Journal of Bone & Joint Surgery (2025).
Background: Total knee arthroplasty (TKA) is among the most commonly performed elective procedures. Tourniquet use remains debated regarding patient outcomes and postoperative experience. Methods: Within the PEPPER trial framework, 5,684 primary TKAs were analyzed; 4,866 (85.6%) used a tourniquet and 818 (14.4%) did not. Primary outcomes were KOOS‑JR, PROMIS‑PH10, and numeric pain rating, collected preoperatively and at 1, 3, and 6 months. Secondary outcomes included length of stay, discharge disposition, analgesic consumption, and complications. Multivariable analyses assessed associations between tourniquet use and PROMs. Results: The percentage achieving MCID for KOOS‑JR differed at 1 month (tourniquet 55.4% vs no‑tourniquet 47.9%) but not at 3 or 6 months. No differences were observed for PROMIS‑PH10 or pain at any time point, nor for opioid use, operative time, LOS, wound complications, or readmissions. Conclusions: Tourniquet use conferred a small early KOOS‑JR advantage at 1 month that was not sustained; overall, tourniquet use did not have a clinically meaningful impact on PROMs.