JOA - 2026-05-19 - Journal Article
Tourniquet Use Increases Harm Without Benefit in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.
Posta AZ, Nemes NJ, Takanouchi S, Galdzytska N, Engh MA, Fazekas KK, Hegyi P, Bejek Z
Topics
Key Takeaway
Tourniquet use in primary TKA increases DVT risk by 60% (RR 1.60, 95% CI 1.25–2.05) without reducing calculated blood loss or transfusion requirements.
Summary Depth
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Summary
This systematic review and meta-analysis of 51 RCTs examined whether tourniquet use during primary TKA affects DVT risk, blood loss, transfusion rate, pain, and ROM. Tourniquet use significantly increased DVT risk (RR 1.60, 95% CI 1.25–2.05) with no significant difference in calculated blood loss or transfusion risk (RR 1.05, 95% CI 0.76–1.44). No significant differences in pain or ROM were detected at any time point, though the abstract conclusion contradicts this by claiming higher pain and lower early ROM in the tourniquet group.
Key Limitation
Moderate-to-high risk of bias in most outcomes with low-to-moderate GRADE evidence strength limits the certainty of conclusions, and the total patient N is not reported, preventing assessment of statistical power across subgroups.
Original Abstract
BACKGROUND
Approximately 60% of orthopaedic surgeons worldwide use tourniquets (TQ) during primary total knee arthroplasty (TKA) surgeries. Currently, there are no established guidelines or recommendations; therefore, we aimed to conduct a systematic review and meta-analysis to investigate the effects of tourniquet application.
METHODS
There were three major databases (PubMed, Cochrane, and Embase) systematically searched in November 2024. Randomized controlled trials (RCTs) comparing primary total knee arthroplasty with or without a tourniquet were included. We identified 6,040 studies, from which we included 41 RCTs. From reference and citation chasing, we added 10 more eligible articles. The risk of bias was assessed using the Cochrane Risk of Bias tool version 2 (RoB2), and the level of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. For continuous outcomes, the difference between the means was used as the effect size measure, along with a 95% confidence interval (CI). In the case of dichotomous outcomes, the risk ratio with a 95% CI was used.
RESULTS
In the tourniquet group, we observed a significantly higher risk of deep vein thrombosis (DVT) (P < 0.0001), risk ratio: 1.60 (95% CI: 1.25 to 2.05). We did not find a significant difference in the calculated total blood loss (CBL), and there was no significant difference in the risk of transfusions, with a relative risk of 1.05 (95% CI: 0.76 to -1.44). Furthermore, we observed no significant differences in pain levels or range of motion at any given time point. We experienced a moderate to high risk of bias in most outcomes, and the strength of evidence was low to moderate after grading.
CONCLUSION
In conclusion, the use of a tourniquet during total knee arthroplasty increases the risk of deep vein thrombosis, results in higher pain levels, and leads to a lower range of motion in the early postoperative days. However, it has no significant effect on blood loss or transfusion requirements.