scope of its advantages.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVisual Analogue Scale (VAS), Iranian Clinical Trial Center (IRCT)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Isfahan University of Medical Sciences, Isfahan, Iran.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone; The authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors are aware of and have provided their consent for the publication of this manuscript. Patients entered our study with full awareness and informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical issues\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis waterproof drape was developed and validated as part of a separate independent study conducted at the research center of the Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences. Furthermore, this approval is reinforced by the issuance of the ethical code IR.ARI.MUI.REC.1400.080 and the formal registration of the study with the Iranian Registry of Clinical Trials, under the registration number IRCT20220718055487N1.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.B. and M.T. designed the study and conducted the experiments. N.R. analyzed the data and contributed to the methodology. M.H.B. provided additional insights and contributed to the manuscript\u0026apos;s writing. S.Y.A. is the corresponding author and oversaw the entire project. All authors reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePinsornsak P, Pinitchanon P, Boontanapibul K. Effect of Different Tourniquet Pressure on Postoperative Pain and Complications After Total Knee Arthroplasty: A Prospective, Randomized Controlled Trial. The Journal of arthroplasty. 2021;36(5):1638-44.\u003c/li\u003e\n\u003cli\u003eCirocchi R, Prigorschi D, Properzi L, Matteucci M, Duro F, Tebala GD, et al. Is the Use of Tourniquets More Advantageous than Other Bleeding Control Techniques in Patients with Limb Hemorrhage? A Systematic Review and Meta-Analysis. Medicina (Kaunas, Lithuania). 2025;61(1).\u003c/li\u003e\n\u003cli\u003eSobhan MR, Saeed Banadaky, Seyed Hossein, Shafiee M, Gheisari M. Evaluation of the Results of Arthroscopic Release in Limits of Movement in Knees %J The Journal of Shahid Sadoughi University of Medical Sciences. 2020;27(9):1886-92.\u003c/li\u003e\n\u003cli\u003eFarhan-Alanie MM, Dhaif F, Trompeter A, Underwood M, Yeung J, Parsons N, et al. The risks associated with tourniquet use in lower limb trauma surgery: a systematic review and meta-analysis. European journal of orthopaedic surgery \u0026amp; traumatology : orthopedie traumatologie. 2021;31(5):967-79.\u003c/li\u003e\n\u003cli\u003eNeufeld ME, McEwen JA, Kerr J, Sidhu A, Howard LC, Masri BA. Optimization of surgical tourniquet usage to improve patient outcomes: Translational cross-disciplinary implications of a surgical practice survey. Frontiers in surgery. 2023;10:1104603.\u003c/li\u003e\n\u003cli\u003eZhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. Journal of orthopaedic surgery and research. 2014;9(1):13.\u003c/li\u003e\n\u003cli\u003eRosenstein AD, Michelov YA, Thompson S, Kaye AD. Benefits of Limited Use of a Tourniquet Combined With Intravenous Tranexamic Acid During Total Knee Arthroplasty. Ochsner journal. 2016;16(4):443-9.\u003c/li\u003e\n\u003cli\u003eYavarikia A, Amjad GG, Davoudpour K. The influence of tourniquet use and timing of its release on blood loss in total knee arthroplasty. Pakistan journal of biological sciences : PJBS. 2010;13(5):249-52.\u003c/li\u003e\n\u003cli\u003eHernandez AJ, Almeida AM, F\u0026aacute;varo E, Sguizzato GT. The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty. Clinics (Sao Paulo, Brazil). 2012;67(9):1053-7.\u003c/li\u003e\n\u003cli\u003eTai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2011;19(7):1121-30.\u003c/li\u003e\n\u003cli\u003eSmith TO, Hing CB. Should tourniquets be used in upper limb surgery? A systematic review and meta-analysis. Acta orthopaedica Belgica. 2009;75(3):289-96.\u003c/li\u003e\n\u003cli\u003eKamath K, Kamath SU, Tejaswi P. Incidence and factors influencing tourniquet pain. Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2021;24(5):291-4.\u003c/li\u003e\n\u003cli\u003eLai YH, Xu H, Su Q, Wan XF, Yuan MC, Zhou ZK. Effect of tourniquet use on blood loss, pain, functional recovery, and complications in robot-assisted total knee arthroplasty: a prospective, double-blinded, randomized controlled trial. Journal of orthopaedic surgery and research. 2022;17(1):118.\u003c/li\u003e\n\u003cli\u003eGuo S. Is Velband still a safe and cost effective skin protection beneath the tourniquet in hand surgery? Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand. 2011;16(1):5-8.\u003c/li\u003e\n\u003cli\u003eDin R, Geddes T. Skin protection beneath the tourniquet. A prospective randomized trial. ANZ journal of surgery. 2004;74(9):721-2.\u003c/li\u003e\n\u003cli\u003eAhmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson CE, et al. Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. The bone \u0026amp; joint journal. 2021;103-b(5):830-9.\u003c/li\u003e\n\u003cli\u003eArafah OM, Alotaibi AM, Alsalloum AM, Alotaibi HM. Safety and Blood Loss Associated With Tourniquets in Total Knee Arthroplasty. Cureus. 2021;13(8):e16875.\u003c/li\u003e\n\u003cli\u003eHan J, Zhang XY, Mu SY, Liu SL, Cui QT, Zhang C, et al. Tourniquet application in primary total knee arthroplasty for osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Frontiers in surgery. 2022;9:994795.\u003c/li\u003e\n\u003cli\u003eZhou K, Ling T, Wang H, Zhou Z, Shen B, Yang J, et al. Influence of tourniquet use in primary total knee arthroplasty with drainage: a prospective randomised controlled trial. Journal of orthopaedic surgery and research. 2017;12(1):172.\u003c/li\u003e\n\u003cli\u003eLedin H, Aspenberg P, Good L. Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta orthopaedica. 2012;83(5):499-503.\u003c/li\u003e\n\u003cli\u003eJawhar A, Skeirek D, Stetzelberger V, Kollowa K, Obertacke U. No effect of tourniquet in primary total knee arthroplasty on muscle strength, functional outcome, patient satisfaction and health status: a randomized clinical trial. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2020;28(4):1045-54.\u003c/li\u003e\n\u003cli\u003eLi S, Zhang X, Liu M, Lu Q, Yu Y, Miao Z, et al. Not using a tourniquet is superior to tourniquet use for high tibial osteotomy: a prospective, randomised controlled trial. Int Orthop. 2022;46(4):823-9.\u003c/li\u003e\n\u003cli\u003eWang L, Zhang Z, Xiong W, Fang Q, Tang Y, Wang G. Impact of tourniquet on short-term outcomes in opening wedge high tibial osteotomy with modern tranexamic acid protocols: a retrospective cohort study. BMC musculoskeletal disorders. 2021;22(1):931.\u003c/li\u003e\n\u003cli\u003eTang JB, Xing SG, Ayhan E, Hediger S, Huang S. Impact of Wide-Awake Local Anesthesia No Tourniquet on Departmental Settings, Cost, Patient and Surgeon Satisfaction, and Beyond. Hand clinics. 2019;35(1):29-34.\u003c/li\u003e\n\u003cli\u003eBullens PH, van Loon CJ, de Waal Malefijt MC, Laan RF, Veth RP. Patient satisfaction after total knee arthroplasty: a comparison between subjective and objective outcome assessments. The Journal of arthroplasty. 2001;16(6):740-7.\u003c/li\u003e\n\u003cli\u003eAhmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson C, et al. Tourniquet use for knee replacement surgery. The Cochrane database of systematic reviews. 2020;12(12):Cd012874.\u003c/li\u003e\n\u003cli\u003eWang J, Xu W, Lv J. Is It Better to Routinely Use Tourniquet for Knee Arthroscopic Surgery: A Systematic Review and Meta-analysis. The journal of knee surgery. 2020;33(9):866-74.\u003c/li\u003e\n\u003cli\u003eTai TW, Chang CW, Lai KA, Lin CJ, Yang CY. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial. The Journal of bone and joint surgery American volume. 2012;94(24):2209-15.\u003c/li\u003e\n\u003cli\u003eZhang C, Yan CH, Chan PK, Fu H, Chiu KY. A Randomized Controlled Study on the Use of Tourniquet in Primary Total Knee Arthroplasty. The journal of knee surgery. 2022;35(6):698-706.\u003c/li\u003e\n\u003cli\u003eAndrade MAP, Monte LFR, Lacerda GC, Dourado TR, Lei P, Abreu ESGM. Are cementation quality and clinical outcomes affected by the use of tourniquet in primary total knee arthroplasty? Archives of orthopaedic and trauma surgery. 2022;142(5):845-50.\u003c/li\u003e\n\u003cli\u003eNahlieli O, Baruchin AM, Levi D, Shapira Y, Yoffe B. Povidone-iodine related burns. Burns : journal of the International Society for Burn Injuries. 2001;27(2):185-8.\u003c/li\u003e\n\u003cli\u003eSarkhel T, Stride V. The TourniquAid: prevention of chemical burns. Injury. 2002;33(1):73-4.\u003c/li\u003e\n\u003cli\u003eTetro AM, Rudan JF. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Canadian journal of surgery Journal canadien de chirurgie. 2001;44(1):33-8.\u003c/li\u003e\n\u003cli\u003eYounger AS, McEwen JA, Inkpen K. Wide contoured thigh cuffs and automated limb occlusion measurement allow lower tourniquet pressures. Clinical orthopaedics and related research. 2004(428):286-93.\u003c/li\u003e\n\u003cli\u003eHoogeslag RA, Brouwer RW, van Raay JJ. The value of tourniquet use for visibility during arthroscopy of the knee: a double-blind, randomized controlled trial. Arthroscopy : the journal of arthroscopic \u0026amp; related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2010;26(9 Suppl):S67-72.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Arthroscopy, knee, tourniquet","lastPublishedDoi":"10.21203/rs.3.rs-6050937/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6050937/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e The use of multiple layers of Vibril under tourniquet cuffs is common. However, these layers can lead to complications. We designed a special waterproof curtain for use under tourniquet cuffs. Its effects on burns, postoperative pain, and operating room staff satisfaction were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials \u0026amp; Methods:\u003c/strong\u003e In this randomized clinical trial study, 34 patients underwent arthroscopic surgery of the knee joint in the operating rooms of selected hospitals of Isfahan University of Medical Sciences in 2022, using a simple random method based on the day. Even and odd days were divided into two groups: Group A (even days: special tourniquet drape: 17 people) and Group B (odd days: usual layers under the tourniquet cuff: 17 people). The degree of pain was evaluated with a visual analogue scale (VAS), the severity of burns was evaluated based on a rating from one to four, and the satisfaction of the operating room personnel was evaluated using a standardized questionnaire with 10 questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Pain intensity in the Group A, compared to the Group B, at all times was lower: immediately after entering recovery (2.29 ± 0.47 vs. 5.00 ± 0.71, P \u0026lt; 0.001), during the first eight hours (1.71 ± 0.47 vs. 3.94 ± 0.56, P \u0026lt; 0.001), the second eight hours (2.82 ± 0.73 vs. 5.12 ± 0.45, P \u0026lt; 0.001), and the third eight hours (1.65 ± 0.61 vs. 3.59 ± 0.62, P \u0026lt; 0.001). None of the participants in the Group A and only one participant (5.9%) in the Group B suffered burns, a difference that was not significant (P = 0.500). All operating room personnel (100%) reported a \"high\" level of satisfaction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e It seems that the use of a special tourniquet in arthroscopic surgeries of the knee joint has a positive effect, considering the reduction of postoperative pain and the increase in the satisfaction of the operating room personnel.\u003c/p\u003e","manuscriptTitle":"Impact of a Special Waterproof Layer Under Tourniquet Cuffs on Postoperative Burn Incidence, Pain Intensity, and Operating Room Staff Satisfaction in Knee Arthroscopic Surgeries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 06:40:22","doi":"10.21203/rs.3.rs-6050937/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-15T08:03:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-14T11:28:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2025-04-12T20:04:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ae0a8ef-3e98-4db9-8f35-9fb24293139d","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T16:03:01+00:00","versionOfRecord":{"articleIdentity":"rs-6050937","link":"https://doi.org/10.1186/s13018-025-05903-z","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2025-05-17 15:58:05","publishedOnDateReadable":"May 17th, 2025"},"versionCreatedAt":"2025-04-21 06:40:22","video":"","vorDoi":"10.1186/s13018-025-05903-z","vorDoiUrl":"https://doi.org/10.1186/s13018-025-05903-z","workflowStages":[]},"version":"v1","identity":"rs-6050937","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6050937","identity":"rs-6050937","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}