Tourniquet is a commonly used in a variety of foot and ankle surgeries in order to improve surgical field visibility, decrease intraoperative blood loss, and reduce operating time. This study aimed to quantify the effect of tourniquet application on postoperative outcomes after minimally invasive surgery of calcaneal fractures. Overall, our study showed that tourniquet application resulted in decreased operating time, improved operative field visibility, and reduced intraoperative blood loss. Besides, the findings of the study showed that tourniquet application was associated with increased postoperative pain, and blood loss in the first 24hr, 48hr, and 72 hr.
To our knowledge, no prior studies have examined the effect of tourniquet use on outcomes in minimally invasive treatment for calcaneal fractures. We believe this is the first article assessing feasibility and visibility of the minimally invasive procedures, so this article adds new information to the published literature.
In this study, we found that the mean operating time was significantly longer in the patients who undergo surgery without tourniquet. This may be due to the care that exerted by the surgeons when staunch the bleeding and to the fact that, partially obstruction of the surgical field without the tourniquet.
We assessed the difficulty of the operation based on the operative field of vision and time. We have found that the visualization was significantly better in the tourniquet group. In the non-tourniquet group, more flushing was required to provide a better view onto the surgical field. However, the visibility improved in 88.9 of cases after tourniquet inflation.
In the patients without tourniquets, the mean amount of estimated postoperative blood loss was significantly lower during the first 24 h. No patients from either group received a blood transfusion. In the without tourniquet group, electrocautery was used to seal off bleeding blood vessels, whereas no homeostasis was used for the tourniquet group, and the tourniquet is deflated only after skin closure. Based on our extensive experience as foot and ankle surgeons; avoiding tourniquet deflation before skin closure has not caused any problems. Interestingly, similar experience was reported by some researcher on their experience with total knee replacement, internal fixation of ankle fractures, and carpal tunnel release [7, 13, 14].
Muscle tissue damage that caused by tourniquet is not well described. The duration of tourniquet use may cause elevated serum CPK levels; this increase may accurse 8 hours following muscle damage. Muscle tissue damage can lead to increased pain postoperatively compared to non-tourniquet group [15]. However, there were no significant differences in the CPK level between tourniquet and non-tourniquet patients during consecutive measurements, and CPK level did not exceed the normal levels at any of the measuring time points.
Patients in the tourniquet group showed significant higher postoperative pain when compared to non-tourniquet group patients. However, our study results showed that the pain was significantly increased 24 h postoperatively after removing the pressure dressing, and then gradually decreased at 48 h, and 72 h, postoperatively, revealed that it is less likely to be a direct result of ischemic edema and hypoxia caused by the tourniquet, but it may be the result of swelling and hematoma. In the non-tourniquet group, ankle swelling was decreased slowly on postoperative days 2 and 3. This may be the reason for the higher postoperative pain in the tourniquet group.
Postoperative pain remains a significant barrier of delay discharging patients, and it has a significant impact on the patient's ability to return to normal activities after discharge [9]. Postoperative analgesia plays a significant role in allowing the patients exercise and restore mobility, promoting recovery while reducing hospital stay [16].
Our finding did not confirm previous studies that the tourniquet application increases postoperative swelling and length of in-hospital stay [7, 9]. Reduced length of stay in hospitals has significant benefits for the hospital, including resource and cost savings. Whilst some factors that prognosticate hospital length of stay have been identified, the direct and indirect interaction between these factors is less clear. The length of stay in a hospital is an important indicator of resource consumption.
The finding of our study showed that tourniquet application did not result in delayed wound healing or return to work and activities. Generally, minimally invasive procedure is associated with less wound complications, early rehabilitation, and good to excellent clinical outcomes [3, 4, 17, 18].
Time to return to work was evaluated in the study of Maffulli et al. [19] which reported an average difference of 7 days between the tourniquet and non-tourniquet group. Further studies are recommended to evaluate the impact of tourniquet use on return to work after calcaneal fracture surgery.
In the tourniquet group, delayed wound healing was seen in 5 patients, and 2 patients in the non-tourniquet group. According to previous studies, patients with increased BMI, Sanders type, smoking, and postoperative hemovacuum drain may at higher risk of infection and delayed wound healing [20–22]. Furthermore, a recent study by Benedick et al. [23] assessed the effect of tourniquet use on wound healing following ankle fracture surgery, demonstrated that the use of a tourniquet did not delay wound healing or increases the incidence of incision complication.
After surgery, it is recommended to apply a compression dressing using ACE elastic bandage as supplementary negative pressure drainage. The flaps are evenly compressed to decrease bleeding and eliminating space enhances the effectiveness of negative pressure.
Critical hypoxia levels where normal cell function is affected usually in patients with higher tourniquet pressure and longer duration of deflation. However, low tourniquet pressure (< 250 mm Hg) may not be risky and tourniquet inflation for 1 to 3 hours as a safe limit for tourniquet time, and if the anticipated time of surgery is more than 2.5 hours, it should be deflate the tourniquet for 10 to 15 minutes and elevate the leg before re-inflating again [24, 25]. However, three hours is much more than the duration of surgery reported in this study in the presence of a tourniquet. In our study, conservative treatment with systemic antibiotic therapy and local wound care were applied for those with delayed wound healing patients.
Calcaneal fractures are a serious injury and the most common fracture of the tarsal bones that may lead to lifelong problems. Pain in the joints, stiffness and arthritis frequently develop. Sometimes a fracture fails to heal in the right position. The long-term consequences of calcaneal fractures are decreased ankle motion and limping when walking, which are caused by fracture collapse and loss of length in the leg. It may require a revision surgery and long-term or permanent use of an orthotic device or brace to deal with complications.
Open reduction versus plate fixation via the sinus tarsi approach are currently accepted treatments method for calcaneal fractures. The good to excellent clinical and radiological outcomes, with less wound complications and early recovery have been reported in the minimal invasive sinus tarsi approach. Even complex calcaneus fractures can be fully exposed using a minimally invasive sinus tarsi approach to achieve anatomic reduction and stable internal fixation [3, 4, 17, 18].
Bleeding in the surgical field is the most important problem without the use of a tourniquet. Tourniquets are widely used during upper and lower limbs surgery to provide a bloodless field. There is a lot of controversy about the use of a tourniquet, and the possible benefits must be weighed against the potential risks. Minimal bleeding in the surgical field is the main advantage of using a tourniquet during upper and lower limb orthopaedic surgery. Due to improved visibility, it can shorten the operation time and reduce the technical difficulty of the operation.
Our study has some limitation worth noting. Firstly, this is a retrospective study from a single institution. Secondly, the tourniquet was inflated just before the incision was made and deflated after skin closure, so we cannot comment on the tourniquet deflation before skin closure. Further studies are needed to clarify these points.