Acceptability of ankle tourniquet use in midfoot and forefoot surgery: audit of 1000 cases

"High ankle block" for surgery at the ankle joint

BACKGROUND

Surgery around the ankle is increasingly embedded in outpatient treatment concepts. Unfortunately, the classic "ankle block" as a concept of regional anesthesia is inappropriate for surgery around the ankle because the injection sites are too distal to block this specific region.

METHODS

The "high ankle block" avoids this disadvantage by dislocating the injection points 15 cm proximal to the malleoli. Three of five peripheral nerves necessary to perform the block can be reached by a circumferential subcutaneous wall. The Posterior Tibial Nerve and the Deep Peroneal Nerve are addressed by an ultrasound guided approach.

RESULTS

The efficacy of the technique is highlighted by a case series (3 cases) in which the new blockade was used as a stand-alone procedure, i.e. without additional general anesthesia.

CONCLUSIONS

The "high ankle block" may serve as an ultrasound guided expansion to the classic techniques, extending the operative spectrum to the ankle region.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Use of peripheral blocks and tourniquets in foot surgery: A survey of Australian orthopaedic foot and ankle surgeons

BACKGROUND

The most common reasons for unplanned admission to the hospital from outpatient surgery have the potential to be minimised or eliminated by peripheral nerve blocks (PNB). Tourniquets are commonly used in elective extremity surgery but it's use is mostly guided by personal preferences and does no correlate with the existing literature. Our aim was to explore the current practice of PNB and tourniquet use by foot and ankle surgeons in Australia.

METHODS

The Australian Orthopaedic Foot and Ankle Surgery Society (AOFAS) annual meeting was held in Adelaide in 2011. Members were asked to complete an electronic survey on their current use of peripheral nerve blocks and tourniquets. Two specific elective case scenarios were included for comment, one pertaining to forefoot pathology, the other hindfoot pathology.

RESULTS

Twenty-three AOFAS members replied to the survey, an overall response rate of 76.6%. Of these, only two surgeons did not use ankle blocks in elective surgery and none were prepared to operate without a tourniquet. Most Australian foot and ankle surgeons were reluctant to use local anaesthetic techniques without an accompanying GA.

CONCLUSIONS

While the literature suggests that GA may add to complications without any benefit for the procedure and that distally based tourniquets may add benefit, these are not the favoured techniques in Australian foot and ankle surgeons.

Surgical efficacy of the ankle tourniquet for forefoot surgery

For precise, safe and proficient procedures haemostasis is critical. For forefoot surgery, the customary thigh tourniquet is commonly accepted for this role as the additional muscle mass and minimal bony prominences in the thigh avert neuromuscular and skin injury. However, for patients with pathophysiological issues that may be exacerbated by a thigh tourniquet, application of an ankle tourniquet may decrease the risks and increase cuff tolerance as the volume of ischaemic tissue is reduced.

Tourniquet in surgery of the limbs: a review of history, types and complications

CONTEXT

A tourniquet is a device that is used frequently in most orthopaedic surgeries but this routine device can lead to serious complications so we decided to review and declare it for safe instruction and use.

EVIDENCE ACQUISITION

We searched the word "tourniquet" in PubMed and Google and reviewed all full text English articles and abstracts of non-English articles. In addition, we read all the reference pages of articles to find the new references.

RESULTS

The use of tourniquet in orthopedic surgery can lead to serious but rare complications that can be prevented by its correct knowledge and use.

CONCLUSIONS

At present, there is not enough evidence to discontinue the routine uses of tourniquets.

Ankle tourniquet pain control in forefoot surgery: a randomized study

BACKGROUND

Forefoot surgery is often performed under regional anesthesia in awake patients, using tourniquet or Esmarch bandage to obtain a bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under ankle block anesthesia.

MATERIALS AND METHODS

We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive either subcutaneous local anesthetic mixture under the tourniquet or no additional anesthetic. We checked for local tourniquet pain score (VAS 0 to 100) and skin condition during and after the procedure.

RESULTS

The tourniquet was quite tolerable in both groups, with an average VAS score of 7 to 21. No difference was observed between groups throughout most of the procedure. No correlation between VAS scores and procedure length or patient's age or gender was found.

CONCLUSION

An ankle tourniquet was well-tolerated by patients without need for local anesthetic beneath the cuff.

Automated cuff occlusion pressure effect on quality of operative fields in foot and ankle surgery: a randomized prospective study

BACKGROUND

Limb occlusion pressure, which is present when blood flow ceases, has not had a practical method described for attainment. An automated tourniquet system was modified to set tourniquet pressure based on measurement of limb occlusion pressure (LOP). In this single surgeon randomized prospective study, the effectiveness of this system was assessed on patients undergoing foot and ankle surgery.

MATERIALS AND METHODS

Two hundred forty-four patients were randomized to the study group of automated pressure (n = 112) or to the control group (n = 132). The primary outcome measure was tourniquet pressure used for either group. Secondary measures included the time to set the pressure and number of patients failing LOP measurement. The tourniquet field was assessed intraoperatively and postoperatively in a blinded manner.

RESULTS

The tourniquet pressure was significantly lower in the study group at 198.5 ± 20.2 mmHg compared to 259.6 ± 4.4 in the control group (p < 0.001). The time to measure the LOP was 20 ± 6 seconds. Six patients failed to be measured. The quality of the surgical field was judged to be better in the study group based on all three methods of assessment.

CONCLUSION

LOP measurement was a practical way of setting tourniquet pressures for limb surgery. The automated pressure averages were lower than those routinely used by most surgeons for thigh tourniquets.

A report of UK experience in 917 cases of day care foot surgery using a validated outcome tool

BACKGROUND

Day case surgery is an increasingly important treatment modality and one that foot surgery is particularly well suited to.

OBJECTIVES

This article presents an in depth evaluation of the outcomes of day case foot surgery undertaken in the primary care setting.

METHOD

917 consecutive day surgery cases were evaluated with the Foot Health Status Questionnaire (FHSQ), patient satisfaction questionnaires and complication audits.

RESULTS

917 separate day care admissions were audited (696 females and 221 males). The average age at time of surgery was 50 years (range 14-100, S.D. 11). Post-operative follow up was usually complete by 26 weeks (range 21-218 weeks, S.D. 145). A total of 2772 individual procedures with patients receiving between one and five procedures per admission. The majority of patients (81%, N=743) opted for local anaesthesia. The FHSQ scores for foot pain, foot function, foot health, shoe fitting, general health, physical activity, social capacity and vigour improved. Patient satisfaction results were favourable and complication rates were within acceptable limits.

CONCLUSIONS

Podiatric surgery is well placed to meet both the demands of government and patients in delivering a high quality, safe and efficient treatment for patients requesting elective surgical intervention for foot deformity.

Clinical Experiences With a New Tourniquet Device

Cessation of blood flow to the extremity improves the comfort of the surgeon. So pneumatic tourniquets are commonly used to obtain a bloodless field during upper- and lower-extremity surgery despite the several problems that tourniquet pressure may lead to. In this paper, we present our clinical experiences with a new tourniquet device called S-MART (OHK Medical Devices, Haifa, Israel) and compared the device with the traditional pneumatic tourniquet in terms of efficacy and complications. A total of 30 patients were included in the study. Preoperative systolic blood pressure measurements were obtained, and patients with a systolic blood pressure >190 mm Hg were excluded. S-MART was used in stead of pneumatic tourniquet in half of the patients in group 1. Pneumatic tourniquet was applied to the patients in group 2. The patient groups were compared. No major complications were observed in either group. But it was observed that S-MART was unsuccessful to maintain a bloodless field during the whole operative procedure in some of the cases. In conclusion, application of S-MART is practical, provides bloodless field for a certain time, and does not increase the complication rate related with the pressure applied to underlying tissues, but it is not a suitable tourniquet device for long surgical procedures.