One hundred sixty-nine patients with primary knee osteoarthritis undergoing unilateral total knee arthroplasty were randomized into three groups: Group 1 received tourniquet application throughout the operation (n=56), Group 2 had the tourniquet applied before the osteotomy (n=61), and Group 3 had the tourniquet applied after osteotomy (n=52). The primary outcome was postoperative pain (VAS scores) at the surgical and tourniquet sites. Secondary outcomes included bloodless osteotomy surface preparation, intraoperative blood loss, transfusion rate, knee flexion deformity, limb circumference changes, KSS scores, and perioperative complications. Outcomes were assessed at 24 and 48 hours, and at 2 and 12 weeks postoperatively. Overall, the results revealed that applying the tourniquet after osteotomy significantly reduced pain at 24 and 48 hours, minimized thigh swelling and complications, and maintained comparable cement interface quality. These findings suggest that late tourniquet application may optimize recovery while preserving surgical efficacy.