**3.6. Thing pain, weakness, and postoperative recovery**

For patients who undergo tourniquet-controlled TKA, thigh pain is a very common complaint during the early postoperative period. Performing TKA without a tourniquet could reduce postoperative thigh pain in several literature [1, 3, 12, 13], but the benefit declines with time and becomes insignificant different at follow-ups longer than 6 months.

Compromised knee motion after tourniquet use has also been mentioned in some literature [35, 40, 44]. The possible reasons are as follows: (1) using a tourniquet may injure the nerve and the skeletal muscle, even causing rhabdomyolysis [40, 54] and (2) increased postoperative pain would limit the patient's ability to perform postoperative training [40, 55].

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

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 follow-up.
