The Effect of Tourniquet Use and Sterile Carbon Dioxide Gas Bone Preparation on Cement Penetration in Primary Total Knee Arthroplasty

J Arthroplasty. 2019 Aug;34(8):1634-1639. doi: 10.1016/j.arth.2019.03.050. Epub 2019 Mar 28.


Background: Tourniquetless total knee arthroplasty (TKA) is experiencing resurgence in popularity due to potential pain control benefits. Furthermore, optimal cement technique and implant fixation remain paramount to long-term cemented TKA success, as aseptic loosening continues to be a leading cause of revision. The purpose of this study is to determine how tourniquet use and/or novel bone preparation using sterile, compressed carbon dioxide (CO2) gas affected cement penetration in TKA.

Methods: A retrospective review was performed on 303 consecutive primary TKAs with the same implant in 3 groups: (1) a tourniquet without sterile CO2 compressed gas used for bone preparation, (2) no tourniquet with CO2 gas, and (3) tourniquet use and CO2 gas bone preparation. Cement penetration was measured on radiographs by two independent, blinded raters across 7 zones defined by the Knee Society Radiographic Evaluation System.

Results: The 3 groups did not differ on age, body mass index, or gender (P ≥ .1). Cement penetration was greater in 6 of 7 zones with significantly greater cement penetration in 3 zones (tibial anteroposterior zone 2, femoral lateral zones 3A and 3P) in groups that utilized CO2 gas bone preparation compared to the tourniquet only group (P ≤ .039).

Conclusion: Bone prepared with CO2 gas showed significantly more cement penetration in 3 zones with greater cancellous bone. The results suggest that use of CO2 gas bone preparation may achieve greater cement penetration than using a tourniquet with lavage only.

Keywords: Radiographic Evaluation System; bone preparation; cement penetration; total knee arthroplasty; tourniquet.

MeSH terms

  • Aged
  • Arthroplasty, Replacement, Knee / instrumentation*
  • Arthroplasty, Replacement, Knee / methods
  • Bone Cements*
  • Carbon Dioxide*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Radiography
  • Retrospective Studies
  • Therapeutic Irrigation / methods
  • Tibia / surgery
  • Tourniquets*
  • Treatment Outcome


  • Bone Cements
  • Carbon Dioxide