Foot and ankle surgery: Tourniquet placement site to cause as little postoperative pain as possible

Abstract

There is controversy in the literature on where to place the tourniquet (thigh, calf, ankle) for foot and ankle surgery. While some authors prefer the ankle tourniquet to the calf tourniquet, others state that the surgeon can decide between using the thigh tourniquet or the ankle tourniquet, since there was no difference in postoperative pain between them. Where to place the tourniquet during foot and ankle surgery to cause the least possible postoperative pain to the patient as a result of the tourniquet is a common question in clinical practice. The reality is that, unfortunately, there is no consensus on this issue. Perhaps the only possible way to answer this question would be to conduct a comparative study with sufficient statistical power to reach scientifically sound conclusions. It does not seem easy to carry out such a study, but it would be important to be able to answer the question posed in the title of this Editorial once and for all.

Key Words: Surgery; Foot; Ankle; Tourniquet; Site; Postoperative pain

Core Tip: It is well known that the use of tourniquet produces postoperative pain, as evidenced by several authors. Another important question is where the tourniquet should be placed to produce less postoperative pain. The literature on where to place the tourniquet (thigh, calf, ankle) for foot and ankle surgery is controversial. While some authors prefer the ankle tourniquet to the calf tourniquet, others state that the surgeon can decide between using the thigh tourniquet or the ankle tourniquet, since there was no difference in postoperative pain between them.

INTRODUCTION

It is common in foot and ankle surgery to use a tourniquet to achieve a bloodless surgical field that allows good visualization of the anatomical structures by the surgeons[1-5]. It is also well known that the use of tourniquet produces postoperative pain, as reported by several authors[1-5].

THERE IS CONTROVERSY IN THE LITERATURE

In 2015, Kruse et al[1] analyzed opioid consumption in ankle surgery using a tourniquet. They observed that the longer the tourniquet time the higher the opioid consumption (0.43 mg per 10 min of tourniquet use). In foot and ankle surgery patients, Kukreja et al[2] found correlation between prolonged tourniquet times at high pressures and morphine equivalents used in the perioperative period and length of stay in the post-anesthesia care unit. In 2023, Lehto et al[3] observed that tourniquet use and prolonged tourniquet time were associated with increased opioid consumption during the first 24 h postoperatively in surgically fixed ankle fractures.

An important question is where the tourniquet should be placed to produce less postoperative pain. In this regard, in 2012 a study published by Piyavunno and Mahaisavariya[4] compared the calf tourniquet and the ankle tourniquet in foot surgery. With the ankle tourniquet the visual analog scale pain scores were significantly lower than with the calf tourniquet. Therefore, these authors supported the use of the ankle tourniquet.

In a recent prospective study published in the World Journal of Orthopedics by Mishra et al[5] the pressure at which the tourniquet was placed, the site of tourniquet placement (thigh or ankle) and the postoperative pain experienced by patients operated on for foot and ankle problems did not show a statistically significant correlation. Mishra et al[5] used a tourniquet pressure of 250 mmHg at the ankle and 300 mmHg at the thigh. In addition, tourniquet placement site and pain scores at 6 and 24 h postoperatively did not show a statistically significant correlation. Mishra et al[5] stated that the choice of utilizing a tourniquet should be based on the surgeon's preference.

It is obvious that there is controversy in the literature on where to place the tourniquet (thigh, calf, ankle) for foot and ankle surgery. While some authors prefer the ankle tourniquet to the calf tourniquet (Piyavunno and Mahaisavariya)[4], others (Mishra et al)[5] state that the surgeon can decide between using the thigh tourniquet or the ankle tourniquet, since there was no difference in postoperative pain between them.

CONCLUSION

Where to place the tourniquet during foot and ankle surgery to cause the least possible postoperative pain to the patient as a result of the tourniquet is a common question in clinical practice. The reality is that, unfortunately, there is no consensus on this issue. Perhaps the only possible way to answer this question would be to conduct a comparative study with sufficient statistical power to reach scientifically sound conclusions. It does not seem easy to carry out such a study, but it would be important to be able to answer once and for all the question posed in the title of this Editorial.

ACKNOWLEDGEMENTS

My sincere thanks to Leonard A. Valentino, MD, Rush University, Chicago, Illinois, United States, for editing the English of this manuscript.