**1. Introduction**

Total knee arthroplasty (TKA) is associated with substantial postoperative blood loss for which blood transfusion might be necessary. Various strategies to hemostasis had been proposed, including the use of tourniquet during surgery. The use of tourniquet was believed to help reduce intraoperative blood loss [1–4], provide better visualization, save operative time [4, 5], and facilitate the cementing quality and other surgical procedures. However, some conflicting results were reported regarding blood loss and fixation of cemented [6–8]. Furthermore, certain drawbacks were mentioned after the use of tourniquet, including thigh pain, nerve

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

palsy, ischemia [9], soft tissue damage, thromboembolic complications [10], decrease muscle strength [11], and knee range of motion (ROM) [3]. In spite of the common use of tourniquet in orthopedic surgeries, the role of tourniquet in TKA remains controversial, and some surgeons suggested that tourniquet is not necessary [12, 13].

but others did not agree. Numerous studies reported no significant difference in the amount of blood loss with or without tourniquet use [24, 25], and others even suggested that the use of

Tourniquet Use in Total Knee Arthroplasty http://dx.doi.org/10.5772/intechopen.73644 83

There are some parameters commonly used to evaluate the blood loss of the surgery. Directly measured items include *the intraoperative blood loss* and *the transfusion rate. Measurable total blood loss*, the summation of intra- and postoperative blood loss, is determined by the increasing weight of soaked gauze added the amount of postoperative drainage. *Calculated total blood loss*, which is always regarded as true total blood loss, was measured by Hb and Hct levels

In the research model of meta-analysis, some authors suggested that the use of tourniquet did not affect total blood loss [3, 5, 8, 28], which was opposed by Alcelik et al. [29]. However, Alcelik et al. [29] estimated total blood loss simply based on the measurable blood loss while overlooking the hidden blood loss. Thus, the evidence available indicates that tourniquet indeed signifi-

The application of a tourniquet in TKA was believed to afford a relative bloodless surgical field, facilitating time saving. However, the critical timing of deflation should be mentioned regarding the operation time. The pooling data showed significantly shortened surgical duration in the tourniquet group once the tourniquet was released after wound closure and compressive dressing [2, 27, 30]. In comparison, early release of the tourniquet right after cementing the prosthesis for hemostasis would prolong the operation time for troublesome oozing [5, 20, 31–34]. Thus, the studies with early release of tourniquet did not correlate with significant

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

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 track-

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,

ing and it is reliable to test intraoperative congruity a tourniquet in place.

cantly reduce the intraoperative blood loss rather than the total blood loss.

tourniquet induces more blood loss [26, 27].

before and after surgery.

**3.2. Operation time**

shortened operation time [23, 24, 26].

reconstructed with and without the tourniquet use.

**3.3. Alignment and stability**

To reduce the aforementioned drawbacks, adjunctive measures such as skin protection [14], elastic cuff [15], and reducing cuff pressure [16, 17] are frequently taken while applying the tourniquet during TKAs. Recently, early deflation of tourniquet has drawn increasing attention. Since most surgeons use tourniquet to facilitate the procedure mainly, there are no need for prolonged use of tourniquet. Various timings of deflation have been proposed in the literature, such as deflating tourniquet after cementing the implants [18–20], after closure of arthrotomy [21], or immediately after wound closure [22]. However, no consensus has been achieved to date.

To clarify the role of tourniquet in TKA, a comprehensive review was therefore conducted. An extensive search as well as review of the related literature regarding the tourniquet use was performed. This review focused on:

