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Introduction: Tourniquetless total knee arthroplasty (TKA) is experiencing resurgence in popularity due to potential pain control benefits. Further, 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 was to determine how tourniquet use and/or novel bone preparation using sterile, compressed carbon dioxide (CO 2 ) gas affected cement penetration in TKA.Methods: A retrospective review was performed on 303 consecutive primary TKAs with the same implant in three groups: (1) a tourniquet without sterile CO 2 compressed gas used for bone preparation, (2) no tourniquet with CO 2 gas, and (3) tourniquet use and CO 2 gas bone preparation. Cement penetration was measured on radiographs by two independent, blinded raters across seven zones defined by the Knee Society Radiographic Evaluation System. Results:The three groups did not differ on age, BMI, or sex (p≥0.1). Cement penetration was greater in six of seven zones with significantly greater cement penetration in three zones (Tibial AP Zone 2, Femoral Lateral Zones 3A and 3P) in groups that utilized CO 2 gas bone preparation compared to the tourniquet only group (p≤0.039). Conclusion:Bone prepared with CO 2 gas showed significantly more cement penetration in three zones with greater cancellous bone. The results suggest use of CO 2 gas bone preparation may achieve greater cement penetration than using a tourniquet with lavage only.

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