Pneumatic tourniquets have traditionally been used to achieve a bloodless operative field in foot and ankle surgery but are associated with postoperative pain, ischemia-reperfusion injury, and neurologic complications. This review compares tourniquet-based and epinephrine-based hemostasis regarding mechanisms, safety, effectiveness, and outcomes. Tourniquets provide reliable visualization, particularly in complex or prolonged procedures, but increase pain and tissue injury. Epinephrine induces transient vasoconstriction while preserving partial perfusion, demonstrating strong safety with reduced postoperative pain and opioid use. Optimal results require proper dosing and timing. Hemostatic strategy should be individualized based on procedure and patient factors. Further studies comparing standardized protocols are needed.