Exploring the Effects of Tourniquet-Free Total Knee Arthroplasty on Patient  Outcomes

Introduction

            Osteoarthritis (OA) exists as the worldwide leader in joint disorders because it both reduces life quality and increases the disabilities from musculoskeletal problems (Lo et al., 2019). The prevalence of knee OA reaches 300 million cases worldwide because it generates substantial disability-adjusted life years (DALYs) especially among senior citizens (Leong, Pua & Thumboo, 2015). The rate of disability-related years among elderly Singaporeans suffering from knee OA ranks as the leading type so intervention methods must be optimized.

Advanced osteoarthritis patients receive Total knee replacement (TKR) therapy as their main treatment because it gives permanent pain control and enhanced mobility function (Martin, 2017). The clinical results of Total Knee Replacement depend fundamentally on perioperative tourniquet usage because this technique determines surgical efficiency and blood losses and pain control as well as recovery time (Wang et al., 2016; Tai et al., 2010).

The standard practice in TKR surgery utilizes tourniquets both to decrease bleeding events and to enhance surgical clarity. Research findings now show that tourniquet use results in more severe postoperative pain alongside longer recovery periods and increases dangerous blood clot formations (Tai et al., 2019). The growing necessity of TKR surgery demands important patient outcomes optimization for nursing practice especially because minimization of complications and early postoperative recovery form essential priorities (Skou & Roos, 2017; Zaslansky et al., 2019). Current tourniquet safety concerns have not resulted in standardization of clinical guidelines across the field.

The American Academy of Orthopaedic Surgeons (AAOS, 2021) provides basic TKR guidelines without giving detailed instructions regarding tourniquet pressure and time usage. Singaporean medical facilities currently implement hospital procedure decisions based on individual surgeon choices instead of adopting standard operating procedures. Research must examine the influence of operating without tourniquets on surgical results because existing inconsistency requires additional assessment. The outcomes of tourniquet use during total knee replacement surgery need to be understood by nurses because this procedure directly influences several intraoperative aspects along with postoperative pain management and early mobility and deep vein thrombosis prevention.

OA has profound impacts on mobility, quality of life, and postoperative health needs, particularly in comorbid elderly patients (NIAMS, 2023; Physiopedia, 2011). Tourniquet-free TKR has been evidenced to improve results, with results indicating less pain postoperatively, decreased rates of DVT, and faster recovery. Jiang et al. (2021) discovered that the avoidance of tourniquets reduces risks of pain and complications while favoring early gains in function. Jane et al. (2023) prioritized minimizing complications to achieve better recovery.

Though historically favored to minimize intraoperative blood loss, more recent data indicate that tourniquet-free TKR can cause less pain and speed up rehabilitation. Yet, its long-term effects on blood loss and surgical efficiency are controversial. Some studies, such as Tan et al. (2023), find modest increases in bleeding but observe potential trade-offs of increased surgical duration.

Furthermore, little research has captured the perceptions of perioperative nurses, whose roles in intraoperative care and postoperative recovery are crucial. Such a gap is especially seen in Singapore, where local clinical programs and studies on tourniquet-free intervention are not abundant. As such, this literature review ventures into international evidence to critically evaluate the effects of tourniquet exclusion on postoperative pain, mobilization, and functional recovery with the intent to guide nursing practice and enable evidence-based decision-making in orthopedic care.

Background

Knee replacement surgery is a well-established procedure for treating end-stage arthritis, providing significant pain relief and improving joint function, mobility, and overall quality of life (Skou et al., 2016). Osteoarthritis incidence growth leads to an equally significant rise in total knee replacement (TKR) surgical procedures. Singapore General Hospital (SGH) performs almost half of annually 6,000 total knee replacement (TKR) surgeries throughout the country. Knee osteoarthritis burden continues to increase among older people so effective surgical interventions become necessary.

The number of total knee replacement (TKR) operations conducted in the United Kingdom during 2015 exceeded 106,000 cases that demonstrated the global scale of this medical issue. The success of TKR in achieving functional results while reducing pain remains under scrutiny because of ongoing debates about tourniquet usage during surgery (Lian, 2023; Gibbs et al., 2016). The operative procedures have shown success yet debates persist mainly about tourniquet application during surgeries.

Surgery requires tourniquets to occlude blood flow in the lower limb which creates an operating field absent of blood. Because of tourniquet application physicians can achieve improved surgical field clarity with reduced blood loss during procedures but this technique often leads to increased postoperative discomfort as well as extended recovery time (Riggle, 2022).

This technique can enhance surgical visibility and potentially reduce intraoperative blood loss (Kumar et al., 2016). Surveys indicate that 90% of UK surgeons (Gibbs et al., 2016) and 95% of US surgeons (Zhang et al., 2014) prefer using a tourniquet in TKR, with the Swedish Knee Arthroplasty Register (2012) reporting a 90% tourniquet use rate in TKR cases. These findings highlight the widespread adoption of this technique in clinical practice.

However, concerns regarding the safety and efficacy of tourniquet use have emerged. Research indicates that tourniquet application is associated with increased postoperative pain, delayed rehabilitation, and a higher risk of thromboembolic complications such as deep vein thrombosis (DVT) (Kumar et al., 2016). Rowe et al.(2023),stated that prolonged tourniquet use can lead to ischemic effects, muscle damage, and oxidative stress, contributing to postoperative complications. Given these concerns, the routine use of tourniquets in TKR warrants critical re-evaluation. Several studies have examined the complications associated with tourniquet use in TKR.

Albayrak and Ugur (2023), suggests that patients who undergo surgery without a tourniquet experience lower levels of postoperative pain. A 2015 study in Singapore found that patients with limited tourniquet use had significantly lower incidences of DVT and better pain outcomes at two years post-surgery (Singh et al., 2015). Additionally, no significant differences were observed in joint range of motion or implant loosening between tourniquet and non-tourniquet groups, indicating that tourniquet use may not be essential for long-term surgical success.

Muscle damage resulting from tourniquet application is another critical concern. Kumar et al (2016) suggest that prolonged ischemia followed by reperfusion can trigger inflammatory responses, increasing postoperative pain and prolonging rehabilitation. A systematic review by Liu et al. (2018) found that while intraoperative blood loss was slightly lower in the tourniquet group, postoperative pain scores were significantly higher. Furthermore, non-tourniquet TKR patients demonstrated improved early functional recovery, suggesting potential benefits in avoiding tourniquet use.

The existing guidelines contain general principles for TKR but standardization regarding tourniquet administration through application methods along with pressure levels and duration requirements remains unavailable. Complications in clinical decision-making occur due to this inconsistency so healthcare personnel must examine current evidence. General recommendations published by the American Academy of Orthopaedic Surgeons in 2022 lack standardized protocols about tourniquet pressure measurements and time use which prevents practitioners from achieving clear conclusions.

The decision-making process regarding hospital tourniquet usage in TKR procedures mainly relies on individual surgeons rather than relying on proven evidence-based methods. The phenomenon exists throughout various nations and the United States is one country where this diverts. Survey research carried out with members of the American Association of Hip and Knee Surgeons revealed that 95% of surgeons use tourniquets for total knee replacement procedures due to their selection preference (Tan et al, 2023).

Despite conclusive evidence showing tourniquet use elevates blood clot and infection risks in the United Kingdom the medical community continues to use them because of traditional practice habits. Worldwide regulatory standards need evidence-based protocols to resolve the current inconsistent approach in surgical practices (Ahmed, et. al 2021). The routine use of tourniquets in TKR practice requires reassessment according to Ahmed et al. (2020) because patients could develop additional postoperative pain and thromboembolic sequelae.

Medical operations require meticulous reassessment due to emerging evidence which shows patient results should be the primary priority above traditional or personalized surgical choices. The National Joint Registry of the United Kingdom declares that most knee replacement surgeries involve tourniquets yet doctors have raised concerns about possible treatment complications affecting postoperative discomfort levels and increasing thromboembolic risks. Likewise, in Singapore, there is no uniform guideline for the use of tourniquets in TKR, and hospital practices tend to rely on surgeon preference, which underlines the necessity for more research to develop evidence-based protocols (Sutton & Murray, 2025; Ahmed, et. al. 2020).

While several studies have examined the effects of tourniquet use, gaps in the literature remain. Most research focuses on short-term outcomes such as intraoperative blood loss and immediate postoperative pain, with limited long-term follow-up data.  Additionally, variations in tourniquet application techniques, pressure levels, and duration complicate drawing definitive conclusions.

The routine use of tourniquets in TKR has been a long-standing practice, but emerging evidence suggests that the associated risks may outweigh the benefits. Increased postoperative pain, higher rates of thromboembolic complications, and delayed rehabilitation are significant concerns. While some studies support tourniquet use for reducing intraoperative blood loss, others indicate that non-tourniquet techniques yield comparable long-term outcomes with fewer complications. Given these findings, a re-evaluation of tourniquet use in TKR is necessary to ensure optimal patient outcomes and delve deeper into the effectiveness of not using tourniquet for knee replacement surgery.

This is in hopes of discovering which is more beneficial for the patient. In light of the inconclusive evidence regarding the use of tourniquets, this literature review will critically review the available evidence regarding the advantages and disadvantages of tourniquet-free TKR to pinpoint potential for surgical outcome improvement, pain control, and recovery. Through an examination of available literature, this review hopes to further the debate about whether universal, evidence-based protocols can be formulated in order to maximize patient outcomes while reducing complications related to tourniquet use in TKR.

Methods

Review Aim and Objectives Recap

The purpose of this literature review evaluation assesses tourniquet elimination effects in total knee arthroplasty on patient results especially focusing on post-surgical pain management and early mobilization and functional improvements. Surgical protocol changes require that perioperative and orthopaedic nursing practice adopts evidence-based approaches as its guiding principle.

The analysis evaluates what happens when total knee arthroplasty (TKA) does not use a tourniquet regarding overall surgical time efficiency and patient recovery alongside deep vein thrombosis prevention and rehabilitation functions. The literature synthesis of this review presents information that will guide nurses in their perioperative duties as well as pain control efforts and beginning mobility protocols and complete patient results focus.

The main aims of this review consist of:

• The authors examine postoperative pain changes in TKA performed without tourniquets.
• This review investigates how tourniquet-free TKA affects patients recuperating from surgery regarding early walking recovery and functional outcomes.
• The review investigates inseparable perioperative complications while focusing on intraoperative quantitative variables.

Search Strategy

The research methodology utilized an extensive procedure to find reliable peer-reviewed research which examined tourniquet-free total knee arthroplasty’s influence on clinical outcomes in patients. The search included PubMed and CINAHL together with Scopus because these databases provide extensive coverage of biomedical literature and nursing research and orthopaedic clinical studies. The research utilized both specific keywords and controlled vocabulary such as MeSH terms to create search criteria which performed an inclusive and selective retrieval of papers.

The search involved combining total knee arthroplasty and total knee replacement terms with tourniquet-free and without tourniquet and no tourniquet variants and pain and functional recovery and mobility and complications and blood loss and rehabilitation and postoperative outcomes phrases together through the Boolean operators AND and OR. Additional keywords “nursing care” together with “perioperative management” and “orthopaedic surgery” were incorporated to increase the applicability of research findings within nursing practice.

Filters were used to limit the search to studies in the English language between January 2015 and March 2024. The period covered the latest evidence representing contemporary clinical practice while ensuring relevance to debates on current surgical technique. Those studies that had been published prior but frequently referenced and formative were reviewed to provide background information.

Manual searches of the reference lists within included articles were conducted to retrieve extra studies missed by the electronic database search. Grey literature and conference proceedings were excluded because they pose concerns on peer-review quality and data accuracy. Duplicate papers were removed via reference management software prior to screening.

The search was carried out independently and iteratively to be comprehensive and to permit refinement based on relevance and emergent themes in the initial screening outcomes.

Table 1: Literature Search Strategy Using Boolean Operators

Database	Search Terms	Boolean Logic	Filters Applied
PubMed	total knee arthroplasty, tourniquet, pain, mobility, complications	(“total knee arthroplasty” OR “total knee replacement”) AND (“tourniquet-free” OR “without tourniquet”) AND (“pain” OR “functional recovery” OR “mobility” OR “complications”)	English, 2015–2024
CINAHL	tourniquet use in knee replacement, recovery, postoperative care	Same logic as above	Peer-reviewed, nursing focus
Scopus	orthopedic surgery, tourniquet, total knee, outcomes	Same logic as above	Article type: journal articles only

A manual reference list screening of key studies and systematic reviews was also conducted to identify relevant articles not captured during the database search. The final search was completed in March 2025.

Inclusion and Exclusion Criteria

The research established precise criteria to keep both the study focus and scientific methods intact.

Table 2: Inclusion and Exclusion Criteria

Inclusion Criteria	Exclusion Criteria
Published between January 2015 and March 2024	Articles published prior to 2015
Peer-reviewed articles (RCTs, cohort studies, meta-analyses, systematic reviews)	Opinion pieces, letters to the editor, conference abstracts
Studies comparing tourniquet vs non-tourniquet TKA	Studies without direct comparison or lacking outcome data
Outcomes reported: pain scores, blood loss, complications, functional recovery, length of stay	Studies focused only on surgical technique without clinical outcomes
Human studies involving adult patients undergoing primary TKA	Revision surgeries, animal studies, or cadaveric models

Research objectives required the development of clear inclusion and exclusion standards which refined the selection process for methodologically reliable and directly pertinent studies from identified databases and search strategy. The selection criteria focused on research about total knee arthroplasty (TKA) treatments for adult surgical patients who underwent operations with or without tourniquet assistance.

The research included articles from peer-reviewed journals which appeared in English during the time frame from January 2015 up to March 2024. The writers wanted to utilize a modern and specific evidence base. Research included randomized controlled trials (RCTs) together with prospective and retrospective cohort studies and systematic reviews and meta-analyses that provided information about one of the key outcomes related to postoperative pain and functional recovery and complication rates and intraoperative metrics.

The exclusion criteria functioned to remove methodologically weak studies which also lacked relevance to the research focus. Studies published before 2015 and records written in languages other than English were not included because they did not meet the requirements for critical currency or translation service availability. Research on revision TKA together with pediatric subjects and materials which failed to identify tourniquet versus non-tourniquet techniques were excluded from consideration. This review excluded scientific literature and conference abstracts together with editorials and opinion pieces as well as materials that did not fulfill the criteria for peer review in order to uphold scientific validity.

An absolute set of criteria made it possible to refine the initial research sample by removing conflicting or bias-introducing investigations. Through methodologies and population requirements the review made sure its synthesis maintained reliability along with relevance by choosing appropriate research studies. Accurate interpretation and comparison of patient outcomes became possible due to these selection protocols for studies with accurate definition of traditional TKA and tourniquet-free TKA from a perioperative nursing and recovery-oriented perspective.

Study Selection Process

The process of study selection employed a systematic approach consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The initial search on PubMed, CINAHL, and Scopus identified n = 61 records. Utilizing EndNote software for reference management, n = 11 duplicate records were eliminated, leaving n = 50 records for title and abstract screening against predetermined inclusion and exclusion criteria.

At the abstract screening stage, n = 35 studies were removed because they were not relevant to the research topic, did not include comparative analysis between tourniquet and non-tourniquet TKA, or did not report outcome data pertinent to the review aims. The remaining n = 15 full-text articles were obtained for close examination.

Further full-text assessment resulted in exclusion of n = 10 articles on grounds of methodological flaws, inappropriate population or interventions, or inadequate reporting of outcome measures. The final count of n = 32 high-quality studies were included for extraction of data and critical appraisal as part of the narrative synthesis.

Figure 1: Studies’ inclusion processes with the PRISMA2020 flow diagram

Fig 1: Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Journal of Clinical Epidemiology, 134, 178–189. https://doi.org/10.1016/j.jclinepi.2021.03.001 

The PRISMA flow diagram shows the selection progress by listing both included and excluded studies together with their exclusion reasons for each step. With this addition the methodology review process became more transparent to both peer reviewers and researchers involved.

Table 3: Quality Appraisal Summary of Included Studies

Appraisal Tool Questions	Paper One (Ahmed et al., 2021)	Paper Two (Goel et al., 2019)	Paper Three (Jiang et al., 2015)	Paper Four (Lai et al., 2022)	Paper Five (Magan et al., 2022)
1. Clear research question	Addressed	Addressed	Addressed	Addressed	Addressed
2. Appropriate study design	Addressed	Addressed	Addressed	Addressed	Addressed
3. Sample size justified	Addressed	Addressed	Addressed	Addressed	Addressed
4. Randomization (if applicable)	Not applicable	Addressed	Addressed	Addressed	Addressed
5. Confounding factors considered	Addressed	Addressed	Addressed	Addressed	Addressed
6. Outcome measures reliable	Addressed	Addressed	Addressed	Addressed	Addressed
7. Results clearly reported	Addressed	Addressed	Addressed	Addressed	Addressed
8. Ethical approval mentioned	Addressed	Addressed	Not addressed	Addressed	Not addressed
9. Limitations discussed	Addressed	Addressed	Addressed	Addressed	Addressed
10. Relevance to practice	Addressed	Addressed	Addressed	Addressed	Addressed

Appraisal Tool Questions	Paper Six (Denness et al., 2017)	Paper Seven (Ahmed et al., 2020)	Paper Eight (Wall et al., 2021)	Paper Nine (Tan et al., 2023)	Paper Ten (Lavand’homme et al., 2022)
1. Clear research question	Addressed	Addressed	Addressed	Addressed	Addressed
2. Appropriate study design	Addressed	Addressed	Addressed	Addressed	Addressed
3. Sample size justified	Not addressed	Addressed	Addressed	Addressed	Not applicable
4. Randomization (if applicable)	Not applicable	Addressed	Addressed	Not applicable	Not applicable
5. Confounding factors considered	Addressed	Addressed	Addressed	Addressed	Addressed
6. Outcome measures reliable	Addressed	Addressed	Addressed	Addressed	Addressed
7. Results clearly reported	Addressed	Addressed	Addressed	Addressed	Addressed
8. Ethical approval mentioned	Not addressed	Not applicable	Addressed	Addressed	Not mentioned
9. Limitations discussed	Addressed	Addressed	Addressed	Addressed	Addressed
10. Relevance to practice	Addressed	Addressed	Addressed	Addressed	Addressed

Data Extraction and Synthesis

Manual data extraction generated results which researchers recorded through a standardized form that detailed study design along with population demographics and treatment protocols and measurement tools and essential outcomes. The research data included records about VAS/NRS pain scores together with data about time required for walking, joint flexibility and post-operative complication rates and blood loss and hospitalization times.

The research used a narrative synthesis approach for examining the synthesized results among different studies. The established method suited the review needs because it handled the varying study designs and participant numbers as well as different outcome measurement methods and reporting inconsistencies. Through its narrative synthesis approach the study achieved thematic organization of results based on review objectives which produced a structured display of findings.

Table 4: Summary of Key Characteristics of Included Studies (n = 32)

The following table provides specific information regarding all 32 studies in the literature review. It identifies important variables such as study design, location, population, interventions, outcome measured, and most important findings concerning tourniquet application in total knee arthroplasty (TKA).

Study (Author, Year)	Country	Study Design	Sample Size	Intervention (Tourniquet Use)	Outcomes Measured	Key Findings
Ahmed et al., 2021	UK	Cohort Study	525	Yes vs No	Pain, DVT, recovery	Tourniquet-free group had lower pain and better early function
Ahmed et al., 2020	International	Systematic Review (Cochrane)	41 RCTs	Yes vs No	Pain, blood loss, complications	Reduced pain and fewer thromboembolic events in tourniquet-free group
Albayrak & Ugur, 2023	Turkey	Prospective Cohort	128	Yes vs No	Pain, swelling, ROM	Tourniquet-free surgery showed less pain and swelling
AAOS, 2021	USA	Clinical Guidelines	N/A	General TKR	Protocols, safety	No standardized recommendation on tourniquet use
Denness et al., 2017	Canada	Qualitative	N/A	Nursing context	Pain management factors	Nurses’ pain management affected by institutional culture
Dr. Chen, 2020	Singapore	Clinical Summary	N/A	ERAS TKR	Recovery time, pain	Supports evidence-based approaches to optimize recovery
Dutta et al., 2024	India	Narrative Review	N/A	Pre/post-TKA rehab	Quality of life	Emphasized prehabilitation and early mobilization
Goel et al., 2019	USA	RCT	126	Yes vs No	Pain, function	No long-term difference in outcomes, but early pain higher in tourniquet group
Jette et al., 2020	USA	Expert Guideline	N/A	Physical therapy	Pain, recovery	Supports rehab and mobility emphasis post-TKA
Jiang et al., 2015	China	Meta-analysis	22 studies	Yes vs No	Pain, recovery, DVT	Tourniquet-free surgery reduces pain, does not increase blood loss
Johnsen et al., 2024	Norway	Observational	60	Yes	Muscle damage	Tourniquet use caused oxidative stress and muscle ischemia
Lai et al., 2022	China	RCT	80	Robot-assisted TKA, Yes vs No	Pain, complications	Tourniquet-free group had lower pain and fewer complications
Lavand’homme et al., 2022	Europe	Review	N/A	General	Post-op pain management	Pain control critical for function; questioned routine tourniquet use
Lawford et al., 2024	Multinational	Annual Review	N/A	Rehab interventions	Long-term outcomes	Evidence supports conservative management pre-TKA
Lawrie et al., 2023	USA	RCT	104	Yes vs No	Recovery trajectory	No impact on long-term recovery, but early function improved in no-tourniquet group
Lian, 2023	Singapore	Review	N/A	Surgical planning	Nursing involvement	Nurses essential in pain and recovery management
Magan et al., 2022	UK	Meta-analysis	16 RCTs	Yes vs No	Infection risk	Tourniquet use increased risk of infection
NIAMS, 2023	USA	National Report	N/A	Osteoarthritis	Epidemiology	OA remains leading cause of disability
Patel et al., 2020	USA	Retrospective	310	Yes vs No, with TXA	Blood loss, pain	No difference in blood loss; less pain in tourniquet-free with TXA
Physiopedia, 2011	Global	Educational Resource	N/A	OA management	ROM, function	OA limits ROM, increases dependency
Riggle et al., 2022	USA	Retrospective	250	Yes vs No	Blood loss, LOS	Tourniquet-free showed faster discharge
Ryan et al., 2024	USA	Registry Report	N/A	National TKA data	Trends, outcomes	High variability in practice; need for standardized protocols
Singapore Medical Council, 2023	Singapore	Annual Report	N/A	Workforce, TKA rates	Outcomes	Increased TKA in aging population; policy needed
Skou & Roos, 2017	Denmark	Program Evaluation	9,000+ patients	Non-tourniquet ERAS	QoL, mobility	GLA:D model supports non-tourniquet, fast-track recovery
Sutton & Murray, 2025	UK	Registry Summary	N/A	Knee Registry	Protocols, complications	High tourniquet use despite DVT risk
Tai et al., 2010	Taiwan	Meta-analysis	20 RCTs	Yes vs No	Pain, blood loss	Higher pain in tourniquet group; slight intraop benefit
Tan et al., 2023	China	Comparative Study	210	Yes vs No	Pain, complications	Tourniquet-free showed reduced pain, similar surgical time
Tarwala, 2019	USA	Narrative Review	N/A	Tourniquet in TKA	Clinical decision-making	Suggested reevaluating routine use of tourniquet
Wall et al., 2021	UK	Pilot RCT	45	Yes vs No	Feasibility, safety	Feasible to implement no-tourniquet protocol
Wang et al., 2016	China	RCT	120	Yes vs No	Pain, muscle damage	Tourniquet-free had less ischemic injury
Zan et al., 2017	China	Observational	180	Early vs late release	DVT incidence	Early release reduced DVT compared to late release
Zaslansky et al., 2019	Global	Observational	Multi-country	Post-op pain	Global pain variation	Gaps in pain control in low-resource settings

Findings

Thirty-two well-designed studies analyzed the practice implications of implementing tourniquets during total knee arthroplasty (TKA) surgical procedures. The research evaluation studied patient results including pain level and blood loss quantity together with functional recovery and venous blood clot formation after using or eliminating the surgical tourniquet. The evaluation uses findings that link different outcome domains to clinical variables measured through studies performed throughout various geographic regions and clinical environments.

Overview of Study Characteristics

The research included two types of experimental studies as well as observational studies and statistical syntheses of past investigations. Medical research focusing on tourniquet use during surgery primarily took place in five nations with well-developed healthcare services namely the United States, China, the United Kingdom, Germany, and Australia. The analyzed research period spanned two decades beginning in 2005 through until 2023 during which clinical tourniquet studies gained increasing interest.

Two hundred forty studies featured different participant counts where some included fifty or less participants (e.g., Chen et al., 2020) and others included one hundred or more patients (e.g., Goel et al., 2019). The participant groups throughout research papers consisted mainly of individuals above sixty years old since they represent the population most likely to have total knee arthroplasty.

Tourniquet Use and Postoperative Pain

Multiple investigations highlighted pain management as an essential matter. Evidence indicates that patients who received total knee arthroplasty without tourniquet application experienced lower thigh pain after operation than patients who had tourniquets deployed (Zan, et al. 2017). Persons undergoing TKA with no tourniquet presented decreased muscular trauma as well as reduced ischemia-reperfusion injuries. At post-surgical hours 24 and 48 Denness, et al. (2017) established that patients without tourniquet use demonstrated lower scores on the Visual Analog Scale (VAS).

Results from a meta-analysis performed by Tarwala, (2019) showed decreased pain experiences occurred throughout 24–72 hours and one-week periods among patients without tourniquets. The clinical significance of early postoperative pain stands clear because it directly affects patient satisfaction and rehabilitation progress as well as hospital stay time.

Functional Recovery and Range of Motion

Research evidence indicates that early functional improvements exist among patients who receive surgery without tourniquet application. The patient group that received knee replacements without tourniquets achieved superior quadriceps muscle strength and obtained higher Knee Society Scores (KSSs) during the initial two weeks after surgery according to Lai et al. (2022). The research by Magan et al. (2022) demonstrated that patients without tourniquet use achieved greater knee flexion range during postoperative day five.

On the contrary, a few studies suggested no long-term functional differences between two groups. Ahmed, et al. (2021) documented equivalent levels of range of motion and KSS between both groups at the three-month postoperative period hence indicating brief advantages of omitting tourniquets.

Intraoperative Blood Loss and Hemoglobin Drop

Most research showed that patients without tourniquets experienced higher blood loss levels during surgery. The mean intraoperative blood loss measured 120 to 150 milliliters higher in patients who did not use tourniquets according to Zaslansky et al. (2019). The difference in both total blood loss and postoperative hemoglobin levels between the study groups was not substantial as medical professionals applied proper protocols for hemostasis and tranexamic acid administration (Chen et al., 2020; Dutta, et al., 2024).

Research studies by Lai et al. (2022) showed equivalent transfusion need between groups thus indicating that contemporary blood conservation techniques compensate for tourniquet absence during procedures.

Incidence of Thromboembolic Events and Complications

The application of tourniquets leads to an elevated danger of developing thromboembolic complications. The research conducted by Skou, et al. (2017) and Riggle et al. (2022) demonstrated that patients in deep vein thrombosis suffered when subjected to long durations of tourniquet inflation. Conversely, individuals who received TKA under tourniquet control had decreased postoperative D-dimer levels, reflecting less activation of coagulation (Jiang et al., 2015). Table 5 provides an overview of the most important characteristics, approaches, and results of the investigated studies.

Table 5: Summary of Selected Studies on Tourniquet vs Tourniquet-Free TKA

Author, Year	Region	Title	Aims	Methodology	Population / Sample	Key Findings	Factors Investigated
Chen et al., 2020	Singapore	Enhanced Recovery After Surgery for Total Knee Replacement	To evaluate early recovery protocols including non-tourniquet use	Descriptive Clinical Study	Patients undergoing elective TKA at SGH	Tourniquet-free TKA within an ERAS framework improved early mobility, shortened hospital stay, and reduced postoperative discomfort	Recovery time, mobilization, nursing protocols
Sutton et al., 2025	Singapore	DVT and Pain Outcomes in Limited Tourniquet Use	To assess pain and thrombotic risks with short tourniquet duration	Observational Study	Older adult patients in tertiary hospital	Limited tourniquet use showed lower DVT rates and better 2-year pain outcomes compared to full-tourniquet methods	DVT, long-term pain, rehab
Lian, 2023	Singapore	The Role of Nurses in Surgical Pain Control	To highlight perioperative nursing contributions to pain outcomes	Review and Practice Paper	Orthopaedic surgery cases in Singapore	Emphasized the impact of nursing care on patient outcomes, pain education, and decision-making in tourniquet vs non-tourniquet planning	Pain management, patient education, team communication
Zan, et al., 2017	China	Tourniquet Use and Postoperative Pain	To measure pain and functional impact post-TKA	RCT	Over 100 patients receiving TKA	Less pain and better early recovery were reported in the non-tourniquet group without compromising overall outcomes	Pain levels, mobility
Zaslansky, et al., 2019	UK	Comparative Blood Loss in TKA	To assess intraoperative bleeding and total blood loss	Prospective Cohort	Moderate-sized surgical cohort	Tourniquet-free group had more visible blood loss but no increase in transfusion; modern blood management tools mitigated risks	Intraoperative blood loss, TXA
Lai et al., 2022	USA	Functional Outcomes Without Tourniquet	To compare muscle strength and mobility post-TKA	RCT	Over 100 patients in rehab program	Patients without tourniquet use showed faster return of strength and better early function than those with tourniquet	Quadriceps strength, early mobility
Skou, et al., 2017	Korea	Thromboembolism Risk in TKA	To evaluate tourniquet link to DVT	Retrospective Study	Mixed-gender older adult patients	Tourniquet group had higher DVT incidence, especially in prolonged surgeries; mechanical compression alone was insufficient	DVT, duration of surgery
Riggle, et al., 2022	Denmark	Biochemical Response to Tourniquet	To study coagulation and inflammation	Prospective Comparative Study	Adults scheduled for primary TKA	Tourniquet use raised D-dimer and inflammatory biomarkers, suggesting increased thrombotic and tissue stress	D-dimer, IL-6, CRP
Wang et al., 2016	China	Systemic Inflammation After Tourniquet TKA	To analyze cytokine response post-surgery	RCT	General orthopedic patients	IL-6 and CRP levels were elevated in the tourniquet group, showing stronger systemic stress and delayed wound healing	Inflammation, recovery, healing speed
Dr. Chen et al., 2020	Taiwan	Tourniquet-Free TKA with TXA	To evaluate efficacy of TXA in blood control	RCT	Patients undergoing elective primary TKA	Tourniquet-free TKA using TXA achieved effective hemostasis, minimized pain, and avoided ischemic muscle injury	Blood loss control, TXA, muscle damage

Inflammatory Markers and Biomolecular Indicators

Scientists have initiated research about tourniquet-related inflammation responses that occur in blood samples collected after application. The research of Wang et al. (2016) documented that patients using prolonged tourniquets presented higher postoperative serum CRP and IL-6 markers. The elevated levels of these markers indicate that the tissues experience increased tension together with heightened systemic inflammation that results in delayed healing and worsens postoperative discomfort. Research by Sutton et al. (2025) established that omitting tourniquet use generated superior oxygenation of cells along with lower oxidative stress markers so patients could experience improved healing environments.

Duration of Surgery and Cement Fixation Quality

Multiple research studies showed that omitting tourniquet use added 5–10 minutes to surgery duration although cement fixation quality maintained the same level. The study by Jette et al. (2020) did not observe any noteworthy difference between groups regarding early prosthesis loosening thus contradicting the notion that tourniquets boost fixation strength. A reliable cement fixation results from modern surgical techniques and advancements in cement viscosity according to Tai, et al. (2010).

Patient Satisfaction and Hospital Stay

The no-tourniquet patient group recorded superior scores based on PROMs regarding pain and earlier joint function recovery. The no-tourniquet TKA approach met early recovery needs for 72% of patients while only 54% of patients in the tourniquet group reported similar levels of satisfaction according to Goel et al. (2019). The patient population with no-tourniquet treatment experienced statistically notable decreases in hospital length of stay according to Ryan, et al. (2024), resulting in 1.2 days less hospitalization on average.

Table 6: Summary of Key Patient Outcomes Compared Between Tourniquet and Non-Tourniquet TKA

Outcome Domain	Findings in Tourniquet (TQ) Group	Findings in Non-Tourniquet (No-TQ) Group
Intraoperative Blood Loss	Less visible blood loss	More visible blood loss but similar transfusion need
Post-op Pain (Day 1–3)	Higher VAS scores	Lower VAS scores
Swelling/Thigh Circumference	More swelling, higher CRP	Reduced swelling, better comfort
Early ROM (Week 1–2)	Delayed flexion >90°	Faster flexion recovery
Functional Scores (6 months)	Comparable	Comparable
Complications	Higher DVT and wound issues	Lower complication rates
Patient Satisfaction	Lower early satisfaction	Higher satisfaction, faster mobility

Summary of Findings

All available data from 32 studies supports tourniquet-free TKA as an effective method because it reduces postoperative pain while improving patients’ strength and knee flexion and decreasing their risk of thromboembolic complications. Although it is related to mildly greater intraoperative blood loss and longer operative times, both of these can be minimized through improved preoperative planning and perioperative care protocols. Most notably, recent improvements in cement technology and hemostasis render tourniquet use elective without sacrificing long-term implant stability or patient results.