Is closed-suction drain necessary in unicompartmental knee replacement? A prospective randomised study

THE EFFECTS OF DRAINAGE TUBE ON PAIN AND FUNCTIONAL RECOVERY AFTER UNICOMPARTMENTAL KNEE ARTHROPLASTY

Objective

The objective of this study was to evaluate the impact of drainage tube placement on postoperative pain, recovery, and opioid consumption within a 72-hour period following unicompartmental knee arthroplasty (UKA).

Methods

Patients with medial knee osteoarthritis who underwent UKA from January 2019 to August 2020 were enrolled in the study and divided into two groups based on whether they received a drain postoperatively.

Results

The drainage group had significantly lower VAS scores on day 1, day 2, and day 3, in addition to significantly smaller changes in the circumference of the knee joint within 3 days postoperatively (P <0.05). The ROM in the drainage group significantly increased at 3 days and 1 month post-surgery, with a statistically significant difference in morphine consumption between the two groups at 3 days (P<0.05). The incidence of postoperative nausea and vomiting (5 cases) and wound bleeding (1 case) was lower in the drainage group compared to the non-drainage group (P<0.05).

Conclusions

The placement of a drainage tube in UKA may reduce the swelling of knee joint and pain, which not only reduces the use of Opioid but also facilitates early functional activities of the knee joint. Level of Evidence III; Retrospective Comparative Study.

Efficacy of postoperative drainage in total knee arthroplasty: Review of the literature

Postoperative drainage after total knee arthroplasty (TKA) is an established routine procedure for orthopedic surgeries, and is considered a useful practice in postoperative, but the use of drainage is controversial. Our study aims to clarify this aspect of knee prosthetic surgery. A systematic review of the literature was performed in the electronic databases to investigate the risks and the benefits of wound drainage in total knee arthroplasty: 30 articles were included in our review for eligibility. After the analysis of the literature performed, we found no significant advantages related with the use of wound drain following total knee replacement (TKR) in terms of pain, transfusion rate, blood loss, swelling, postoperative range of motion, wound complications, deep infection and hospital stay, while no drainage means a significant cost saving compared to drainage use. Thus, the use of drainage after TKA cannot be justified on the basis of the results of this study.

Optimal release timing of temporary drain clamping after total knee arthroplasty

Background

Bleeding control is critical after total knee arthroplasty (TKA). The purpose of this study was to evaluate the optimal time to release the clamped drain after TKA.

Methods

We performed unilateral TKA in 120 patients using three methods of drainage. Group A (N = 40) had a 3-hour clamp applied, and group B (N = 40) had a 4-hour clamp applied. Group C (N = 40) underwent conventional negative drainage. We evaluated the drainage volume, as well as the hemodynamic markers, transfusion volume, visual analog scale (VAS) scores, and range of motion (ROM).

Results

The drained blood volume in groups A and B was significantly less than that in group C. No significant difference was found between groups A and B. The level of hemoglobin in group A was significantly higher than that in group C at 2 days after surgery. The ROM of groups A and C was larger than that of group B at 5 days after surgery. Furthermore, the VAS scores of groups A and C were significantly lower than those of group B at both 2 and 5 days after surgery.

Conclusions

The temporary drain clamping method after TKA significantly reduced the volume of bleeding and blood transfusion. The 3-h clamping method reduced the drained volume as effectively as the 4-hour clamping method and resulted in less acute phase pain and more rapid recovery of ROM than the 4-hour clamping method. In conclusion, we recommend 3-h clamping after TKA as the optimal release time to reduce blood loss and acute phase pain.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

No need for use of drainage after minimally invasive unicompartmental knee arthroplasty: a prospective randomized, controlled trial

OBJECTIVE

Drainage is a common procedure in unicompartmental knee arthroplasty (UKA), but evidence regarding its effectiveness is lacking. The aim of this study was to investigate the benefits of drainage after minimally invasive UKA with effective blood loss management.

METHODS

This was a prospective, randomized, controlled trial to determine whether drainage after UKA provides benefits with respect to blood loss, drainage volume, complications, pain score, knee score, range of motion and cost. The 96 patients who underwent surgery between January 2012 and March 2013 were randomly divided into two groups: group A (n = 48) was treated without drainage, and group B (n = 48) with drainage. All UKA procedures were performed with the same minimally invasive surgical technique. Tranexamic acid and bone wax were used for the management of blood loss in all patients. The preoperative baseline parameters of the two groups did not differ significantly.

RESULTS

The mean drainage volume in group B was 75.7 ± 51.2 mL when the drainage was present. Total blood loss in group A and group B was 240.3 ± 73.3 mL and 274.1 ± 99.5 mL, respectively. These amounts did not differ significantly but both were significantly lower than the data reported for total knee arthroplasty. There was no difference in mean postoperative hemoglobin and hematocrit between groups. Differences in wound infection, incidence of deep vein thrombosis, postoperative Hospital for Special Surgery knee score, visual analog score, and range of motion were not statistically significant between groups. Hospitalization costs for UKA were lower in the absence of drainage.

CONCLUSIONS

The use of drainage in unilateral UKA provides no apparent advantage. With effective blood loss management and a minimally invasive procedure, blood loss and drainage volume in UKA are very low. Drainage does not improve the results. Foregoing non-drainage after UKA reduces both hospital costs and visible blood loss. Therefore, drainage is unnecessary in routine UKA.

Administration of enoxaparin 24 h after total knee arthroplasty: safer for bleeding and equally effective for deep venous thrombosis prevention

BACKGROUND

The purpose of this study was to determine the safety and effectiveness, as assessed by risk of bleeding and incidence of deep venous thrombosis (DVT), of administering delayed low-molecular-weight heparin (LMWH) after total knee arthroplasty.

METHODS

A prospective study of 210 consecutive patients undergoing primary unilateral total knee arthroplasty was undertaken. The patients were randomized into two groups: one of which was managed according to a standard LMWH program (LMWH-s group) and the other with delayed LMWH (LMWH-p). LMWH was initiated 12 h after wound closure in the LMWH-s group, and 24 h after wound closure in the LMWH-p group.

RESULTS

The total blood loss in the first three postoperative days was calculated and all complications were recorded. The mean total blood loss was 435 and 387 mL in the LMWH-s group and LMWH-p group, respectively (p < 0.01). No significant difference in the incidence of symptomatic DVT was observed. The mean length of hospital stay was 7.29 days in the LMWH-s group and 6.56 days in the LMWH-p group (p < 0.05).

CONCLUSIONS

After total knee arthroplasty, LMWH-p is safer for bleeding than LMWH-s and equally effective concerning prevention of DVT.

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.

Blood transfusion and drainage catheter clamping are associated with ecchymosis formation at the surgical site after total knee arthroplasty: an analysis of 102 unilateral cases

BACKGROUND

Many previous studies have focused on the postoperative complication of postoperative knee pain, infection, knee prosthesis loosening, periprosthetic fractures, and so on. There have been few studies focused on postoperative ecchymosis formation surrounding the wound of the TKA site. A certain degree of effect on the early functional recovery of the patients may occur due to the mental stress caused by the ecchymosis, which raises doubts regarding the success of the surgery. Therefore, it is particularly important to understand the risk factors for postsurgical ecchymosis formation after TKA, and specific measures for preventing ecchymosis should be taken. In this study, we reviewed the record of patients who received TKAs in our hospital, and a comprehensive analysis and assessment was conducted regarding 15 clinical factors causing postsurgical ecchymosis formation.

METHODS

The records of 102 patients who received unilateral TKAs between January 2007 and May 2010 were retrospectively analyzed. Patients were divided into two groups based on the occurrence of ecchymosis.

RESULTS

Of the 102 patients, 14 (13.7%) developed ecchymosis. Blood transfusion and drainage catheter clamping during the first few postoperative hours had a significant impact on the development of ecchymosis (p < 0.05). There was no difference in age, BMI, operation time, pre- and postoperative platelet count, and length of postoperative anticoagulant therapy between the two groups. Multivariate logistic regression revealed major risk factors for ecchymosis were postoperative blood transfusion (odds ratio (OR) = 15.624) and drainage catheter clamping (OR 14.237) (both, p < 0.05).

CONCLUSION

Blood transfusion and drainage catheter clamping after TKA due to excessive blood suction were associated with higher risks for ecchymosis formation surrounding the surgical site.

Diagnosis of periprosthetic joint infections of the hip and knee

No preferred test for diagnosis of periprosthetic joint infection exists, and the algorithm for the workup of patients suspected of infection remains unclear. The work group evaluated the available literature to determine the role of each diagnostic modality and devise a practical algorithm that allows physicians to reach diagnosis of periprosthetic joint infection. Ten of the 15 recommendations have strong or moderate evidence in support. These include matters involving erythrocyte sedimentation rate and C-reactive protein level testing, knee and hip aspiration, and stopping the use of antibiotics prior to obtaining intra-articular cultures. The group recommends against the use of intraoperative Gram stain but does recommend the use of frozen sections of peri-implant tissues in reoperation patients in whom infection has not been established, as well as multiple cultures in reoperation patients being assessed for infection. The group recommends against initiating antibiotic treatment in patients with suspected infection until after joint cultures have been obtained, but recommends that prophylactic preoperative antibiotics not be withheld in patients at lower probability for infection.

Is a closed-suction drain advantageous for penile implant surgery? The debate continues

INTRODUCTION

The debate about leaving a closed-suction drain during penile implant surgery remains unsolved. What is the current thinking about the pros and cons of leaving a scrotal drain for inflatable penile implant (IPP) surgery?

AIMS

The aim of this study is to explore the fund of existing information, and formulate a point and counterpoint debate analyzing the drain issue for implant surgery.

METHODS

Two differing points of view are given to answer the question of benefit vs. risk drains in implant patients.

MAIN OUTCOME MEASURES

To facilitate the debate about a longstanding urologic question.

RESULTS

There are two conflicting points presented in this manuscript, one supporting drain placement, the other opposing it in light of the risks and benefits.

CONCLUSIONS

Without prospective randomized controlled trials specifically looking at drain placement following IPP, it is unclear whether or not this intervention is beneficial. Until a study of this type is performed, leaving a drain will largely remain a surgeon preference.

[Pain therapy for the lower extremities]

Pain therapy after surgical procedures of the lower extremity is an important goal, whereas insufficient analgesia leads to an essential reduction of the patient's mobility and convalescence. If possible, regional anaesthetic and intrathecal procedures for pre-, intra- and postoperative analgesia should be used. Systemic analgesics should not be used preoperatively, whereas non-opioids and opioids are recommended postoperatively. Surgical options that adequately reduce pain are intra-articular injection of local anaesthetics alone or in combination with opioids and cooling and physiotherapeutic treatment regimens after joint procedures. There is no scientific rationale as an argument for inserting drains. The surgical approach depends more on the individual patient's anatomical characteristics. Whereas the regional analgesic regimen is more effective than systemic therapy, sufficient tools for pain reduction during surgical procedures of the lower extremity are at the orthopaedic surgeon's disposal, too.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty

The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).

Closed suction surgical wound drainage after anterior cruciate ligament reconstruction: a systematic review of randomised controlled trials

There is still debate over the use of drains following anterior cruciate ligament reconstruction surgery. We have performed a systematic review of the literature for randomised trials that related to the use of closed suction drains following anterior cruciate ligament reconstruction surgery. Five studies involving 349 patients were identified. There was no significant difference in the occurrence of wound healing complications, infections or the number of aspirations for haemarthrosis. There was also no difference in post-operative range of movement, functional score or incidence of limb swelling. The difference in pain scores varied between authors with some reporting increased pain in the drained group. All other outcomes reported failed to show any benefit for the use of drains. The authors recommend not using a drain following anterior cruciate ligament reconstruction with either Bone-Patellar Tendon-Bone or Quadrupled Hamstring graft.

Closed suction surgical wound drainage after orthopaedic surgery

BACKGROUND

Closed suction drainage systems are frequently used to drain fluids, particularly blood, from surgical wounds. The aim of these systems is to reduce the occurrence of wound haematomas and infection.

OBJECTIVES

To evaluate the effectiveness of closed suction drainage systems for orthopaedic surgery.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), and contacted the Cochrane Wounds Group. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), and MEDLINE (1966 to March 2006). Articles of all languages were considered.

SELECTION CRITERIA

All randomised or quasi-randomised trials comparing the use of closed suction drainage systems with no drainage systems for all types of elective and emergency orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality, using a nine item scale, and extracted data. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Thirty-six studies involving 5464 participants with 5697 surgical wounds were identified. The types of surgery involved were hip and knee replacement, shoulder surgery, hip fracture surgery, spinal surgery, cruciate ligament reconstruction, open meniscectomy and fracture fixation surgery. Pooling of results indicated no statistically significant difference in the incidence of wound infection, haematoma, dehiscence or re-operations between those allocated to drains and the un-drained wounds. Blood transfusion was required more frequently in those who received drains. The need for reinforcement of wound dressings and the occurrence of bruising were more common in the group without drains.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised trials to support the routine use of closed suction drainage in orthopaedic surgery. Further randomised trials with larger patient numbers are required for different operations before definite conclusions can be made for all types of orthopaedic operations.