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. 2021 Jul 2;55(5):1087–1095. doi: 10.1007/s43465-021-00450-1

Effectiveness and Safety of Tourniquet Application Strategies in Total Knee Arthroplasty: a Meta-analysis

Yi-Xiang He 1, Wan-Jia Qiao 1, Yu-Hao Zhao 1, Zhao Gao 1, Wen-Ji Wang 2,✉
PMCID: PMC8586100  PMID: 34824708

Abstract

Background

We conducted the present meta-analysis to assess the effectiveness and safety of long-duration tourniquet and short-duration tourniquet for patients with total knee arthroplasty (TKA).

Methods

Published randomized controlled trials (RCTs) were identified from the following electronic databases: PubMed, Embase, Web of Science and Cochrane Library from inception to January 1, 2021. Studies comparing long-duration tourniquet and short-duration tourniquet in total knee arthroplasty were included. Either a random-effects model or a fixed-effects model was used for meta-analysis depending on the heterogeneity. Statistical analysis was assessed using RevMan 5.3 software.

Results

A total of 8 RCTs with a total of 484 patients were eligible and ultimately included in the meta-analysis. Compared with patients in the long-duration tourniquet, those in the short-duration tourniquet were significantly correlated with postoperative drainage volume (WMD = -71.85, 95% CI − 76.52 to − 67.17, P = 0.31), but an increased risk of total blood loss (WMD = 68.13, 95% CI 5.15–131.12, P = 0.03) and intraoperative blood loss (WMD = 137.13, 95% CI 69.06–205.20, P < 0.00001). Two groups showed no significant difference in operation time, visual analogue scale score of knee in early, transfusion rate and incidence of deep venous thrombosis.

Conclusions

Our meta-analysis suggested that the short-duration tourniquet in TKA significantly decreased the postoperative drainage volume, increased the total blood loss and intraoperative blood loss. However, it did not marked decrease the occurrence of transfusion rate. Although the incidence of deep venous thrombosis was reduced in some study, it was not statistically significant. Additional high quality RCTs are needed to identify the hypothesis. Therefore, we recommend prolonged use of tourniquets during TKA surgery.

Keywords: Joint arthroplasty, Total knee arthroplasty, Tourniquet, Meta-analysis

Introduction

Total knee arthroplasty (TKA) has been commonly used to treat end-stage knee diseases such as osteoarthritis [1]. During the operation, it is necessary to keep the operative field dry to allow the cement to harder, and the implant can fit to the bone surface. The clearly field can also reduce the operation time indirectly. For this reason, surgeons often use tourniquets in the lower extremities to reduce blood loss during surgery [2]. However, there are some risks associated with tourniquets, such as soft tissue ischemia, stiffness and swelling of the joints, fat necrosis and deep vein thrombosis in the lower extremities [3]. Therefore, the strategy of using tourniquets is still controversial [4]. Especially with the development of enhance recovery after surgery (ERAS), it is important to balance the advantages and disadvantages of surgery and maximize benefits, less pain and better postoperative recovery of patient during the perioperative period. In this study, the use of intraoperative tourniquets was divided into a long-duration tourniquet (the tourniquet was inflated before the skin incision to the end of operation) and a short-duration tourniquet (the tourniquet was inflated just prior to cement application and deflated once the cement had hardened or after the end of operation) in TKA, and the effectiveness and safety of the two methods were evaluated by systematic evaluation.

Methods

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for the meta-analysis of intervention trials.

Search Strategies

PubMed, Embase, Web of Science and the Cochrane Library were searched up to January 2021 for any relevant studies involving long-duration tourniquet and short-duration tourniquet in total knee arthroplasty. The search terms were as follows: “total knee arthroplasty,” "tourniquet,” “total knee replacement.” There was no language or publication date limited. Reference lists of all eligible studies were searched manually for additional studies. This meta-analysis collected data from published articles and thus no ethical approval was necessary for this article.

Search Strategy of PubMed:

#1 “Arthroplasty, Replacement, Knee” [Mesh]

#2 Total Knee Arthroplasty [Title/Abstract]

#3 Total Knee Replacement [Title/Abstract]

#4 TKA [Title/Abstract]

#5 TKR [Title/Abstract]

#6 #1 OR #2 OR #3 OR #4 OR #5

#7 “Tourniquets” [Mesh]

#8 Tourniquet [Title/Abstract]

#9 #7 OR #8

#10 “Randomized Controlled Trial” [Publication Type]

#11 Randomized [Title/Abstract]

#12 placebo [Title/Abstract]

#13 #10 OR #11 OR #12

#14 #6 AND #9 AND #13

Inclusion Criteria

(1) Studies were RCT; (2) participants underwent total knee arthroplasty; (3) the interventions included the long-duration tourniquet (the tourniquet was inflated before the skin incision to the end of operation) and short-duration tourniquet (the tourniquet was inflated just prior to cement application and deflated once the cement had hardened or after the end of operation) in TKA; (4) one of the following results was reported: operation time, total blood loss, intraoperative blood loss, postoperative drainage volume, visual analogue scale score of knee in early, the requirement for transfusion, and incidence of deep venous thrombosis of lower extremity.

Exclusion Criteria

No RCTs, reviews, single abstracts, the case reported or studies without full text available.

Data Extraction and Methodology Quality Assessment

For eligible studies, following information was extracted and imported to a predesigned Excel table: authors, published year, study design, patients’ general characteristics (number, mean age), intervention measure and outcomes. Method quality was assessed against the following items recommended by the Cochrane Handbook version 5.1.0. Low risk of bias, unclear risk of bias, and high risk of bias were assessed for 7 dimensions (random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias). Any disagreements in the evaluation were resolved through discussion with the third author to reach a consensus.

Statistical Analysis

Review Manager 5 software (version 5.3, Cochrane Collaboration, Oxford, UK) was used to evaluate statistical analysis. Continuous data were calculated by mean difference (MD) and 95% confidence interval (CI). Dichotomous data were calculated by risk ratio (RR) and 95% confidence interval (CI). Heterogeneity was measured by the I2 statistic (I2 > 50% indicated there was a high heterogeneity). A random-effects model was used if the heterogeneity I2 > 50%. Sensitivity analysis was performed to explore the impact of an individual study by deleting one study each time. A P value less than 0.05 was considered statistically significant.

Results

Search Results and Quality Assessment

The steps involved in the study search and selection are shown in Fig. 1. A total of 1562 articles were detected in the preliminary search process (PubMed = 325, Embase = 353, Web of Science = 481, Cochrane Library = 403). There were no additional papers researched through other sources. After removing duplicate items using Endnote X9 software, 708 studies remained for the study. Subsequently, 685 studies were excluded based on inclusion criteria and exclusion criteria. Ultimately, 484 samples from 8 trials met our inclusion criteria and were included in this meta-analysis [5–12]. The general characteristics of the included studies are shown in Table 1. Data regarding the risk of bias summary and risk of bias graphs for each study are presented in Figs. 2, 3.

Fig. 1.

Fig. 1

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The flow diagram of the study selection process for this meta-analysis

Table 1.

The general characteristics of the included studies

Author Study design Number (N) Age (Y) Outcomes
Short group Long group Short group Long group
Kvederas [5] RCTs 12 12 67.3 + 6.4 72.9 + 4.5 1
Hakkalamani [6] RCTs 30 30 66.7 + 8.5 69 + 8.5 1,5
Ozkunt [7] RCTs 20 24 – – 4,7
Wang [8] RCTs 25 25 72.5 + 6.8 72.3 + 7.1 1,2,3,4,7,8
Fan [9] RCTs 30 30 63.27 + 7.39 65.37 + 7.11 1,6,8
Mittal [10] RCTs 31 34 67.5 + 8.9 66.6 + 8.4 2,7,8
Tarwala [11] RCTs 40 39 64.6 + 9.3 66.1 + 9.8 1,2,3,4,5,6
Cao [12] RCTs 51 51 65.2 + 6.4 64.9 + 7.5 1,2,3,4,7
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Fig. 2.

Fig. 2

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The risk of bias summary

Fig. 3.

Fig. 3

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The risk of bias graphs

1 = operation time, 2 = total blood loss, 3 = intraoperative blood loss, 4 = postoperative drainage volume, 5 = visual analogue scale score of knee in POD1, 6 = visual analogue scale score of knee in POD3, 7 = transfusion, 8 = incidence of deep venous thrombosis. POD = postoperative day.

Operation Time

A total of 6 studies provided data on operation time (188 and 187 patients in the short and long groups). Pooling the data demonstrated that it was no significant difference on operation time between the short-duration tourniquet and long-duration tourniquet (WMD = 0.44, 95% CI 4.35–5.24, P = 0.01; I2 = 65%). Thus, we used a random-effects model to pool the relevant data (Fig. 4).

Fig. 4.

Fig. 4

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Forest plot of comparison of the operation time between the two groups

Total Blood Loss

A total of 4 studies provided data on total blood loss (147 and 149 patients in the short and long groups). Pooling the data demonstrated that long-duration tourniquet led to significantly less total blood loss than short-duration tourniquet (WMD = 68.13, 95% CI 5.15–131.12, P = 0.03; I2 = 67%). Thus, we used a random-effects model to pool the relevant data (Fig. 5).

Fig. 5.

Fig. 5

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Forest plot of comparison of the total blood loss between the two groups

Intraoperative Blood Loss

A total of 3 studies provided data on intraoperative blood loss (116 and 115 patients in the short and long groups). Pooling the data demonstrated that long-duration tourniquet led to significantly less intraoperative blood loss than short-duration tourniquet (WMD = 137.13, 95% CI 69.06–205.20, P < 0.00001; I2 = 96%). Thus, we used a random-effects model to pool the relevant data (Fig. 6).

Fig. 6.

Fig. 6

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Forest plot of comparison of the intraoperative blood loss between the two groups

Postoperative Drainage Volume

A total of 4 studies provided data on postoperative drainage volume (136 and 139 patients in the short and long groups). Pooling the data demonstrated that short-duration tourniquet led to significantly less postoperative drainage volume than long-duration tourniquet (WMD =  − 71.85, 95% CI − 76.52 to − 67.17, P = 0.31; I2 = 17%). Thus, we used a fixed-effects model to pool the relevant data (Fig. 7).

Fig. 7.

Fig. 7

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Forest plot of comparison of the postoperative drainage volume between the two groups

Visual Analogue Scale Score of Knee

A total of 3 studies provided data on visual analogue scale score on POD1 and POD3 (100 and 99 patients in the short and long groups). Pooling the data demonstrated that it was no significant difference on visual analogue scale score between the short-duration tourniquet and long-duration tourniquet. Visual analogue scale score on POD1 (WMD =  − 0.19, 95% CI −0.91–0.54, P = 0.79; I2 = 0%). Thus, we used a fixed-effects model to pool the relevant data (Fig. 8); visual analogue scale score on POD3 (WMD =  − 0.75, 95% CI −2.32–0.81, P = 0.001; I2 = 91%). We used a random-effects model to pool the relevant data (Fig. 8).

Fig. 8.

Fig. 8

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Forest plot of comparison of the postoperative visual analogue scale scores of the knee on POD1 and POD3 between the two groups

Transfusion

A total of 4 studies provided data on transfusion (127 and 134 patients in the short and long groups). Pooling the data demonstrated that it was no significant difference on transfusion rate between the short-duration tourniquet and long-duration tourniquet (RR = 1.35, 95% CI 0.47–3.87, P = 0.10; I2 = 52%). Thus, we used a random-effects model to pool the relevant data (Fig. 9).

Fig. 9.

Fig. 9

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Forest plot of comparison of the transfusion rate between the two groups

Incidence of Deep Venous Thrombosis

A total of 3 studies provided data on incidence of deep venous thrombosis (86 and 89 patients in the short and long groups). Pooling the data demonstrated that it was no significant difference on incidence of deep venous thrombosis between the short-duration tourniquet and long-duration tourniquet (RR = 0.31, 95% CI 0.09–1.09, P = 0.16; I2 = 46%). Thus, we used a fixed-effects model to pool the relevant data (Fig. 10).

Fig. 10.

Fig. 10

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Forest plot of comparison of the incidence of deep venous thrombosis between the two groups

Discussion

In some studies, it has been suggested that the total perioperative blood loss of unilateral TKA can be up to 1000 ml [13]. Meanwhile, the excessive presence of blood, fat and other substances in the surgical area will reduce the viscosity of bone cement, and reduce the penetration of bone trabecula and affect the fixation effect of bone cement [9]. Bleeding during surgery may also cause an inability to accurately identify the anatomical structures under direct vision, resulting in iatrogenic injuries. Hasanain et al. [14] found that two cases of injury of patella tendon occurred in the short-duration tourniquet group with high intraoperative blood loss. Therefore, the application of tourniquets in TKA can effectively reduce bleeding, help to improve the intraoperative operating environment and better fix the prosthesis [15].

However, there are still controversies about whether to apply tourniquets and how to apply tourniquets in TKA. Some studies have pointed out that the application of tourniquets in TKA has no correlation with total blood loss, and the total blood loss of the two methods is similar [16]. Other studies have shown that the tissue reperfusion injury will occur after the tourniquet is deflated, and increase the patient's hidden blood loss [17]. Moreover, it also produces related complications, such as soft tissue and muscle injury, fat necrosis, joint swelling, etc. It may also lead to the formation of venous thrombosis and affect the strength of the quadriceps femoris. Dennis et al. [18] reported that the quadriceps femoris strength of patients who used tourniquets during surgery was weakened within 3 months after surgery, which lead to reduced knee joint activity and instability during exercise.

It has been suggested that tourniquets should not be used in TKA to reduce complications. A study conducted by Zhou [19] on the use of tourniquets showed that non-tourniquet TKA could reduce blood loss, swelling and pain in the early postoperative period, and more conducive to postoperative functional recovery. It was confirmed that the tourniquet can reduce the operative time and intraoperative blood loss, but it has no benefit to the total blood loss. The lost blood into the soft tissue, which may lead to swelling of the limb and affecting the patient's functional recovery. Zhang et al. [20] reported that the application of tourniquet had a negative effect on postoperative rehabilitation. Zhao et al. [21] treated TKA patients with intravenous tranexamic acid and grouped them into groups using tourniquets. They found that the non-tourniquet group had less blood loss, inflammation response, muscle injury and VAS score, and the patients had better early functional recovery.

As for the application of tourniquet, Rama [22] studied the impact of tourniquet release time on the affected limb through a meta-analysis, which indicated that with the increase of tourniquet time, the incidence of complications, including neurological impairment, would increase. Although early release of tourniquet increased blood loss, it could reduce the influence of related local complications. Therefore, it is recommended that the application of tourniquet should be minimized. There is no consensus on the best way to use tourniquets. Studies [6] have shown that using a tourniquet only during cement hardening reduces swelling of the affected limb and results in fewer wound complications compared to using the tourniquet throughout the process. Wang et al. [8] proposed that long-term use of tourniquets can reduce total blood loss, while short-term use of tourniquets can reduce postoperative blood loss with faster postoperative recovery and less pain. Kvederas et al. [5] calculated by six methods and found that the use of tourniquet in the hardening process of bone cement would lead to higher blood loss. Huang [23] determined the blood loss and inflammatory indexes of patients undergoing minimally invasive TKA, and found that after the whole application of tourniquet, less intraoperative blood loss was observed, but more serious inflammation and muscle injury was observed, although this had no significant effect on postoperative functional recovery.

For patients with unilateral TKA, differences between patients may affect outcome indicators. Therefore, Hasanain [14] used a tourniquet for the entire procedure versus a tourniquet only during cement application for both knees of patients who underwent bilateral TKA at the same time, eliminating interindividual differences. It was found that the total blood loss in the group using tourniquets during bone cement application was twice as high as in the other group, while there was no significant difference in pain, soft tissue swelling and postoperative complications. Vaishya [24] also found that the use of short-term tourniquets increased blood loss and operative time through a concurrent study of bilateral TKA patients.

In response to these controversies, a meta-analysis was conducted to compare these two tourniquet application methods. In our study, the results suggest that with good perioperative management, prolonged tourniquet use in TKA will be more beneficial in reducing perioperative bleeding in patients. There was also no significantly increase in the incidence of postoperative lower extremity deep vein thrombosis, transfusion rates and patient pain scores in early. Therefore, prolonged use of tourniquets during surgery (the tourniquet was inflated before the skin incision to the end of operation) is recommended when the patient's indications are known.

Conclusion

The main results in current meta-analysis are as follows:

  1. Compared with the long-duration group, the short-duration group could significantly reduce the postoperative drainage volume, but the intraoperative blood loss and total blood loss were significantly higher than the long-duration group.

  2. There is no significantly differences between the two groups in operation time, blood transfusion rate and VAS scores in the early postoperative period.

  3. In terms of the incidence of deep venous thrombosis in the lower extremity, although the overall incidence was reduced in the short-duration group, the combined results showed no statistical difference between the two groups.

Therefore, this study suggests that in total knee arthroplasty, although the short-duration application of a tourniquet can reduce postoperative drainage, it does not provide a significant advantage in other respects. Thus we recommend prolonged use of tourniquets in routine TKA.

In addition, because the use of anticoagulants such as tranexamic acid was not described in detail in the included original studies, it may have had an impact on the amount of blood loss and the incidence of lower extremity deep vein thrombosis. In the future, we need more large sample sizes and high-quality randomized controlled studies to further test the relevant hypotheses.

Declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical standard

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study, informed consent is not required.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Yi-Xiang He, Email: heyix1995@163.com.

Wen-Ji Wang, Email: ldyyjzwwj@163.com.

References

  • 1.Dixon MC, Brown RR, Parsch D, et al. Modular fixed-bearing total knee arthroplasty with retention of the posterior cruciate ligament: a study of patients followed for a minimum of fifteen years. Journal of Bone Joint Surgery American. 2005;87:598–603. doi: 10.2106/JBJS.C.00591. [DOI] [PubMed] [Google Scholar]
  • 2.Harvey EJ, Leclerc J, Brooks CE, et al. Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty. Journal of Arthroplasty. 1997;12:291–296. doi: 10.1016/S0883-5403(97)90025-5. [DOI] [PubMed] [Google Scholar]
  • 3.Rathod P, Deshmukh A, Robinson J, et al. Does tourniquet time in primary total knee arthroplasty influence clinical recovery? Journal of Knee Surgery. 2015;28:335–342. doi: 10.1055/s-0034-1388654. [DOI] [PubMed] [Google Scholar]
  • 4.Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. The Knee. 2010;17:141–147. doi: 10.1016/j.knee.2009.06.007. [DOI] [PubMed] [Google Scholar]
  • 5.Kvederas G, Porvaneckas N, Andrijauskas A, et al. A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty. Knee Surgery Sports Traumatology Arthroscopy. 2013;21:2790–2799. doi: 10.1007/s00167-012-2221-1. [DOI] [PubMed] [Google Scholar]
  • 6.Hakkalamani S, Clark V, Pradhan N. Short versus standard duration tourniquet use during total knee replacement a pilot study. Acta Orthopaedica Belgica. 2015;2015(81):52–56. [PubMed] [Google Scholar]
  • 7.Ozkunt O, Sariyilmaz K, Gemalmaz HC, et al. The effect of tourniquet usage on cement penetration in total knee arthroplasty: a prospective randomized study of 3 methods. Medicine. 2018;97:e9668. doi: 10.1097/MD.0000000000009668. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Wang K, Ni S, Li Z, et al. The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surgery Sports Traumatology Arthroscopy. 2017;25:2849–2857. doi: 10.1007/s00167-015-3964-2. [DOI] [PubMed] [Google Scholar]
  • 9.Fan Y, Jin J, Sun Z, et al. The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial. The Knee. 2014;21:1263–1268. doi: 10.1016/j.knee.2014.08.002. [DOI] [PubMed] [Google Scholar]
  • 10.Mittal R, Ko V, Adie S, et al. Tourniquet application only during cement fixation in total knee arthroplasty: a double-blind, randomized controlled trial. ANZ Journal of Surgery. 2012;82:428–433. doi: 10.1111/j.1445-2197.2012.06083.x. [DOI] [PubMed] [Google Scholar]
  • 11.Tarwala R, Dorr LD, Gilbert PK, et al. Tourniquet use during cementation only during total knee arthroplasty: a randomized trial. Clinical Orthopaedics and Related Research. 2014;472:169–174. doi: 10.1007/s11999-013-3124-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Cao Q, He Z, Fan Y, et al. Effects of tourniquet application on enhanced recovery after surgery (eras) and ischemia-reperfusion post-total knee arthroplasty: full- versus second half-course application. Journal of Orthopaedic Surgery (Hong Kong) 2020;28:2309499019896026. doi: 10.1177/2309499019896026. [DOI] [PubMed] [Google Scholar]
  • 13.Zhang Y, Li D, Liu P, et al. Effects of different methods of using pneumatic tourniquet in patients undergoing total knee arthroplasty: a randomized control trial. Irish Journal of Medical Science. 2017;186:953–959. doi: 10.1007/s11845-017-1585-0. [DOI] [PubMed] [Google Scholar]
  • 14.Hasanain MS, Apostu D, Alrefaee A, et al. Comparing the effect of tourniquet vs tourniquet-less in simultaneous bilateral total knee arthroplasties. Journal of Arthroplasty. 2018;33:2119–2124. doi: 10.1016/j.arth.2018.02.013. [DOI] [PubMed] [Google Scholar]
  • 15.Wakankar HM, Nicholl JE, Koka R, et al. The tourniquet in total knee arthroplasty - a prospective, randomised study. Journal of Bone and Joint Surgery-British. 1999;81B:30–33. doi: 10.1302/0301-620X.81B1.0810030. [DOI] [PubMed] [Google Scholar]
  • 16.Tetro AM, Rudan JF. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Canadian Journal of Surgery. 2001;2001(44):33–38. [PMC free article] [PubMed] [Google Scholar]
  • 17.Matziolis D, Perka C, Hube R, et al. influence of tourniquet ischemia on perioperative blood loss after total knee arthroplasty. Orthopäde. 2011;40:178–182. doi: 10.1007/s00132-010-1727-9. [DOI] [PubMed] [Google Scholar]
  • 18.Dennis DA, Kittelson AJ, Yang CC, et al. Does tourniquet use in tka affect recovery of lower extremity strength and function? A randomized trial. Clinical Orthopaedics and Related Research. 2016;474:69–77. doi: 10.1007/s11999-015-4393-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Zhou K, Ling T, Wang H, et al. Influence of tourniquet use in primary total knee arthroplasty with drainage: a prospective randomised controlled trial. Journal of Orthopaedic Surgery and Research. 2017;12(172):2017. doi: 10.1186/s13018-017-0683-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Zhang W, Li N, Chen S, et al. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. Journal of Orthopaedic Surgery and Research. 2014;9:13. doi: 10.1186/1749-799X-9-13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Zhao HY, Yeersheng R, Kang XW, et al. The effect of tourniquet uses on total blood loss, early function, and pain after primary total knee arthroplasty a prospective, randomized controlled trial. Bone and Joint Research. 2020;9:322–332. doi: 10.1302/2046-3758.96.BJR-2019-0180.R3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Rama KRBS, Apsingi S, Poovali S, et al. Timing of tourniquet release in knee arthroplasty - meta-analysis of randomized, controlled trials. Journal of Bone and Joint Surgery-American. 2007;89A:699–705. doi: 10.2106/00004623-200704000-00001. [DOI] [PubMed] [Google Scholar]
  • 23.Huang ZY, Pei FX, Ma J, et al. Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective non-randomized clinical trial. Archives of Orthopaedic and Trauma Surgery. 2014;134:561–570. doi: 10.1007/s00402-014-1948-1. [DOI] [PubMed] [Google Scholar]
  • 24.Vaishya R, Agarwal AK, Vijay V, et al. Short term outcomes of long duration versus short duration tourniquet in primary total knee arthroplasty: a randomized controlled trial. Journal of Clinical Orthopaedics and Trauma. 2018;9:46–50. doi: 10.1016/j.jcot.2017.11.016. [DOI] [PMC free article] [PubMed] [Google Scholar]

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