Lower tourniquet cuff pressure reduces postoperative thigh pain in obese patients undergoing total knee arthroplasty


  • Wenxian Png Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road
  • Wuchean Lee Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road
  • Mann Hong Tan Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road




Tourniquet, Limb occlusion pressure, Obesity, Thigh pain, Total knee arthroplasty


Background: The use of high tourniquet pressures in obese patients undergoing total knee arthroplasty increases the risk of postoperative thromboembolic events and skin complications. Measurement of limb occlusion pressure (LOP) before surgery may lead to the use of lower tourniquet cuff pressure during surgery and thereby reduce the risk of postoperative pain and complications.

Methods: Eighty-six obese patients scheduled for total knee arthroplasty were randomized to a control group (n=43) with tourniquet pressures at 300 mmHg or the LOP group (n=43) where a recommended tourniquet pressure was determined based on the patient’s limb occlusion pressure. The primary outcome measure was postoperative thigh pain; the secondary outcome measures were the quality of bloodless field, postoperative drop in haemoglobin, postoperative complications and Oxford knee scores.

Results: The tourniquet cuff pressure was significantly lower in the LOP group than in the control group (p<0.001). Patients in the LOP group showed significantly lower postoperative thigh pain scores till postoperative day 3. Our study did not show any difference in intraoperative quality of bloodless field (p<0.103), postoperative complications and Oxford knee scores (p<0.775) at six months after surgery.

Conclusions: Our results show that the use of limb occlusion pressure method results in decreased postoperative thigh pain without reducing the quality of the bloodless field. We believe that this method in tourniquet application is safe and beneficial for the subset of obese patients undergoing total knee arthroplasty. 


Murphy CG, Winter DC, Bouchier-Hayes DJ. Tourniquet injuries: Pathogenesis and modalities for attenuation. Acta Orthop Belg. 2005;71:635-45.

Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2014;9:13.

Chen JY, Lo NN, Chong HC, Bin Abd Razak HR, Pang HN, Tay DK, et al. The influence of body mass infex on functional outcome and quality of life after total knee arthroplasty. Bone Joint J. 2016;98(6):780-5.

Gower SN, Beaumont AC. A burst sphygmo-manometer cuff during intravenous regional anaesthesia. Anaesthesia. 1989;44(12):1016-7.

Younger AS, McEwen JA, Inkpen K. Wide contoured thigh cuffs and automated limb occlusion measurement allow lower tourniquet pressures. Clin Orthop Relat Res. 2004;(428):286-93.

Pedowitz RA, Gershuni DH, Botte MJ, Kuiper S, Rydevik BL, Hargens AR. The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and an integrated cuff inflation system. Clin Orthop Relat Res. 1993;(287):237-44.

Olivecrona C, Ponzer S, Hamberg P, Blomfeldt R. Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty:a randomized controlled study of 164 patients. J Bone Joint Surg Am. 2012;94:2216-21.

Krackow KA. A maneuver for improved positioning of a tourniquet in the obese patient. Clinical Orthopedics and related research 1982;158:80-82.

Noordin S, McEwen JA, Kragh JF Jr, Eisen A, Masri BA. Surgical tourniquets in orthopaedics. J Bone Joint Surg Am. 2009;91(12):2958-67.

Tejwani NC, Immerman I, Achan P, Egol KA, McLaurin T. Tourniquet cuff pressure:the gulf between science and practice. J Trauma. 2006;61(6):1415-8.

McGraw RW, McEwen JA. The tourniquet. In: McFarlane RM, ed. The Hand and Upper Limb. Churchill Livingstone; 1987: 5-13.

Tai TW, Chang CW, Lai KA, Lin CJ, Yang CY. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty:a randomized controlled trial. J Bone Joint Surg Am. 2012;94:2209-15.

Reilly CW, McEwen JA, Leveille L, Perdios A, Mulpuri K. Minimizing tourniquet pressure in pediatric anterior cruciate ligament reconstructive surgery:a blinded, prospective randomized controlled trial. J Pediatr Orthop. 2009;29(3):275-80.

Ledin H, Aspenberg P, Good L. Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta Orthop. 2012;83:499-503.

Liu D, Graham D, Gillies K, Gillies RM. Effects of Tourniquet Use on Quadriceps Function and Pain in Total Knee Arthroplasty. Knee Surg Related Res. 2014;26:207-13.

Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M. Effect of tourniquet on activation of coagulation in total knee replacement. Clin Orthop 2000;371:169–77.

Li B, Wen Y, WuH, Qian Q, Lin X, Zhao H. The effect of tourniquet use on hidden blood loss in total knee arthroplasty. Int Orthop. 2009;33:1263–8.

Padala PR, Rouholamin E, Mehta RL. The role of drains and tourniquet in primary total knee replacement: a comparative study of TKR performed with drains and tourniquet versus no drains and adrenaline and saline infiltration. J Knee Surg. 2004;17:24–7.

Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement? A meta-analysis and systematic review. Knee. 2010;17:141–7.

Iorio R, Healy WL. Tourniquet use during total knee arthroplasty did not reduce total blood loss. J Bone Joint Surg Am. 2001;83:1282.

Tetro AM, Rudan JF. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Can J Surg. 2001;44:33–8.

Konrad G, Markmiller M, Lenich A, Mayr E, R¨uter A. Tourniquets may increase postoperative swelling and pain after internal fixation of ankle fractures. Clin Orthop Relat Res. 2005;433:189-94.

Estebe JP, Davies JM, Richebe P. The pneumatic tourniquet:mechanical, ischaemia-reperfusion and systemic effects. Eur J Anaesthesiol. 2011;28(6):404-11.

Kam PC, Kavanagh R, Yoong FF. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia. 2001;56:534-45.

Horlocker TT, Hebl JR, Gali B, Jankowski CJ, Burkle CM, Berry DJ, et al. Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesth Analg. 2006;102:950–5.

Aho K, Sainio K, Kianta M, Varpanen E. Pneumatic tourniquet paralysis. Case report. J Bone Joint Surg Br. 1983;65:441-3.

Bolton CF, McFarlane RM. Human pneumatic tourniquet paralysis. Neurology. 1978;28:787-93.

Clarke MT, Longstaff L, Edwards D, Rushton N. Tourniquet-induced wound hypoxia after total knee replacement. J Bone Joint Surg Br. 2001;83:40–4.

Babcock HM, Matava MJ, Fraser V. Postarthroscopy surgical site infections: review of the literature. Clin Infect Dis. 2002;34:65–71.

Nishiguchi M, Takamura N, Abe Y, Kono M, Shindo H, Aoyagi K. Pilot study on the use of tourniquet:a risk factor for pulmonary thromboembolism after total knee arthroplasty. Thromb Res. 2005;115:271–6.

Jules-Elysee K, Blanck T, Catravas J, Chimento G, Miric A, Kahn R, et al. Angiotensin-converting enzyme activity:a novel way of assessing pulmonary changes during total knee arthroplasty. Anesth Analg. 2004;99:1018–22.

Reikeras O, Clementsen T. Thrombosis markers in hip versus knee arthroplasty:a pilot study. J Orthop Surg (Hong Kong). 2009;17:291–5.

Guss D, Bhattacharyya T. Perioperative Management of the Obese Orthopaedic Patient. J Am Acad Orthop Surg. 2006;14(7):425-32.

Lieberman JR, Staheli LT, Dales MC. Tourniquet pressures on pediatric patients:a clinical study. Orthopedics. 1997;20:1143-7.






Original Research Articles