Effect of Tourniquet Use During Ankle Fracture Fixation on Wound Healing and Infectious Complications

Abstract

Background:

Tourniquets are common during extremity surgery; however, effects of tourniquets on complications following ankle fracture surgery have not been well described. The purpose was to evaluate effects of tourniquet usage on wound complications and infections after ankle fracture fixation.

Methods:

Consecutive patients (N = 903) treated operatively for torsional ankle injury were identified. Patients for whom a tourniquet was used intraoperatively (n = 523) were compared to those without (n = 380). Subgroup analysis included patients possibly sensitive to tissue ischemia (diabetes, obesity, tobacco, age >65 years, and open fracture). Multiple logistic regression analysis was performed.

Results:

A tourniquet was used in 523 (57.9%) of cases. Overall, 22.9% of patients had open fractures in the group with no tourniquet, vs 11.3% (P < .001), with no differences in fracture pattern or medical comorbidities, except tobacco use was more frequent in the no tourniquet group (51.9% vs 44.4%, P = .032). No significant differences in complications were noted, including superficial infection (4.2% [no tourniquet] vs 5.2%), deep infection (2.1% vs 2.3%), and wound healing problems (6.3% vs 4.0%). Similarly, subgroup analysis failed to reveal any differences in complications based on diabetes, obesity, tobacco use, age, or open fracture. However, patients with open fractures or diabetes were more likely to experience deep infection (OR 3.73, P = .014, and OR 4.01, P = .021, respectively).

Conclusions:

Tourniquet use did not affect rates of wound healing problems or infections. However, patients with open fractures or diabetes were at higher risk. Tissue ischemia produced by a tourniquet did not appear to result in more wound healing or infectious complications.

Level of Evidence:

Level III, prognostic, comparative study

Keywords

ankle fracture tourniquet complication infection wound healing

Introduction

Pneumatic tourniquets are commonly used in a variety of orthopedic procedures in order to improve visualization of the operative field, reduce intraoperative blood loss, and decrease operative times.¹⁹ However, tourniquet-related complications have been identified, including local skin breakdown, nerve and vascular injuries, and compartment syndrome.^1,3,5,12,16

Although the local adverse effects of tourniquet use have been well described, less is known regarding the effect of tourniquet use on infectious and wound healing complications. Tourniquet use during total knee arthroplasty has been shown to increase postoperative wound hypoxia, potentially priming the site for subsequent infection or delayed wound healing.⁴ Previous studies have identified risk factors for wound complications following ankle fracture surgery, including advanced age,^10,11 diabetes,^10,11 tobacco use,^2,11 open fracture,^2,10,11 and obesity¹³; however, the effect of tourniquet use on wound complications in these higher-risk populations remains unknown. The purpose of this study was to evaluate potential effects of intraoperative lower extremity tourniquet use on wound healing and infectious complications after ankle fracture fixation.

Methods

This was a retrospective cohort study evaluating patients sustaining a torsional ankle fracture who presented to a single urban, Level I trauma center between March 2003 and August 2016. Institutional review board approval was obtained. Patients who met the following inclusion criteria were eligible for inclusion in the study: (1) age 18 years or older at the time of injury; (2) sustained an Orthopaedic Trauma Association (OTA) 44B or 44C⁹ torsional ankle fracture; (3) underwent fixation of their ankle fracture; and (4) had at least 6 weeks of clinical follow-up from the date of surgery (Figure 1). Patients with missing data regarding intraoperative lower extremity tourniquet use were excluded. A total of 903 patients were eligible for inclusion. Patients for whom a lower extremity tourniquet was used intraoperatively (n = 523) were compared to those for whom a tourniquet was not used (n = 380).

Fracture Management

Ankle fractures were treated operatively using standard open reduction and internal fixation (ORIF) techniques (small fragment and/or minifragment stainless steel implants) or in a staged fashion with initial external fixation to allow for soft tissue rest, followed by ORIF. Open fractures underwent urgent surgical debridement followed by ORIF. Intraoperative tourniquet use, including the pressure and duration, was at the discretion of the operating surgeon. When used, intraoperative tourniquets were placed at the level of the proximal thigh. All patients were placed in a short leg plaster splint postoperatively, made nonweightbearing (NWB), and instructed to elevate the operative leg frequently. Weightbearing was deferred for 6 to 12 weeks at the treating surgeon’s discretion, with progression of weightbearing status dependent on fracture pattern and clinical and radiographic evidence of healing.

Data Collection

The orthopedic trauma registry at our institution was queried for patients treated for torsional ankle fracture. Medical records and radiographs were subsequently reviewed. Demographic information, including age at injury, sex, race, body mass index (BMI), medical comorbidities (obesity [BMI > 30], diabetes mellitus, peripheral neuropathy, and renal disease), and substance use (tobacco use, alcohol use, alcohol abuse, and illicit drug use) were recorded. American Society of Anesthesiologists (ASA) score at time of injury was collected. Injury features, including laterality, presence of ankle fracture-dislocation, open injury, and OTA classification were also recorded.

Additionally, postoperative complications were recorded. Complications included superficial wound infections (SWIs) (peri-incisional erythema/induration, slight drainage, no communication with implants; treated on an outpatient basis with local wound care and/or oral antibiotics), deep wound infections (DWIs) (frank purulence from incision, communication with or exposed implants; required surgical irrigation and debridement and intravenous antibiotics), and wound healing complications (delayed wound healing beyond 3 weeks or wound dehiscence without signs of infection and not requiring antibiotic treatment).

Statistical Analysis

Statistical analysis was performed using SPSS, version 25 (IBM Corp, Armonk, NY). Pearson chi-squared or Fisher exact test was used for analysis of categorical variables, where appropriate. Independent samples t tests, with Welch corrections in the setting of unequal variance, were used for analysis of continuous variables. Analysis was initially performed on the entire cohort, followed by subgroup analysis on patients that might be more sensitive to the transient tissue ischemia encountered with tourniquet use (including those with diabetes, obesity, tobacco users, age greater than 65 years, and open fracture). Multiple logistic regression analysis was performed using patient demographic, medical history, injury, and operative characteristics to identify independent risk factors for the development of each complication. All statistical analyses were two-tailed and statistical significance was defined as P <.05.

Results

Patient Demographics

A tourniquet was used in 523 (57.9%) of 903 total cases. Mean patient age was 45.3 years, and 50.6% were female (Table 1). Patients were predominantly white (63.3%). Overall, 49.4% of patients were obese and 13.8% of patients had diabetes mellitus. Follow-up occurred at a mean of 47.6 weeks (range: 6 weeks to 10 years), with no differences between groups. No differences in demographics or rates of comorbid medical conditions were identified between the tourniquet and no tourniquet groups (in all cases, P > .05). Tobacco use was more prevalent among the no tourniquet group (51.9%) compared to the tourniquet group (44.4%, P = .032). However, alcohol use, alcohol abuse, and illicit drug use rates were similar. Similar rates of ankle-fracture dislocations were seen in each group, though open fractures were less common in the tourniquet group (11.3% vs 22.9%, P < .001) (Table 1). A total of 658 OTA 44B fractures (72.9%) and 245 OTA 44C fractures (27.1%) were identified, with similar rates occurring in each group.

Table 1.

Comparison of Demographics, Medical Comorbidities, Substance Use, Injury Features, and Complications Based on Tourniquet Use.^a

Characteristic	All Patients (N = 903)	No Tourniquet (n = 380)	Tourniquet (n = 523)	P Value^b
Demographics
Age, y, mean (SD)	45.3 (16.3)	45.4 (17.1)	45.2 (15.8)	.88
Female	457 (50.6)	185 (48.7)	272 (52.0)	.32
Race				.77
White	570 (63.3)	232 (61.4)	338 (64.8)	.30
Black	267 (29.7)	118 (31.2)	149 (28.5)	.39
Hispanic	58 (6.4)	26 (6.9)	32 (6.1)	.65
Other	5 (0.6)	2 (0.5)	3 (0.6)	>.99
BMI	31.3 (8.0)	31.4 (8.6)	31.2 (7.5)	.70
Medical comorbidities
Obesity	434 (49.4)	184 (50.1)	250 (48.8)	.70
Diabetes	125 (13.8)	50 (13.2)	75 (14.3)	.61
Neuropathy	11 (1.2)	4 (1.1)	7 (1.3)	.77
Renal disease	19 (2.1)	4 (1.1)	15 (2.9)	.06
ASA score, mean (SD)	2.23 (0.64)	2.26 (0.69)	2.22 (0.61)	.37
Substance use
Tobacco use	402 (47.5)	181 (51.9)	221 (44.4)	.032
Alcohol use	407 (48.6)	166 (48.7)	241 (48.6)	.98
Alcohol abuse	50 (5.5)	23 (6.1)	27 (5.2)	.56
Drug use	94 (11.4)	40 (11.9)	54 (11.1)	.73
Injury features
Open	146 (16.2)	87 (22.9)	59 (11.3)	<.001
Dislocation	365 (40.4)	161 (42.4)	204 (39.0)	.31
OTA 44B	658 (72.9)	276 (72.6)	382 (73.0)	.89
OTA 44C	245 (27.1)	104 (27.4)	141 (27.0)	.89

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; OTA, Orthopaedic Trauma Association.

Unless otherwise noted, values are n (%).

Bold represents statistical significance.

Overall Complication Rate

Wound healing issues were most common, occurring in 45 patients (5.0%), followed by SWI (4.8%), and DWI (2.2%) (Table 1). Postoperative complications occurred at similar rates in both the tourniquet and no tourniquet groups (SWI: 5.2% vs 4.2%, P = .51; DWI: 2.3% vs 2.1%, P = .84; Wound healing issue: 4.0% vs 6.3%, P = .12).

Complications: Subgroup analysis (advanced age, obesity, diabetes, tobacco use, and open fracture)

Results of subgroup analysis performed on patient groups potentially more sensitive to transient tissue ischemia associated with tourniquet use are shown in Table 2. Among these groups, SWIs and wound healing issues occurred most commonly among patients with an open fracture (8.2% and 14.4%, respectively). Rates of wound healing issues were also relatively high among patients older than 65 years, occurring in 13 patients (12.5%), with a trend for more wound healing issues occurring in the no tourniquet group (18.0% vs 7.4%, P = .10). Deep wound infections were most common among diabetics, occurring in 9 patients (7.2%). However, no differences in rates of wound healing or infectious complications were seen between the tourniquet and no tourniquet groups for any of the subgroups analyzed (in all cases, P = .10 to >.99).

Table 2.

Comparison of Infectious and Wound Healing Complications for All Patients and Subgroups More Sensitive to Transient Tissue Ischemia.

	n	Superficial Wound Infection,n (%)	Deep Wound Infection,n (%)	Wound Healing Issue,n (%)
All patients
Total	903	43 (4.8)	20 (2.2)	45 (5.0)
No tourniquet	380	16 (4.2)	8 (2.1)	24 (6.3)
Tourniquet	523	27 (5.2)	12 (2.3)	21 (4.0)
P		.51	.84	.12
Age ≥65 y
Total	104	6 (5.8)	3 (2.9)	13 (12.5)
No tourniquet	50	4 (8.0)	2 (4.0)	9 (18.0)
Tourniquet	54	2 (3.7)	1 (1.9)	4 (7.4)
P		.42	.61	.10
Obese
Total	434	21 (4.8)	13 (3.0)	24 (5.5)
No tourniquet	184	8 (4.3)	7 (3.8)	10 (5.4)
Tourniquet	250	13 (5.2)	6 (2.4)	14 (5.6)
P		.68	.40	.94
Diabetes
Total	125	8 (6.4)	9 (7.2)	9 (7.2)
No tourniquet	50	2 (4.0)	5 (10.0)	6 (12.0)
Tourniquet	75	6 (8.0)	4 (5.3)	3 (4.0)
P		.47	.48	.15
Tobacco use
Total	402	21 (5.2)	10 (2.5)	15 (3.7)
No tourniquet	181	9 (5.0)	4 (2.2)	9 (5.0)
Tourniquet	221	12 (5.4)	6 (2.7)	6 (2.7)
P		.84	>.99	.24
Open fracture
Total	146	12 (8.2)	7 (4.8)	21 (14.4)
No tourniquet	87	6 (6.9)	4 (4.6)	15 (17.2)
Tourniquet	59	6 (10.2)	3 (5.1)	6 (10.2)
P		.55	>.99	.23

Risk factors for wound healing and infectious complications

When controlling for other demographic, medical, injury, and operative characteristics, male sex (odds ratio [OR] 2.51, P = .013), renal disease (OR 5.25, P = .011), and open fracture (OR 2.32, P = .031) were identified as significant independent predictors for developing SWI (Table 3). Diabetes (OR 3.67, P = .021) and open fracture (OR 3.68, P = .015) were significant independent predictors for DWI, whereas only open fracture (OR 4.90, P < .001) was identified as a significant independent predictor for developing a wound healing issue. Advanced age, obesity, and tobacco use were not associated with complications. Similarly, intraoperative tourniquet use was not identified as a significant independent predictor for developing infectious or wound healing complications (P = .18 to 0.65).

Table 3.

Results of Multiple Logistic Regression Using Patient Demographics, Medical History, Injury, and Operative Characteristics to Predict Postoperative Complications.^a

	Superficial Wound Infection			Deep Wound Infection			Wound Healing Problem
	OR	95% CI	P	OR	95% CI	P	OR	95% CI	P
Age ≥65 y	0.79	0.24, 2.59	.70	0.73	0.17, 3.18	0.68	1.60	0.65, 3.94	.31
Sex (male)	2.51	1.22, 5.17	.013	0.90	0.34, 2.37	.83	0.78	0.39, 1.54	.47
White race		Referent			Referent			Referent
Black race	1.24	0.62, 2.49	.541	0.25	0.06, 1.13	.07	0.67	0.29, 1.54	.34
Hispanic race	−	−	>.99	0.84	0.10, 6.91	.87	2.38	0.82, 6.88	.11
Other race	−	−	>.99	−	−	>.99	−	−	>.99
Obesity	1.02	0.51, 2.03	.95	1.46	0.52, 4.11	.47	1.24	0.61, 2.50	.55
Diabetes	1.24	0.49, 3.13	.65	3.67	1.22, 11.06	.021	0.98	0.38, 2.52	.97
Neuropathy	1.61	0.17, 15.50	.68	3.66	0.57, 23.38	.17	1.47	0.15, 14.47	.74
Renal disease	5.25	1.46, 18.84	.011	2.19	0.35, 13.78	.40	0.87	0.10, 7.68	.90
Tobacco use	1.22	0.61, 2.43	.57	1.85	0.68, 5.05	.23	0.84	0.40, 1.73	.63
Open fracture	2.32	1.08, 4.97	.031	3.68	1.29, 10.50	.015	4.90	2.41, 9.95	<.001
Tourniquet	1.63	0.80, 3.31	.18	1.26	0.46, 3.42	.65	0.76	0.39, 1.48	.42

Abbreviations: 95% CI, 95% confidence interval for odds ratio; OR, odds ratio; P, probability value for each predictor.

Bold represents statistical significance.

Discussion

In the present study, infectious and wound healing complications were compared for cohorts of patients who underwent fixation of an ankle fracture with or without use of an intraoperative tourniquet. Overall, tourniquet use did not result in significantly different rates of superficial wound infection, deep wound infection, or wound healing issues. Further, subgroup analysis of higher risk patient groups (those with advanced age, diabetes, obesity, tobacco use, or open fractures) did not reveal any differences in complication rates with the use of a tourniquet with the numbers available. Multiple regression analysis failed to identify tourniquet use as an independent predictor of infectious or wound healing complications. To our knowledge, this is the largest modern study to evaluate potential effects of tourniquet use on wound complications.

Results of prior studies evaluating the effect of tourniquet use on outcomes following ankle fracture surgery have been mixed and have generally focused on postoperative pain^6,7,14,17 and length of hospital stay.^17,18 However, studies evaluating the relationship between tourniquet use and postoperative complications involving the operative site are rare. Maffulli et al⁸ performed a prospective randomized trial to determine complication rates following tourniquet use during fixation of simple, closed distal fibula fractures and reported higher rates of infectious complications with tourniquet use. Although these results are discordant with those presented in the current study, this discrepancy may be a result of the smaller sample size (n = 80) of the prior study and differences in characteristics of patients included in each study, where the authors excluded patients older than 60 years, unstable ankle fractures, open fractures, fractures involving more than just the distal fibula, diabetics, and patients who smoked 5 or more cigarettes per day.

Numerous studies have been performed to identify patient- and operation-related risk factors associated with wound complications following ankle fracture.^2,10,11,13 These studies have found that advanced age, diabetes, obesity, tobacco use, and open fracture all portend an increased risk; however, none of these studies evaluated the effect of tourniquet use on complications in these high-risk populations. We were unable to identify any difference in infectious or wound healing complication rates with or without tourniquet use in these particular patients, suggesting that tourniquet use is well tolerated and no additional risk is incurred in these patients who are at higher risk of wound complications at baseline.

Similar to previous studies,^2,10,11 we found that open fracture was an independent risk factor for infectious and wound healing complications, whereas diabetes was an independent risk factor for deep wound infection. However, we did not find tourniquet use to be an independent risk factor for development of infectious or wound healing complications. These findings are corroborated by those of Ovaska et al,¹⁵ who performed an age- and sex-matched case-control study to identify risk factors for deep surgical site infection following ankle fracture fixation and similarly failed to identify tourniquet use as an independent risk factor for developing deep infection. Another study evaluating patients undergoing elective foot and ankle surgeries found the odds of developing a postoperative infectious or wound healing complication to be 7 times higher in cases where tourniquet time exceeded 90 minutes; however, use of a tourniquet by itself was not associated with increased risk.²⁰ Thus, in terms of wound complications, comorbidities and injury features appear to be more important determinants.

Our study was not without limitations, the first of them being the retrospective nature of the study. Medical records were used to retrospectively collect data, and thus the completeness and validity of the data relied solely on the content of the medical record. Medical comorbidities including those that may predispose a patient to poor healing were not collected, such as peripheral vascular disease or immunocompromise. However, we propose that these underlying diseases were likely present with equal frequency in the tourniquet and no tourniquet groups. Also, we were not able to record the hemoglobin A1c values to assess whether diabetes control had an effect on the rate of wound or infectious complications. Furthermore, we did not evaluate the effect of tourniquet pressure or tourniquet inflation time on development of complications, as these data were often missing from the medical record. Additionally, we were not able to accurately compare operative time and blood loss with and without tourniquet use. Although this data was available, it was frequently confounded by the fact that some of the patients included in the study were polytraumatized and underwent multiple procedures during a single trip to the operating room, resulting in longer operative times and increased blood loss unrelated to ankle fracture fixation. Finally, the decision to use a tourniquet was at the operating surgeon’s discretion, which may have introduced allocation bias. Thus, patients believed to be at higher risk of complications related to tissue ischemia secondary to tourniquet use may have disproportionately been excluded from the tourniquet group, which may have falsely lowered the complication rate in this group.

In conclusion, we found postoperative infectious and wound healing complication rates to be similar irrespective of tourniquet use during ankle fracture surgery, even in those with advanced age, diabetes, obesity, tobacco use, or open fractures. Although certain patient-related factors were associated with higher rates of infectious and wound healing complications after ankle fracture fixation, the tissue ischemia produced by a tourniquet did not appear to result in higher rates of these complications.

Supplemental Material

FAI907379_disclosures – Supplemental material for Effect of Tourniquet Use During Ankle Fracture Fixation on Wound Healing and Infectious Complications

Supplemental material, FAI907379_disclosures for Effect of Tourniquet Use During Ankle Fracture Fixation on Wound Healing and Infectious Complications by Alex Benedick, Trenton Rivera and Heather A. Vallier in Foot & Ankle International

Footnotes

Author Note

This study was performed at MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University. All of the devices in this manuscript are FDA approved.

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. ICMJE forms for all authors are available online.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Heather A. Vallier MD,

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