Background <p>This prospective randomized controlled study explores the effectiveness of two exsanguination techniques in total knee arthroplasty (TKA), comparing Esmarch bandages and simple leg elevation concerning surgical field visualization, intra-operative metrics, and post-operative outcomes.</p> Methods <p>Patients who underwent primary unilateral TKA (<i>n</i> = 100) were randomized and equally divided into the Esmarch bandage (EM group) and simple leg elevation (LE group) groups. Surgical field visualization was assessed using the Fromme–Boezaart grading scale. The operative time, intra-operative blood loss, total blood loss, post-operative pain, leg swelling, and post-operative complications were also assessed.</p> Results <p>Surgical field visualization was significantly better in the EM group for all steps except for wound closure. The overall surgical field scales were 1.16 ± 0.29 and 1.46 ± 0.34 in the EM and LE groups, respectively (<i>p</i> &lt; 0.001). The operative time and intra-operative blood loss were not significantly different between the two groups. Post-operative pain levels on days 1 and 3, and total blood loss were comparable between the groups. The knee circumference significantly increased in the EM group compared to the LE group (4.6% vs. 2.9%; <i>p</i> = 0.04).</p> Conclusions <p>Although Esmarch bandages enhance surgical field visualization, they do not reduce operative time or blood loss compared to simple leg elevation. However, the improved visualization is associated with increased post-operative knee swelling.</p> Trial registration <p>Clinical Trials Gov (NCT03989648) (18/06/2019).</p>