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DOI: 10.1177/1071100713518504
2014 35: 478 originally published online 27 December 2013 Foot Ankle Int
Razi Zaidi, Kamrul Hasan, Aadhar Sharma, Nicholas Cullen, Dishan Singh and Andrew Goldberg
Ankle Arthroscopy: A Study of Tourniquet Versus No Tourniquet

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Foot & Ankle International
2014, Vol. 35(5) 478 482
The Author(s) 2013
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DOI: 10.1177/1071100713518504
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Article
Ankle arthroscopy is a useful operative tool for the foot and
ankle or sports surgeon, with more than 10 000 procedures
carried out in the United Kingdom annually.
10
For ankle
procedures standard practice is to use a pneumatic tourni-
quet applied to the thigh and inflated, with much variation
in practice regarding inflation pressures.
1,16,23,26,29
In knee
arthroscopy, improved operative field visibility has been
cited as the main reason for use of a tourniquet,
2,4,12
how-
ever this is not without risk.
5,15,19
In a study of 118 590 knee
arthroscopies, 7% of 930 reported complications were neu-
rological, and of these 80% were believed to be tourniquet
related.
5
The pathophysiology of a tourniquet related nerve
injury is likely related to both mechanical compression and
neural ischemia causing a disruption in axonal conduc-
tion.
13
The spectrum of these injuries can be from transient
loss of function to irreversible damage.
1
Other postopera-
tive complications include swelling and joint stiffness,
25

decreased muscle endurance, functional weakness,
17,24
and
EMG changes for up to 6 months due to ultra-structural
changes.
14,22
Vascular changes due to tourniquet use may
also include direct vascular injury, hyperemia on tourniquet
deflation, and increased incidence of deep venous thrombo-
sis, pulmonary embolism, and cardiac arrest.
8,19
Increased
risk of superficial infection with increasing tourniquet time
has also been demonstrated.
21
The purpose of our study was to establish the feasibility
of a subsequent larger randomized controlled trial, to test
the hypothesis that tourniquet use might be unnecessary in
ankle arthroscopy.
518504FAIXXX10.1177/1071100713518504Foot & Ankle InternationalZaidi et al
research-article2013
1
Royal National Orthopaedic Hospital, NHS Trust, Stanmore, UK
2
Whipps Cross University Hospital, London, UK
Corresponding Author:
Razi Zaidi, BSc, MRCS, Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, HA7 4LP, UK.
Email: razizaidi@doctors.net.uk
Ankle Arthroscopy: A Study of Tourniquet
Versus No Tourniquet
Razi Zaidi, BSc, MRCS
1
, Kamrul Hasan, MRCS, PhD
2
, Aadhar Sharma, MBBS
1
,
Nicholas Cullen, FRCS(Tr&Orth)
1
, Dishan Singh, FRCS(Tr&Orth)
1
,
and Andrew Goldberg, FRCS(Tr&Orth), MD
1
Abstract
Background: More than 10 000 ankle arthroscopy procedures are performed in the United Kingdom annually. Tourniquet
use is thought to allow improved visibility and reduce operative time. However this is not without risk as it predisposes
to neurovascular injury. The purpose of our study was to establish the feasibility of a subsequent larger randomized
controlled trial, to test the hypothesis that tourniquet use might be unnecessary in ankle arthroscopy.
Methods: We performed a prospective nonrandomized case control study on 63 patients undergoing ankle arthroscopy
to assess the feasibility of a randomized control trial comparing tourniquet versus no tourniquet. All patients had a
tourniquet placed on the thigh and a standard arthroscopic technique. In 1 group (n = 31) the tourniquet was routinely
inflated, whereas in a second group (n = 32) the tourniquet was not inflated. Demographic data, intraoperative fluid
pressures, and visibility were recorded, as were any intraoperative or postoperative complications.
Results: There were no significant differences between the 2 groups with respect to duration of operation, maximum
intraoperative fluid pressures or visibility, and postoperative complications. In no cases where a tourniquet was not used
did the surgeon need to inflate the tourniquet during the case.
Conclusion: Most orthopaedic surgeons continue to use a tourniquet routinely for ankle arthroscopy, presumably on the
belief that a clear operative view can be achieved only with a tourniquet. The findings of our feasibility study revealed that
ankle arthroscopy was possible without the use of a tourniquet. We propose a randomized clinical trial to determine the
best option for patient care.
Level of Evidence: Level III, comparative series.
Keywords: ankle, arthroscopy, tourniquet, visibility
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Zaidi et al 479
Methods
Study Design
Following local institutional review board approval, we
carried out a prospective case-controlled study. All patients
scheduled for ankle arthroscopy in our unit were included
over a period of 6 months. A consecutive series of 63
patients were included. Thirty-one patients were in the tour-
niquet group, with 32 patients in the no-tourniquet group.
No exclusion criteria were applied as patients unsuitable for
use of a tourniquet were by definition excluded prior to
being added to a waiting list for surgery.
The control group (under care of DS and NC) had stan-
dard care where the tourniquet was routinely inflated prior
to the procedure, whereas the cases (under the care of AG)
had the tourniquet applied, but not inflated, as has been his
normal practice for more than 3 years. In the tourniquet
group, exsanguination was done with an Esmarch bandage,
prior to skin preparation. The tourniquet was inflated to 280
mmHg. In the no-tourniquet group, the tourniquet was
applied to the thigh but not inflated.
Outcome Measures
Visibility was selected as our primary outcome measure
with operating time, intraoperative fluid pressure and com-
plications as secondary outcome measures. The duration of
surgery was recorded as the time from the beginning of
application of skin antiseptic to the time the drapes were
removed from the patient.
Operative Technique
All patients underwent standard general anesthetic and
anterior ankle arthroscopy with the patient supine. Bony
landmarks and important neurovascular structures were
marked preoperatively. A noninvasive Guhl ankle joint dis-
tractor (Smith & Nephew, York, UK) was applied and dis-
traction applied following injection of 10 mL of normal
saline into the joint. Standard anteromedial and anterolat-
eral portals were created with care to preserve neurovascu-
lar structures. A 2.7 mm joint arthroscope with 30 degree
optics was used in every case with normal saline fluid using
a fluid pressure management system (Arthrex Inc, Naples,
FL, USA). Pressure was initially set to 30 mmHg and
increased in increments of 10 mmHg up to 50 mmHg dur-
ing the procedure, as requested by the surgeon. Once the
joint cavity was entered, a systematic inspection of intra-
articular structures was performed. Appropriate arthroscopic
tools and shavers were used as indicated by the relevant
pathology. Port sites were closed with nondissolvable
sutures and 10 mL of local anesthetic was injected into the
joint. A wool and crepe dressing was applied and patients
underwent mobilization as per standard departmental proto-
cols. Patients who had a cartilage repair technique (eg,
microfracture) were kept non-weight-bearing using crutches
for 3 to 4 weeks but range of motion exercises started imme-
diately. Any intraoperative visualization difficulties were
recorded as none (visibility fine at 30 mmHg), some bleed-
ing that required the pressure to be increased, or bleeding
that made the procedure impossible and had to be aban-
doned (Table 1). In patients in the no-tourniquet group any
conversion to tourniquet inflation was recorded (Table 1).
All patients were followed-up at 2, 6, and 12 postopera-
tive weeks. During each visit any complications were noted
and documented.
Statistical Methods
All statistical analysis was performed using Stata/IC ver-
sion 12.0 (StataCorp, College Station, TX, USA). A P value
< .05 was considered statistically significant. Fishers exact
test was used to compare the pathology and visibility grad-
ings. The 2-tailed independent t test was used to compare
approximately normally distributed continuous variables;
for nonparametric data the MannWhitney U-test was used.
Data were summarized as mean and standard deviation for
approximately normal continuous variables and median and
interquartile range for nonparametric continuous variables.
Results
The patient demographics and duration of surgery were
similar (Table 2). The need for a bony procedure (such as a
Table 1. Showing the Grading of Intraoperative Visibility.
Tourniquet Group
(n = 31)
No Tourniquet
Group (n = 32) P Value
Visibility satisfactory 15 13 .62
Fluid pressure increased from 30
mmHg to improve visibility
16 19 .62
Vision poorimpossible to
perform procedure
0 0
Tourniquet inflated N/A 0
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480 Foot & Ankle International 35(5)
microfracture or tibial exostectomy) is listed in Table 2 as
these would be expected to lead to increased bleeding that
might impair visualization.
The mean duration of surgery was similar in both groups,
50 minutes in the tourniquet group and 56 minutes in the
no-tourniquet group (P = .19).
In the no-tourniquet group, 19 of 32 (60%) cases required
an increase in the fluid pressure to improve visualization,
compared with 16 of 31 (52 %) cases in the tourniquet
group. This difference was not significant (Table 1; P =
.62). In either group, no cases recorded visibility as making
the procedure impossible and in no cases in the no-tourni-
quet group was there a need to inflate the tourniquet during
the case. The mean maximum recorded intra-articular pres-
sure was recorded as 38.7 mmHg (SD = 7.6) for the tourni-
quet group and 41.9 mmHg (SD = 6.4) for the no-tourniquet
group (Table 2; P = .08).
Only 1 complication (3%) was observed in the tourni-
quet group. This patient developed a neuroma, thought to be
unrelated to the use of the tourniquet and most likely associ-
ated with the creation of the anterolateral port site. No com-
plications were observed in the no-tourniquet group.
Discussion
The aim of this feasibility study was to determine whether
arthroscopy without a thigh tourniquet would be technically
feasible, and/or posed increased complications compared to
the routine use of a thigh tourniquet. Our aim was to gain
further information to help design a robust definitive clini-
cal trial. Ankle arthroscopy without the use of a tourniquet
has been described previously,
23,28
but we believe this to be
the first article to assess technical feasibility and visibility,
and hence this article adds important new information to the
literature.
Our study did not find any benefit for the use of a tourni-
quet in terms of technical ability to perform the procedure.
Although we found slightly longer operative times and
higher intra-articular pressures in the no-tourniquet group,
this was not statistically significant nor did it have any bear-
ing on outcome. Both groups used a maximum intra-articu-
lar pressure of 50 mmHg and no patients in the no-tourniquet
group required subsequent inflation of the tourniquet during
the case. In the no-tourniquet group there were more bony
procedures carried out (eg, talar microfracture or tibial exos-
tectomy (Table 2), which would have expected to increase
the amount of bleeding, and yet all these procedures were
carried out perfectly feasibly without a tourniquet.
Previous studies in the knee have suggested that visualiza-
tion was better in the tourniquet-assisted group.
16,26
A meta-
analysis of tourniquet assisted arthroscopic knee surgery
concluded that the use of tourniquet improved visualization
during arthroscopic ACL reconstruction compared to surgery
without a tourniquet, but there was no significant difference
between any of the other parameters.
26
In contrast, our study
did not show problems with visualization, but we did show
that the operative time was similar with or without a tourni-
quet, which is in keeping with 2 previous randomized con-
trolled trials involving knee arthroscopy.
11,16
In the tourniquet group we did identify 1 complication,
a neuroma formation near the anterolateral portal site, but
this was thought to be unrelated to the use of the tourni-
quet. The literature reports between 5-10% complication
rate with ankle arthroscopies.
6,7
All of these studies used
thigh tourniquets as standard practice. This feasibility
study showed no complications in the absence of a tourni-
quet in a cohort of 32 consecutive patients. Tsarouhas et al
recently reported that tourniquet use for less than 30 min-
utes during arthroscopic knee meniscectomy did not affect
postoperative pain or return to light work and jogging.
27
In
Table 2. Patient Demographics and Study Data.
Tourniquet (n = 31) No Tourniquet (N = 32) P Value
Age
a
38 (10) 36 (13) .62
BMI
a
29 (6) 28 (5) .41
Mean maximum recorded intra-
articular fluid pressure
38.71 (7.63) 41.88 (6.44) .08
Follow-up (weeks)
b
34 (14-64) 24 (12-50) .45
Duration of op (minutes)
a
50 (16) 56 (21) .19
Pathology
Tibial cheilectomy 4 12 .04
Cartilage repair (eg, microfracture
or abrasion arthroplasty used)
14 20 .65
Other 13
a
Approximately normally distributed data, presented as mean (SD) and compared across treatments groups with the independent t test.
b
Nonnormal data, presented as median (IQR) compared nonparametrically across treatment groups with the MannWhitney U-test. Pathology
presented as N and compared across treatment groups with Fishers exact test.
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Zaidi et al 481
addition, tourniquet-induced muscle damage after
arthroscopic meniscectomy, though potentially present
locally, was not detectable in the systemic circulation.
27
While not using a tourniquet has many potential benefits
such as potentially lowering the complication rate, improv-
ing rehabilitation process for patients, who may be ambula-
tory sooner and return to work and sports at an earlier
stage,
9,18,20
the only way to definitively answer this question
would be to carry out an adequately powered randomized
controlled trial (RCT).
Limitations
Our literature search prior to this study identified that most
published studies included analgesia requirements and
changes in clinical scores.
2,11,12,27
We elected not to include
postoperative analgesia and clinical scores in our analysis,
as we felt that both would reflect the pathology and success
of treatment rather than the influence of the tourniquet per
se, but any subsequent robust RCT would likely need to
stratify for pathology and capture a wide range of outcome
measures including clinical and patient reported outcome
measure scores. Another limitation to this study was that a
single surgeon carried out the surgery without a tourniquet,
and the results could therefore reflect performance bias.
Such issues could all be dealt with in well-designed ran-
domized controlled trial .
Conclusion
Our feasibility study identified that ankle arthroscopy with-
out a tourniquet was technically possible without reducing
operative visibility and without complications. We recom-
mend an RCT to determine the best option for patient care.
Acknowledgments
Special thanks to Miss Suzie Cro, statistician for the Royal
National Orthopaedic Hospital, for her assistance with the statisti-
cal analysis.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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