Awareness, Not Seniority, Is Associated With Change in Tourniquet Practice for Ankle Fracture Fixation: An International Cross-Sectional Survey

IntroductionRecent randomised evidence and the 2021 British Orthopaedic Association Standard for Trauma (BOAST) have questioned routine, unselective tourniquet use.This study aimed to describe tourniquet practice in ankle fracture fixation and identify factors associated with evidence-and guideline-concordant practice. MethodologyAn international cross-sectional online survey of orthopaedic surgeons who perform ankle fracture fixation was distributed through the OrthoXcel Collaborator Network between 10 May and 4 June 2026.It covered tourniquet practice, awareness of recent evidence and of BOAST, local policy and willingness to change.Associations were tested with χ², Fisher's exact and trend tests and logistic regression. ResultsIn all, 85 surgeons from four countries responded (United Kingdom 45, Egypt 29, India 6, UAE 5; 26 consultants, 26 specialty doctors and 33 trainees).Overall, 75/85 (88.2%) used a tourniquet routinely, with no difference by grade (p = 0.677).Only 17/85 (20.0%) were fully aware of recent randomised evidence and 44/85 (51.8%) of BOAST, and 11/85 (12.9%) reported a local policy.Of routine users, 58/75 (77.3%) used a fixed pressure rather than one individualised to systolic blood pressure.Reported practice change rose from 13.9% among surgeons unaware of the evidence to 58.8% among those fully aware (adjusted odds ratio (OR) 10.1; 95% confidence interval (CI) 2.4-42.4),and BOAST application rose from 13.6% to 85.0% with BOAST awareness (adjusted OR 33.6; 95% CI 5.3-214.0).Grade, experience and country were not independently associated with either outcome.BOAST appliers more often individualised pressure ((14/42, 33.3% vs. 3/33, 9.1%; P = 0.014).Most routine users (66/75, 88.0%) were open to change. ConclusionsRoutine thigh tourniquet use at a fixed pressure remains the norm in ankle fracture fixation, with little institutional governance.Awareness, rather than seniority, was associated with change.Targeted dissemination of the evidence and BOAST, supported by local policies, is a practical lever while definitive trials are awaited.