Tibial cement mantle thickness is not affected by tourniquetless total knee arthroplasty when performed with tranexamic acid

  • Carl L. HerndonEmail author
  • Matthew J. Grosso
  • Nana O. Sarpong
  • Roshan P. Shah
  • Jeffrey A. Geller
  • H. John Cooper



Evidence exists that tourniquet use leads to increased cement penetration in total knee arthroplasty (TKA) due to decreased blood and fat in the bone during cementation. The use of tranexamic acid (TXA) has led to decreased blood loss and transfusion rates. The purpose of this study was to determine if the use of a tourniquet while utilising modern TXA protocols affects the tibial cement mantle penetration.


140 patients who underwent primary TKA with and without a tourniquet (70 in each group) were retrospectively reviewed. All patients received a standard TXA protocol. The primary outcome measure was cumulative depth of cement mantle penetration of the tibial plateau on post-operative radiographs. Secondary outcome measures included post-operative change in haemoglobin and hematocrit levels, blood loss, and transfusion rates.


There was no significant difference in age, sex, or pre-operative haemoglobin or hematocrit levels between groups. Tourniquet use resulted in significantly lower blood loss (100.0 mL versus 154.7 mL, p < 0.001), and significantly reduced drop in haemoglobin (1.8 g/dL vs 2.5 g/dL, p < 0.001) and hematocrit (5.7% vs 7.4%, p = 0.04) levels. However, depth of tibial cement mantle penetration did not differ between the tourniquet group (15.3 mm) and non-tourniquet group (15.0 mm, p value n.s.). No patient in either group required a blood transfusion.


Tourniquet use in primary TKA results in decreased blood loss and less change in pre-operative vs post-operative haemoglobin and hematocrit levels. However, with the use of TXA, not using a tourniquet resulted in similar cement mantle penetration around the tibial component as with a tourniquet.


Total knee arthroplasty Total knee replacement Tranexamic acid Tourniquet Cementation Cement penetration 



Total knee arthroplasty


Tranexamic acid


Institutional review board








No tourniquet


Confidence interval


Author contributions

CLH devised the study, did the data collection, analysis, and wrote the manuscript. MJG devised the study, did the data collection, analysis, and wrote the manuscript. NOS did the data collection, analysis and wrote the manuscript. RPS edited the manuscript and provided guidance with the study. JAG edited the manuscript and provided guidance with the study. HJC provided patient data, devised the study, and edited the manuscript. All the authors have read and approve of the final manuscript.

Compliance with ethical standards

Conflict of interest

All authors report no relevant conflicts of interest in this study.


This study received no outside or additional funding.

Ethical approval

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


  1. 1.
    Bannister GC, Miles AW (1988) The influence of cementing technique and blood on the strength of the bone-cement interface. Eng Med 17:131–133CrossRefGoogle Scholar
  2. 2.
    Bert JM, McShane M (1998) Is it necessary to cement the tibial stem in cemented total knee arthroplasty? Clin Orthop Relat Res 356:73–78CrossRefGoogle Scholar
  3. 3.
    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 33:1585–1590CrossRefGoogle Scholar
  4. 4.
    Ewald FC (1989) The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12Google Scholar
  5. 5.
    Franchini M, Mengoli C, Marietta M, Marano G, Vaglio S, Pupella S et al (2018) Safety of intravenous tranexamic acid in patients undergoing major orthopaedic surgery: a meta-analysis of randomised controlled trials. Blood Transfusion 16:36–43Google Scholar
  6. 6.
    Gomez-Barrena E, Ortega-Andreu M, Padilla-Eguiluz NG, Pérez-Chrzanowska H, Figueredo-Zalve R (2014) Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial. J Bone Joint Surg Am 96:1937–1944CrossRefGoogle Scholar
  7. 7.
    Gruen TA, Markolf KL, Amstutz HC (1976) Effects of laminations and blood entrapment on the strength of acrylic bone cement. Clin Orthop Relat Res 119:250–255Google Scholar
  8. 8.
    Huang Z, Ma J, Zhu Y, Pei F, Yang J, Zhou Z et al (2015) Timing of Tourniquet Release in Total Knee Arthroplasty. Orthopedics 38:445–451CrossRefGoogle Scholar
  9. 9.
    Jawhar A, Stetzelberger V, Kollowa K, Obertacke U (2018) Tourniquet application does not affect the periprosthetic bone cement penetration in total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy 1-11Google Scholar
  10. 10.
    Krause WR, Krug W, Miller J (1982) Strength of the cement-bone interface. Clin Orthop Relat Res 163:290–299Google Scholar
  11. 11.
    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 312:261–265Google Scholar
  12. 12.
    Majkowski RS, Bannister GC, Miles AW (1994) The effect of bleeding on the cement-bone interface: An experimental study. Clin Orthop Relat Res 299:293–297Google Scholar
  13. 13.
    Ozkunt O, Sariyilmaz K, Gemalmaz HC, Dikici F (2018) The effect of tourniquet usage on cement penetration in total knee arthroplasty: a prospective randomized study of three methods. Medicine 97:4CrossRefGoogle Scholar
  14. 14.
    Parvizi J, Diaz-Ledezma C (2013) Total knee replacement with the use of a tourniquet: more pros than cons. Bone Joint J 95-B:133–134CrossRefGoogle Scholar
  15. 15.
    Peters CL, Craig MA, Mohr RA, Bachus KN (2003) Tibial component fixation with cement: full- versus surface-cementation techniques. Clin Orthop Relat Res 409:158–168CrossRefGoogle Scholar
  16. 16.
    Pfitzner T, von Roth P, Voerkelius N, Mayr H, Perka C, Hube R (2016) Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 24:96–101CrossRefGoogle Scholar
  17. 17.
    Rama KRBS, Apsingi S, Poovali S, Jetti A (2007) Timing of tourniquet release in knee arthroplasty: meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 89:699–705Google Scholar
  18. 18.
    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 76:60–65CrossRefGoogle Scholar
  19. 19.
    Shemshaki H, Nourian SM, Nourian N, Dehghani M, Mokhtari M, Mazoochian F (2015) One step closer to sparing total blood loss and transfusion rate in total knee arthroplasty: a meta-analysis of different methods of tranexamic acid administration. Arch Orthop Trauma Surg 135:573–588CrossRefGoogle Scholar
  20. 20.
    Touzopoulos P, Ververidis A, Mpogiatzis C, Chatzigiannakis A, Drosos GI (2019) The use of tourniquet may influence the cement mantle thickness under the tibial implant during total knee arthroplasty. Eur J Orthop Surg Traumatol 29(4):869–875CrossRefGoogle Scholar
  21. 21.
    Vertullo CJ, Nagarajan M (2017) Is cement penetration in TKR reduced by not using a tourniquet during cementation? A single blinded, randomized trial. Journal of Orthopaedic Surgery 25:2309499016684323CrossRefGoogle Scholar
  22. 22.
    Walker PS, Soudry M, Ewald FC, McVickar H (1984) Control of cement penetration in total knee arthroplasty. Clin Orthop Relat Res 185:155–164Google Scholar
  23. 23.
    Wang K, Ni S, Li Z, Zhong Q, Li R, Li H et al (2017) The effects of tourniquet use in total knee arthroplasty: a randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 25:2849–2857CrossRefGoogle Scholar
  24. 24.
    Zhang H, Chen J, Chen F, Que W (2012) The effect of tranexamic acid on blood loss and use of blood products in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 20:1742–1752CrossRefGoogle Scholar
  25. 25.
    Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J (2017) Timing of tourniquet release in total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 96:e6786CrossRefGoogle Scholar
  26. 26.
    Zhang W, Liu A, Hu D, Tan Y, Al-Aidaros M, Pan Z (2014) Effects of the timing of tourniquet release in cemented total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 9:125CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Orthopedic Surgery, Center for Hip and Knee ReplacementColumbia University Irving Medical CenterNew YorkUSA

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