{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,12]],"date-time":"2026-04-12T14:09:37Z","timestamp":1776002977103,"version":"3.50.1"},"reference-count":28,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,1]]},"abstract":"\n OBJECTIVES:<\/jats:title>\n To provide insights into the implications of prolonged tourniquet use on the battlefield, ultimately contributing to the optimization of clinical practices in military and civilian health care settings.<\/jats:p>\n <\/jats:sec>\n \n METHODS:<\/jats:title>\n <\/jats:sec>\n \n Design:<\/jats:title>\n Retrospective observational study.<\/jats:p>\n <\/jats:sec>\n \n Setting:<\/jats:title>\n Two academic Level I Trauma Centers.<\/jats:p>\n <\/jats:sec>\n \n Patient Selection Criteria:<\/jats:title>\n Adults who sustained high-energy battlefield injuries to the limbs on October 7, 2023, with prolonged battlefield tourniquet application (>4 h). Patients who underwent immediate limb amputation on arrival at the hospital were excluded.<\/jats:p>\n <\/jats:sec>\n \n Outcome Measures and Comparisons:<\/jats:title>\n Clinical outcomes including hemodynamic status, vascular repairs, rhabdomyolysis, renal injury, infection, nerve injury, amputation, and functional outcomes were reviewed.<\/jats:p>\n <\/jats:sec>\n \n RESULTS:<\/jats:title>\n Eighteen patients (mean age 24 years; range 19\u201350 years) with 21 high-energy limb injuries and >4 h tourniquet application were included (100% male); 9 (42.9%) upper-limb injuries and 12 (57.1%) lower-limb injuries. The mean age of the cohort was 24 years (SD 8.9, range 19\u201350). The mean tourniquet time was 5.8 h (SD 1.2, range 4\u20139 h). All the patients (100%) underwent urgent fasciotomies on arrival. Five patients (27.8%) required vascular repair. Seven patients (38.9%) developed temporary acute kidney injury, and 2 patients (11.1%) required hemodialysis. Eight patients (44.4%) developed bacterial infections and required additional surgical interventions. Of these 8, limb salvage occurred in 6 (33.3%) and the remaining 2 (11.1%) underwent limb amputation. A total of 5 patients (27.8%) ultimately underwent amputation, all of which were lower-limb amputations. Sixteen patients (88.9%) sustained lingering nerve injuries. The average Upper Extremity Functional Index score was 40.6 (SD 14.9 range 30\u201357) and the average Lower Extremity Functional Index was 42.3 (SD 20.1, range 14\u201368), indicating moderate functional limitation. Longer tourniquet time was associated with a higher complication rate. CPK levels increased with each additional hour, and 100% of the patients requiring hemodialysis had tourniquet time exceeding 6 hours. In addition, 80% of amputation and 75% of infections occurred when tourniquet time exceeded 6 hours.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS:<\/jats:title>\n In a cohort of 18 patients with 21 high-energy limb injuries, a tourniquet time >4 h did not preclude limb salvage, with an overall amputation rate of 23.8%. Tourniquet times exceeding 6 hours were associated with higher rates of complications.<\/jats:p>\n <\/jats:sec>\n \n LEVEL OF EVIDENCE:<\/jats:title>\n Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.<\/jats:p>\n <\/jats:sec>","DOI":"10.1097\/bot.0000000000003089","type":"journal-article","created":{"date-parts":[[2025,9,30]],"date-time":"2025-09-30T18:00:17Z","timestamp":1759255217000},"page":"44-50","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["Outcomes of Prolonged Tourniquet Application on the Battlefield: Is a Liberal Application Policy Always Justifiable?"],"prefix":"10.1097","volume":"40","author":[{"given":"Alona","family":"Katzir","sequence":"first","affiliation":[{"name":"Orthopaedic Trauma Service, Orthopaedic Department, Hadassah Medical Center, Jerusalem, Israel;"},{"name":"Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jonathan","family":"Krispel","sequence":"additional","affiliation":[{"name":"Orthopaedic Trauma Unit, Orthopedic Department, Soroka University Medical Center, Beer Sheva, Israel; and"},{"name":"Faculty of Health Sciences, The Ben Gurion University of the Negev, Beer Sheva, Israel."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Asaf","family":"Acker","sequence":"additional","affiliation":[{"name":"Orthopaedic Trauma Unit, Orthopedic Department, Soroka University Medical Center, Beer Sheva, Israel; and"},{"name":"Faculty of Health Sciences, The Ben Gurion University of the Negev, Beer Sheva, Israel."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mahmoud","family":"Jammal","sequence":"additional","affiliation":[{"name":"Orthopaedic Trauma Service, Orthopaedic Department, Hadassah Medical Center, Jerusalem, Israel;"},{"name":"Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rami","family":"Mosheiff","sequence":"additional","affiliation":[{"name":"Orthopaedic Trauma Service, Orthopaedic Department, Hadassah Medical Center, Jerusalem, Israel;"},{"name":"Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Meir","family":"Liebergall","sequence":"additional","affiliation":[{"name":"Orthopaedic Trauma Service, Orthopaedic Department, Hadassah Medical Center, Jerusalem, Israel;"},{"name":"Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yoram A.","family":"Weil","sequence":"additional","affiliation":[{"name":"Orthopaedic Trauma Service, Orthopaedic Department, Hadassah Medical Center, Jerusalem, Israel;"},{"name":"Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel;"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"276","reference":[{"key":"R5-20251212","first-page":"S4","article-title":"Died of wounds on the battlefield: causation and implications for improving combat casualty care","volume":"71","author":"Eastridge","year":"2011","journal-title":"J Trauma"},{"key":"R6-20251212","doi-asserted-by":"crossref","first-page":"e207","DOI":"10.1093\/milmed\/usx016","article-title":"The platinum 5 min in TCCC: analysis of junctional and extremity hemorrhage scenarios with a mathematical model","volume":"183","author":"Tjardes","year":"2018","journal-title":"Mil Med."},{"key":"R7-20251212","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1136\/jrnms-101-147","article-title":"A systematic review of the use of tourniquets and topical haemostatic agents in conflicts in Afghanistan and Iraq","volume":"101","author":"Mawhinney","year":"2015","journal-title":"J R Nav Med Serv."},{"key":"R8-20251212","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1097\/TA.0000000000001403","article-title":"Point of injury tourniquet application during operation protective edge-what do we learn?","volume":"83","author":"Shlaifer","year":"2017","journal-title":"J Trauma Acute Care Surg."},{"key":"R9-20251212","first-page":"S219","article-title":"The tourniquet controversy","volume":"54","author":"Navein","year":"2003","journal-title":"J Trauma"},{"key":"R10-20251212","doi-asserted-by":"crossref","first-page":"3847","DOI":"10.1007\/s00068-021-01828-4","article-title":"Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip","volume":"48","author":"Sabate-Ferris","year":"2022","journal-title":"Eur J Trauma Emerg Surg."},{"key":"R1-20251212","doi-asserted-by":"crossref","first-page":"243","DOI":"10.3138\/ptc.2013-45","article-title":"Reliability and validity of two versions of the upper extremity functional index","volume":"66","author":"Chesworth","year":"2014","journal-title":"Physiother Can."},{"key":"R2-20251212","first-page":"371","article-title":"The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. 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