Uso de drenos de sucção fechada após artroplastia total de quadril primária: um estudo prospectivo, randomizado e controlado

Does the Use of Negative Pressure Wound Therapy and Postoperative Drains Impact the Development of Surgical Site Infections?: A PARITY Trial Secondary Analysis

BACKGROUND

Surgical site infections (SSIs) represent a major complication following oncologic reconstructions. Our objectives were (1) to assess whether the use of postoperative drains and/or negative pressure wound therapy (NPWT) were associated with SSIs following lower-extremity oncologic reconstruction and (2) to identify factors associated with the duration of postoperative drains and with the duration of NPWT.

METHODS

This is a secondary analysis of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial, a multi-institution randomized controlled trial of lower-extremity oncologic reconstructions. Data were recorded regarding the use of drains alone, NPWT alone, or both NPWT and drains, including the total duration of each postoperatively. We analyzed postoperative drain duration and associations with tourniquet use, intraoperative thromboprophylaxis or antifibrinolytic use, incision length, resection length, and total operative time, through use of a linear regression model. A Cox proportional hazards model was used to evaluate the independent predictors of SSI.

RESULTS

Overall, 604 patients were included and the incidence of SSI was 15.9%. Postoperative drains alone were used in 409 patients (67.7%), NPWT alone was used in 15 patients (2.5%), and both postoperative drains and NPWT were used in 68 patients (11.3%). The median (and interquartile range [IQR]) duration of drains and of NPWT was 3 days (IQR, 2 to 5 days) and 6 days (IQR, 4 to 8 days), respectively. The use of postoperative drains alone, NPWT alone, or both drains and NPWT was not associated with SSI (p = 0.14). Increased postoperative drain duration was associated with longer operative times and no intraoperative tourniquet use, as shown on linear regression analysis (p < 0.001 and p = 0.03, respectively). A postoperative drain duration of ≥14 days (hazard ratio [HR], 3.6; 95% confidence interval [CI], 1.3 to 9.6; p = 0.01) and an operative time of ≥8 hours (HR, 4.5; 95% CI, 1.7 to 11.9; p = 0.002) were independent predictors of SSI following lower-extremity oncologic reconstruction.

CONCLUSIONS

A postoperative drain duration of ≥14 days and an operative time of ≥8 hours were independent predictors of SSI following lower-extremity oncologic reconstruction. Neither the use of postoperative drains nor the use of NPWT was a predictor of SSI. Future research is required to delineate the association of the combined use of postoperative drains and NPWT with SSI.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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.

A prospective randomized study, use of closed suction drainage after revision hip arthroplasty may lead to excessive blood loss

Suction drainage after primary total hip arthroplasties (THA) offers no benefits. Revision hip arthroplasties (RHA) are more demanding procedures and associated with greater blood loss compared to primary cases. There is still a lack of literature regarding the application of drainage in RHA. A total of 40 patients who underwent RHA were included in this prospective study. Simple randomization with an allocation ratio 1:1 was performed. Primary outcomes: total blood loss, hemoglobin drop, joint hematoma size in USG, infection. Secondary outcomes: blood transfusion rate, soft tissue hematomas, C-reactive protein levels, Visual Analogue Scale before and on 3rd day after surgery, Harris Hip Score before and 6 weeks after surgery. An intention to treat analysis was performed, with a 2-year follow up. Statistically significant differences between groups was in blood loss: drainage 1559.78 ml, non-drainage 1058.27 ml, (p = 0.029) and hemoglobin level on 1st day after surgery: drainage 10.58 g/dl, non-drainage 11.61 g/dl (p = 0.0496). In terms of the other analyzed parameters, statistical differences were not found. Our study revealed that the use of suction drainage may lead to higher blood loss in the early postoperative period. Further studies are needed to evaluate our results.

Evaluation of the potential complications of surgical wound drainage in primary total hip arthroplasty: a prospective controlled double-blind study

BACKGROUND

The routine use of postoperative wound drainage following total hip arthroplasty (THA) to avoid the creation of excessive haematomas is controversial because of the potential risk of blood loss and wound infection.

METHODS

In a prospective double-blind controlled study, 2 groups of patients with hip joint osteoarthritis were operated with primary THA, 1 with surgical wound negative pressure drainage (Group 1 - 635 patients) and the other without (Group 2 - 527 patients). Postoperative blood haemoglobin and haematocrit levels, the necessity for blood transfusion, values of the potential infection markers (serum C-reactive protein values and erythrocyte sedimentation rate), postoperative pain level (according to the VAS scale) and functional outcome (according to Harris Hip Score [HHS] and SF-36 scores) at 12 months postoperatively were compared.

RESULTS

A significantly higher drop in blood haemoglobin and haematocrit values was observed in the Group 1 patients (mean drop of 2.2 gr/dl ± 0.25 vs. 1.6 gr/dl ± 0.35 and mean drop of 16% ± 4.0 vs. 11% ± 3.0, respectively, p < 0.01, paired t test). The need for blood transfusion was significantly higher in the Group 1 patients (4.9% vs. 3.9%, p < 0.05, t test). The severity of pain (VAS scale) on the first day after the operation was significantly lower in the Group 1 patients (p < 0.05, t test), but overall, in both groups it was of low intensity (VAS <3). A similar postoperative wound infection rate was observed in both groups (0.4%). HHS and SF-36 scores were similar in both groups.

CONCLUSIONS

The drainage of surgical wounds following primary THA due to hip osteoarthritis has a low added value and might cause an increased requirement for blood transfusion.

Comparative study of suction drainage placement in cementless hip replacement among patients undergoing extended thromboprophylaxis: a prospective randomized study

Background

The use of drains reportedly does not improve surgical outcomes after hip replacement. There is still a lack of strict recommendations for drain placement after primary hip replacement. This study aimed to assess the safety of not using suction drainage after primary hip replacement in a population of patients undergoing extended thromboprophylaxis.

Methods

In this prospective randomized study, all patients were qualified for primary hip replacement and were divided into two groups: with and without drainage. The inclusion criterion was idiopathic hip osteoarthritis. The exclusion criteria were secondary coxarthrosis, autoimmune disease, coagulopathy, venous/arterial thrombosis, hepatic/renal insufficiency, cement, or hybrid endoprostheses. We performed an intention-to-treat analysis. Clinical, laboratory, and radiographic parameters were measured for the first three days after surgery. Hematoma collection, due to extended thromboprophylaxis, in the joint and soft tissues was evaluated precisely. The patients underwent follow-up for 30 days.

Results

The final analysis included a total of 100 patients. We did not find any significant statistical differences between groups in terms of hip fluid collection (9.76 vs. 10.33 mm, with and without drainage, respectively; mean difference, 0.6 mm; 95 % confidence interval [CI] -2.8 to 3.9; p = 0.653), estimated blood loss (1126 vs. 1224 ml; mean difference, 97.1 ml; 95 % CI -84.1 to 278.2; p = 0.59), and hemoglobin levels on postoperative day 3 (11.05 vs. 10.85 g/dl; mean difference, 0.2; 95 % CI -2.1 to 2.5; p = 0.53). In addition, the other parameters did not show significant differences between groups. Notably, two cases of early infections were observed in the no-drainage group, whereas there were no such complications in the drainage group.

Conclusions

We conclude that the use of closed suction drainage after primary hip replacement is a safe procedure in patients undergoing extended thromboprophylaxis. Further research is warranted to validate these findings.

Trial registration

The study was successfully registered retrospectively at Clinicaltrial.gov with the identification number NCT04333264 03 April 2020.

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.