Non-Tourniquet Strategy with High-Position Low-Perfusion in Distal Humeral Fracture Surgery: Reduces Swelling Without Increasing Blood Loss

Non-Tourniquet Strategy with High-Position Low-Perfusion in Distal Humeral Fracture Surgery: Reduces Swelling Without Increasing Blood Loss | 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 Non-Tourniquet Strategy with High-Position Low-Perfusion in Distal Humeral Fracture Surgery: Reduces Swelling Without Increasing Blood Loss Zhimeng Wang, Xianjie Ai, Taotao Ren, Bo Wu, Kun Zhang, Zhong Li, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9028011/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Introduction: To evaluate the feasibility of non-tourniquet strategy combined with “High-position Low-Perfusion” positioning in distal humeral fractures ORIF (DHF-ORIF), and to investigate its effects on perioperative blood loss, postoperative rehabilitation, and functional outcomes. Methods Prospective inclusion of patients aged 18–45 with distal humeral fractures, randomly divided into an experimental group without tourniquets (Group A) and a control group with traditional tourniquets (Group B). The Group A adopted a lateral position with high and low perfusion of the affected limb, and received intravenous injection of TXA (15 mg/kg) combined with continuous flushing with 4 ℃ physiological saline during the operation; The control group received routine use of tourniquets. Primary Outcomes: perioperative blood loss, elbow ROM and degree of limb swelling. Secondary Outcomes: Postoperative VAS scorMayo elbow joint score and DASH score, and incidence of complications. Results No significant difference was observed in total perioperative blood loss between the Group A and the Group B (240.78 mL vs. 228.53 mL, p > 0.05). However, the Group A demonstrated significantly reduced postoperative drainage volume and hidden blood loss (p < 0.05). The Group A exhibited significantly superior outcomes in terms of VAS scores and limb swelling, compared with the control group. Additionally, elbow ROM improvement was more significant at 2–4 weeks and 2 months postoperatively in the Group A. At the 6-month follow-up, the Group A showed significantly higher Mayo scores (89.78 ± 11.89 vs. 83.55 ± 16.29) compared with the control group (p = 0.036). Furthermore, the Group A had significantly lower wound complication rates and shorter hospital stays (7.25 ± 1.53 vs. 8.11 ± 2.34 days, p = 0.037). Conclusion The non-tourniquet strategy combined with “High-position Low-Perfusion” positioning is safe and effective for DHF-ORIF. It effectively controls postoperative swelling and pain without increasing perioperative blood loss, leading to improved clinical outcomes and quality of life. Humeral fractures Intra-articular fractures Tourniquet Rehabilitation Surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Since Harvey Cushing first introduced pneumatic tourniquets into limb orthopedic surgery in 1904, they have played a crucial role in such procedures 1 , 2 . The introduction of pneumatic tourniquet aims to maintain a relatively bloodless field during extremity surgery, minimize blood loss, aid identification of vital structures, and expedite the procedure. However, with the widespread use of tourniquets, surgeons have realized that this is not a perfect solution as they may induce ischemia-reperfusion injury, delayed muscle strength recovery, compressive nerve loss, potentially infected wound hematoma, vascular injury, tissue necrosis, and compartment syndrome, among other adverse outcomes 3 , 4 . Following the success of wide-awake local anaesthesia without tourniquet (WALANT) in hand surgery 5 , an increasing number of centres have abandoned tourniquet use during total knee arthroplasty (TKA) without increasing peri-operative blood loss while maintaining favourable clinical outcomes 6 – 8 . A meta-analysis suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively 9 .Complex distal humeral fractures (AO/OTA C2–C3) are notoriously challenging to manage. In our clinical impression suggests that routine use of a pneumatic tourniquet exacerbates post-operative myalgia and swelling formation, thereby diminishing early elbow range of motion and exerting a protracted, adverse effect on both functional recovery and patient-reported physical and mental health. We hypothesize that distal humeral fracture open reduction and internal fixation (DHF-ORIF) performed without a pneumatic tourniquet will yield superior functional outcomes and improved quality of life without a clinically relevant increase in peri-operative blood loss. Materials and methods A single-surgeon group, randomized, patient- and assessor-blinded (physiotherapist) controlled trial was performed between March 2023 and January 2025. Participants were allocated to either the tourniquet or non-tourniquet group using a computer-generated random number table. The research was carried out in accordance with the Declaration of Helsinki's guiding principles and received approval from the hospital ethics committee (No. 202303003). All participants gave their permission in writing after being fully informed. This prospective randomized controlled study was registered in the Chinese Clinical Trial Registry (28/12/2017, ChiCTR-INC-17014197) and conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement Patients Recruited patients were aged 18–45 years, presented with DHFs and were scheduled for ORIF. Exclusion criteria were: (1) contraindication or allergy to tranexamic acid (TXA); (2) injury-to-surgery interval > 3 weeks; (3) prior elbow fracture, post-traumatic arthritis, rheumatoid arthritis, or osteoarthritis; (4) multiple trauma, open fracture, or concomitant neurovascular injury; (5) BMI > 30 kg/ m² or abnormal muscle mass (e.g., competitive athletes); and (6) incomplete outpatient follow-up data. Furthermore, after randomization but prior to the induction of anesthesia, the surgeon may exclude any patient from the trial for medical reasons; this decision is at the surgeon sole discretion. Surgical Technique, Material Selection and Perioperative Management Prior to 2023, tourniquet application was standard practice for all distal humeral fracture open reduction and internal fixation (DHF-ORIF) procedures in our centre. Consequently, before trial initiation, the surgical team—comprising one senior orthopedic surgeon and two assistants—completed a structured training programe focused on tourniquet-free ORIF techniques. The tourniquet group underwent surgery with a tourniquet (24 inches, single-bladder, dual-port, Zimmer) applied 2–5 cm proximal to the axilla at a pressure of 200 mmHg and the other group underwent surgery without a tourniquet. All patients received general anesthesia under light-to-moderate sedation, combined with a brachial plexus block for intraoperative anesthetic supplementation and postoperative analgesia. Patients were positioned in the lateral decubitus orientation. The surgery was performed via the posterior midline elbow approach in the standard lateral decubitus position, with the affected limb elevated above cardiac level to reduce perfusion pressure (high position low perfusion). The ulnar nerve was routinely exposed and decompressed. Intraoperatively, the primary surgeon individualized the decision to perform an olecranon V-shaped osteotomy based on the specific fracture configuration. Following evacuation of the hematoma and debris, the articular surface was fixed with Kirschner wires (K-wires) or lag screws. Subsequently, internal fixation of the medial and lateral columns of the distal humerus was performed using an anatomical locking compression plate (LCP). A single closed-suction drain was placed in the surgical site postoperatively. In the non-tourniquet cohort, the surgical field was continuously irrigated with 4°C saline throughout the procedure. Intravenous tranexamic acid (TXA, 15mg/Kg) was administered 10 minutes prior to incision in the non-tourniquet group. Prophylactic cefuroxime sodium (1.5 g IV) was administered preoperatively and twice postoperatively; Mannitol (125 mL IV) was administered twice daily during the perioperative period. The postoperative regimen included scheduled celecoxib (200 mg orally twice daily), topical cryotherapy (ice pack application), and oral oxycodone (5 mg) administered as needed for breakthrough pain. Postoperative day 1, the patient underwent rehabilitation training under the supervision of a physiotherapist, including active assistance, active range of motion exercises, and reinforcement exercises until discharge followed. A home-based exercise program followed. Data collection The primary outcome measures were perioperative blood loss (PBL), Hb decrease, postoperative swelling, and active flexion of the elbow joint. • The calculation of PBL was based on the classic Nalder 10 and Gross 11 equations, which have been used in our previous studies. The specific calculation steps are as follows: PBV (L) = K 1 × h 3 + K 2 × w + K 3 [h: height (m), w: weight (kg)]; male patients K 1 = 0.366 9, K 2 = 0.032 19, K 3 = 0.604 1; female patients K 1 = 0.356 1, K 2 = 0.033 08, K 3 = 0.183 319. PBL(mL) = PBV×(Hct 1 - Hct 2 )+Hb trans . Hct 1 is the first routine blood test after the patient admitted to the hospital; Hct 2 is the lowest postoperative value obtained by routine blood tests. • Bilateral elbow circumference was measured to assess swelling. Measurements were taken with a measuring tape at a standardized point 10 cm proximal to the antecubital crease while patients were positioned supine. The difference between the affected and unaffected sides was used to quantify the degree of swelling. Measurements were recorded preoperatively and postoperatively on days 3, 7, 14, and 30. • Active elbow flexion and extension were measured using a standard plastic goniometer with 1° increment markings and 30 cm arms. Patients were positioned supine on an examination table during measurements. Outcome measurements were collected at 2 weeks, 4 weeks, and 2 months postoperatively. All measurements were performed by three independent physical therapists from our institution. To enhance measurement reliability, the physical therapists underwent standardized training prior to study initiation and throughout the data collection period. Secondary outcomes included perioperative pain scores, upper extremity deep venous thrombosis (UEDVT), wound complications, and short-term clinical outcomes. • Perioperative pain was assessed using a Visual Analog Scale (VAS). Measurements were obtained preoperatively, and on postoperative day (POD) #1, POD#3, POD#5, POD#14, and POD#30. All assessments were conducted prior to rehabilitation sessions, with patients at rest and without administration of additional analgesic agents. • Postoperative duplex ultrasonography was routinely performed. Patients with UEDVT received oral Rivaroxaban (10 mg twice daily), with unrestricted active and passive elbow joint movement permitted. • Functional outcomes and quality of life were evaluated by physical therapists at 6-month follow-ups using: (1) the Mayo Elbow Performance Score (MEPS) for elbow-specific function, and (2) the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for upper extremity disability. Statistical analysis SPSS version 22.0 was used for all statistical analyses (IBM Corp., Armonk, NY, USA). To compare continuous factors, Mann-Whitney U or t-tests were used to show continuous variables as mean± standard deviation (SD). Comparations were made using the Chi-square or Fisher's exact test, as applicable, and discrete variables were shown as frequencies with percentages. P values < 0.05 were considered to be statistically significant. Results Patient clinical and demographic information A total of 71 participants were enrolled in this study, with the selection process detailed in the CONSORT flow diagram (Fig. 1 ). The cohort had a mean age of 38.11 ± 7.17 years (range: 22–45 years), comprising 37 males (52.11%) and 34 females (47.89%). The mean BMI was 25.34 ± 4.47 kg/m². Comorbidities were present in 12 patients (16.90%). According to the AO/OTA classification system, 39 fractures (54.93%) were classified as type 13-C2 and 32 (45.07%) as type 13-C3 (Details in Table 1 ). Table 1 Preoperative patient characteristics and surgery-related characteristics Varibles Non-tourniquet Tourniquet P -value Gender Female 19 15 0.128 Male 14 23 Age (years) 37.78 ± 6.73 38.41 ± 7.35 0.354 BMI (kg/m2) 26.80 ± 4.47 26.12 ± 5.54 0.285 Smoke 7 11 0.455 Alcoholism 3 2 0.530 Injury mechanism High energy 13 19 0.370 Low energy 20 19 Medical morbidity Hypertension 2 1 0.474 Diabetes 1 2 0.641 Chronic heart disease 0 1 0.348 Chronic respiratory disease 1 0 0.280 Liver disease 1 1 0.919 Renal disease 0 1 0.348 Comorbidities number 0 28 33 0.810 1–2 5 5 AO/OTA 13-C2 17 22 0.590 I3-C3 16 16 Hb (g/L) 127.22 ± 10.32 126.71 ± 8.52 0.411 Olecranon Osteotomy 7 9 0.804 Duration of surgery 110.55 ± 25.71 106.51 ± 17.17 0.223 Duration of the bloodless field(min) - 57.29 ± 15.45 - Abbreviations: BMI, Body mass index; ASA, Hb, Hemoglobin. Primary Outcomes Non-tourniquet use did not significantly increase perioperative blood loss or reduce Hb levels (P > 0.05) (Details in Table 2 and Figure 2) .All patients developed swelling by postoperative day 1 (POD#1), but the non-tourniquet group showed significantly accelerated resolution from POD#3 onward (Figure 3). Moreover, the non-tourniquet group achieved significantly greater elbow range of motion (ROM) at 2 weeks, 4 weeks, and 2 months postoperatively. Table 2.The primary outcomes Non-tourniquet Tourniquet P -value Hb (g/L) POD#1 121.55±8.16 122.73±7.71 0.266 POD#3 120.64±5.51 122.14±6.09 0.141 Hb drop (g/L) 6.14±2.21 6.05±1.12 0.413 Elbow ROM 2 weeks Flexion 105.11°±17.54° 90.37°±24.45° <0.001 Extension 30.60°±17.41° 44.44°±21.17° 0.002 Pronation 44.73°±16.52° 40.98°±17.41° 0.207 Supination 50.53°±14.49° 47.93°±16.77° 0.245 4 weeks Flexion 110.27°±22.53° 104.23°±27.67° 0.160 Extension 24.14°±16.91° 38.11°±25.85° 0.008 Pronation 48.42°±11.87° 46.14°±16.75° 0.258 Supination 55.54°±7.27° 50.15°±13.73° 0.024 2 months Flexion 120.54°±15.73° 110.10°±18.22° 0.006 Extension 17.84°±15.35° 26.47°±18.46° 0.018 Pronation 68.50°±15.63° 57.97°±13.27° 0.001 Supination 72.55°±15.40° 67.91°±19.74° 0.139 Abbreviations: PBL, perioperative blood loss; ROM, range of motion; POD#1, the first postoperative day; POD#3, the third postoperative day. Note: Elbow ROM was measured under resting conditions without prior administration of oral analgesic medication. Secondary outcomes Patients in the non-tourniquet group demonstrated significantly lower early postoperative pain scores compared to the tourniquet group, with a progressive decline observed over the initial follow-up period. Wound complications were significantly more prevalent in the tourniquet group (6.06% vs. 13.16%, p <0.05), with blister formation being the predominant adverse event (n=3, 4.23%). Furthermore, three patients in the tourniquet group developed confirmed UEDVT postoperatively. At the 6-month outpatient follow-up, analysis of standardized questionnaires revealed that the tourniquet-free group achieved significantly superior clinical outcomes and quality of life scores compared to the control group. (Details in Table 3) Table 3. The secondary outcomes Non-tourniquet Tourniquet P -value VAS Preoperative 4.44±1.49 4.51±1.77 0.429 0.256 0.099 POD#1 5.43±2.01 5.77±2.31 POD#3 4.88±1.79 5.41±1.65 POD#7 4.57±2.18 4.86±1.78 0.269 POD#14 4.43±2.21 4.61±1.51 0.343 POD#30 3.13±1.78 3.57±1.88 0.316 Wound complications 0.317 Blister 1 3 - Dehiscence 0 1 - Hematoma 1 1 - Edgenecrosis 0 0 - Superficial infection 0 0 - UEDVT* 0 1 0.347 MEP Score Pain 39.63±10.14 35.77±14.48 0.102 Motion 19.34±1.17 16.16±4.77 <0.001 Stability 10.00±0.00 10.00±0.00 - Function 22.61±2.74 18.78±7.24 0.002 Total 89.78±11.89 83.55±16.29 0.036 DASH scores 15.88±10.51 20.79±17.77 0.084 Length of stay 7.25 ± 1.53 8.11 ± 2.34 0.037 Abbreviations: VAS, Visual analog scale score MEP; UEDVT, Upper extremity deep venous thrombosis; Mayo elbow performance, DASH: Disabilities of the Arm, Shoulder and Hand. Postoperative upper limb duplex ultrasound examination showed the presence of brachial vein thrombosis. Our Vascular Medicine department recommends starting anticoagulation therapy was initiated with enoxaparin 40 mg subcutaneously once daily for two days followed by rivaroxaban 15 mg twice daily for 21 days. Postoperative rehabilitation program with early passive range of motion followed by gradual transition to active range of motion and strength training with physical therapy There were no recurrent thromboembolic events or any complications of anticoagulant therapy observed during the 30 day postoperative follow-up. Discussion The primary finding of this study is that abandoning traditional tourniquet use during distal humeral fracture (DHF) surgery did not increase perioperative blood loss. The tourniquet-free strategy demonstrated significant advantages in early postoperative pain control and limb swelling management, factors directly related to patient comfort and the initiation of early rehabilitation. Furthermore, this approach yielded satisfactory clinical outcomes and functional scores. Traditional orthopedic practice has long advocated the use of tourniquets in limb surgery, mainly based on their established efficacy in reducing intraoperative blood loss and optimizing the surgical area 12 . Supporters argue that the bloodless surgical field created by tourniquets can promote precise anatomical reduction of fractures and precise placement of prostheses/implants, theoretically reducing blood loss and shortening surgical time 13,14 . However, these conclusions mainly stem from surgeon-centered clinical studies, whose core limitations lie in the systematic neglect of tourniquet related complications (such as nerve damage, compartment syndrome, thromboembolic events) and patient subjective experiences (such as increased postoperative pain, limb numbness).It is worth noting that these overlooked complications and patient perceptions are key factors affecting long-term clinical outcomes, including delayed functional recovery, prolonged hospitalization, and decreased patient satisfaction 15,16 . In this study, the group without tourniquet received intravenous infusion of TXA during surgery and continuous irrigation of the surgical field with cold saline (4°C). The perioperative and blood loss was comparable to that of the tourniquet group (240.78 vs. 228.53 mL; P >0.05).Notably, postoperative drainage and hidden blood loss were significantly lower in the non-tourniquet group than in the tourniquet group. Additionally, patients in the non-tourniquet group experienced milder limb swelling. These data indirectly suggest that the tourniquet-free strategy offers significant advantages in mitigating postoperative soft tissue ischemia-reperfusion injury, a finding also reported by Xie et al. in a total knee arthroplasty (TKA) meta-analysis of randomized controlled 17 . In clinical practice, the first two weeks post-surgery are considered a critical window for functional exercise after DHF-ORIF, and early elbow range of motion (ROM) is a key predictor of clinical outcomes 18-20 . These findings suggest that effective control of pain and swelling not only improves perioperative comfort but also reduces patient apprehension toward postoperative rehabilitation, which is crucial for facilitating early active and passive functional exercises. At the 6-month follow-up, patients in the non-tourniquet group demonstrated superior functional and quality-of-life (QoL) scores. In the study cohort (aged 18-45 years), patients demonstrated significantly greater needs for functional independence and social participation compared to older populations，and most younger patients are in critical career development phases, delayed postoperative functional recovery directly disrupts employment continuity 21,22 . Furthermore, limited social activities and perceived disability significantly increase the risk of anxiety and depression, posing a significant adverse impact on patients’ physical and psychological recovery 23-25 . These outcomes have been systematically overlooked in previous surgeon centered studies, but they are precisely the primary criteria for evaluating surgical success in middle-aged and young patients. To address the potential negative impact of tourniquets, researchers have proposed a series of exploratory studies such as personalized inflation pressure protocols 26 , intermittent tourniquet application 27 , intraoperative silicone tourniquets 28 , and prophylactic oral melatonin administration 29 et al, but their actual clinical effects remains to be definitively established. The Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique has gained widespread adoption in contemporary orthopedic practice and has been successfully applied to ORIF of olecranon 30 , distal radius 31 , clavicle 32 , ankle fractures 33 . It is considered an excellent alternative to local tourniquet, with or without sedation or general anesthesia, and can achieve satisfactory comfort without increasing hospitalization costs 34 . However, applying tourniquet-free techniques to distal humerus ORIF presents formidable challenges, primarily due to the complex three-dimensional anatomy of the elbow and the demanding requirements for surgical exposure. While this approach aligns with the core principles of WALANT—mitigating tourniquet-induced pain and swelling, and facilitating early rehabilitation—its adoption in mainstream practice remains limited. Despite these challenges, our study still highlights several innovative aspects recommending. First, all patients were positioned in the lateral decubitus position, with the affected limb maintained in a “High-position Low-Perfusion” state. Second, a dual-modality hemostatic protocol was implemented: intravenous TXA (15 mg/kg) combined with topical irrigation using 4°C cold saline to minimize intraoperative bleeding. Third, we leveraged an Internet-based hospital platform to facilitate seamless interdisciplinary communication among surgeons, therapists, and patients, enabling the delivery of individualized rehabilitation protocols and real-time guidance on functional exercises. This study has several limitations. First, its single-center, small sample size may limit the generalizability of our findings. Second, the tourniquet-free technique has a learning curve; potential improvements in surgical proficiency throughout the study period could have introduced performance bias. Third, the control group exclusively consisted of patients undergoing general anesthesia with a tourniquet. Consequently, further studies are warranted to evaluate the efficacy of the tourniquet-free strategy when combined with regional or local anesthesia. Finally, we did not analyze inflammatory markers (e.g., WBC, NEUT%, CRP, IL-6), which will be a focus of our future investigations. Conclusion The strategy of non- tourniquet uses a “High position-Low perfusion” and TXA+ low-temperature saline dual-mode hemostasis to ensure perioperative hemostasis while significantly reducing postoperative pain, swelling, accelerating elbow joint function recovery, and improving patients' quality of life. This technology avoids the risk of complications related to tourniquets, meets the core needs of middle-aged and young patients for functional independence and early return to society, and is suitable for the cost control and quality improvement goals of China's DRG/DIP payment reform. Abbreviations VAS, Visual analog scale; PBL, perioperative blood loss; BMI, Body mass index; DASH, Disabilities of the Arm, Shoulder and Hand; ROM, range of motion; TXA, tranexamic acid. Declarations Data Sharing Statement Data is available on reasonable request via contacting the corresponding authors (Ming Li or Qian Wang Funding statement No funding was received for the project. Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the Xi’an Honghui hospital Ethics Committee, reference number 202303003. All participants provided written informed consent to participate. They were informed about the study’s purpose, procedures, potential risks, and benefits. Participants were assured that participation was voluntary and that they could withdraw at any time without any consequences. All images have been completely anonymized through cropping and composition to prevent identification of any individual. Disclosure The authors report no conflicts of interest in this work. References Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. J Am Acad Orthop Surg. 2001;9:345–51. 10.5435/00124635-200109000-00008 . Estebe JP, Davies JM, Richebe P. The pneumatic tourniquet: mechanical, ischaemia-reperfusion and systemic effects. 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Effect of Preoperative Administration of Oral Melatonin on Pneumatic Tourniquet-Induced Ischemia-Reperfusion Injury in Orthopedic Surgery of Lower Extremities: A Randomized Clinical Trial. Iran J Med Sci. 2022;47:123–30. 10.30476/ijms.2021.86960.1701 . Folberg CR, Alves JAO, Pereira FMS, Rabuske WBS. Wide-Awake Olecranon Fracture Fixation: Is it Possible? J hand Surg global online. 2023;5:201–5. 10.1016/j.jhsg.2022.12.006 . Huang YC, et al. WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet. J Orthop Surg Res. 2018;13:195. 10.1186/s13018-018-0903-1 . Ahmad AA, Mustapa Kamal U, Ruslan MA, Abdullah SR, S., Ahmad AR. Plating of clavicle fracture using the wide-awake technique. J Shoulder Elbow Surg. 2020;29:2319–25. 10.1016/j.jse.2020.03.003 . Li YS, et al. Open reduction and internal fixation of ankle fracture using wide-awake local anaesthesia no tourniquet technique. Injury. 2019;50:990–4. 10.1016/j.injury.2019.03.011 . Van Demark RE Jr., Smith VJS, Fiegen A. Lean and Green Hand Surgery. J Hand Surg. 2018;43:179–81. 10.1016/j.jhsa.2017.11.007 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 10 May, 2026 Reviews received at journal 09 May, 2026 Reviews received at journal 20 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviews received at journal 16 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 19 Mar, 2026 Editor assigned by journal 16 Mar, 2026 Submission checks completed at journal 09 Mar, 2026 First submitted to journal 04 Mar, 2026 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-9028011","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610311107,"identity":"a89d6863-c9b7-483d-be88-36c10170361b","order_by":0,"name":"Zhimeng Wang","email":"","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhimeng","middleName":"","lastName":"Wang","suffix":""},{"id":610311108,"identity":"a4f2b86f-dc46-4c80-8fcd-362c97fac165","order_by":1,"name":"Xianjie Ai","email":"","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xianjie","middleName":"","lastName":"Ai","suffix":""},{"id":610311109,"identity":"e6689896-83e0-4336-8e33-2e37f12ded68","order_by":2,"name":"Taotao Ren","email":"","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":false,"prefix":"","firstName":"Taotao","middleName":"","lastName":"Ren","suffix":""},{"id":610311110,"identity":"adf3b575-6b36-4ef8-aee2-4bdb798db05c","order_by":3,"name":"Bo Wu","email":"","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Wu","suffix":""},{"id":610311111,"identity":"7ffb7d11-f699-4d45-bdff-3d017c4db945","order_by":4,"name":"Kun Zhang","email":"","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kun","middleName":"","lastName":"Zhang","suffix":""},{"id":610311112,"identity":"c2aa6dcc-44fd-42b7-8ac3-56890b5abe4f","order_by":5,"name":"Zhong Li","email":"","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhong","middleName":"","lastName":"Li","suffix":""},{"id":610311113,"identity":"dc6dbf60-5936-4c7f-a298-ca8c0afc7ddc","order_by":6,"name":"Hanzhong Xue","email":"","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hanzhong","middleName":"","lastName":"Xue","suffix":""},{"id":610311114,"identity":"7bce3353-12fd-4a0e-824e-90b68cf0cb8e","order_by":7,"name":"Ming Li","email":"","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Li","suffix":""},{"id":610311115,"identity":"5322c753-9db1-49fe-9a97-6976b8a7ca03","order_by":8,"name":"Qian Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYBACNvnHBx98qLDhYWNmbHyQUFFDWAsfQ1qy4YwzaXL87M3NBg/OHCOsRY4hR02at+2QsWTP8TbJhy3MRDiM4QyDNA/bgcQNNxLbKhIb2Bj427sT8Gth7D1gOIfnDljLjcQdMgwSZ85uwK+FmS8h4Y3EM6iWM2wMBhK5BLSw8Rgc4DE4DNZSkNjGTIQWHh7DRp6Ew0DvH2xjIE6LBFsy44wDoEBubJZIOHOMh6Bf5GcwH//x8R8oKtkffvxRUSPH396LXwsG4CFN+SgYBaNgFIwCrAAAp7lOtyVsDPsAAAAASUVORK5CYII=","orcid":"","institution":"Xi'an Honghui Hospital","correspondingAuthor":true,"prefix":"","firstName":"Qian","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-03-04 08:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9028011/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9028011/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105320928,"identity":"41bc3cec-c725-47a1-8bdb-b6635b1dad82","added_by":"auto","created_at":"2026-03-24 17:19:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":434172,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCONSORT flow diagram of patients eligible for this study.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-9028011/v1/88375c10d4d3b13b50df3d84.png"},{"id":105565315,"identity":"772ed090-979f-4641-9f70-0119de29f211","added_by":"auto","created_at":"2026-03-27 12:52:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":197676,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eComparison of Perioperative Blood Loss Between the Non-tourniquet and Tourniquet Groups.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAbbreviations: PBL, perioperative blood loss; IBL, Intraoperative blood loss; HBL, Hidden blood loss; DV,Drainage volume\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-9028011/v1/c0fc54b88e93dce769243366.png"},{"id":105320927,"identity":"1a3bf06a-353b-4a71-b325-2ec5c7859ef6","added_by":"auto","created_at":"2026-03-24 17:19:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":422744,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePerioperative arm circumference and swelling of the affected limb\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNote: Swelling severity was stratified by arm circumference difference: mild (1–3 cm), moderate (3–5 cm), and severe (\u0026gt;5 cm) compared to the contralateral limb.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-9028011/v1/1c267f8b3ec77b93ca2fc3c4.png"},{"id":105320929,"identity":"bf9e8689-64b1-4272-8b67-8d2b2aca2ca3","added_by":"auto","created_at":"2026-03-24 17:19:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":4841594,"visible":true,"origin":"","legend":"\u003cp\u003eA representative case of a 28-year-old female who underwent ORIF for an AO/OTA 13-C3 distal humeral fracture. The surgery was performed using a non-tourniquet strategy combined with “High-position Low-Perfusion” positioning and a dual-modality hemostatic protocol (intravenous TXA and low-temperature saline irrigation). Postoperatively, the patient received remote rehabilitation guidance and performed family-supervised exercises for the affected limb (Figure 4-a), achieving satisfactory clinical outcomes at the 2-week (Figure 4-b), 4-week (Figure 4-c), and 2-month (Figure 4-d) follow-up. The patient initiated active and passive functional exercises on postoperative day 1, with swelling markedly reduced by day 5 (Figure 4-e).\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-9028011/v1/1507f5ea59663ad70049bc35.png"},{"id":105569494,"identity":"c453fb2d-f8f8-4114-a0a5-69403f08f878","added_by":"auto","created_at":"2026-03-27 13:12:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6517930,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9028011/v1/68883fcb-15d2-4f39-98ed-4cb0214af63f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Non-Tourniquet Strategy with High-Position Low-Perfusion in Distal Humeral Fracture Surgery: Reduces Swelling Without Increasing Blood Loss","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince Harvey Cushing first introduced pneumatic tourniquets into limb orthopedic surgery in 1904, they have played a crucial role in such procedures\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The introduction of pneumatic tourniquet aims to maintain a relatively bloodless field during extremity surgery, minimize blood loss, aid identification of vital structures, and expedite the procedure. However, with the widespread use of tourniquets, surgeons have realized that this is not a perfect solution as they may induce ischemia-reperfusion injury, delayed muscle strength recovery, compressive nerve loss, potentially infected wound hematoma, vascular injury, tissue necrosis, and compartment syndrome, among other adverse outcomes\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFollowing the success of wide-awake local anaesthesia without tourniquet (WALANT) in hand surgery\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, an increasing number of centres have abandoned tourniquet use during total knee arthroplasty (TKA) without increasing peri-operative blood loss while maintaining favourable clinical outcomes\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. A meta-analysis suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.Complex distal humeral fractures (AO/OTA C2\u0026ndash;C3) are notoriously challenging to manage. In our clinical impression suggests that routine use of a pneumatic tourniquet exacerbates post-operative myalgia and swelling formation, thereby diminishing early elbow range of motion and exerting a protracted, adverse effect on both functional recovery and patient-reported physical and mental health.\u003c/p\u003e \u003cp\u003eWe hypothesize that distal humeral fracture open reduction and internal fixation (DHF-ORIF) performed without a pneumatic tourniquet will yield superior functional outcomes and improved quality of life without a clinically relevant increase in peri-operative blood loss.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA single-surgeon group, randomized, patient- and assessor-blinded (physiotherapist) controlled trial was performed between March 2023 and January 2025. Participants were allocated to either the tourniquet or non-tourniquet group using a computer-generated random number table. The research was carried out in accordance with the Declaration of Helsinki's guiding principles and received approval from the hospital ethics committee (No. 202303003). All participants gave their permission in writing after being fully informed. This prospective randomized controlled study was registered in the Chinese Clinical Trial Registry (28/12/2017, ChiCTR-INC-17014197) and conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eRecruited patients were aged 18\u0026ndash;45 years, presented with DHFs and were scheduled for ORIF. Exclusion criteria were: (1) contraindication or allergy to tranexamic acid (TXA); (2) injury-to-surgery interval\u0026thinsp;\u0026gt;\u0026thinsp;3 weeks; (3) prior elbow fracture, post-traumatic arthritis, rheumatoid arthritis, or osteoarthritis; (4) multiple trauma, open fracture, or concomitant neurovascular injury; (5) BMI\u0026thinsp;\u0026gt;\u0026thinsp;30 kg/ m\u0026sup2; or abnormal muscle mass (e.g., competitive athletes); and (6) incomplete outpatient follow-up data. Furthermore, after randomization but prior to the induction of anesthesia, the surgeon may exclude any patient from the trial for medical reasons; this decision is at the surgeon sole discretion.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Technique, Material Selection and Perioperative Management\u003c/h3\u003e\n\u003cp\u003ePrior to 2023, tourniquet application was standard practice for all distal humeral fracture open reduction and internal fixation (DHF-ORIF) procedures in our centre. Consequently, before trial initiation, the surgical team\u0026mdash;comprising one senior orthopedic surgeon and two assistants\u0026mdash;completed a structured training programe focused on tourniquet-free ORIF techniques.\u003c/p\u003e \u003cp\u003eThe tourniquet group underwent surgery with a tourniquet (24 inches, single-bladder, dual-port, Zimmer) applied 2\u0026ndash;5 cm proximal to the axilla at a pressure of 200 mmHg and the other group underwent surgery without a tourniquet. All patients received general anesthesia under light-to-moderate sedation, combined with a brachial plexus block for intraoperative anesthetic supplementation and postoperative analgesia. Patients were positioned in the lateral decubitus orientation. The surgery was performed via the posterior midline elbow approach in the standard lateral decubitus position, with the affected limb elevated above cardiac level to reduce perfusion pressure (high position low perfusion). The ulnar nerve was routinely exposed and decompressed. Intraoperatively, the primary surgeon individualized the decision to perform an olecranon V-shaped osteotomy based on the specific fracture configuration. Following evacuation of the hematoma and debris, the articular surface was fixed with Kirschner wires (K-wires) or lag screws. Subsequently, internal fixation of the medial and lateral columns of the distal humerus was performed using an anatomical locking compression plate (LCP). A single closed-suction drain was placed in the surgical site postoperatively.\u003c/p\u003e \u003cp\u003eIn the non-tourniquet cohort, the surgical field was continuously irrigated with 4\u0026deg;C saline throughout the procedure. Intravenous tranexamic acid (TXA, 15mg/Kg) was administered 10 minutes prior to incision in the non-tourniquet group. Prophylactic cefuroxime sodium (1.5 g IV) was administered preoperatively and twice postoperatively; Mannitol (125 mL IV) was administered twice daily during the perioperative period. The postoperative regimen included scheduled celecoxib (200 mg orally twice daily), topical cryotherapy (ice pack application), and oral oxycodone (5 mg) administered as needed for breakthrough pain. Postoperative day 1, the patient underwent rehabilitation training under the supervision of a physiotherapist, including active assistance, active range of motion exercises, and reinforcement exercises until discharge followed. A home-based exercise program followed.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe primary outcome measures were perioperative blood loss (PBL), Hb decrease, postoperative swelling, and active flexion of the elbow joint.\u003c/p\u003e\n\u003cp\u003e\u0026bull; The calculation of PBL was based on the classic Nalder\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and Gross\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e equations, which have been used in our previous studies. The specific calculation steps are as follows:\u003c/p\u003e\n\u003cp\u003ePBV (L) = K\u003csub\u003e1\u003c/sub\u003e \u0026times; h\u003csup\u003e3\u003c/sup\u003e\u0026thinsp;+\u0026thinsp;K\u003csub\u003e2\u003c/sub\u003e \u0026times; w\u0026thinsp;+\u0026thinsp;K\u003csub\u003e3\u003c/sub\u003e [h: height (m), w: weight (kg)];\u003c/p\u003e\n\u003cp\u003emale patients K\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.366 9, K\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.032 19, K\u003csub\u003e3\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.604 1;\u003c/p\u003e\n\u003cp\u003efemale patients K\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.356 1, K\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.033 08, K\u003csub\u003e3\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.183 319.\u003c/p\u003e\n\u003cp\u003ePBL(mL)\u0026thinsp;=\u0026thinsp;PBV\u0026times;(Hct\u003csub\u003e1\u003c/sub\u003e- Hct\u003csub\u003e2\u003c/sub\u003e)+Hb\u003csub\u003etrans\u003c/sub\u003e.\u003c/p\u003e\n\u003cp\u003eHct\u003csub\u003e1\u003c/sub\u003e is the first routine blood test after the patient admitted to the hospital; Hct\u003csub\u003e2\u003c/sub\u003e is the lowest postoperative value obtained by routine blood tests.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Bilateral elbow circumference was measured to assess swelling. Measurements were taken with a measuring tape at a standardized point 10 cm proximal to the antecubital crease while patients were positioned supine. The difference between the affected and unaffected sides was used to quantify the degree of swelling. Measurements were recorded preoperatively and postoperatively on days 3, 7, 14, and 30.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Active elbow flexion and extension were measured using a standard plastic goniometer with 1\u0026deg; increment markings and 30 cm arms. Patients were positioned supine on an examination table during measurements. Outcome measurements were collected at 2 weeks, 4 weeks, and 2 months postoperatively. All measurements were performed by three independent physical therapists from our institution. To enhance measurement reliability, the physical therapists underwent standardized training prior to study initiation and throughout the data collection period.\u003c/p\u003e\n\u003cp\u003eSecondary outcomes included perioperative pain scores, upper extremity deep venous thrombosis (UEDVT), wound complications, and short-term clinical outcomes.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Perioperative pain was assessed using a Visual Analog Scale (VAS). Measurements were obtained preoperatively, and on postoperative day (POD) #1, POD#3, POD#5, POD#14, and POD#30. All assessments were conducted prior to rehabilitation sessions, with patients at rest and without administration of additional analgesic agents.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Postoperative duplex ultrasonography was routinely performed. Patients with UEDVT received oral Rivaroxaban (10 mg twice daily), with unrestricted active and passive elbow joint movement permitted.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Functional outcomes and quality of life were evaluated by physical therapists at 6-month follow-ups using: (1) the Mayo Elbow Performance Score (MEPS) for elbow-specific function, and (2) the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for upper extremity disability.\u003c/p\u003e\n\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eSPSS version 22.0 was used for all statistical analyses (IBM Corp., Armonk, NY, USA). To compare continuous factors, Mann-Whitney U or t-tests were used to show continuous variables as mean\u0026plusmn; standard deviation (SD). Comparations were made using the Chi-square or Fisher\u0026apos;s exact test, as applicable, and discrete variables were shown as frequencies with percentages. P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered to be statistically significant.\u003c/p\u003e\n"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient clinical and demographic information\u003c/h2\u003e \u003cp\u003eA total of 71 participants were enrolled in this study, with the selection process detailed in the CONSORT flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The cohort had a mean age of 38.11\u0026thinsp;\u0026plusmn;\u0026thinsp;7.17 years (range: 22\u0026ndash;45 years), comprising 37 males (52.11%) and 34 females (47.89%). The mean BMI was 25.34\u0026thinsp;\u0026plusmn;\u0026thinsp;4.47 kg/m\u0026sup2;. Comorbidities were present in 12 patients (16.90%). According to the AO/OTA classification system, 39 fractures (54.93%) were classified as type 13-C2 and 32 (45.07%) as type 13-C3 (Details in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative patient characteristics and surgery-related characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaribles\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-tourniquet\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTourniquet\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.128\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.78\u0026thinsp;\u0026plusmn;\u0026thinsp;6.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.354\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.80\u0026thinsp;\u0026plusmn;\u0026thinsp;4.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.12\u0026thinsp;\u0026plusmn;\u0026thinsp;5.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.285\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoke\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.455\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcoholism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.530\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjury mechanism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh energy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow energy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedical morbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.474\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic respiratory disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.919\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities number\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAO/OTA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13-C2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.590\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI3-C3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHb (g/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127.22\u0026thinsp;\u0026plusmn;\u0026thinsp;10.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126.71\u0026thinsp;\u0026plusmn;\u0026thinsp;8.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.411\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOlecranon Osteotomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.804\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110.55\u0026thinsp;\u0026plusmn;\u0026thinsp;25.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106.51\u0026thinsp;\u0026plusmn;\u0026thinsp;17.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of the bloodless field(min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.29\u0026thinsp;\u0026plusmn;\u0026thinsp;15.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\u003cp\u003eAbbreviations: BMI, Body mass index; ASA, Hb, Hemoglobin.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePrimary Outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-tourniquet use did not significantly increase perioperative blood loss or reduce Hb levels (P \u0026gt; 0.05) (Details in Table 2 and Figure 2) .All patients developed swelling by postoperative day 1 (POD#1), but the non-tourniquet group showed significantly accelerated resolution from POD#3 onward (Figure 3). Moreover, the non-tourniquet group achieved significantly greater elbow range of motion (ROM) at 2 weeks, 4 weeks, and 2 months postoperatively.\u003c/p\u003e\n\u003cp\u003eTable 2.The primary outcomes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-tourniquet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTourniquet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\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 style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHb (g/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u0026nbsp;POD#1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e121.55\u0026plusmn;8.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e122.73\u0026plusmn;7.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u0026nbsp;POD#3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e120.64\u0026plusmn;5.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e122.14\u0026plusmn;6.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHb drop\u003c/strong\u003e (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e6.14\u0026plusmn;2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e6.05\u0026plusmn;1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.413\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElbow ROM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e \u003cstrong\u003e2 weeks\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e105.11\u0026deg;\u0026plusmn;17.54\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e90.37\u0026deg;\u0026plusmn;24.45\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Extension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e30.60\u0026deg;\u0026plusmn;17.41\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e44.44\u0026deg;\u0026plusmn;21.17\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Pronation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e44.73\u0026deg;\u0026plusmn;16.52\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e40.98\u0026deg;\u0026plusmn;17.41\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.207\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Supination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e50.53\u0026deg;\u0026plusmn;14.49\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e47.93\u0026deg;\u0026plusmn;16.77\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 4 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFlexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e110.27\u0026deg;\u0026plusmn;22.53\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e104.23\u0026deg;\u0026plusmn;27.67\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.160\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eExtension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e24.14\u0026deg;\u0026plusmn;16.91\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e38.11\u0026deg;\u0026plusmn;25.85\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePronation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e48.42\u0026deg;\u0026plusmn;11.87\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e46.14\u0026deg;\u0026plusmn;16.75\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSupination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e55.54\u0026deg;\u0026plusmn;7.27\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e50.15\u0026deg;\u0026plusmn;13.73\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 2 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFlexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e120.54\u0026deg;\u0026plusmn;15.73\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e110.10\u0026deg;\u0026plusmn;18.22\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eExtension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e17.84\u0026deg;\u0026plusmn;15.35\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e26.47\u0026deg;\u0026plusmn;18.46\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePronation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e68.50\u0026deg;\u0026plusmn;15.63\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e57.97\u0026deg;\u0026plusmn;13.27\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 45.3608%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e Supination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.6804%;\"\u003e\n \u003cp\u003e72.55\u0026deg;\u0026plusmn;15.40\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.5876%;\"\u003e\n \u003cp\u003e67.91\u0026deg;\u0026plusmn;19.74\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3711%;\"\u003e\n \u003cp\u003e0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: PBL, perioperative blood loss; ROM, range of motion; POD#1, the first postoperative day; POD#3, the third postoperative day.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNote: Elbow ROM was measured under resting conditions without prior administration of oral analgesic medication.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eSecondary outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients in the non-tourniquet group demonstrated significantly lower early postoperative pain scores compared to the tourniquet group, with a progressive decline observed over the initial follow-up period. Wound complications were significantly more prevalent in the tourniquet group (6.06% vs. 13.16%, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.05), with blister formation being the predominant adverse event (n=3, 4.23%). Furthermore, three patients in the tourniquet group developed confirmed UEDVT postoperatively. At the 6-month outpatient follow-up, analysis of standardized questionnaires revealed that the tourniquet-free group achieved significantly superior clinical outcomes and quality of life scores compared to the control group. (Details in Table 3)\u003c/p\u003e\n\u003cp\u003eTable 3. The secondary outcomes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-tourniquet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTourniquet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\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 style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;Preoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e4.44\u0026plusmn;1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e4.51\u0026plusmn;1.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.429\u003c/p\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;POD#1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e5.43\u0026plusmn;2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e5.77\u0026plusmn;2.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;POD#3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e4.88\u0026plusmn;1.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e5.41\u0026plusmn;1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;POD#7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e4.57\u0026plusmn;2.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e4.86\u0026plusmn;1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.269\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;POD#14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e4.43\u0026plusmn;2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e4.61\u0026plusmn;1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;POD#30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e3.13\u0026plusmn;1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e3.57\u0026plusmn;1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWound complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.317\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eBlister\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDehiscence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eHematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eEdgenecrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSuperficial infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUEDVT*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.347\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMEP Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e39.63\u0026plusmn;10.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e35.77\u0026plusmn;14.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;Motion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e19.34\u0026plusmn;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e16.16\u0026plusmn;4.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;Stability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e10.00\u0026plusmn;0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e10.00\u0026plusmn;0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;Function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e22.61\u0026plusmn;2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e18.78\u0026plusmn;7.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e89.78\u0026plusmn;11.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e83.55\u0026plusmn;16.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDASH scores\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e15.88\u0026plusmn;10.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e20.79\u0026plusmn;17.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of stay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e7.25 \u0026plusmn; 1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e8.11 \u0026plusmn; 2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations:\u0026nbsp;VAS, Visual analog scale score MEP; UEDVT, Upper extremity deep venous thrombosis; Mayo elbow performance, DASH: Disabilities of the Arm, Shoulder and Hand.\u003c/p\u003e\n\u003cp\u003ePostoperative upper limb duplex ultrasound examination showed the presence of brachial vein thrombosis. Our Vascular Medicine department recommends starting anticoagulation therapy was initiated with enoxaparin 40 mg subcutaneously once daily for two days followed by rivaroxaban 15 mg twice daily for 21 days. Postoperative rehabilitation program with early passive range of motion followed by gradual transition to active range of motion and strength training with physical therapy There were no recurrent thromboembolic events or any complications of anticoagulant therapy observed during the 30 day postoperative follow-up.\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eThe primary finding of this study is that abandoning traditional tourniquet use during distal humeral fracture (DHF) surgery did not increase perioperative blood loss. The tourniquet-free strategy demonstrated significant advantages in early postoperative pain control and limb swelling management, factors directly related to patient comfort and the initiation of early rehabilitation. Furthermore, this approach yielded satisfactory clinical outcomes and functional scores.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTraditional orthopedic practice has long advocated the use of tourniquets in limb surgery, mainly based on their established efficacy in reducing intraoperative blood loss and optimizing the surgical area\u003csup\u003e12\u003c/sup\u003e. Supporters argue that the bloodless surgical field created by tourniquets can promote precise anatomical reduction of fractures and precise placement of prostheses/implants, theoretically reducing blood loss and shortening surgical time\u003csup\u003e13,14\u003c/sup\u003e. However, these conclusions mainly stem from surgeon-centered clinical studies, whose core limitations lie in the systematic neglect of tourniquet related complications (such as nerve damage, compartment syndrome, thromboembolic events) and patient subjective experiences (such as increased postoperative pain, limb numbness).It is worth noting that these overlooked complications and patient perceptions are key factors affecting long-term clinical outcomes, including delayed functional recovery, prolonged hospitalization, and decreased patient satisfaction\u003csup\u003e15,16\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn this study, the group without tourniquet received intravenous infusion of TXA during surgery and continuous irrigation of the surgical field with cold saline (4\u0026deg;C).\u0026nbsp;The perioperative and blood loss was comparable to that of the tourniquet group (240.78 vs. 228.53 mL; \u003cem\u003eP\u003c/em\u003e\u0026gt;0.05).Notably, postoperative drainage and hidden blood loss were significantly lower in the non-tourniquet group than in the tourniquet group. Additionally, patients in the non-tourniquet group\u0026nbsp;experienced milder limb swelling.\u0026nbsp;These data indirectly suggest that the tourniquet-free strategy offers significant advantages in mitigating postoperative soft tissue ischemia-reperfusion injury, a finding also reported by Xie et al. in a total knee arthroplasty (TKA) meta-analysis of randomized controlled\u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn clinical practice, the first two weeks post-surgery are considered a critical window for functional exercise after DHF-ORIF, and early elbow range of motion (ROM) is a key predictor of clinical outcomes \u003csup\u003e18-20\u003c/sup\u003e.\u0026nbsp;These findings suggest that effective control of pain and swelling not only improves perioperative comfort but also reduces patient apprehension toward postoperative rehabilitation, which is crucial for facilitating early active and passive functional exercises.\u0026nbsp;At the 6-month follow-up, patients in the non-tourniquet group demonstrated superior functional and quality-of-life (QoL) scores. In the study cohort (aged 18-45 years), patients demonstrated significantly greater needs for functional independence and social participation compared to older populations，and most younger patients are in critical career development phases, delayed postoperative functional recovery directly disrupts employment continuity\u003csup\u003e21,22\u003c/sup\u003e. Furthermore, limited social activities and perceived disability significantly increase the risk of anxiety and depression, posing a significant adverse impact on patients\u0026rsquo; physical and psychological recovery\u003csup\u003e23-25\u003c/sup\u003e. These outcomes have been systematically overlooked in previous surgeon centered studies, but they are precisely the primary criteria for evaluating surgical success in middle-aged and young patients.\u003c/p\u003e\n\u003cp\u003eTo address the potential negative impact of tourniquets, researchers have proposed a series of exploratory studies such as personalized inflation pressure protocols\u003csup\u003e26\u003c/sup\u003e, intermittent tourniquet application\u003csup\u003e27\u003c/sup\u003e, intraoperative silicone tourniquets\u003csup\u003e28\u003c/sup\u003e, and prophylactic oral melatonin administration\u003csup\u003e29\u003c/sup\u003e et al, but their actual clinical effects remains to be definitively established. The Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique has gained widespread adoption in contemporary orthopedic practice and has been successfully applied to ORIF of olecranon \u003csup\u003e30\u003c/sup\u003e, distal radius \u003csup\u003e31\u003c/sup\u003e, clavicle \u003csup\u003e32\u003c/sup\u003e, ankle fractures\u003csup\u003e33\u003c/sup\u003e. It is considered an excellent alternative to local tourniquet, with or without sedation or general anesthesia, and can achieve satisfactory comfort without increasing hospitalization costs\u003csup\u003e34\u003c/sup\u003e. However, applying tourniquet-free techniques to distal humerus ORIF presents formidable challenges, primarily due to the complex three-dimensional anatomy of the elbow and the demanding requirements for surgical exposure. While this approach aligns with the core principles of WALANT\u0026mdash;mitigating tourniquet-induced pain and swelling, and facilitating early rehabilitation\u0026mdash;its adoption in mainstream practice remains limited.\u003c/p\u003e\n\u003cp\u003eDespite these challenges, our study still highlights several innovative aspects recommending. First, all patients were positioned in the lateral decubitus position, with the affected limb maintained in a \u0026ldquo;High-position Low-Perfusion\u0026rdquo; state. Second, a dual-modality hemostatic protocol was implemented: intravenous TXA (15 mg/kg) combined with topical irrigation using 4\u0026deg;C cold saline to minimize intraoperative bleeding. Third, we leveraged an Internet-based hospital platform to facilitate seamless interdisciplinary communication among surgeons, therapists, and patients, enabling the delivery of individualized rehabilitation protocols and real-time guidance on functional exercises.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, its single-center, small sample size may limit the generalizability of our findings. Second, the tourniquet-free technique has a learning curve; potential improvements in surgical proficiency throughout the study period could have introduced performance bias. Third, the control group exclusively consisted of patients undergoing general anesthesia with a tourniquet. Consequently, further studies are warranted to evaluate the efficacy of the tourniquet-free strategy when combined with regional or local anesthesia. Finally, we did not analyze inflammatory markers (e.g., WBC, NEUT%, CRP, IL-6), which will be a focus of our future investigations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe strategy of non- tourniquet uses a \u0026ldquo;High position-Low perfusion\u0026rdquo; and TXA+ low-temperature saline dual-mode hemostasis to ensure perioperative hemostasis while significantly reducing postoperative pain, swelling, accelerating elbow joint function recovery, and improving patients\u0026apos; quality of life. This technology avoids the risk of complications related to tourniquets, meets the core needs of middle-aged and young patients for functional independence and early return to society, and is suitable for the cost control and quality improvement goals of China\u0026apos;s DRG/DIP payment reform.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eVAS, Visual analog scale; PBL, perioperative blood loss; BMI, Body mass index; DASH, Disabilities of the Arm, Shoulder and Hand; ROM, range of motion; TXA, tranexamic acid.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Sharing Statement\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available on reasonable request via contacting the corresponding authors (Ming Li or Qian Wang\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eFunding statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for the project.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the Xi\u0026rsquo;an Honghui hospital Ethics Committee, reference number\u0026nbsp;202303003.\u003c/p\u003e\n\u003cp\u003eAll participants provided written informed consent to participate. They were informed about the study\u0026rsquo;s purpose, procedures, potential risks, and benefits. Participants were assured that participation was voluntary and that they could withdraw at any time without any consequences. All images have been completely anonymized through cropping and composition to prevent identification of any individual.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eDisclosure\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest in this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. 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J Hand Surg. 2018;43:179\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jhsa.2017.11.007\u003c/span\u003e\u003cspan address=\"10.1016/j.jhsa.2017.11.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Humeral fractures, Intra-articular fractures, Tourniquet, Rehabilitation, Surgery","lastPublishedDoi":"10.21203/rs.3.rs-9028011/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9028011/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eTo evaluate the feasibility of non-tourniquet strategy combined with \u0026ldquo;High-position Low-Perfusion\u0026rdquo; positioning in distal humeral fractures ORIF (DHF-ORIF), and to investigate its effects on perioperative blood loss, postoperative rehabilitation, and functional outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eProspective inclusion of patients aged 18\u0026ndash;45 with distal humeral fractures, randomly divided into an experimental group without tourniquets (Group A) and a control group with traditional tourniquets (Group B). The Group A adopted a lateral position with high and low perfusion of the affected limb, and received intravenous injection of TXA (15 mg/kg) combined with continuous flushing with 4 ℃ physiological saline during the operation; The control group received routine use of tourniquets. Primary Outcomes: perioperative blood loss, elbow ROM and degree of limb swelling. Secondary Outcomes: Postoperative VAS scorMayo elbow joint score and DASH score, and incidence of complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNo significant difference was observed in total perioperative blood loss between the Group A and the Group B (240.78 mL vs. 228.53 mL, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, the Group A demonstrated significantly reduced postoperative drainage volume and hidden blood loss (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The Group A exhibited significantly superior outcomes in terms of VAS scores and limb swelling, compared with the control group. Additionally, elbow ROM improvement was more significant at 2\u0026ndash;4 weeks and 2 months postoperatively in the Group A. At the 6-month follow-up, the Group A showed significantly higher Mayo scores (89.78\u0026thinsp;\u0026plusmn;\u0026thinsp;11.89 vs. 83.55\u0026thinsp;\u0026plusmn;\u0026thinsp;16.29) compared with the control group (p\u0026thinsp;=\u0026thinsp;0.036). Furthermore, the Group A had significantly lower wound complication rates and shorter hospital stays (7.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.53 vs. 8.11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34 days, p\u0026thinsp;=\u0026thinsp;0.037).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe non-tourniquet strategy combined with \u0026ldquo;High-position Low-Perfusion\u0026rdquo; positioning is safe and effective for DHF-ORIF. It effectively controls postoperative swelling and pain without increasing perioperative blood loss, leading to improved clinical outcomes and quality of life.\u003c/p\u003e","manuscriptTitle":"Non-Tourniquet Strategy with High-Position Low-Perfusion in Distal Humeral Fracture Surgery: Reduces Swelling Without Increasing Blood Loss","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 17:18:57","doi":"10.21203/rs.3.rs-9028011/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-11T01:08:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-09T22:08:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-20T21:24:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290612714406022437329014267653279013442","date":"2026-04-18T09:23:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126226675426933996899858383871109316249","date":"2026-04-18T07:45:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-16T19:26:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76223893224292298150898956668161582825","date":"2026-04-16T06:01:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148761013535133155175125232675273687022","date":"2026-04-16T04:24:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-20T03:05:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-16T20:35:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-09T15:09:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2026-03-04T08:42:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5d5c85bf-9a15-43f5-82bc-310d010e9d91","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-11T01:08:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-09T22:08:38+00:00","index":27,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T01:23:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 17:18:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9028011","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9028011","identity":"rs-9028011","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}