Tourniquet Use in Cemented Total Knee Arthroplasty: Small Gains in Fixation, No Clear Benefit in Aseptic Loosening. A Systematic Review and Meta-Analysis.

Abstract

The effect of tourniquet (TQ) use in primary total knee arthroplasty (TKA) on implant fixation and survival remains uncertain. This review evaluated fixation and revision outcomes after TKA performed with versus without TQ. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, three databases were searched up to September 26, 2025. Comparative studies of primary cemented TKA were included if one group was operated on with and another without the use of a TQ. Outcomes were cement penetration, radiostereometric analysis (RSA)/maximum total point motion (MTPM), radiolucent lines (RLLs), aseptic loosening, and revision. Random-effects meta-analyses generated mean differences (MD) or risk ratios (RR) with 95% confidence intervals (CI). There were 26 studies comprising 54,561 knees (13,540 no TQ, 40,931 full TQ, and 90 partial TQ) included. The use of a TQ was associated with greater cumulative tibial baseplate cement penetration (six zones: MD: -0.92 mm (95% CI [-1.77 to -0.08]), P = 0.03; 10 zones: MD: -2.59 mm (95% CI [-4.67 to -0.52]), P = 0.01), while most femoral and isolated tibial zones did not differ. There were no between-group differences found in RSA/MTPM studies at 12 or 24 months as well as in RRL studies. All-cause revision at three to 12 years was modestly higher without a TQ (RR: 1.38 (95% CI [1.18 to 1.61]), P < 0.0001), whereas the rate of revision for and diagnosis of aseptic loosening did not differ. The use of a tourniquet in primary cemented TKA was associated with reduced all-cause revision, but not with consistently improved radiographic fixation and cement penetration or a reduced rate of aseptic loosening, which limits causal interpretation.