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



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.

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Fig. 1
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Total knee arthroplasty


Tranexamic acid


Institutional review board








No tourniquet


Confidence interval


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Author information




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.

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Correspondence to Carl L. Herndon.

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Herndon, C.L., Grosso, M.J., Sarpong, N.O. et al. Tibial cement mantle thickness is not affected by tourniquetless total knee arthroplasty when performed with tranexamic acid. Knee Surg Sports Traumatol Arthrosc 28, 1526–1531 (2020). https://doi.org/10.1007/s00167-019-05559-3

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