Closed Suction Drainage Is Not Necessary for Total Knee Arthroplasty: A Prospective Study on Simultaneous Bilateral Surgeries of a Mean Follow-Up of 5.5 Years

doi:10.1016/j.arth.2015.10.005

The Journal of Arthroplasty

Volume 31, Issue 3, March 2016, Pages 641-645

https://doi.org/10.1016/j.arth.2015.10.005 Get rights and content

Abstract

Background

Closed suction drainage has been widely used for orthopedic surgeries including total knee arthroplasty (TKA) to prevent fluid collections at the operative site such as blood around the wound. However, it is still controversial whether suction drainage is necessary for TKA. The present study aimed to clarify the need for suction drainage by assessing short-term and long-term clinical outcomes of simultaneous bilateral TKA.

Methods

Our subjects were 63 patients (126 knees) who underwent simultaneous bilateral TKA using a cemented posterior stabilized prosthesis, classified into 3 groups: 20 patients with a closed suction drain on both sides (bilateral group), 22 patients with a closed suction drain on one side and no drain on the other side (unilateral group), and 21 patients with no drain (no-drainage group). Short- and long-term clinical outcomes were evaluated.

Results

Mean hemoglobin drop on the day after surgery was significantly greater in the bilateral group (2.2 g/dL, P = .038) and unilateral group (2.2 g/dL, P = .045) compared with the no-drainage group (1.5 g/dL). The incidence of short-term and long-term complications was not significantly different between knees with drainage and those without drainage. In side-to-side comparisons, no significant differences were found in knee extension, flexion, or circumference in the unilateral group. In group comparisons, we found no significant differences in clinical outcomes between the bilateral group and no-drainage group, either.

Conclusion

These findings suggest closed suction drainage is not necessary after TKA with cemented posterior-stabilized prostheses.

Section snippets

Subjects

Of 71 patients who underwent primary simultaneous bilateral TKA using a cemented posterior stabilized prosthesis (NexGen LPS_Flex_Fixed; Zimmer, Warsaw, IN) from June 2007 to January 2009, we investigated 63 patients (126 knees) who had provided written informed consent for this institutional review board–approved study. Mean age at time of surgery was 74 years (range, 56-89). The patients comprised 52 females and 11 males with 53 cases of osteoarthritis and 10 cases of rheumatoid arthritis.

Short-Term Results

Hemoglobin drop on the day after surgery was significantly greater in the bilateral group (2.2 ± 1.2 g/dL, P = .038) and unilateral group (2.2 ± 0.9 g/dL, P = .045) compared with the no-drainage group (1.5 ± 0.8 g/dL). The number of cases with hemoglobin drop of more than 3 g/dL tended to be greater in the bilateral group (5 of 20, 25%, P = .050) compared with the no-drainage group (0 of 21, 0%), although the unilateral group showed no significant difference compared with the no-drainage group

Discussion

Primary clinical findings that emerged from this study were that patients with a no-drainage procedure showed less hemoglobin drop compared to those with bilateral drainage or unilateral drainage, and the number of cases with hemoglobin drop of more than 3 g/dL tended to be greater in the bilateral group compared with the no-drainage group, although the unilateral group showed no significant differences. We clamped the suction drain for 1 hour after surgery in the drainage knee, which is a

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Cited by (31)

Drainage in primary and revision hip and knee arthroplasty
2024, Orthopaedics and Traumatology: Surgery and Research
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.
V, expert opinion.
Mid-term clinical outcomes of a posterior stabilized total knee prosthesis for Japanese patients: A minimum follow-up of 5 years
2023, Journal of Orthopaedic Science
Citation Excerpt :
In all patients, the implants were fixed with cement (Simplex P Bone Cement, Stryker, Kalamazoo, MI, USA). No drains were used in any of the patients [16]. One ampule of tranexamic acid (10% Transamin, 10 mL, 1000 mg; Daiichi-Sankyo, Tokyo, Japan) was routinely administered into the joint using an 18-gauge needle after skin closure.
A high–flexion posterior-stabilized total knee prosthesis has been developed for the Asian population. The component design was based on computed tomography images of Japanese osteoarthritic knees. The femoral component is composed of zirconia ceramics, which exhibit low friction and high durability. The present study aimed to evaluate the mid-term clinical outcomes of this implant.
This study included 334 knees of 210 patients who underwent primary total knee arthroplasty with this implant at our hospital between October 2010 and December 2014. The patients comprised 28 men and 172 women with an average age of 73 years. The average follow-up period was 5.9 years, and the follow-up rate was 71.1%. Clinical outcomes were assessed using the Knee Society scoring system, 2011 Knee Society questionnaire, and Knee Injury and Osteoarthritis Outcome Score. Kaplan–Meier survivorship analysis was performed to determine the cumulative prosthesis survival rate.
In terms of clinical outcomes at the final follow-up, the average ranges of motion were −2.0 in extension and 126.7 in flexion. The Knee Society knee and function scores were 94.2% and 72.6%, respectively. With revision surgery or radiographic failure for any reason as the endpoint, the survival rates at 5 and 9 years were 98.2% and 95.5%, respectively. The most common reason for revision surgery or radiological failure was aseptic loosening.
Despite several revision cases mainly due to aseptic loosening, the present study found that this new high-flexion posterior-stabilized total knee arthroplasty prosthesis design showed comparable results for Asian populations with other PS prosthesis.
Level Ⅱ (Prospective cohort study).
Drainage in hip and knee replacement and revision implants
2023, Revue de Chirurgie Orthopedique et Traumatologique
Le drainage postopératoire après prothèse de hanche (PH) ou de genou (PG) a été longtemps une attitude systématique visant à éviter les complications en particulier l’hématome et l’infection. L’amélioration des pratiques, l’introduction de protocoles limitant le saignement et surtout les conclusions de nombreuses études ont remis en question ce comportement dogmatique. En effet, la littérature est relativement abondante en études sur les avantages et inconvénients du drainage, comparés à ceux de l’absence de drainage après PH ou PG de première intention. Les principaux critères d’étude sont le taux et le volume de transfusion, la perte sanguine totale et la variation du taux d’hémoglobine. Les critères cliniques sont la douleur, l’œdème, l’hématome postopératoire et plus rarement la fonction à court et moyen termes. Si l’on excepte quelques études qui montrent que la douleur et l’œdème peuvent être plus importants sans drainage, la littérature est concordante pour affirmer que non seulement le drainage ne procure aucun avantage mais qu’il favorise le saignement postopératoire. Les études sur le drainage des reprises sont moins nombreuses pour la hanche, et même rares pour le genou. L’intérêt du drainage ne semble pas démontré, celui-ci favorisant d’ailleurs le saignement postopératoire. Qu’il s’agisse des prothèses de première intention ou de révision, l’usage de l’acide tranexamique est recommandé, sauf contre-indication, quel qu’en soit le protocole d’administration. En revanche, il ne saurait être considéré comme l’arme exclusive et déterminante de l’abandon du drainage.
V, avis d’expert.
Non-use of intra-articular drain after anterior cruciate ligament reconstruction does not affect postoperative knee pain and muscle strength on early period
2023, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology
This study aimed to determine the effect of using an intra-articular drain after anterior cruciate ligament (ACL) reconstruction on early postoperative pain, range of motion (ROM), muscle strength, and complications.
Between 2017 and 2020, of the 200 consecutive patients who underwent anatomical single-bundle ACL reconstruction, 128 patients underwent primary ACL reconstruction with hamstring tendons and were evaluated for postoperative pain and muscle strength at 3 months postoperatively. Sixty-eight patients who received intra-articular drain before April 2019 were classified as group D and 60 patients without an intra-articular drain after ACL reconstruction after May 2019 were classified as group N. Patient background, operative time, postoperative pain, number of additional analgesics used, presence of intra-articular hematoma, ROM at 2, 4, and 12 weeks postoperatively, extensor and flexor muscle strength at 12 weeks postoperatively, and perioperative complications were compared between the two groups.
The postoperative pain at 4 h after surgery was significantly greater in group D than in group N although no significant difference was found in the pain felt in the immediate postoperative period and at 1 day and 2 days postoperatively and in the number of additional analgesics used. No significant difference in the postoperative ROM and muscle strength was noted between the two groups. Six patients with intra-articular hematomas in group D and four patients in group N needed puncture by 2 weeks postoperatively, and no significant difference was found between the two groups.
Postoperative pain was greater at 4 h postoperatively in group D. Furthermore, the intra-articular drain did not affect muscle strength, ROM, and complications on the early postoperative period. The usefulness of intra-articular drain after ACL reconstruction was considered low.
Level IV.
Closed suction drainages in Lower Limb Joint Arthroplasty: A level I evidence based meta-analysis
2022, Surgeon
Citation Excerpt :
Despite accurate haemostasis during surgery, hematomas after TJA may still occur, and their prevalence and size can be aggravated by the anticoagulation implemented following such procedures to prevent venous thromboembolism.7,8 Hematomas increase intrachamber pressure, thereby impairing vascularisation, wound healing and postoperative joint function.5,9 Additionally, hematomas are an optimal culture medium for bacteria.10,11
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).
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.
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).
There is no evidence to support the routine use of closed suction drainage in THA or TKA patients.
Level I, meta-analysis of randomized clinical trials.
Editorial Commentary: The Benefits of Tranexamic Acid May Outweigh Risks in Arthroscopy and Sports Medicine
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
Tranexamic acid (TXA) is an antifibrinolytic that lowers the risk of hemarthrosis-related surgical complications and has been extensively studied in orthopaedic trauma surgery, primary and revision total joint replacement, open shoulder reconstruction, and spine surgery. Its use, however, has been minimally studied in orthopaedic sport medicine, and, in particular, arthroscopic surgery. Despite being an inexpensive medication with a minimal side effect profile, there has been a paucity of Level I and II studies to support or refute its use in some of the most common procedures performed in orthopaedic surgery. TXA may be of small benefit in routine partial meniscectomy or routine, outpatient, anterior cruciate ligament reconstruction. However, although there are potential risks and side effects of TXA, the risk is very low, the cost is very low, and even a small benefit may justify its use.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.10.005.

: Authors received research support from Kyocera Medical, Japan.

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Primary ArthroplastyClosed Suction Drainage Is Not Necessary for Total Knee Arthroplasty: A Prospective Study on Simultaneous Bilateral Surgeries of a Mean Follow-Up of 5.5 Years

Abstract

Background

Methods

Results

Conclusion

Section snippets

Subjects

Short-Term Results

Discussion

J Arthroplasty

Suction drainage of orthopaedic wounds

J Bone Joint Surg Am

Measurement of joint effusion and haematoma formation by ultrasound in assessing the effectiveness of drains after total knee replacement: a prospective randomised study

J Bone Joint Surg Br

Drainage versus nondrainage in simultaneous bilateral total knee arthroplasties

Clin Orthop Relat Res

Closed suction drainage following knee arthroplasty. Effectiveness and risks

Clin Orthop Relat Res

The use of a closed-suction drain in total knee arthroplasty. A prospective, randomised study

J Bone Joint Surg Br

Comparison of complications in one-stage bilateral total knee arthroplasty with and without drainage

J Orthop Surg Res

The use of postoperative suction drainage in total knee arthroplasty: a systematic review

Int Orthop

Primary Arthroplasty
Closed Suction Drainage Is Not Necessary for Total Knee Arthroplasty: A Prospective Study on Simultaneous Bilateral Surgeries of a Mean Follow-Up of 5.5 Years