
==== Front
World J Orthop
WJO
World Journal of Orthopedics
2218-5836
Baishideng Publishing Group Inc

jWJO.v15.i9.pg828
10.5312/wjo.v15.i9.828
93168
Editorial
Choosing ankle tourniquets in foot and ankle surgery: Beyond postoperative pain considerations
Ghandour S et al. Ankle tourniquets in foot and ankle surgery
Ghandour Samir The Faculty of Medicine and Biomedical Sciences, The University of Balamand, Beirut 1100, Lebanon

Jain Vijay Kumar Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, Delhi 110001, India

Gupta Ashim Department of Orthopaedics and Regenerative Medicine, Future Biologics, Lawrenceville, GA 30043, United States. ashim6786@gmail.com

Author contributions: Gupta A conceptualized the study; Ghandour S wrote the initial draft; Jain VK and Gupta A critically reviewed and edited the manuscript. All authors approved the final version of the article for publication.

Corresponding author: Ashim Gupta, MS, PhD, MBA, DABRM, FABRM, Founder and CEO, President, Professor, Department of Orthopaedics and Regenerative Medicine, Future Biologics, 2505 Newpoint Pkwy, Lawrenceville, GA 30043, United States. ashim6786@gmail.com

18 9 2024
18 9 2024
15 9 828830
21 2 2024
7 8 2024
9 8 2024
©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.
This editorial critically explores the use of ankle vs thigh tourniquets in foot and ankle surgery based on a recent study that found no significant difference in postoperative pain between the two placement techniques. Despite these findings, we argue for the preferential use of ankle tourniquets, highlighting their potential benefits in reducing venous blood stasis and minimizing soft tissue injury. This approach underscores the importance of considering long-term patient outcomes and vascular health beyond immediate postoperative pain. By integrating study findings with broader clinical considerations, we hereby advocate for a nuanced approach to tourniquet use that prioritizes patient safety and long-term recovery in conjunction with immediate postoperative pain.

Lower extremity
Deep venous thrombosis
Recovery
Postoperative outcomes
Intraoperative decision-making
==== Body
pmc Core Tip: This editorial advocates for the selection of ankle tourniquets in foot and ankle surgery. While ankle tourniquets do not significantly reduce postoperative pain compared to thigh tourniquets, ankle tourniquets may minimize lower extremity venous stasis and soft tissue compression, especially in high-risk patients, which can enhance long-term vascular health and promote uneventful patient recovery.

INTRODUCTION

The recent study titled "Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery" presents important findings investigating tourniquet use in orthopedic procedures[1]. While the study, conducted on 201 patients undergoing foot and ankle surgery, concludes that there is no significant correlation between the site of tourniquet application (ankle vs thigh) and immediate postoperative pain scores, it opens the door to a broader discussion on the choice of tourniquet placement[1]. This editorial aims to delve into why, despite the study’s findings, choosing an ankle tourniquet might be preferable in certain surgical scenarios, particularly to mitigate venous blood stasis in the leg and soft tissue injury, especially in procedures of longer duration and at-risk patients.

TOURNIQUET

The use of tourniquets in surgery is a long-standing practice primarily aimed at providing a bloodless field for optimal surgical visibility and reducing intraoperative blood loss[2]. However, the choice of tourniquet placement has varied, with some surgeons preferring the thigh for its ease of application and perceived patient comfort, while others opt for the ankle to localize pressure effects[3-5]. This study’s finding of no significant correlation between tourniquet site and postoperative pain intensity might initially suggest that the choice of tourniquet location is inconsequential concerning pain management. Yet, this view overlooks other crucial factors, such as the potential risk of venous blood stasis, limb ischemia in patients with compromised vascular health, and associated complications[4].

Venous stasis, the stagnation of blood flow in the veins, is a known risk factor for deep vein thrombosis (DVT) and other vascular complications[6]. When a tourniquet is applied to the thigh, it exerts pressure over a larger area and encompasses major blood vessels, potentially increasing the risk of venous blood pooling and stasis in the entire leg. This is especially concerning in patients with pre-existing vascular conditions or those at higher risk for DVT. In contrast, an ankle tourniquet applied over the supramalleolar region localizes the pressure to a smaller area distal to the calf, reducing the risk of venous stasis in the leg.

Moreover, the study's methodology, while robust in its approach, does not specifically address the long-term vascular implications of tourniquet placement. The focus on immediate and short-term postoperative pain, while clinically relevant, does not encompass the broader spectrum of potential complications arising from tourniquet use, especially in patients who are immobilized for long periods of time postoperatively, with a history of DVT or suffer from peripheral vascular disease. Notably, prolonged tourniquet ischemia following thigh tourniquet use in patients with compromised extremity blood supply may lead to post-tourniquet syndrome, tissue edema, and even compartment syndrome[7]. Therefore, when interpreting the study’s findings, surgeons should consider these unaddressed aspects and weigh them against the immediate postoperative pain outcomes.

It is also essential to consider the anatomical and physiological aspects of tourniquet application. With its larger circumference, the thigh often requires higher tourniquet pressures to achieve effective blood occlusion[3,4]. This increased pressure can contribute to more extensive tissue compression and potential damage[8,9]. On the other hand, the ankle, with its smaller circumference, may require lower pressures, thereby potentially reducing the overall risk of tissue injury and complications associated with high-pressure tourniquet application. Such phenomena may be better elucidated by the use of emerging computational analytical technologies, such as finite or discrete element analysis that has enabled researchers to better understand the biomechanical implications of extrinsic and intrinsic forces on anatomical structures[10]. However, to our knowledge, there is little to no computational evidence in the literature investigating the effects of tourniquet use, particularly on the ankle and thigh.

Further, the effect of ankle tourniquet placement on the rate of postoperative wound healing, surgical success, and infection rates must be studied. Some experts have recommended against the use of tourniquets for certain surgeries. For example, a study by Konrad et al[11] found that using a tourniquet during open reduction and internal fixation of ankle fractures increased postoperative swelling and pain, reporting a trend toward decreased range of motion in the ankle during follow-up. As a result, they do not recommend the use of a tourniquet for osteosynthesis of ankle fractures, citing the potential for increased complications such as wound healing disturbances and infections. Therefore, the evaluation of the impact of ankle tourniquets on both closed and open-foot fractures for different surgical procedures is also a critical area for future research, adding more depth to the conversation regarding the effects of tourniquet use and its placement for foot and ankle surgery.

CONCLUSION

In conclusion, while the study "Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery" provides valuable insights into the relationship between tourniquet placement and postoperative pain[1]. The choice of tourniquet placement site must consider other patient-specific variables. The potential benefits of using an ankle tourniquet, particularly in reducing the risk of venous blood stasis and its complications, merit serious consideration. As with all surgical decisions, the choice of tourniquet placement should be tailored to each patient, considering both the immediate and long-term implications for patient health and recovery.

Conflict-of-interest statement: The authors declare no conflicts of interests.

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Corresponding Author's Membership in Professional Societies: American Academy of Regenerative Medicine.

Specialty type: Orthopedics

Country of origin: United States

Peer-review report’s classification

Scientific Quality: Grade A

Novelty: Grade A

Creativity or Innovation: Grade A

Scientific Significance: Grade A

P-Reviewer: Ammarullah MI S-Editor: Qu XL L-Editor: A P-Editor: Wang WB
==== Refs
1 Mishra A Barakat A Mangwani J Kazda J Tiwatane S Shaikh SMA Houchen-Wolloff L Kaushik V Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery World J Orthop 2024 15 163 169 38464352
2 Zaid HHG Di W Yang R Zhao T Yang M Effect of tourniquet application on postoperative outcomes in sinus tarsi approach for intra-articular calcaneus fractures Arch Orthop Trauma Surg 2022 142 2695 2700 34244875
3 Younger AS Kalla TP McEwen JA Inkpen K Survey of tourniquet use in orthopaedic foot and ankle surgery Foot Ankle Int 2005 26 208 217 15766423
4 Kalla TP Younger A McEwen JA Inkpen K Survey of tourniquet use in podiatric surgery J Foot Ankle Surg 2003 42 68 76 12701074
5 Meyr AJ Mirmiran R Naldo J Sachs BD Shibuya N American College of Foot and Ankle Surgeons(®) Clinical Consensus Statement: Perioperative Management J Foot Ankle Surg 2017 56 336 356 28231966
6 Stone J Hangge P Albadawi H Wallace A Shamoun F Knuttien MG Naidu S Oklu R Deep vein thrombosis: pathogenesis, diagnosis, and medical management Cardiovasc Diagn Ther 2017 7 S276 S284 29399531
7 Derner R Buckholz J Surgical hemostasis by pneumatic ankle tourniquet during 3027 podiatric operations J Foot Ankle Surg 1995 34 236 246 7550186
8 Worland RL Arredondo J Angles F Lopez-Jimenez F Jessup DE Thigh pain following tourniquet application in simultaneous bilateral total knee replacement arthroplasty J Arthroplasty 1997 12 848 852 9458249
9 Unver B Karatosun V Tuncali B Effects of tourniquet pressure on rehabilitation outcomes in patients undergoing total knee arthroplasty Orthop Nurs 2013 32 217 222 23881019
10 Cheung JT Nigg BM Clinical Applications of Computational Simulation of Foot and Ankle Sport-Orthopädie - Sport-Traumatologie - Sports Orthopaedics and Traumatology 2008 23 264 271
11 Konrad G Markmiller M Lenich A Mayr E Rüter A Tourniquets may increase postoperative swelling and pain after internal fixation of ankle fractures Clin Orthop Relat Res 2005 189 194
