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1. The Foot 13 (2003) 66–69
Above ankle tourniquets in young and adolescent
children foot surgery
Freih Odeh Abu Hassan
Department of Orthopedics Surgery, Jordan University Hospital, P.O. Box 73, Jubaiha 11941, Jordan
Received 29 April 2002; accepted 6 August 2002
Abstract
We undertook a prospective study of 53 consecutive foot surgery under general anesthesia in young and adolescent children over a
4.5-year period to assess the safety and efficacy of above ankle tourniquet in the surgery of certain pediatric foot disorders. The average
age was 8.4 (1–14) years. The tourniquet pressure used ranged from 200–225 mmHg (average 217.92 mmHg). The average duration
of tourniquet ischemia was 39.7 min (6–73 min). There were no post-operative complications noted with ankle cuffs. No patient has
neurological complications. The above ankle tourniquet was a safe and effective means in providing a bloodless field for foot surgery in
children, and provides a suitable alternative to the routine use of a thigh tourniquet in children.
© 2003 Elsevier Science Ltd. All rights reserved.
Keywords: Ankle tourniquets; Young and adolescent children; Foot surgery
1. Introduction
Most orthopedic and pediatric orthopedic surgeons prefer
to operate on toes and feet with a bloodless operating field.
This can be achieved with a pneumatic tourniquet applied to
the thigh after exsanguinations of the limb with a rubber ban-
dage [1], or with an Esmarch rubber bandage alone placed
below the knee [2]. Calf or above ankle tourniquet are rarely
used in adult foot surgery [3]. A pneumatic thigh tourniquet
associated with the risk of post-operative swelling, delay of
recovery of muscle power, compression neurapraxia, wound
hematoma with the potential for infection, vascular injury,
tissue necrosis, and compartment syndrome [4]. We studied
prospectively the use and safety of above ankle tourniquet
in pediatric foot surgery which needed a bloodless field to
facilitate the operative procedure.
2. Patients and methods
Between September 1997 and February 2002, we carried
out 53 foot operations in young and adolescent children
in 53 patients, using an above ankle tourniquet. Forty-two
patients (79.24%) treated as in-patients and 11 patients
(20.75%) treated as day care surgery. There were 29 males
E-mail address: freih@joinnet.com.jo (F.O.A. Hassan).
(54.71%) and 24 females (45.28%) with an average age of
8.4 years (range 1–14 years) at the time of operation. The
diagnosis of the cases is listed in Table 1. We intentionally
chose cases where all the surgery was confined to the foot
and did not extend to the ankle, or above the ankle. Patients
were excluded if they had congenital talipes equinovarus
and required post-medial release or tendon transfer, but
were included if they needed salvage surgery for residual
deformities, e.g. metatarsus adductus, heel varus, or cavo-
varus deformity. Reasons for exclusion from the study were
extension of pathology to the ankle joint, the need to do
tendon transfer, malignant tumors of the foot or crush in-
jury to the foot. Patients also were excluded if their age was
less than 1 year. We assessed the value of the above ankle
tourniquet by looking at the bleeding during the opera-
tion, failure of the tourniquet, post-operative complications,
difficulty during surgery, and adverse effect at the site of
application, e.g. pinches and wrinkles in the skin surface.
2.1. Method of application
The size and pressure of the cuff depends on the patient’s
age and circumference of his leg. The plaster wool is applied
in four layers just above the ankle level (Figs. 1 and 2). The
foot is exanguinated by rubber bandage in children above
the age of 5 years (38 feet, 71.7%) or squeezed by hands
after elevation for 3 min for children younger than 5 years
(15 feet, 28.3%).
0958-2592/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved.
PII: S0958-2592(02)00120-7

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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