2. F.O.A. Hassan / The Foot 13 (2003) 66–69 67
Table 1
Details of the paediatric foot disorders and the surgical procedures
Diagnosis Number of feet Operation
Calcaneo navicular coalition 1 Resection and fat graft
Talo calcaneal coalition 2 Resection and fat graft
Overlapping fifth toe 2 V-Y arthroplasty
Overlapping fifth toe 2 Butler’s procedure
Calcaneo valgus foot in cerebral palsy 3 Grice Green arthrodesis and talocalcaneal screw fixation
Cavovarus foot due to residual CTEV 6 Dorsolateral mid tarsal wedge osteotomy
Metatarsus adductus 4 Tarsometatarsal capsulotomies
Metatarsus adductus 2 Metatarsal osteotomies
Needle foreign body in the sole and heel 4 Removal
Metatarsus adductus due to old CTEV 1 Dillwyn’s Evans procedure
Complex syndactyly 2 Ray excision
Post-burn contracture 2 Soft tissue release and graft
Macrodactyly 2 Amputation
Polydactyly 4 Amputation ± reconstruction
Os-navicularis 2 Excision and advancement of tibialis post
Bunnionnte 2 Metatarsal osteotomy
Ganglion 2 Excision
Synovial chondromatosis talonaviculat joint 1 Excision
Osteochondroma head of talus 1 Excision
Hallux valgus 1 Soft tissue procedure
Osteochondroma second metatarsal 1 Excision
Lymphangioma dorsum foot 1 Excision
Flat foot 1 Williams calcaneal lengthening
Curly toes 2 Flexor tenotomy
Cavus foot 2 Plantar fascia release
Total 53
Fig. 1. Above ankle tourniquet in place pre-operatively in a 14-year-old
girl with residual deformity of congenital talipus equinovarus treated by
corrective osteotomy.
3. Results
Depending on the studies performed by Diamond et al. [5]
on the average pressure needed to obtain a bloodless field in
young normotensive patients (203.9 ± 22.3 mmHg), the av-
erage pressure utilized in all our patients was 217.92 mmHg.
There were no adverse effects at the site of placement of
the pneumatic tourniquets or unexpected post-operative
problems at the surgical site, apart from slight pinches
and wrinkles in the skin surface seen after removal of the
plaster wool, which disappeared at 1 week. No difficulty
Fig. 2. Above ankle tourniquet in place pre-operatively in an 11-year-old
girl with Osteochondroma of the talus.
was encountered during the operation from the tourniquet
and all cases had excellent bloodless field (Fig. 3). Only
five cases (9.4%) demonstrated mild oozing during surgery,
but it did not alter the operation. Those cases were from
the group which we used elevation and squeezing before
inflation of the tourniquet cuff. Post-operatively, after 1
and 6 weeks, the first web spaces dorsally and ventrally
were examined for altered sensation in patients older than
5 years (38 feet, 71.7%). In all cases, there was no altered
sensation.
3. 68 F.O.A. Hassan / The Foot 13 (2003) 66–69
Fig. 3. Intraoperative view of the Osteochondroma of the talus with
excellent bloodless field.
4. Discussion
The use of a thigh tourniquet during operations on
lower limbs to establish a bloodless field is widespread
[6–8]. Although post-tourniquet syndrome is well known
[9] its effects on post-operative morbidity in routine clinical
practice have only recently been assessed in a prospective,
randomized studies [10]. Tourniquet use is not without
problems, there is continuous concern regards the neuro-
muscular compromise. The neuromuscular problems has
been documented in animal studies with the use of high
pressures on long time application [11,12]. Lower limb
nerve injury were very rare and most of them were neuro-
praxia especially after the use of Esmarch tourniquet [3].
There is increasing evidence that tourniquets cause muscle
and nerve damage which may have long-term consequences
for the recovery of function following surgery [8,13–15],
leading some authors to recommend that a tourniquet not
be used in simple procedures [10,16]. It is a routine prac-
tice that tourniquet should be applied in an area where
the neurovascular bundle are well protected by soft tissues
[17]. On the other hand, high-pressure tourniquet will in-
jure well protected nerves [3]. Skin, muscles, nerves, and
vessels suffer maximally under tourniquet because of me-
chanical pressure, with both a sagittal force, responsible for
compression and an axial force responsible for stretchening
[18]. Use of thigh tourniquet can increase post-operative
wound hypoxia, especially when inflated to high pressures,
and may be relevant to wound healing and the development
of wound infection [19]. The use of a pneumatic tourniquet
to provide a bloodless field in orthopedic surgery is often
complicated by tourniquet pain [18]. Post-operative pain
with thigh tourniquet use is hard to control compared with
non-use of tourniquet in malleolar fracture fixation [20].
The literature reports incidents of rhabdomyolysis with
associated myoglobinurea as a consequence of prolonged
thigh tourniquet use [21] or compartment syndrome [22].
The leg just above the ankle is thin, and it is possible
that a lower than normal cuff pressure may be adequate
[3]. It is suggested that tourniquet application at the an-
kle may be equally effective and less traumatic [23]. An
above ankle pneumatic tourniquet in adult forefoot surgery
has significant less pain and minimal risk of neurolog-
ical compromise because less muscle is compressed by
the tourniquet [3]. Clinical and electrophysiological stud-
ies showed no evidence of neurovascular damage with
above ankle tourniquets in adult foot surgery [24]. The
mean arterial occlusion pressure with a pneumatic ankle
tourniquet = 161.7 mmHg, depending on blood pressure
(brachial), height, weight, body fat percentage, ankle cir-
cumference, and leg circumference measurements [25]. The
average pressure needed to obtain a bloodless field in pneu-
matic ankle tourniquets was 218.6 ± 34.6 mmHg. However,
in the young, normotensive patients, the average pressure
utilized was 203.9 ± 22.3 mmHg [5]. There are no reasons
why above ankle tourniquets cannot be used in certain foot
surgery of adolescents and young children. A calf tourniquet
has minimal morbidity if placed proximally with adequate
cast padding to achieve a bloodless surgical field for foot
and ankle surgery [26]. It is a common practice to use a
thigh tourniquet in foot surgery in young and adolescent
children, no studies looked at the safety of the above ankle
tourniquet in children. On the other hand, the above ankle
pneumatic tourniquet has been used successfully, safely
and effectively in providing hemostasis during foot surgery
in adult under local anesthesia and ankle block anesthesia
with minimal risks and few complications [3,27]. All our
cases performed under general anesthesia due to difficulty
in doing such surgery under local regional anesthesia in pe-
diatric age group. Our prospective study of using the above
ankle tourniquet in foot surgery in children did not show
any morbidity to the patients, nor did it alter the operative
bloodless field; on the other hand, it did not increase the
risk of complications.
5. Conclusion
An above ankle tourniquet with adequate padding is a safe
and effective method to achieve a bloodless surgical field
for foot surgery in children above the age of five.
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