Nineteen studies, including 1,094 patients undergoing total knee arthroplasty, were included in this systematic review and meta-analysis comparing tourniquet-assisted versus tourniquet-free TKA. Pooled outcomes of interest included intraoperative blood loss, total blood loss (TBL), venous thromboembolism (VTE) incidence, wound complications, and transfusion rates. Tourniquet use significantly reduced intraoperative blood loss but had no significant impact on TBL or calculated blood loss. Tourniquet-assisted TKA was associated with a significantly higher incidence of wound complications (p = 0.01) and a trend toward increased VTE risk. A subgroup analysis demonstrated that TXA reduced intraoperative blood loss in both tourniquet-assisted and tourniquet-free groups while mitigating the risks of VTE. These findings suggest that while tourniquets are effective at limiting intraoperative bleeding, they may not provide additional benefits in the postoperative period when TXA is used, potentially increasing surgical complications.