The use of tourniquet may influence the cement mantle thickness under the tibial implant during total knee arthroplasty

  • Panagiotis TouzopoulosEmail author
  • Athanasios Ververidis
  • Christos Mpogiatzis
  • Athanasios Chatzigiannakis
  • Georgios I. Drosos
Original Article • KNEE - ARTHROPLASTY



It is still unknown whether the creation of blood-free surfaces by the use of tourniquet during total knee arthroplasty (TKA) has an influence on cement penetration and on implant fixation. The aim of this study is to evaluate the cement mantle under tibial component and the occurrence of progressive radiolucent lines (RLLs) according to the use of tourniquet in primary TKA.

Materials and methods

Fifty patients undergone TKA without the use of tourniquet (group 1) were well matched regarding baseline characteristics with 50 TKAs with the use of tourniquet (group 2). Patients were followed up prospectively. Cement mantle thickness was measured using immediate postoperative X-rays, and the occurrence of progressive radiolucency was finally evaluated in 3-year follow-up. New Knee Society Score (KSS) was used to compare clinical outcome between groups.


Mean cement mantle thickness was 9.27 ± 1.86 mm in group 1 versus 10.49 ± 2.31 mm in group 2 (p = 0.005). Mean cumulated width of RLLs in anterioposterior (AP) view was 7.74 ± 6.68 mm in group 1 versus 3.48 ± 4.69 mm in group 2 (p < 0.001). The percentage of RLLs in AP view was related to the cumulated cement mantle thickness in the same view (r = − 0.218, p < 0.05). There was no significant difference between groups at the final follow-up in terms of ROM and new KSS.


Our results suggest that the use of tourniquet increased the cement mantle thickness under tibial implant and had an influence on the occurrence of RLLs in cement–bone interface, which is related to implant survivorship, with this implant design.


TKA Tourniquet Cement Mantle thickness Fixation Stability 


Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.


  1. 1.
    Dorr LD, Lindberg JP, Claude-Faugere M et al (1984) Factors influencing the intrusion of methylmethacrylate into human tibiae. Clin Orthop Relat Res 183:147–152Google Scholar
  2. 2.
    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
  3. 3.
    Vanlommel J, Luyckx JP, Labey L et al (2011) Cementing the tibial component in total knee arthroplasty: which technique is the best? J Arthroplasty 26:492–496CrossRefGoogle Scholar
  4. 4.
    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 52:490–494Google Scholar
  5. 5.
    Bauze AJ, Costi JJ, Stavrou P et al (2004) Cement penetration and stiffness of the cement-bone composite in the proximal tibia in a porcine model. J Orthop Surg 12:194–198CrossRefGoogle Scholar
  6. 6.
    Krause WR, Krug W, Miller J (1982) Strength of the cement-bone interface. Clin Orthop Relat Res 163:290–299Google Scholar
  7. 7.
    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
  8. 8.
    Aggarwal VK, Goyal N, Deirmengian G, Rangavajulla A, Parvizi J, Austin MS (2014) Revision total knee arthroplasty in the young patient: is there trouble on the horizon? J Bone Joint Surg Am 96:536–542CrossRefGoogle Scholar
  9. 9.
    Arsoy D, Pagnano MW, Lewallen DG, Hanssen AD, Sierra RJ (2013) Aseptic tibial debonding as a cause of early failure in a modern total knee arthroplasty design. Clin Orthop Relat Res 471:94–101CrossRefGoogle Scholar
  10. 10.
    Dalury DF, Pomeroy DL, Gorab RS, Adams MJ (2013) Why are total knee arthroplasties being revised? J Arthroplasty 28:120–121CrossRefGoogle Scholar
  11. 11.
    Hazelwood KJ, O’Rourke M, Stamos VP, McMillan RD, Beigler D, Robb WJ (2015) Case series report: early cement-implant interface fixation failure in total knee replacement. Knee 22:424–428CrossRefGoogle Scholar
  12. 12.
    Lombardi AV Jr., Berend KR, Adams JB (2014) Why knee replacements fail in 2013: patient, surgeon, or implant? Bone Joint J 96-B(11 Suppl A):101–104CrossRefGoogle Scholar
  13. 13.
    Schroer WC, Berend KR, Lombardi AV, Barnes CL, Bolognesi MP, Berend ME et al (2013) Why are total knees failing today? Etiology of total knee revision in 2010 and 2011. J Arthroplasty 28:116–119CrossRefGoogle Scholar
  14. 14.
    Thiele K, Perka C, Matziolis G, Mayr HO, Sostheim M, Hube R (2015) Current failure mechanisms after knee arthroplasty have changed: polyethylene wear is less common in revision surgery. J Bone Joint Surg Am 97:715–720CrossRefGoogle Scholar
  15. 15.
    Vessely MB, Whaley AL, Harmsen WS, Schleck CD, Berry DJ (2006) The Chitranjan Ranawat Award: long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties. Clin Orthop Relat Res 452:28–34CrossRefGoogle Scholar
  16. 16.
    Sundfeldt M, Carlsson LV, Johansson CB, Thomsen P, Gretzer C (2006) Aseptic loosening, not only a question of wear: a review of different theories. Acta Orthop 77:177–197CrossRefGoogle Scholar
  17. 17.
    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(1):96–101CrossRefGoogle Scholar
  18. 18.
    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 7(19):1121–1130CrossRefGoogle Scholar
  19. 19.
    Ritter MA, Herbst SA, Keating EM, Faris PM (1994) Radiolucency at the bone-cement interface in TKR. J Bone Joint Surg Am 76:60–65CrossRefGoogle Scholar
  20. 20.
    Schneider R, Hood RW, Ranawat CS (1982) Radiologic evaluation of knee arthroplasty. Orthop Clin North Am 13:225–244Google Scholar
  21. 21.
    Ecker ML, Lotke PA, Windsor RE, Cella JP (1987) Long-term results after total condylar knee arthroplasty: significance of radiolucent lines. Clin Orthop Relat Res 216:151–158Google Scholar
  22. 22.
    Hofmann AA, Goldberg TD, Tanner AM, Cook TM (2006) Surface cementation of stemmed tibial components in primary total knee arthroplasty: minimum 5-year follow-up. J Arthroplasty 21:353–357CrossRefGoogle Scholar
  23. 23.
    Smith S, Naima VS, Freeman MA (1999) The natural history of tibial radiolucent lines in a proximally cemented stemmed total knee arthroplasty. J Arthroplasty 14:3–8CrossRefGoogle Scholar
  24. 24.
    Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN (2012) The new knee society knee scoring system. Clin Orthop Relat Res 470:3–19CrossRefGoogle Scholar
  25. 25.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteoarthrosis. Ann Rheum Dis 16:494CrossRefGoogle Scholar
  26. 26.
    Ewald FC (1989) The knee society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12Google Scholar
  27. 27.
    Bach CM, Steingruber IE, Peer S, Nogler M, Wimmer C, Ogon M (2001) Radiographic assessment in total knee arthroplasty. Clin Orthop Relat Res 385:144–150CrossRefGoogle Scholar
  28. 28.
    Bach CM, Biedermann R, Goebel G, Mayer E, Rachbauer F (2005) Reproducible assessment of radiolucent lines in total knee arthroplasty. Clin Orthop Relat Res 434:183–188CrossRefGoogle Scholar
  29. 29.
    Chalmers BP, Sculco PK, Fehring KA, Trousdale RT, Taunton MJ (2017) A novel Percentage-Based system for determining aseptic loosening of total knee arthroplasty tibial components. J Arthroplasty 32:2274–2278CrossRefGoogle Scholar
  30. 30.
    Rosner B (2011) Fundamentals of biostatistics, 7th edn. Brooks/Cole, BostonGoogle Scholar
  31. 31.
    Berry DJ, Bozic KJ (2010) Current practice patterns in primary hip and knee arthroplasty among members of the American association of hip and knee surgeons. J Arthroplasty 25(6 Suppl):2–4CrossRefGoogle Scholar
  32. 32.
    Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer PA (2011) Comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty 27(3):331–340CrossRefGoogle Scholar
  33. 33.
    Stannage K, Shakespeare D, Bulsara M (2003) Suction technique to improve cement penetration under the tibial component in total knee arthroplasty. Knee 10(1):67–73CrossRefGoogle Scholar
  34. 34.
    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
  35. 35.
    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
  36. 36.
    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):499–503CrossRefGoogle Scholar
  37. 37.
    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):396–401CrossRefGoogle Scholar
  38. 38.
    Vandenbussche E, Duranthon LD, Couturier M, Pidhorz L, Augereau B (2002) The effect of tourniquet use in total knee arthroplasty. Int Orthop 26(5):306–309CrossRefGoogle Scholar
  39. 39.
    Reckling FW, Asher MA, Dillon WL (1977) A longitudinal study of the radiolucent line at the bone-cement interface following total joint-replacement procedures. J Bone Joint Surg 59A:355–358CrossRefGoogle Scholar
  40. 40.
    Li MG, Nilsson KG (2000) Changes in bone mineral density at the proximal tibia after total knee arthroplasty: a 2-year follow-up of 28 knees using dual energy X-ray absorptiometry. J Orthop Res 18:40–47CrossRefGoogle Scholar
  41. 41.
    Lonner JH, Klotz M, Levitz C et al (2001) Changes in bone density after cemented total knee arthroplasty: influence of stem design. J Arthroplasty 16:107–111CrossRefGoogle Scholar
  42. 42.
    Meneghini RM, Mont MA, Backstein DB, Bourne RB, Dennis DA, Scuderi GR (2015) Development of a modern Knee Society Radiographic Evaluation System and methodology for total knee arthroplasty. J Arthroplasty 30:2311e4Google Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of OrthopaedicsUniversity General Hospital of AlexandroupoliAlexandroupoliGreece
  2. 2.Department of Orthopaedics, Faculty of Medicine, Democritus University of ThraceUniversity General Hospital of AlexandroupoliAlexandroupoliGreece

Personalised recommendations