**3.3. Alignment and stability**

A tourniquet use is believed to improve the visualization of anatomical structures [35] due to better control of intraoperative bleeding. However, this advantage does not necessarily promise the improved implant position or surgical accuracy. Stetzelberger et al. [36] found that the mechanical leg alignment, the joint line level, and the patellar height could be accurately reconstructed with and without the tourniquet use.

On the other hand, an inflated tourniquet could alter the patellofemoral tracking [28] and may give the impression of an enhanced lateral tracking because of an increased lateral retinacular tension [37, 38]. Some authors recommend the deflation of the tourniquet prior to a lateral release to avoid unnecessary interventions. However, Matsui et al. [39] found that there is low clinical relevance even tourniquet deflation significantly improved the patellofemoral tracking and it is reliable to test intraoperative congruity a tourniquet in place.

There is a lack of data available in the literature whether the use of a tourniquet increases implant fixation in TKA. Radiostereometric analysis (RSA) has been used to investigate the influence of the tourniquet on implant fixation, but no difference was found [40, 41]. Recently, Pfitzner et al. found that the use of a tourniquet in primary TKA increased the tibial cement mantle thickness [42], which could increase implant stability and survival [43].

Considering the acting and involving region of tourniquet, quadriceps weakness is a hallmark of TKA [56, 57], though few studies investigated this issue. Abdel-Salam and Eyres observed a quicker ability to achieve a straight leg raise maneuver in whom a tourniquet was not used [44]. Dennis et al. [11] also reported the diminished strength of quadriceps during the first 3 months after TKA using a tourniquet. However, no significant difference of knee-extension

Tourniquet Use in Total Knee Arthroplasty http://dx.doi.org/10.5772/intechopen.73644 85

Long-term effect of tourniquet use on the postoperative ROM is still debating. Ledin et al. [40] reported that the ROM was 11° greater in the non-tourniquet group after 2-year follow-up, but Abdel-Salam and Eyres [44] and Liu et al. [13] found no difference in knee flexion after 1-year

To reduce the ischemic duration and the incidence of complications aforementioned, some surgeons suggested the early release of tourniquet. The different timings of tourniquet deflation include immediately after wound closure [22], after a tight arthrotomy closure [21] and mostly

Although there were some reviewing articles related to the timing of tourniquet release in TKA, the results varied. For blood loss, Huang et al. [59] and Zan et al. [47] suggested that tourniquet release before wound closure for hemostasis wound significantly increase not only total measured blood loss but also calculated blood loss. Zhang et al. [31] found that releasing tourniquet before wound closure could increase only total blood loss. However, Tie et al. [60] reported no significant difference existed in calculated blood loss nor total blood losses. To analyze the blood loss in detail, intraoperative blood loss may contribute to most of increased blood loss. Releasing tourniquet before wound closure theoretically could ensure a better view of hemostasis, and patients would have better blood conservation. Nevertheless, fibrinolytic activity rises after the release of an arterial tourniquet [61], contributing to the higher perioperative blood loss. In addition, it was impossible to find all bleeding sources, especially the oozing spots. These are the reasons why total blood loss is higher when tourniquet is

Several studies demonstrated that releasing tourniquet before wound closure had a decreased risk of postoperative complications such as wound complications [22], deep infection, DVT [31], and so on [47, 60, 62]. Although there is no significant difference in some meta-analysis [18, 59], it had a trend that releasing tourniquet before wound closure could decrease the inci-

Clinical and experimental studies supported a positive correlation between the degree of neuromuscular injury and the amount of pressure or the ischemia duration. Olivecrona et al. [16]

strength 48 h after surgery was reported by Harsten et al. [58].

**4. Timing of tourniquet release**

after the implantation of the prostheses [18, 20, 32].

released before wound closure in some reviewing article.

dence rate of major complication.

**5. Pressure**

follow-up.
