Half-duration tourniquet plus intra-articular tranexamic acid injection reduces blood loss and improves early recovery after total knee arthroplasty

BackgroundTotal knee arthroplasty is often complicated by perioperative blood loss. Tourniquets reduce visible bleeding; however, prolonged use may increase hidden blood loss. Intra-articular tranexamic acid may enhance hemostasis without increasing the risk.MethodsWe retrospectively analyzed 85 unilateral primary total knee arthroplasties for osteoarthritis (September 2022 to March 2025). All patients received 1 g intravenous tranexamic acid before incision and were nonrandomly assigned to either of three groups based on evolving institutional protocols and surgeon discretion during the study period as follows: (a) Group A (full-duration tourniquet, n = 28); (b) Group B (half-duration tourniquet, n = 27); and (c) Group C (half-duration tourniquet plus 2 g intra-articular tranexamic acid, n = 30). The primary outcome was postoperative day 3 hemoglobin level; secondary outcomes were calculated blood loss, transfusion, pain scores, early Hospital for Special Surgery knee score (function), and perioperative complications.ResultsA total of eighty-five unilateral primary total knee arthroplasties were analyzed (Group A, n = 28; Group B, n = 27; and Group C, n = 30). Baseline variables were comparable across the three groups. On postoperative day 3, hemoglobin level was highest in Group C (10.97 ± 0.69 g/dL) compared with those in Groups A (9.89 ± 0.80) and B (10.05 ± 0.58) (overall p < 0.001; Groups C vs. A/B, both p < 0.001). Total blood loss decreased stepwise (Group A, 1403 ± 136 mL; Group B, 1163 ± 124 mL; and Group C, 770 ± 121 mL; all pairwise p < 0.001); a similar pattern was observed for hidden blood loss (Group A, 1388 ± 137 mL; Group B, 929 ± 128 mL; and Group C, 529 ± 121 mL; all pairwise p < 0.001). Intraoperative blood loss was lowest in Group A (median 15 mL) compared with those in Groups B (220 mL) and C (230 mL) (p < 0.001). Transfusion rates were 28.6% in Group A, 14.8% in Group B, and 3.3% in Group C (overall p = 0.024). Postoperative pain, as indicated by visual analog scale scores, was lowest in Group C (scores on postoperative days 1 and 3: 4.95 ± 0.85 and 3.57 ± 0.61, respectively) compared with those in Groups B (scores on postoperative days 1 and 3: 6.02 ± 1.22 and 4.63 ± 0.87, respectively) and A (scores on postoperative days 1 and 3: 7.86 ± 0.85 and 6.54 ± 1.00, respectively) (both time points p < 0.001). Based on a comparison of the Hospital Special Surgery knee scores of the three groups, Group C demonstrated superior early functional outcomes (scores: 62.33 ± 2.71 at postoperative 1 week and 83.73 ± 3.14 at postoperative 1 month) compared with Groups B (scores: 56.81 ± 3.11 at postoperative 1 week and 79.11 ± 3.64 at postoperative 1 month) and A (47.86 ± 3.39 at postoperative 1 week and 72.36 ± 3.72 at postoperative 1 month) (all p < 0.01). However, the 6-month Hospital for Special Surgery knee scores of the three groups were comparable (Group A: 89.93 ± 2.42; Group B, 89.96 ± 2.53; and Group C, 91.13 ± 2.06; p = 0.09). Overall complication rates did not differ between the three groups (Group A, 7.1%; Group B, 7.4%; Group C, 3.3%; p = 0.734).ConclusionIn total knee arthroplasty patients, the combination of a half-duration tourniquet with intra-articular tranexamic acid may provide superior perioperative blood management compared with a full-duration tourniquet or half-duration tourniquet alone. This strategy may reduce total and hidden postoperative blood loss, reduce hemoglobin loss, and lower transfusion rates. Additionally, it may reduce postoperative pain and promote earlier recovery of knee function. In addition, this treatment combination did not cause a significant increase in complications, including thrombosis or infection.