Purpose <p>This study aimed to compare the clinical outcomes and postoperative complications between silicone ring tourniquets and pneumatic tourniquets in arthroscopic anterior cruciate ligament (ACL) reconstruction surgery.</p> Methods <p>This retrospective study enrolled 200 patients who underwent unilateral knee ACL reconstruction between April 2022 and April 2023. Patients were grouped according to the type of tourniquet used. Preoperative and postoperative hemoglobin levels, total blood loss, operative time, tourniquet application time, length of postoperative hospital stay, and frequency of dressing changes were evaluated. Pain was assessed using a visual analog scale (VAS) preoperatively and on postoperative days 1–3. Knee circumference was measured to evaluate knee swelling. In addition, all patients underwent 6-month follow-up to assess complications and knee joint functional recovery.</p> Results <p>Patients in the silicone ring tourniquet group had a shorter postoperative hospital stay (<i>P</i> = 0.011) and lower postoperative day 1 pain scores (<i>P</i> = 0.003). No statistically significant between-group differences were observed in operative time, hemostasis efficacy, frequency of dressing changes, knee swelling, complications rates or 6-month follow-up knee functional scores (all <i>P</i> &gt; 0.05).</p> Conclusion <p>In arthroscopic ACL reconstruction, the silicone ring tourniquet was superior to the pneumatic tourniquet in postoperative day 1 VAS pain scores and length of postoperative hospital stay, with no significant difference in complication incidence between the two groups. However, this study is limited by its non-randomized design, sample size and statistical power, and as the pain difference did not reach the minimal clinically important difference threshold, the present conclusion is preliminary and requires validation in large-sample, multicenter studies.</p> Level of evidence <p>Level III retrospective comparative study.</p>