Defining tourniquetless total knee arthroplasty: A systematic review

Performing total knee arthroplasty (TKA) without the use of tourniquet is gaining popularity. However, performing a "tourniquetless TKA" has a variety of meanings regarding the timing and application of a tourniquet and associated techniques. The purpose of this systematic review was to evaluate the literature and more accurately define "tourniquetless TKA."

A systematic review following PRISMA guidelines was performed of the PubMed, Web of Science, and Cochrane databases for articles published from 2016 to 2021. Inclusion criteria included papers that used "tourniquetless" or a similar term to describe their TKA procedure, original clinical studies, English language, and full-text studies.

A total of 1,096 studies were identified, of which 84 full text studies with 9,349 total patients were included. Overall, 17 (20.2%) of the studies performing tourniquetless TKA never applied a tourniquet, 17 (20.2%) applied a tourniquet but kept it deflated throughout the entire procedure, 2 (2.4%) applied a tourniquet and inflated during cementation only, and 48 (57.1%) did not specify. Ultimately, of the studies that did specify tourniquet use, only 17 studies (47.2%) truly never applied a tourniquet throughout the procedure. A review of 7 recommended techniques to control blood loss in tourniquetless TKA found that no one technique was performed in more than 10.6% of patients.

Variation in the definition of tourniquetless TKA and the utilization of augmented techniques to control blood loss remains. We propose the terms "tourniquetless" for no tourniquet application, "tourniquet-available" for tourniquet applied but kept deflated throughout surgery, and "tourniquet-assisted" for tourniquet inflation during cementation only. These terms can help better differentiate the literature, guide surgeons as they transition to tourniquetless TKA, and assist in the development of more definitive protocols for tourniquetless TKA.