There were multiple studies evaluating pain and tourniquet use with six high quality studies (Ozkunt 2018, Liu 2017, Yi 2021, Hamawanadi 2021, Liu 2014, Ledin 2012) showing increased pain in the immediate postoperative period. Additionally, there is moderate evidence to support avoidance of using a tourniquet in order to decrease opioid consumption (Hamawanadi 2021, Kheir 2018, Nicolaiciuc 2019).
Studies regarding outcomes were heterogenous and inconclusive. Two high quality studies (Ozkunt 2018, Hamawanadi 2021) did not favor using a tourniquet and two high quality studies (Ayik 2019, Liu 2017) showed no significant difference for KSS. Four high quality studies showed no significant difference in motion, including total ROM (Ayik 2019, Liu 2017), flexion (Goel 2019, Alexandersson 2019), or extension (Alexandersson 2019).
Five high quality studies (Ledin 2012, Harsten 2015, Mori 2016, Goel 2019, Hamawanadi 2021) were in favor of using a tourniquet to reduce blood loss. However, there were different methods of blood loss calculation, and two studies (Ledin 2012, Mori 2016) did not use tranexamic acid (TXA). Three high quality studies (Goel 2019, Liu 2017, Hamawanadi 2021) showed no difference for deep vein thrombosis, moderate evidence (Alexandersson 2019, Yi 2021, Hamawanadi 2021) showed no difference for length of stay, and there were not enough high quality studies to show a difference for quadricep strength, wound complications, or operating time.
*KSS = Knee Society Score, ROM = range of motion
Benefits/ Harms of Implementation
Surgeons should take care to balance the advantages and disadvantages of using a tourniquet. Reported advantages of using a tourniquet include dry field, shorter operative time, better visibility, reduced blood loss, dry bone surfaces for better cement interdigitation and implant survivorship. Adverse effects include ischemia, quadricep muscle damage, increased swelling and stiffness, nerve compression, injury to calcified vessels, and potential for deep venous thrombosis (DVT). If a tourniquet is used, it is recommended to keep the surgical time down to decrease the risk for DVT.
Outcome Importance
The outcomes for TKA with tourniquet versus no tourniquet were equivalent. While there are limited studies in young patient populations, this recommendation may be used with caution in surgeon practices with younger patient populations as the use of tourniquet may cause increased quadricep pain and weakness.
Cost Effectiveness / Resource Utilization
This recommendation likely does not affect cost-effectiveness or resource utilization for a majority of surgeons. However, surgeons who desire to improve their efficiency may consider using it to decrease operating room time.
Acceptability
Surgeons will likely find the cumulative study results and recommendation acceptable.
Feasibility
There are a number of studies showing comparable outcomes with or without tourniquet use. It would be feasible for surgeons to consider the patient’s history when making a decision about using a tourniquet. Specific considerations would include a history of DVT, lower extremity vascular stents, and poor bone quality if cementing implants.
Future Research
There is a gap in the literature regarding the long term effect of tourniquet use and quadricep strength in younger patients. As the operative age continues to decrease and activity and expectations after total knee arthroplasty continue to increase, future studies should focus on this group of patients.
- Alexandersson, M., Wang, E. Y., Eriksson, S. A small difference in recovery between total knee arthroplasty with and without tourniquet use the first 3 months after surgery: a randomized controlled study. Knee Surgery, Sports Traumatology, Arthroscopy 2019; 4: 1035-1042
- Ayik, O., Demirel, M., Birisik, F., Ersen, A., Balci, H. I., Sahinkaya, T., Batibay, S. G., Ozturk, I. The Effects of Tourniquet Application in Total Knee Arthroplasty on the Recovery of Thigh Muscle Strength and Clinical Outcomes. The Journal of Knee Surgery 2020; 0: 19
- Goel, R., Rondon, A. J., Sydnor, K., Blevins, K., O'Malley, M., Purtill, J. J., Austin, M. S. Tourniquet Use Does Not Affect Functional Outcomes or Pain After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial. Journal of Bone & Joint Surgery - American Volume 2019; 20: 1821-1828
- Hamawandi, S. A., Amin, H. I., Al-Humairi, A. K. Effects of the Use of Tourniquet in Total Knee Arthroplasty on the Clinical and Functional Outcomes with 5 Years of Follow-up: A Randomized Controlled Trial. The Journal of Knee Surgery 2021; 0: 14
- Harsten, A., Bandholm, T., Kehlet, H., Toksvig-Larsen, S. Tourniquet versus no tourniquet on knee-extension strength early after fast-track total knee arthroplasty; a randomized controlled trial. Knee 2015; 2: 126-30
- Kheir, M. M., Ziemba-Davis, M., Dilley, J. E., Hood, M. J., Meneghini, R. M. Tourniquetless Total Knee Arthroplasty With Modern Perioperative Protocols Decreases Pain and Opioid Consumption in Women. Journal of Arthroplasty 2018; 11: 3455-3459
- Ledin, H., Aspenberg, P., Good, L. Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta Orthopaedica 2012; 5: 499-503
- Liu, D., Graham, D., Gillies, K., Gillies, R. M. Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty. 2014; 4: 207-13
- Nicolaiciuc, S., Probst, P., von Eisenhart-Rothe, R., Burgkart, R., Hube, R. Modern Total Knee Arthroplasty (TKA): With Or Without a Tourniquet?. Surgical Technology International 2019; 0: 336-340
- Ozkunt, O., Sariyilmaz, K., Gemalmaz, H. C., Dikici, F. The effect of tourniquet usage on cement penetration in total knee arthroplasty. Medicine (United States) 2018; 4:
- Yi, Z., Yan, L., Haibo, S., Yuangang, W., Mingyang, L., Yuan, L., Bin, S. Effects of tourniquet use on clinical outcomes and cement penetration in TKA when tranexamic acid administrated: a randomized controlled trial. BMC Musculoskeletal Disorders 2021; 1: 126
- Mori, N., Kimura, S., Onodera, T., Iwasaki, N., Nakagawa, I., Masuda, T. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: A prospective, randomized study. Knee 2016; 5: 887-9