Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 24, Issue 1, pp 96–101 | Cite as

Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty

  • Tilman PfitznerEmail author
  • Philipp von Roth
  • Ninja Voerkelius
  • Hermann Mayr
  • Carsten Perka
  • Robert Hube



The purpose of the study was whether the use of a tourniquet increases cement mantle thickness in primary total knee arthroplasty and influences the calculated blood loss and postoperative pain.


Ninety patients with a primary total knee arthroplasty (TKA) were enroled in this prospective randomised trial and divided into a group with (n = 45) and without tourniquet (n = 45). The radiological tibial cement mantle thickness was evaluated postoperatively in four zones on anteroposterior and two zones on lateral radiographs, and values were cumulated. Additionally, the calculated blood loss and postoperative pain levels were recorded.


There was a median cumulative cement mantle thickness of 13 mm (range 8–19 mm) without tourniquet and of 14.2 mm (range 9–18 mm) with tourniquet (p = 0.009). The median calculated blood loss was 0.6 L (range 0.2–2.0 L) without and 0.9 L (range 0.3–1.5 L) (p = 0.02) with tourniquet. Patient-reported postoperative pain levels were significantly higher in the tourniquet group during mobilisation (p = 0.01) and at rest (p = 0.001).


The use of a tourniquet in primary TKA increased the tibial cement mantle thickness but also increased the postoperative calculated blood loss and postoperative pain. Surgeons might take this into consideration for decision-making whether to use a tourniquet during TKA.

Level of evidence



Total knee arthroplasty Tourniquet Cement mantle thickness Blood loss Cementing technique 


Conflict of interest

Tilman Pfitzner, Philipp von Roth, Ninja Voerkelius, Hermann Mayr and Carsten Perka declare that they have no conflicts of interest. Robert Hube is a consultant for Zimmer.


  1. 1.
    Abdel-Salam A, Eyres KS (1995) Effects of tourniquet during total knee arthroplasty: a prospective randomised study. J Bone Joint Surg Br 77(2):250–253PubMedGoogle Scholar
  2. 2.
    Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M (2000) Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res 371:169–177PubMedCrossRefGoogle Scholar
  3. 3.
    Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer P (2012) A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplast 27(3):331–340CrossRefGoogle Scholar
  4. 4.
    Argenson JN, Parratte S, Ashour A, Saintmard B, Aubaniac JM (2012) The outcome of rotating-platform total knee arthroplasty with cement at a minimum of 10 years of follow-up. J Bone Joint Surg Am 94(7):638–644PubMedCrossRefGoogle Scholar
  5. 5.
    Authier B (1988) Reactive hyperemia monitored on rat muscle using perfluorocarbons and 19F NMR. Magn Reson Med 8(1):80–83PubMedCrossRefGoogle Scholar
  6. 6.
    Bannister GC, Miles AW (1988) The influence of cementing technique and blood on the strength of the bone-cement interface. Eng Med 17(3):131–133PubMedCrossRefGoogle Scholar
  7. 7.
    Barwell J, Anderson G, Hassan A, Rawlings I (1997) The effects of early tourniquet release during total knee arthroplasty: a prospective randomized double-blind study. J Bone Joint Surg Br 79(2):265–268PubMedCrossRefGoogle Scholar
  8. 8.
    Bert JM, McShane M (1998) Is it necessary to cement the tibial stem in cemented total knee arthroplasty? Clin Orthop Relat Res 356:73–78PubMedCrossRefGoogle Scholar
  9. 9.
    Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y (2001) The visual analog scale for pain: clinical significance in postoperative patients. Anesthesiology 95(6):1356–1361PubMedCrossRefGoogle Scholar
  10. 10.
    Bourke DL, Smith TC (1974) Estimating allowable hemodilution. Anesthesiology 41(6):609–612PubMedCrossRefGoogle Scholar
  11. 11.
    Clarius M, Hauck C, Seeger JB, James A, Murray DW, Aldinger PR (2009) Pulsed lavage reduces the incidence of radiolucent lines under the tibial tray of Oxford unicompartmental knee arthroplasty: pulsed lavage versus syringe lavage. Int Orthop 33(6):1585–1590PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Coll AM, Ameen JR, Mead D (2004) Postoperative pain assessment tools in day surgery: literature review. J Adv Nurs 46(2):124–133PubMedCrossRefGoogle Scholar
  13. 13.
    Ewald FC (1989) The knee society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12PubMedGoogle Scholar
  14. 14.
    Feng B, Weng X, Lin J, Jin J, Wang W, Qiu G (2013) Long-term follow-up of cemented fixed-bearing total knee arthroplasty in a Chinese population: a survival analysis of more than 10 years. J Arthroplast 28(10):1701–1706CrossRefGoogle Scholar
  15. 15.
    Galasso O, Jenny JY, Saragaglia D, Miehlke RK (2013) Full versus surface tibial baseplate cementation in total knee arthroplasty. Orthopedics 36(2):151–158CrossRefGoogle Scholar
  16. 16.
    Gruen TA, Markolf KL, Amstutz HC (1976) Effects of laminations and blood entrapment on the strength of acrylic bone cement. Clin Orthop Relat Res 119:250–255PubMedGoogle Scholar
  17. 17.
    Hube R, Keim M, Mayr HO (2009) The mini-midvastus approach for total knee arthroplasty. Oper Orthop Traumatol 21(1):3–13PubMedCrossRefGoogle Scholar
  18. 18.
    Klenerman L, Chakrabarti R, Mackie I, Brozovic M, Stirling Y (1977) Changes in haemostatic system after application of a tourniquet. Lancet 1(8019):970–972PubMedCrossRefGoogle Scholar
  19. 19.
    Kopec M, Milbrandt JC, Duellman T, Mangan D, Allan DG (2009) Effect of hand packing versus cement gun pressurization on cement mantle in total knee arthroplasty. Can J Surg 52(6):490–494PubMedPubMedCentralGoogle Scholar
  20. 20.
    Krause WR, Krug W, Miller J (1982) Strength of the cement-bone interface. Clin Orthop Relat Res 163:290–299PubMedGoogle Scholar
  21. 21.
    Kvederas G, Porvaneckas N, Andrijauskas A, Svensen CH, Ivaskevicius J, Mazunaitis J, Marmaite U, Andrijauskas P (2013) A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21(12):2790–2799PubMedCrossRefGoogle Scholar
  22. 22.
    Larsson J, Lewis DH, Liljedahl SO, Lofstrom JB (1977) Early biochemical and hemodynamic changes after operation in a bloodless field. Eur Surg Res 9(5):311–320PubMedCrossRefGoogle Scholar
  23. 23.
    Ledin H, Aspenberg P, Good L (2012) Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta Orthop 83(5):499–503PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Li B, Wen Y, Wu H, Qian Q, Lin X, Zhao H (2009) The effect of tourniquet use on hidden blood loss in total knee arthroplasty. Int Orthop 33(5):1263–1268PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Maistrelli GL, Antonelli L, Fornasier V, Mahomed N (1995) Cement penetration with pulsed lavage versus syringe irrigation in total knee arthroplasty. Clin Orthop Relat Res 312:261–265PubMedGoogle Scholar
  26. 26.
    Majkowski RS, Bannister GC, Miles AW (1994) The effect of bleeding on the cement-bone interface: an experimental study. Clin Orthop Relat Res 299:293–297PubMedGoogle Scholar
  27. 27.
    Manen Berga F, Novellas Canosa M, Angles Crespo F, Bernal Dzekonski J (2002) Effect of ischemic tourniquet pressure on the intensity of postoperative pain. Rev Esp Anestesiol Reanim 49(3):131–135PubMedGoogle Scholar
  28. 28.
    Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG (2010) Consolidated standards of reporting trials CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. J Clin Epidemiol 63(8):1–37CrossRefGoogle Scholar
  29. 29.
    Molt M, Harsten A, Toksvig-Larsen S (2014) The effect of tourniquet use on fixation quality in cemented total knee arthroplasty a prospective randomized clinical controlled RSA trial. Knee 21(2):396–401PubMedCrossRefGoogle Scholar
  30. 30.
    Peters CL, Craig MA, Mohr RA, Bachus KN (2003) Tibial component fixation with cement: full- versus surface-cementation techniques. Clin Orthop Relat Res 409:158–168PubMedCrossRefGoogle Scholar
  31. 31.
    Ritter MA, Herbst SA, Keating EM, Faris PM (1994) Radiolucency at the bone-cement interface in total knee replacement: the effects of bone-surface preparation and cement technique. J Bone Joint Surg Am 76(1):60–65PubMedGoogle Scholar
  32. 32.
    Ryd L, Albrektsson BE, Carlsson L, Dansgard F, Herberts P, Lindstrand A, Regner L, Toksvig-Larsen S (1995) Roentgen stereophotogrammetric analysis as a predictor of mechanical loosening of knee prostheses. J Bone Joint Surg Br 77(3):377–383PubMedGoogle Scholar
  33. 33.
    Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM (2002) Insall award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res 404:7–13PubMedCrossRefGoogle Scholar
  34. 34.
    Tai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY (2011) Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 19(7):1121–1130PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Tarwala R, Dorr LD, Gilbert PK, Wan Z, Long WT (2014) Tourniquet use during cementation only during total knee arthroplasty: a randomized trial. Clin Orthop Relat Res 472(1):169–174PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Tetro AM, Rudan JF (2001) The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Can J Surg 44(1):33–38PubMedPubMedCentralGoogle Scholar
  37. 37.
    Vandenbussche E, Duranthon LD, Couturier M, Pidhorz L, Augereau B (2002) The effect of tourniquet use in total knee arthroplasty. Int Orthop 26(5):306–309PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Walker PS, Soudry M, Ewald FC, McVickar H (1984) Control of cement penetration in total knee arthroplasty. Clin Orthop Relat Res 185:155–164PubMedGoogle Scholar
  39. 39.
    Worland RL, Arredondo J, Angles F, Lopez-Jimenez F, Jessup DE (1997) Thigh pain following tourniquet application in simultaneous bilateral total knee replacement arthroplasty. J Arthroplast 12(8):848–852CrossRefGoogle Scholar
  40. 40.
    Zhang FJ, Xiao Y, Liu YB, Tian X, Gao ZG (2010) Clinical effects of applying a tourniquet in total knee arthroplasty on blood loss. Chin Med J (Engl) 123(21):3030–3033Google Scholar
  41. 41.
    Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L (2014) The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res 9(1):13PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Zhang Y, Li L, Wang J, Li ZH, Shi ZJ (2013) Do patients benefit from tourniquet in arthroscopic surgeries of the knee? Knee Surg Sports Traumatol Arthrosc 21(5):1125–1130PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Authors and Affiliations

  • Tilman Pfitzner
    • 1
    Email author
  • Philipp von Roth
    • 1
  • Ninja Voerkelius
    • 2
  • Hermann Mayr
    • 2
  • Carsten Perka
    • 1
  • Robert Hube
    • 2
  1. 1.Orthopaedic Department, Center for Musculoskeletal SurgeryCharité – Universitätsmedizin BerlinBerlinGermany
  2. 2.Orthopädische Chirurgie MünchenMunichGermany

Personalised recommendations