Simplified wound care and earlier wound recovery without closed suction drainage in elective total hip arthroplasty. A prospective randomized trial in 100 operations

Minimizing the Risk of Surgical Site Infection Following Hip Fracture Operation

Introduction: Hip fractures are the most common serious injury in the elderly, associated with disability, morbidity, and mortality. Surgical site infection (SSI) is a serious post-operative complication. This prospective cohort study outlines how our center made cumulative improvements in SSI incidence rates, reaching a 12-month average of 0.5%. Methods: All patients undergoing hip fracture operation between 2016 and 2021 were included. The primary outcome measure was confirmed SSI, according to the Public Health England definition. Results were compared with the baseline recordings by an independent SSI team in 2013. Demographic data were compared with National Hip Fracture Database records. Peri-operative infection control and wound management tactics introduced between 2014 and 2021 were collated to gain an overview care bundle. Results: Baseline recordings identified a 9.0% SSI rate in a three-month observation period. In our study, 3,138 hip fracture operative cases were completed between October 2016 and December 2021. There were 9 superficial and 32 deep infections identified, yielding an overall infection rate of 1.3%. However, when analyzing the 12-month average, there was consistent decline in SSI from the baseline 9.0% in 2013 to 0.5% in 2021 (p < 0.05). A peri-operative care bundle included pre-operative bleeding risk assessment. Intra-operatively, double preparation and draping is used for arthroplasty. Broad-spectrum antibiotic agents and tranexamic acid are administered. Meticulous hemostasis and watertight wound closure are observed. Anti-coagulated patients received negative pressure dressings. Post-operatively, a dedicated senior lead team provided daily inpatient review of patients, with urgent consultant review of all wound healing concerns. Conclusion: Patients with a hip fracture have numerous risk factors for SSI. A dedicated multi-focal tactic, adopted by a multi-disciplinary department, can yield substantial risk reduction. Each intervention is evidence based and contributes to cumulative improvement. By prioritizing infection prevention, we have minimized the need for complex infection management interventions and achieved an annual saving of £860,000 for our trust.

Drainage in primary and revision hip and knee arthroplasty

Drainage after total hip or knee arthroplasty (THA, TKA) used to be systematic to prevent complications and notably hematoma and infection. However, improvement in practices, the introduction of blood-sparing protocols and above all the conclusions reported in many studies have cast doubt on this dogma. There is abundant literature on the pros and cons of drainage after primary THA and TKA. The main endpoints were transfusion rates and volumes, total blood loss and variations in hemoglobin levels. Clinical endpoints comprised pain, edema, postoperative hematoma and, more rarely, short-to-medium-term function. Except for a few studies reporting greater pain and edema without drainage, there is agreement that drainage not only provides no benefit but actually aggravates postoperative bleeding. There are fewer studies of drainage in revision procedures for the hip and very few for the knee. The interest of drainage has not been demonstrated and again postoperative bleeding is aggravated. Whether in primary or revision arthroplasty, tranexamic acid is recommended when not contraindicated, whatever the administration protocol. However, it should not be seen as the sole and determining reason for abandoning drainage. LEVEL OF EVIDENCE: V, expert opinion.

Routine Use of Closed Suction Drains Following Revision Arthroplasty May Not be Necessary

BACKGROUND

There are numerous studies demonstrating that closed suction drainage (CSD) usage after primary total joint arthroplasty (TJA) has little to no benefit. There are little data on the role of CSDs after revision TJA. The purpose of our study was to evaluate whether there is any clinical advantage to CSD usage after revision TJA.

METHODS

This retrospective study evaluated the clinical records of 2,030 patients undergoing revision TJA between 2007 and 2021. CSD was used in 472 patients and not used in 1,558 patients. Primary outcome was blood transfusion rate and secondary outcomes included total blood loss (TBL), as determined by Gross formula, wound complications (hematoma, infection, and dehiscence), and length of hospital stay. Patients undergoing revision TJA for oncologic reasons or those with incomplete datasets were excluded.

RESULTS

There were no statistically significant differences in rates of allogeneic blood transfusion, TBL, and wound complications (hematoma, infection, and dehiscence) between the two groups (P = .159, .983, .192, .334, and .548, respectively). When adjusted for demographic and surgical confounders, there was no difference in transfusion and TBL rates between groups (Odds Ratio 1.04, 95% Confidence Interval 0.78-1.38, P = .780 and estimate -105.71 mL, 95% confidence interval -333.96 to 122.55, P = .364, respectively). CSD cohort had a shorter length of stay (4.30 versus 5.82 days, P < .001).

CONCLUSION

We acknowledge that there is a role for CSD usage in a selected group of patients. Nevertheless, our study revealed that routine use of CSD after revision TJA does not provide an additional clinical benefit.

Analysis of the Need for Postoperative Drainage Application for Hip Arthroplasty: A Systematic Review and Meta-Analysis

OBJECTIVE

To synthesize the evidence regarding the effect and safety of drainage after the hip arthroplasty in randomized control trials.

BACKGROUND

Although the standard of hip replacement has matured in recent years, the need for postoperative drainage is still controversial which also is a clinical problem that needs to be addressed.

DESIGN

A systematic review and meta-analysis based on the Cochrane methods and Prisma guideline. Data Resources. A systematic search of the Cochrane Library, PubMed, EMBASE, CINAHL, Ovid, Wan Fang database, CNKI, and CBM database was carried out from January 1, 2000, to December, 2021. Review Methods. The quality of included randomized controlled trials was assessed individually by two reviewers independently using criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0.

RESULTS

Nineteen randomized control trials involving 3354 participants were included in this analysis. From the above analysis, we can know that compared with nondrainage, there was a statistically significant difference in VAS score on the postoperative first day (SD = -0.6; 95% CI: -0.79, -0.41) and second day (SD = -0.38, 95% CI: -0.58, -0.18), hematocrit reduction (MD =2.89; 95% CI: 1.3, 4.48), blood transfusion rate (OR =1.47; 95% CI: 1.12, 1.92), change of thigh circumstance (SMD = -0.48; 95% CI: -0.66, -0.31), and hospital stay (MD = 1.06; 95% CI: 0.73, 1.39) in drainage. However, there were no statistically significant differences in hemoglobin and hematocrit level, hip function, total blood loss, transfusion volume, dressing use, and complications between them.

CONCLUSION

Drainage after hip arthroplasty can reduce swelling in the thigh and relieve pain while no drainage can bring down hematocrit reduction, decrease dressing uses, and shorten the hospital stay which promotes rapid recovery. This review provides a detailed theoretical reference for the proper clinical application of drains and improves the efficient use of resources.

Closed suction drainages in Lower Limb Joint Arthroplasty: A level I evidence based meta-analysis

INTRODUCTION

The role of closed suction drainage during elective total joint arthroplasty is still unclear. The present study compared the use of closed suction drains to no drainage for elective total knee arthroplasty (TKA) and in total hip arthroplasty (THA) through a meta-analysis of randomized clinical trials (RCTs).

METHODS

Following the PRISMA guidelines, a meta-analysis of randomized controlled trials identified in December 2021. All randomized clinical trials comparing the use of closed suction drains to no drainage for elective THA or TKA were considered.

RESULTS

Twenty-five RCTs were included in the final analysis. 49% (1722 of 3505) of patients received no-drainage, and 51% (1783 of 3505) received closed suction drainage. There was no evidence of a statistically significant evidence between the two groups in occurrence of postoperative infections (P = 0.4), mean total postoperative hemoglobin (P = 0.2) or length of hospital stay (P = 0.1). The no-drainage group showed a lower rate of blood transfusion (P < 0.0001).

CONCLUSION

There is no evidence to support the routine use of closed suction drainage in THA or TKA patients.

LEVEL OF EVIDENCE

Level I, meta-analysis of randomized clinical trials.

Closed suction drainage offers no more clinical benefit than non-drainage after primary total knee arthroplasty with the administration of tranexamic acid in Chinese patients

Background

If closed suction drainage (CSD) should be used after primary total knee arthroplasty (TKA), remains controversial. The current study aimed to explore whether CSD offers more clinical benefit with the administration of tranexamic acid in Chinese patients.

Methods

A retrospective study was conducted on 200 patients who had received TKA. One hundred patients were placed on drainage after TKA, whereas the rest of 100 patients were not. Multiple clinical parameters were dynamically monitored and compared between the two groups.

Results

The length of the hospitalization days was significantly shorter in patients who did not receive CSD (6.0 ± 0.8 vs. 7.0 ± 0.8 days, p < 0.001). The patients in the drainage group had more Hb drop on the first postoperative day (14.82 ± 6.58 vs. 11.27 ± 5.71 g/L, p < 0.001). No statistically significant difference was observed in VAS score, ROM and thigh circumference at baseline during the follow-up between two groups.

Conclusions

Additional drainage after primary TKA had no clinical benefit after the tranexamic acid had already been administered during the treatment.

Prognostic risk factors of surgical site infection after primary joint arthroplasty: A retrospective cohort study

Surgical site infection (SSI) can be a devastating complication in joint arthroplasty. Objective of this study was to identify potential risk factors associated with SSI following primary joint arthroplasty.This retrospective cohort study was performed from January 2016 to October 2017. A total of 986 patients were enrolled. We extracted the patients' baseline information, treatment-related variables and indexes of laboratory examination during their hospitalization. Receiver operating characteristic (ROC) analysis was performed to find the optimum cut-off value for serum albumin. Univariate and multivariate logistic analysis models were performed respectively to determine independent predictors of SSI.Nine hundred eighty-six patients with complete data were included in the final analysis. There were 314 male and 672 females in this study with a mean age of 64.6 years, and twenty patients developed SSI. The overall incidence of SSI was 2.03%, with 0.20% for deep infection and 1.83% for superficial SSI. Independent predictors of SSI identified by multivariate analysis were ALB < 36.7 g/L (odds ratio = 3.42; 95% CI = 1.24-9.48; P = .018), BMI ≥28 (odds ratio = 5.08; 95%CI = 1.52-17.01; P = .008) and ASA class 3 or higher (odds ratio = 3.36; 95% CI = 1.22-9.30; P = .019). Drain use was demonstrated as a protective factor of postoperative wound healing.The incidence of SSI following primary joint arthroplasty was 2.03%. ASA ≥3, BMI ≥28 and ALB < 36.7 g/L were demonstrated as risk factors of postoperative wound infection. Supplementary nutrition support is necessary to reduce the risk of infection in patients who underwent artificial joint arthroplasty.

Factors affecting the incidence of surgical site infection after geriatric hip fracture surgery: a retrospective multicenter study

Background

Geriatric hip fracture is a common type of osteoporotic fracture with high mortality and disability; surgical site infection (SSI) can be a devastating complication of this injury. By far, only a few studies identified easily remediable factors to reduce infection rates following hip fracture and less researches have focused on geriatric patients. The objective of this study was to identify potentially modifiable factors associated with SSI following geriatric hip fracture surgery.

Methods

This retrospective, multicenter study involves three level I hospitals. A total of 1240 patients (60 years or older) underwent hip surgery with complete data were recruited between January 2016 and June 2018. Demographics information, medications and additional comorbidities, operation-related variables, and laboratory indexes were extracted and analyzed. Receiver operating characteristic (ROC) analysis was performed to detect the optimum cut-off value for quantitative data. Univariate and multivariate logistic analysis model were performed respectively to identify the independent predictors.

Results

Ninety-four (7.58%) patients developed SSI in this study, and 76 (6.13%) had superficial infection, while 18 (1.45%) were diagnosed with deep infection. Results of univariate and multivariate analysis showed age > 79 years (OR, 2.60; p < 0.001), BMI > 26.6 kg/m² (OR, 2.97; p < 0.001), operating time > 107 min (OR, 2.18; p = 0.001), and ALB < 41.6 g/L (OR, 2.01; p = 0.005) were associated with an increased incidence of SSI; drainage use (OR, 0.57; p = 0.007) could reduce the incidence of wound infection for patients after geriatric hip fracture.

Conclusion

Accurate modifiable variables, operating time > 107 min, serum albumin < 41.6 g/L, BMI > 26.6 kg/m², and age > 79 years could be applied to distinguish geriatric patients with high-risk of postoperative surgical site infection.

Post-operative drain use in patients undergoing decompression and fusion: incidence of complications and symptomatic hematoma

Background

Surgical drains are commonly used after spine surgery to minimize infection and hematoma formation. The aim of this study was to determine the incidence of post-operative complications after spinal decompression and fusion with and without a subfascial drain.

Methods

The medical records of 139 adult (≥18 years old) spinal deformity patients undergoing elective spinal decompression and fusion at a major academic institution were reviewed. We identified 116 (83.5%) who had a post-operative drain and 23 (16.5%) who did not have a postoperative drain (No-Drain: n=23; Drain-Use: n=116). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative complications, specifically surgical site infections (SSI) and hematoma formation.

Results

Patient demographics and comorbidities were similar between both cohorts, with the body mass index (BMI) slightly higher in the Drain-Use cohort (No-Drain: 26.1 kg/m²vs. Drain-Use: 29.1 kg/m², P=0.02). Operative time and the median number of levels fused were similar between the cohorts. The postoperative complications profile was similar between both cohorts, including deep and superficial SSIs (P=0.52 and P=0.66, respectively), and incidence of hematoma formation (P=0.66). Length of hospital stay (LOS) was significantly higher for the Drain-use cohort compared to the No-Drain cohort (5.0 vs. 2.8 days, P<0.0001). There were no significant differences in the 30-day hospital readmission rate or incidence of 30-day wound dehiscence, draining wound, incision & drainage (I & D), or bleeding between both patient groups.

Conclusions

Our study suggests that the use of postoperative subfascial drains in patients undergoing spinal decompression with fusion may not be associated with a reduction in SSIs or hematoma formation.

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background:

Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Study Design:

This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format.

Results:

Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning.

Conclusion:

This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

Use of closed suction drainage after primary total hip arthroplasty: a prospective randomized controlled trial

Objective

This study aimed to investigate drain use in a controlled population of patients with hip osteoarthritis undergoing primary total hip arthroplasty.

Methods

This prospective controlled trial evaluated 93 patients randomized into two groups: a group that received drains and a group that did not. The patients who were randomized to the drain group used a 3.2 mm drain placed under the fascia that was kept in place for 24 h. Postoperative evaluations were performed after 24 h and then three, six, and 12 weeks after total hip arthroplasty. The primary outcome was perioperative blood loss in both groups 24 h after total hip arthroplasty. The other parameters that were evaluated included mid-thigh circumference, the rate of blood transfusion, hematocrit, inflammatory serum levels, and the Harris Hip Score.

Results

The clinical and laboratory data revealed no differences between the study groups with respect to blood loss and need for blood transfusion, duration of hospital stay, reoperation rate, complications, inflammatory serum markers, and the Harris Hip Score. Patients without closed suction drainage reported higher pain levels after 24 h (VAS score 1 vs. 2, p < 0.01).

Conclusion

Similar clinical and laboratory outcomes were found in both cohorts.

Evidence base and practice variation in acute care processes for knee and hip arthroplasty surgeries

BACKGROUND

Lack of evidence contributes to unnecessary variation in treatment costs and outcomes. This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence.

METHODS

Part 1: Systematic search of electronic library databases for systematic reviews and practice guidelines concerning seven acute-care interventions. Intervention-specific recommendations concerning routine use were extracted by assessors. Part 2: Prospective medical record audit of the acute-care received by 1900 patients involving 120 orthopaedic surgeons. Surgeon use per intervention was summarized using caterpillar plots. Surgeon-specific routine and non-routine use was defined as use in ≥ 90% and ≤ 10% of patients, respectively. Primary analysis included only surgeons contributing ≥ 10 patients.

RESULTS

Continuous passive motion (TKA): Routine use not recommended; 85.7% of surgeons did not use it routinely. Tranexamic Acid: Routine use recommended; 26.9% of surgeons used it routinely. Cryotherapy: Routine use not recommended; 45.7% of surgeons used it routinely for TKA; 31.8% used it routinely for THA. Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 5.7% of surgeons used it routinely for TKA, 0.0% used it routinely for THA. Antibiotic loaded bone cement: Routine use for TKA not supported, recommendations for use for THA are inconsistent; 90.0% of surgeons used it routinely for TKA, 100.0% used it routinely for THA. Patella resurfacing (TKA): No recommendation could be made; 57.1% of surgeons routinely resurfaced the patella. Indwelling urinary catheterisation: Routine use recommended; 59.6% of surgeons used it routinely.

CONCLUSION

Recommendations for routine use or not exist for some of the acute-care interventions examined. Surgeon practices vary widely even in the presence of high-level recommendations. It is unclear whether further evidence alone would lessen unwarranted practice variation.

Efficacy of a Four-Hour Drainage Clamping Technique in the Reduction of Blood Loss Following Total Hip Arthroplasty: A Prospective Cohort Study

Background

During total hip arthroplasty (THA) drainage is used by most surgeons. However, the optimal drainage strategy remains controversial. The aim of this prospective cohort study was to determine the safety and efficacy of a four-hour drainage clamping technique in patients undergoing THA.

Material/Methods

There were 64 patients who underwent THA from March 2012 to December 2015 who were enrolled in the study; 32 patients were randomly assigned to four hours of a drainage clamping technique (clamping group); 32 patients were treated with a non-clamping drainage technique (non-clamping group). All perioperative clinical details were recorded for comparative analysis.

Results

The postoperative drainage volume and calculated blood loss were significantly greater in the drainage non-clamping group, p<0.001 and p=0.028, respectively. Significantly more patients in the drainage non-clamping group required a blood transfusion, seven cases versus one case (p=0.023). Significantly more units of blood were transfused in the drainage non-clamping group (p=0.001). No significant differences were found for all other clinical outcome factors.

Conclusions

The four-hour drainage clamping technique following THA, compared with drainage non-clamping technique reduced blood loss and requirement for blood transfusion. There was no increase in adverse clinical events using the four-hour drainage clamping method. Therefore, four-hour drainage clamping has the potential for routine use in THA.

Closed suction drainage has no benefits in revision total hip arthroplasty: a randomized controlled trial

PURPOSE

Several studies have failed to show significant benefits of closed suction drainage (CSD) in routine primary total hip arthroplasty (THA). However, blood loss, haematoma formation and wound complications are generally much greater in revision THA as compared to primary THA. The purpose of this study was to determine if CSD is beneficial for revision THA patients.

METHODS

We conducted a prospective, randomized, controlled trial at our institution between July 2013 and July 2014. Eighty-eight patients undergoing revision THA were enrolled and randomly assigned to receive a CSD (n = 44) or to not receive a CSD (n = 44). All first-stage revision surgeries for infection were excluded. Primary outcomes were haemoglobin loss and number of patients transfused. Secondary outcomes included functional outcome evaluated with Harris hip score (HHS), pain evaluated with visual analogue scale (VAS), and length of hospital stay.

RESULTS

There were significantly more patients in the CSD group that required blood transfusions (20/44 as compared to 11/44, p = 0.04). Patients in the no CSD group were discharged earlier than patients in the CSD group (4.3 days as compared to 5.4 days, p = 0.002). No statistical significant difference was found in the HHS or pain VAS between the groups.

CONCLUSIONS

This study did not demonstrate any benefit with the use of CSD for revision THA with regard to wound related complications, infection or early functional outcome. Post-operative blood loss, transfusion rate, and length of hospital stay may be higher with CSD.

Developing an evidence-based nursing protocol on wound drain management for total joint arthroplasty

BACKGROUND

Although various drains have long been used for many years in total joint replacement, there is a paucity of evidence for the benefit of drain applications. Evidence suggests inconsistent practice in the use of drainage systems, whether intermittently applying suction or free of suction in the application of drainage systems, as well as the optimal timing for wound drain removal.

AIM

It aimed to perform a systematic review to develop an evidence-based nursing protocol to manage wound drainage following total joint arthroplasty.

METHODS

A comprehensive systematic review of available evidence up to 2013. Searches of the EMBASE, Cochrane library, CINAHL, Medline electronic databases and an internet search by Yahoo and Google engine returned 2840 records, of which 11 met the inclusion criteria for this review. A further two papers were obtained through scanning the reference lists of those articles included from the initial literature search.

RESULTS

Different clamping times were retrieved from the literature. A protocol was adapted for clinical application according to the summary of the retrieved information. It is suggested that clamping is performed 1 h after the insertion of suction drains post-operatively in the operating theatre. Wound drains should be clamped for 1 h if blood loss is more than 600 ml in 6 h in first 24 h. Wound drains should be clamped for 1 h if blood loss is more than 800 ml in 8 h thereafter. It is suggested that the drainage reservoir bottle should be mark and findings recorded in line with the principle of drain clamping. This means that the amount of drainage is measured and recorded every 6 h in first 24 h and every 8 h thereafter. It is suggested that wound drains should be remove before 48 h after TJR. If blood loss is less than 50 ml in past 6 h or less than 70 ml in past 8 h, the drain should be remove and the wound site should be monitored closely.

CONCLUSION

This paper has guided nurses to develop an evidence-based protocol to improve patient care on wound drain management. Further study is necessary to evaluate the effectiveness of the protocol.

Is closed suction drainage effective in early recovery of hip joint function? Comparative evaluation in one-stage bilateral total hip arthroplasty

One-stage primary bilateral cementless total hip arthroplasty with unilateral closed suction drainage (CSD) was prospectively performed for 51 patients (102 hips), and local effects of CSD were quantitatively evaluated. Postoperatively, pain scores evaluated by visual analog scale and periwound temperatures measured by thermography were lower in the CSD side than the non-CSD side. CT measurements also showed that postoperative cross-sectional area of the thigh was smaller in the CSD side. Active straight leg raising and weight bearing were more accelerated in the CSD side., showing earlier recovery of hip joint function. CSD for hip arthroplasty has an advantage in reducing postoperative local inflammation and be recommended from the viewpoint of postoperative pain relief and early recovery of hip joint function.

Comparison between autologous blood transfusion drainage and no drainage/closed-suction drainage in primary total hip arthroplasty: a meta-analysis

PURPOSE

Primary aim of this meta-analysis of randomized controlled trials (RCTs) was to compare blood loss, transfusion rate and postoperative hemoglobin levels at 24-48 h after primary total hip arthroplasty (THA) between autologous blood transfusion (ABT) drainage and no drainage/closed-suction drainage and to obtain a powerful conclusion which way of drainage had the best clinical efficacy. Secondary aim was to compare the postoperative complication rates during the first year to indentify which way of drainage was safest.

METHODS

We searched the PubMed, Embase and Cochrane Central Register of Controlled Trials and identified 12 RCTs (including a total of 1,574 patients) for the meta-analysis. Methodological quality was assessed by the Physiotherapy Evidence Database scale. Two researchers extracted relevant data including study characteristics, blood loss, transfusion rate, hemoglobin levels, hospital stay and complications. After data extraction, we compared results using fixed-effects or random-effects models depending on the heterogeneity of the included studies.

RESULTS

Autologous blood transfusion drainage had less total blood loss and lower superficial infection rate than no drainage/closed-suction drainage. While there were no statistical differences in postoperative pain, hematoma, hemoglobin levels, hospital stay and other complications between ABT drainage and no drainage/closed-suction drainage.

CONCLUSIONS

Autologous blood transfusion drainage and no drainage/closed-suction drainage have similar clinical efficacy and safety in primary THA with regard to clinical outcomes and complication rates.

Drain technique in elective total joint arthroplasty

The authors report a simple technique for effective management of surgical drains and their reliable removal in elective hip and knee arthroplasty. Many surgeons use surgical drains for elective total hip and knee arthroplasties and instruct residents in their use despite limited evidence to support routine use of surgical drains in noninfected cases. There are many different types of drains and equally varied methods for implantation, monitoring, and removal. Technical issues regarding use of closed suction surgical drainage postoperatively deal primarily with the questions of when to remove the surgical drain and how to manage difficulties with drain removal or breakage.

Outcome in primary cemented total knee arthroplasty with or without drain: A prospective comparative study

BACKGROUND

Suction drain insertion is a common practice in orthopedic surgery, especially after joint arthroplasty to prevent the formation of a hematoma. Theoretically the use of a drain should diminish the volume of hematoma; however the literature has conflicting data. Some authors state that drainage evacuates fluid from a limited area only and can be a cause of infection due to retrograde migration of bacteria. It can also impair the early postoperative rehabilitation. The aim of this study was to evaluate the clinical outcome (especially postoperative pain) and intake of analgesics in patients who had undergone primary cemented total knee arthroplasty (TKA) with or without a postoperative drain.

MATERIALS AND METHODS

A prospective comparative study of 108 consecutive patients (121 knees) was conducted. They were divided into two groups: A study group, with no drainage and a control group with drain inserted at the end of surgery. A total of 121 patients were recruited into two groups. A study group consisted of 59 knees, in which we did not use drainage after TKA and a control group with 62 knees, in which drain was inserted post surgery. Both groups were comparable in terms of preoperative characteristics. The indication for TKA was osteoarthritis (n = 105) and rheumatoid arthritis (n = 16).

RESULTS

In patients without drainage we observed lower need for opioids, higher blood loss on the 1(st) postoperative day and a lower need for change of dressings. There were no statistically significant differences in terms of total blood loss, hidden blood loss, transfusion rate, range of motion, length of hospital stay or incidence of complications between the two groups. In 1 year observation there were no differences in clinical outcome between the two groups.

CONCLUSIONS

The present study conclude that there is no rationale for the use of drain after primary TKA. There are benefits in terms of lower opioid intake, lower blood loss on the first postoperative day and lower need for dressing reinforcement during hospitalization.

Do we really need closed-suction drainage in total hip arthroplasty? A meta-analysis

PURPOSE

The clinical use of closed-suction drainage, which aims to reduce postoperative wound haematomas and infection, is common. This study was performed to determine whether closed-suction drainage is safe and effective in promoting wound healing and reducing blood loss and other complications compared with no-drainage in total hip arthroplasty.

METHODS

The literature search was based on PubMed, the Cochrane Library, MEDLINE, and EMBASE. The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group, and then analysed using RevMan 5.0. Twenty randomised controlled trials involving 3,186 patients were included in our analysis.

RESULTS

The results of our meta-analysis indicate that closed-suction drainage reduces the requirement for dressing reinforcement, but increases the rate of homologous blood transfusion. No significant difference was observed in the incidence of infection, blood loss, changes in haemoglobin and haematocrit, functional assessment, or other complications when the drainage group was compared with the no-drainage group.

CONCLUSIONS

Our results of the comparison between closed-suction drainage and no drainage in THA have indicated that the routine use of closed-suction drainage for elective total hip arthroplasty may be of more harm than benefit.

Is wound drainage necessary in hip arthroplasty? A meta-analysis of randomized controlled trials

PURPOSE

The use of closed suction drainage systems for hip arthroplasty (HA) is a common practice. However, the effectiveness and safety are still questionable. Thus, the aim of this meta-analysis was to review the advantages and adverse effects of closed suction drainage systems in hip arthroplasty.

METHODS

All randomized or quasi-randomized trials comparing the use of closed suction drainage systems with no drainage systems for hip arthroplasty were searched in PubMed, Medicine, EMBASE and other internet databases. We assessed the methodological quality of the studies and abstracted the relevant data independently.

RESULTS

Sixteen studies involving 1,663 participants with surgical wounds comparing HA with and without the use of drainage were included in our analysis. Our results demonstrated blood transfusion was required more frequently the same as the persistent discharge in those who received drains. No significant differences in the incidence of wound hematoma, dehiscence or deep vein thrombosis were found between those allocated to drains and the non-drained wounds. Wound infection and the range of movement of the joint after surgery were similar between the two groups.

CONCLUSIONS

Based on the current evidence, there is insufficient evidence to support the routine use of closed suction drainage in hip arthroplasty. At the same time, our meta-analysis study suggested that using of closed suction drainage in HA increased requirement for postoperative blood transfusion. However, there is a moderate possibility of selection bias and publication bias in this review. Because of the limited number of studies which may weaken the strength of the evidence of our results, more samples, high-quality randomized trials are needed to increase the reliability of evidences.

LEVEL OF EVIDENCE

II.

Wound drainages in total hip arthroplasty: to use or not to use? Review of the literature on current practice

Aim of this study is to analyze data reported in literature concerning the efficacy of using wound low-vacuum suction drainages in orthopedic surgery after total hip arthroplasty. We analyzed studies concerning the use of drainages in prosthetic hip replacement surgery, performing our research through Pubmed, Cochrane database and Google Scholar, and selecting the ones evaluating the following parameters: bleeding, the need for blood transfusions, number or reinforcement of post-operative medications, length of hospitalization, functional results, periprosthetic and surgical wound infection, post-operative hematoma. Our review did not show any demonstrated advantage from the use of wound drainages in total hip arthroplasty. Moreover, some studies enlighted a possible complication related to their employment, represented by the greater need for blood transfusions. Despite the absence of a statistically demonstrated positive influence on wound outcome using suction drains after total hip replacement, many orthopedic surgeons still recommend using drainages, just because there is no certified proof of a negative effect.

Evidence-based review for patients undergoing elective hip and knee replacement

BACKGROUND

The objective of this study was to evaluate the evidence for different interventions in the preoperative, perioperative and post-operative care for people undergoing elective total hip (THR) and knee (TKR) replacement surgery.

METHOD

A multidisciplinary working group comprising consumers, managers and clinicians from the areas of orthopaedics, rheumatology, aged care and rehabilitation evaluated randomized controlled trials (RCTs) and systematic reviews/meta-analyses concerning aspects of preoperative, perioperative and post-operative clinical care periods for THR/TKR through systematic searching of Medline, Embase, CENTRAL and the Cochrane Database of Systematic Reviews from May 2007 to April 2011. Multiple reviewers determined study eligibility and one or more members extracted primary study findings. The body of evidence were assessed and specific recommendations made according to NHMRC guidelines.

RESULTS

Twenty-five aspects were identified for review. Recommendations for 16 of 25 areas of care were made: impact of waiting, multidisciplinary preparation, preoperative exercise, smoking cessation, interventions for comorbid conditions, predictors of outcome, clinical pathways, implementation of a blood management programme, antibiotic prophylaxis, regional anaesthesia and analgesia, use of a tourniquet in knee replacement, venous thromboembolism prophylaxis, early post-operative cryotherapy, early mobilization and continuous passive motion. In the post-operative period, study heterogeneity across all aspects of care precluded specific recommendations.

CONCLUSIONS

There was a deficiency in the quality of the evidence supporting key aspects of the continuum of care for primary THR/TKR surgery. Consequently, recommendations were limited. Prioritization and funding for research into areas likely to impact clinical practice and patient outcomes after elective joint replacement surgery are the next important steps.

Closed suction drainage with or without re-transfusion of filtered shed blood does not offer advantages in primary non-cemented total hip replacement using a direct anterior approach

INTRODUCTION

Wondering if the use of drains allowing re-transfusion of shed blood as opposed to closed suction drains or no drains would improve quality of care to patients undergoing simple non-cemented primary total hip replacement (THR) using a direct anterior approach, a three-arm prospective randomized study was conducted.

METHOD

One hundred and twenty patients were prospectively randomized to receive no drain, closed suction drains or drains designed for re-transfusion of shed blood. Blood loss, VAS pain scores, thigh swelling, hematoma formation, number of dressings changed and hospital stay were compared and patients followed for 3 months.

RESULTS

Drains did not have any significance on postoperative haemoglobin and haematocrit levels or homologous blood transfusion rates. Patients receiving homologous blood transfusions had too small drain volumes to benefit from re-transfusion and patients, who get drained fluid re-transfused, were far away from being in need of homologous blood transfusion. Omitting drains resulted in more thigh swelling accompanied with a tendency of slightly more pain during the first postoperative day but without effect on clinical and radiological outcome at 3 months. Earlier dry operation sites resulting in simplified wound care and shorter hospital stay was encountered when no drain was used.

CONCLUSION

The possibility to re-transfuse drained blood was not an argument for using drains and, accepting more thigh swelling, we stop to use drains in simple non-cemented primary THR using the direct anterior approach.