tourniquet or no toruniquet

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http://fai.sagepub.com/ Foot & Ankle International http://fai.sagepub.com/content/35/5/478 The online version of this article can be found at: 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 Published by: http://www.sagepublications.com On behalf of: American Orthopaedic Foot & Ankle Society can be found at: Foot & Ankle International Additional services and information for http://fai.sagepub.com/cgi/alerts Email Alerts: http://fai.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: What is This? - Dec 27, 2013 OnlineFirst Version of Record - Apr 30, 2014 Version of Record >> at NEW YORK COLG PODIATRIC MED on May 5, 2014 fai.sagepub.com Downloaded from at NEW YORK COLG PODIATRIC MED on May 5, 2014 fai.sagepub.com Downloaded from

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Tourniquet or No Toruniquet

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http://fai.sagepub.com/Foot & Ankle International

http://fai.sagepub.com/content/35/5/478The online version of this article can be found at:

 DOI: 10.1177/1071100713518504

2014 35: 478 originally published online 27 December 2013Foot Ankle IntRazi Zaidi, Kamrul Hasan, Aadhar Sharma, Nicholas Cullen, Dishan Singh and Andrew Goldberg

Ankle Arthroscopy: A Study of Tourniquet Versus No Tourniquet  

Published by:

http://www.sagepublications.com

On behalf of: 

  American Orthopaedic Foot & Ankle Society

can be found at:Foot & Ankle InternationalAdditional services and information for    

  http://fai.sagepub.com/cgi/alertsEmail Alerts:

 

http://fai.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

What is This? 

- Dec 27, 2013OnlineFirst Version of Record  

- Apr 30, 2014Version of Record >>

at NEW YORK COLG PODIATRIC MED on May 5, 2014fai.sagepub.comDownloaded from at NEW YORK COLG PODIATRIC MED on May 5, 2014fai.sagepub.comDownloaded from

Foot & Ankle International®2014, Vol. 35(5) 478 –482© The Author(s) 2013Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1071100713518504fai.sagepub.com

Article

Ankle arthroscopy is a useful operative tool for the foot and ankle or sport’s 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.

518504 FAIXXX10.1177/1071100713518504Foot & Ankle InternationalZaidi et alresearch-article2013

1Royal National Orthopaedic Hospital, NHS Trust, Stanmore, UK2Whipps Cross University Hospital, London, UK

Corresponding Author:Razi Zaidi, BSc, MRCS, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK. Email: [email protected]

Ankle Arthroscopy: A Study of Tourniquet Versus No Tourniquet

Razi Zaidi, BSc, MRCS1, Kamrul Hasan, MRCS, PhD2, Aadhar Sharma, MBBS1, Nicholas Cullen, FRCS(Tr&Orth)1, Dishan Singh, FRCS(Tr&Orth)1, and Andrew Goldberg, FRCS(Tr&Orth), MD1

AbstractBackground: 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. Fisher’s 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 Mann–Whitney 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 .62Fluid pressure increased from 30

mmHg to improve visibility16 19 .62

Vision poor—impossible 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

Agea 38 (10) 36 (13) .62BMIa 29 (6) 28 (5) .41Mean maximum recorded intra-

articular fluid pressure38.71 (7.63) 41.88 (6.44) .08

Follow-up (weeks)b 34 (14-64) 24 (12-50) .45Duration of op (minutes)a 50 (16) 56 (21) .19Pathology Tibial cheilectomy 4 12 .04Cartilage repair (eg, microfracture

or abrasion arthroplasty used)14 20 .65

Other 13 — —

aApproximately normally distributed data, presented as mean (SD) and compared across treatments groups with the independent t test.bNonnormal data, presented as median (IQR) compared nonparametrically across treatment groups with the Mann–Whitney U-test. Pathology presented as N and compared across treatment groups with Fisher’s 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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