Timing of the tourniquet in foot surgery

NewsBot · Oct 12, 2012

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Ankle block in forefoot reconstruction before or after inflation of tourniquet—Does timing matter?
Vinay Kumar Singh, Sophia Ridgers, Andrea Helene Sott
Foot and Ankle Surgery 3 October 2012

Background
Forefoot surgery causes postoperative pain frequently requiring strong painkillers. Regional blocks are now increasingly used in order to control postoperative pain especially in the first 24 h when the pain is at its worst. We conducted a prospective study to see if timing of ankle block i.e. before or after inflation of tourniquet showed any difference in efficacy in postoperative pain control in first 24 h.

Methods
A prospective randomised study was conducted between September 2010 and August 2011 involving 60 patients. Group A (n = 30) had the ankle block administered after and Group B (n = 30) had a block before inflation of a thigh tourniquet. Patients were given assessment forms to chart their pain on visual analogue scale (VAS) score at 4 h and 24 h postoperatively.

Results
Both groups demonstrated good postoperative pain control. Average VAS pain score at four and twenty fours after surgery was 2.5 and 4.5 in Group A and 3.9 and 6.3 in Group B respectively. Pain control, both at 4 and 24 h surgery was better in Group A but this was statistically significant only at 24 h.

Conclusions
A regional anaesthetic ankle block should be routinely used in forefoot surgery to control postoperative pain. The ankle block should be applied after the inflation of tourniquet as this appears to provide better pain control.
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NewsBot · Oct 12, 2012

NewsBot said: ↑

Ankle block in forefoot reconstruction before or after inflation of tourniquet—Does timing matter?
Vinay Kumar Singh, Sophia Ridgers, Andrea Helene Sott
Foot and Ankle Surgery 3 October 2012
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Press Release:
Tourniquet timing alters foot surgery pain outcomes

The timing of thigh tourniquet application may affect pain control in patients undergoing forefoot surgery, research published in Foot and Ankle Surgery suggests.

The findings show that patients given ankle bock after tourniquet inflation had significantly better pain control 24 hours after surgery on a visual analog scale (VAS) than patients whose tourniquet was inflated before ankle block, at 4.5 versus 6.3 points.

Pain scores were also better in the post- than pretourniquet group 4 hours after surgery, at 2.5 versus 3.9 points, but this difference was not significant, report Vinay Kumar Singh and co-workers from Epsom and St Helier Hospital in Carshalton, UK.

"These results could be explained by our hypothesis that local concentration of anaesthetic falls due to systemic absorption in patients who had the block before tourniquet application leading to early wearing of block," they say.

This appears to counteract the predicted benefit of applying block before tourniquet - allowing the use of peripheral pulses to improve location of peripheral nerves over use of bony landmarks alone, the team explains.

Sing et al randomly assigned 60 patients undergoing Hallux Valgus reconstruction using Chevron or Scarf osteotomy to receive ankle block with 20 ml of 0.5% bupivacaine before (n=30) tourniquet application or after application, a delay of approximately 5 minutes. Patients were operated on by a single surgeon.

As well as improved VAS scores, patients given ankle block after tourniquet were less likely to require oral analgesia than pretourniquet patients both 4 hours (5 vs 30%) and 24 hours (65 vs 85%) after surgery.

The researchers say their findings show that "ankle block can be effective even when its application is solely based on anatomical land marks in absence of pulses showing that the anatomical knowledge and experience of the operating surgeon is of great importance."

They also note that their results indicate that "timing of block to tourniquet may not be as relevant in early hours but is crucial in later postoperative hours."
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NewsBot · Sep 27, 2023

Tourniquet Use in Ankle Arthroscopy: A Systematic Review
B. Lau et al
Foot and Ankle Surgery 14 September 2023

Background
Ankle arthroscopy is commonly performed using a thigh tourniquet and is thought to improve visibility and reduce operative time. However, the current evidence is unclear as to whether the use of a tourniquet provides these benefits. The aim of this study was to investigate whether there is any clinical benefit of using a tourniquet in ankle arthroscopy.

Methods
A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, PubMed and the Cochrane Library Database from inception until January 2023 reporting on the use of a tourniquet in ankle arthroscopy were included.

Results
180 studies were identified of which 3 (165 patients) met the inclusion criteria. All studies showed no statistically significant difference in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. Overall, the quality of the evidence was moderate to poor without data in favour or against the routine use of tourniquets in ankle arthroscopy.

Conclusion
The current literature suggests that there are no significant differences in mean surgical time and complication rate between the tourniquet and non-tourniquet groups.
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