Non-drainage is better than 4-hour clamping drainage in total knee arthroplasty

Postoperative Hemodynamics of Total Knee Arthroplasty Unaffected by Cementless Approach under Contemporary Patient Blood Management Protocol: A Propensity Score-Matched Study

(1) Background: A cementless total knee arthroplasty (TKA) is a recent and an increasingly popular innovation that enhances porous fixation surfaces. However, the lack of cemented sealing of an exposed resected bone has raised concerns about the potential for greater blood loss. The goals of this study were to determine if a cementless approach impacts post-TKA hemodynamics and to identify risk factors for blood loss in instances of cementless (vs. cemented) TKAs under a contemporary patient blood management (PBM) protocol. (2) Methods: We recruited 153 consecutive patients undergoing unilateral TKAs between 2019 and 2023. All enrollees received cementless or cemented prostheses of the same design (cementless, 87; cemented, 66). After propensity score matching for demographics, there were 46 patients in each group. We then compared blood loss metrics (total [TBL] and estimated [EBL]), drainage volumes, hemoglobin (Hb) levels, and transfusion rates by group. (3) Results: Post-TKA hemodynamics (i.e., TBL, EBL, drainage, Hb level, and transfusion rate) of cementless (n = 46) and cemented (n = 46) TKA groups did not differ significantly. In addition, the proportions of patients with Hb drops > 3.0 g/dL were similar for the two groups. A logistic regression analysis revealed that only preoperative Hb and EBL during the early postoperative period were predictive of a substantial fall in Hb levels. The fixation method was not associated with Hb decline > 3.0 g/dL by postoperative Day 3. (4) Conclusion: The cementless TKA has no impact on customary post-TKA hemodynamics and is not associated with greater TKA-related blood loss when implementing a contemporary PBM protocol.

The Impact of Room-Sharing on Length of Stay After Total Hip or Knee Arthroplasty: A Retrospective Study

Background

Prolonged length of stay (LOS) after elective total hip (THA) and knee (TKA) arthroplasty is often associated with worse patient outcomes. Social support through room-sharing has been identified as a factor that may reduce LOS in a hospital setting, but has not yet been examined in an orthopedic population. The aim of this study was to evaluate the effect of single- vs shared-room accommodation after elective TKA or THA on hospital LOS.

Method

A retrospective study was conducted using data from hospital medical records at our institution. Patients receiving unilateral, elective THA or TKA over a 2-year period were eligible. Patients were allocated to either a single room or four-bed shared room. The primary outcome was LOS; secondary outcomes included complications, discharge destination, and return to operating theater.

Results

One hundred eighty-five patients (70 THA, 115 TKA; mean age 65.74 ± 10.38, 59% female) were included, of whom 82 were allocated to a single room and 103 to a shared room. There was no statistically significant difference in LOS between the 2 groups (5.18 ± 2.21 days [single] vs 4.88 ± 2.12 days [shared]; mean difference −0.29 [95% CI −0.92-0.33], P = .36). Analysis modeling for multiple confounders found no association among room allocation, LOS, and discharge destination. However, more patients in single rooms required discharge to rehabilitation (27% vs 9%) and return to theater (7% vs 1%).

Conclusions

Room allocation did not correlate with a difference in LOS in patients undergoing elective THA or TKA.

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.

3-h drain clamping is not effective to reduce total blood loss after primary total knowledge

Purpose

Total knee arthroplasty (TKA) is a clinically efficacious surgical option for end-stage knee osteoarthritis. However, TKA increases the risk of serious bleeding and blood transfusion. The objective of this study was to evaluate the difference in postoperative blood loss in groups subjected to 3 h of clamping and non-clamping and determine the variations in rate and amount of transfusion after TKA between the two groups.

Materials and methods

Propensity score matching of the group subjected to 3-h drain clamping (43 patients; September 2015 to April 2016) and the control group (43 patients; before initiating the clamping method) was performed in patients undergoing unilateral primary posterior stabilized TKA. The two groups were compared. We measured the total drained blood volume until the drain was removed 48 h after surgery, and we compared the preoperative levels of hemoglobin and hematocrit with levels observed on days 1 and 2 after surgery. We also determined the blood transfusion rate and volume as well as the occurrence of clamping-associated complications.

Results

In the group subjected to 3-h drain clamping, the mean volume of total drained blood was significantly lower than in the control group (333.8 ± 190.2 mL vs. 839.9 ± 339.8 mL, P <0.001). There was no significant difference in total blood loss between the two groups (1226.9 ± 488.1 mL vs. 1127.1 ± 424.5 mL, P = 0.315), but the hidden blood loss was significantly higher in the 3-h drain clamping group than in the control group (893.1 ± 487.7 mL vs. 294.7 ± 531.8 mL, P <0.001). Both the transfusion rate and amount in the 3-h drain clamped group were higher than in the control group but were not statistically significant (30.2% vs. 37.2%, P = 0.494 and 269.8 ± 483.8 mL vs. 316.3 ± 158.2 mL, P = 0.648, respectively). No significant differences in complications, including deep vein thrombosis, pulmonary thromboembolism, and oozing, were noted between the two groups (all, P = 1.000).

Conclusions

The 3-h drain clamping method after primary TKA using posterior stabilized implant reduced the loss of postoperative drained blood. However, hidden blood loss was significantly higher in the 3-h drain clamping group; as a result, there were no differences in total blood loss and transfusion rate. The clamping method did not significantly alter the complication rate.

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

BACKGROUND AND PURPOSE

Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research.

METHODS AND MATERIALS

We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital.

RESULTS

Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction.

CONCLUSION

The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

Perioperative blood management strategies for patients undergoing total knee replacement: Where do we stand now?

Total knee replacement (TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions (ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.

Influence of wound drainage in primary total knee arthroplasty without tourniquet

PURPOSE

Although it remains the golden standard, several authors have questioned the role of pneumatic tourniquets in primary knee arthroplasty in recent studies. An intra-articular wound drainage is widely used in the field of total knee arthroplasty although the benefit of postoperative wound drainage is controversial in the literature. This study questioned whether the use of an intra-articular drain is an advance over the lack of a drain in total knee arthroplasty which is performed without a tourniquet.

METHODS

We documented the ROM, the knee circumference at the upper patellar pole pre-operatively and on days two, four and six postoperatively. The blood volume and loss was calculated. As surrogate parameter for wound healing we counted the number of days until no residual secretion was observed via the wound/drainage site.

RESULTS

The results of our investigation showed a significantly better wound healing without the use of a drain. All other parameters revealed no significant differences.

CONCLUSION

The data of this study demonstrate a faster wound healing without the use of a postoperative wound drain in primary total knee arthroplasty which is performed without a tourniquet. Other parameters could not show any significant differences thus indicating that a postoperative wound drain has no significant advantage and the risk of a retrograde bacterial colonisation is well documented. Based on these data we recommend performing a primary total knee arthroplasty without a postoperative drain if the procedure is done without a tourniquet.

The effect of drainage tube on bleeding and prognosis after total knee arthroplasty: a prospective cohort study

Background

To evaluate the effect of drainage tube on prognosis after total knee arthroplasty (TKA) and explore an effective treatment with favorable prognosis.

Methods

In a prospective study, 18 patients with TKA for the first time were included and randomly divided into three groups, group A (no placement of drainage tube), group B (negative pressure drainage), and group C (4 h clamping drainage). Intraoperative and postoperative blood loss, operation time, and the drainage volume were recorded and analyzed. Arthrocele, ecchymosis, and range of motion (ROM) were examined postoperatively. The degree of pain was scored by Visual Analog Scale (VAS) after 6, 12, and 24 h of operation. The complications were examined and HSS (hospital for special surgery) knee score was taken during the follow-up period.

Results

There was no significant difference in operation time, total blood loss, intraoperative blood loss, and VAS score among three groups. Meanwhile, the hidden blood loss in group B was significantly decreased compared with group A (P = 0.0015). The postoperative drainage volume of group B was significantly increased compared with group C (P = 0.0002). No drainage increased the rate of arthrocele and ecchymosis. Compared with group A, ROM after 3 days of operation in groups B and C was significantly increased (P = 0.0357, P = 0.0372, respectively). During follow-up study, no deep infection or deep venous thrombosis was found.

Conclusion

After TKA, early clamping of the drainage tube reduced the bleeding loss without adverse effect on prognosis, which might be useful for clinical application in future.

No difference in total blood loss, haemoglobin and haematocrit between continues and intermittent wound drainage after total knee arthroplasty

PURPOSE

The purpose of this prospective randomized study was to compare the visible, hidden, total blood loss and postoperative haemodynamic change of 4-h clamping and nonclamping of the drain after TKA. The hypothesis in the present study was that intermittent drain clamping with injection of diluted epinephrine solution would decrease the visible, hidden blood loss and reduction of postoperative haemoglobin or haematocrit change after TKA.

METHODS

From January 2010 to January 2011, 100 TKAs were performed at our hospital. In group I (50 knees), drainage was clamped for the first 4 postoperative hours with injection of diluted epinephrine solution. In group II (50 knees), drainage was not clamped without injection of diluted epinephrine solution. Two drains with an external diameter of 3.2 mm were inserted into the knee joint. We checked the amount of drainage recorded at 6, 12, 24, and 48 h postoperatively. Also, we checked the haemoglobin and haematocrit on the preoperation, first, 5th and 10th postoperative days. We analysed the transfusion rate, the possible adverse issues with clamping drainage, and the range of motion of the knee.

RESULTS

The mean total bloody drainage was significantly less in group I than group II (560.7 ± 249.9 mL vs 978.3 ± 327.5 mL) (p < 0.001). The decrease of haemoglobin and haematocrit after surgery was not significant between the two groups (n.s.). The hidden blood loss was significantly more in group I than group II (541.1 ± 439.4 mL vs 32.1 ± 21.9 mL) (p < 0.001). So, total blood loss showed no significant difference between the two groups (1,101.8 ± 373.6 mL vs 1,010.4 ± 385.9 mL) (n.s.). The postoperative range of motion and transfusion rate between the two groups were not significant (n.s.). But immediate wound problem, such as oozing, was significantly more in group I (p < 0.001).

CONCLUSION

It is not necessary to perform the intermittent drain clamping with injection of the diluted epinephrine solution in TKA because there is no impact on the postoperative haemoglobin and haematocrit. If anything, the intermittent drain clamping with injection of the diluted epinephrine solution increased the hidden blood loss and immediate wound problem than nonclamping without injection of the diluted epinephrine solution.

A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty

PURPOSE

The optimal timing of pneumatic lower limb tourniquet application during primary elective total knee arthroplasty surgery (TKA) is a matter of debate. Most previous reports have failed to show significant differences between different tourniquet timings. The aim of the work was to determine how three strategies of lower limb pneumatic tourniquet application affect the outcome for TKA patients.

METHODS

Forty-three patients who undergo TKA were randomized into one of the three groups, and 36 of these patients completed the study. The tourniquet was inflated just before incision and deflated after the hardening of the cement for twelve patients (Group 1), it was inflated just before cement application and deflated after its hardening for another twelve patients (Group 2), and it was inflated before incision and deflated after the last suture of the skin for a further twelve patients (Group 3). Fit-to-discharge criteria and six methods for calculating estimated blood loss were used.

RESULTS

The estimated blood loss in Group 1 was lower than in Group 2, as determined by six methods of calculation (p < 0.05). Estimated blood loss in Group 3 was lower than in Group 2, as determined by one method (p = 0.050). The mobilization performance in Group 1 was better than in Group 2 (p = 0.023) and in Group 3 (p = 0.033). Group 1 was better fit to discharge than Group 3 (p = 0.030).

CONCLUSIONS

Inflation of an automatic pneumatic lower limb tourniquet before skin incision and its deflation after hardening of cement tends to give better outcomes in TKA patients during six postoperative days. The estimated blood loss was highest when the tourniquet was inflated just before cement application and deflated after its hardening.

Periosteal Transplantation Combined with the Autologous Matrix-Induced Chondrogenesis (AMIC) Technique in Isolated Patellofemoral Osteoarthritis: A Case Report

OBJECTIVE

Isolated cases of osteoarthritis of the knee represent a major clinical problem. A particular challenge is a case in which both articular surfaces are affected. Such is the case with the isolated form of patellofemoral osteoarthritis. Studies that describe methods for treating such conditions are few, and the results are not too promising.

METHODS

In this article, we present one such case of isolated patellofemoral osteoarthritis in which we used a new approach combining periosteal transplantation on one side and the autologous matrix-induced chondrogenesis (AMIC) technique on the other side.

RESULTS

The patient has improved, measured by the Knee injury and Osteoarthritis Outcome Score (KOOS) from 48 preoperatively to 77 at 1 year postoperatively (mean improvement) and measured by the Lysholm score from 45 preoperatively to 90 at 1 year postoperatively.

CONCLUSION

This original approach has shown promising results in this patient and could be tested in a larger group of patients with the same type of osteoarthritis in order to estimate its real clinical value.