Tourniquetless Total Knee Arthroplasty: History, Controversies, and Technique

Benjamin M. Stronach, MS, MD; Richard E. Jones, MD; R. Michael Meneghini, MD


J Am Acad Orthop Surg. 2021;29(1):17-23. 

In This Article

Abstract and Introduction


We present a literature review with technique for tourniquetless TKA for surgeons interested in transitioning away from the tourniquet. Tourniquet use provides a bloodless field and improved visualization with decreased intraoperative blood loss, but the arguments for tourniquet use of improved cement fixation and decreased overall blood loss have not been supported by the literature. Regarding recovery, tourniquetless TKA has demonstrated less postoperative pain and improved knee function. There is also the potential for patient harm with tourniquet use. The process of tourniquetless TKA begins preoperatively with anemia screening and treatment. Tranexamic acid decreases the overall blood loss and blood transfusion risk. We recommend preemptive analgesia. The surgery is performed with the knee flexed for a near bloodless field. For cementation, the knee irrigation removes lipids from the exposed bone along with meticulous cement technique. Tourniquetless TKA is able to be safely performed on a routine basis and brings potential benefits to the patient with no evident increased risk in comparison to tourniquet use.


The field of arthroplasty has traditionally been based on an apprenticeship model where knowledge is passed down from one generation of surgeons to the next with many common practices having little to no evidence to support their use. This type of education allows for clinical care to be based on tradition rather than evidence-based science.[1] Fortunately, there has been a dramatic shift in the arthroplasty community toward evidence-based practices with a move away from traditional medicine based on little to no substantiation such as surgical drains, Foley catheters, and prolonged bed rest.[1] These practices were previously all standard care but were found to provide no clinical benefit or be detrimental when placed under scientific scrutiny with many surgeons abandoning their use.

Tourniquet use has been an integral part of total knee arthroplasty (TKA) since its inception. There is a growing body of literature that raises concerns regarding tourniquet use during TKA; however, tourniquet use still remains common practice.[1–7]

The process of TKA is complex with many small steps required for a successful surgery and long-term outcome. The simplification of that process can save time and money and potentially avoid injury to the patient. We present a review of the literature to provide the science about TKA without tourniquet along with technique recommendations for surgeons who are interested in moving away from the use of a tourniquet.