Total knee arthroplasty with or without a tourniquet: a meta-analysis of randomized controlled trials

The use of a tourniquet in total knee arthroplasty (TKA) remains debated. This meta-analysis compared outcomes in TKA performed with versus without a tourniquet.

A systematic search of PubMed, Scopus, Cochrane Library, Google Scholar, and Embase was conducted through June 2025. A total of 50 randomized controlled trials were included. Outcomes assessed included clinical, functional, biological, perioperative, and complication-related parameters.

Tourniquet use in TKA was associated with significantly lower intraoperative blood loss (mean reduction 88 mL; p < 0.00001) and shorter operative time (mean difference - 2.95 min; p = 0.0002). However, it resulted in significantly greater postoperative drainage (mean difference 41.83 mL; p < 0.00001) and slightly higher early knee pain (mean increase 0.39 points; p < 0.00001) and thigh pain (mean increase 0.54 points; p = 0.01). Early functional scores also slightly favored the no-tourniquet group, with lower KSS function at 3 months in the tourniquet group (p = 0.01), though no differences were observed at 6 or 12 months. No significant differences were found between groups in swelling ratio (p = 0.34-0.46), quantitative opioid use (p = 0.09), inflammatory markers (CRP, IL-6, D-dimer; all p > 0.07), hemoglobin and hematocrit levels or hemoglobin loss (all p > 0.50), transfusion requirement (p = 0.18), or hospital length of stay (p = 0.30). Active and passive knee flexion, quadriceps and hamstring strength, as well as HSS, total KSS, OKS, and WOMAC scores showed no statistically significant differences at any follow-up point (all p > 0.16). Complication rates were overall similar between groups (p = 0.09), though acute kidney injury (p = 0.02) and postoperative numbness (p = 0.003) were more frequent with tourniquet use. In contrast, 60-day readmission was significantly lower in the tourniquet group (RR 0.16; p = 0.04), while DVT risk did not differ (p = 0.69).

Avoiding a tourniquet in TKA may offer advantages in terms of pain, early recovery, and complication reduction, without compromising functional or radiological outcomes. Surgeons may consider selective or limited tourniquet use based on patient risk factors and surgical goals.