Published: 2018-12-25

Blood loss following medial unicondylar knee replacements without a tourniquet: is there a need to group and save?

Sayyied J. Kirmani, Mark Middleton, Andreas Fontalis, Raka Srivastava, Feroz Dinah


Background: There are current trends towards not using a tourniquet in total knee replacement (TKR), but there is nothing published on what the effects of not using a tourniquet on unicondylar knee replacements (UKR) may be in terms of blood loss.

Methods: A retrospective case series of 36 consecutive UKR from our institution were analysed. All procedures were carried out without a tourniquet and also utilised a standardised interventions protocol including withholding of anticoagulants and antiplatelet medications, administration of periarticular local anaesthetic and adrenaline injection, and both IV and topical tranexamic acid. Outcomes measured were estimated intra-operative blood loss, overall blood loss through comparison of pre and post-operative haemoglobin laboratory values, and the need for post-operative blood transfusion.

Results: Most patients (61.1%) experienced an estimated intra-operative blood loss of less than100 mls. There was a mean haemoglobin drop of 16.1 g/l (range 1–26, SD ±5.9), with a mean post operatively haemoglobin level of 125.1 g/l (range 107-142, SD ±8.7). No patients required a blood transfusion.

Conclusions: A low level of blood loss is encountered when UKR is undertaken without a tourniquet and with our standard interventions to reduce bleeding. The level of post-operative haemoglobin and absence of requirement for blood transfusion suggests that this operation can be undertaken without the need for a group and save. It is our hope that surgeons will be encouraged to perform this procedure without a tourniquet and benefit from the cost-saving opportunity of not performing a group and save.


Unicondylar knee replacement, Tourniquet, Blood loss, Blood transfusion

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NJR 14th Annual Report 2017. Available at Accessed 23 April 2018.

Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer P. A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty. 2012;27:331–40.

Shixiong Yi, Jixiang Tan, Cheng Chen, Hong Chen, Wei Huang. The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2014;134:1469–76.

Zhang W, Ning L, 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

Tai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2011;19:1121–30.

Wang K, Ni S, Li Z, Zhong Q, Li R, Li H, et al. The effects of tourniquet use in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017;25:2849–57.

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

Li B, Wen Y, Wu H, 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.

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.

Blood Transfusion, NICE guideline, Published: 18 November 2015. Available at: Accessed on 25 May 2018

Schwab PE, Lavand'homme P, Yombi JC, Thienpont E. Lower blood loss after uni-compartmental than total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3494-500.

Brown NM, Sheth NP, Davis K, Berend ME, Lombardi AV, Berend KR, Della Valle CJ. Total knee arthroplasty has higher postoperative morbidity than unicompartmental knee arthroplasty: a multicenter analysis. J Arthroplasty. 2012;27(8):86-90.

Amin AK, Patton JT, Cook RE. Unicompartmental or total knee arthroplasty?:results from a matched study. Clin Orthop Relat Res. 2006;451:101–6.

Zhang XQ, Ni J, Ge WH. Combined use of intravenous and topical versus intravenous tranexamic acid in primary total joint arthroplasty:A meta-analysis of randomized controlled trials. Int J Surg. 2017;38:15-20.

Wu Q, Zhang HA, Liu SL, Meng T, Zhou X, Wang P. Is tranexamic acid clinically effective and safe to prevent blood loss in total knee arthroplasty? A meta-analysis of 34 randomized controlled trials. Eur. J. Orthop. Surg. Traumatol. 2015;25:525-41.

Tan J, Chen H, Liu Q, Chen C, Huang W. A meta-analysis of the effectiveness and safety of using tranexamic acid in primary unilateral total knee arthroplasty. J Surg Res. 2013;184:880.

Anderson LA, Engel GM, Bruckner JD, Stoddard GJ, Peters CL. Reduced blood loss after total knee arthroplasty with local injection of bupivacaine and epinephrine. J Knee Surg. 2009;22:130–6.

Gasparini G, Papaleo P, Pola P, Cerciello S, Pola E, Fabbriciani C. Int Orthop. 2006;30(4):253-6.

Juelsgaard P, Larsen UT, Sørensen JV, Madsen F, Søballe K. Hypotensive Epidural Anesthesia in Total Knee Replacement Without Tourniquet: Reduced Blood Loss and Transfusion. Regional Anesthesia Pain Med. 2001;26:2.

Russo R, Dasa V, Duarte R, Beakley B, Mishra M, Thompson H. Post-Operative Hypertension after Total Knee Arthroplasty and the Effects on Transfusion Rates. PLoS ONE. 2012;7(12):e50967.

Ewan B. Goudie, Cal Robinson, Phil Walmsley, Ivan Brenke. Changing trends in total knee replacement. Eur J Orthop Surg Traumatol. 2017;27:539–44

Metcalfe CW, Jayatilaka ML, Cope MR. Is a preoperative group and save necessary for enhanced recovery joint replacement patients? Br J Hosp Med (Lond). 2014;75(12):708-10.

Thomson PM, Ross J, Mukherjee S, Mohammadi B. Are Routine Blood Group and Save Samples Needed for Laparoscopic Day Case Surgery? World J Surg. 2016;40(6):1295-8.

Barrett-Lee J, Vatish J, Vazirian-Zadeh M, Waterland P. Routine blood group and antibody screening prior to emergency laparoscopy Ann R Coll Surg Engl. 2018;100(4):322-5.