Evaluation of Drain Need in Total Knee Replacement Surgery

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Journal of MedVerse Research & Practice

nurexus.com

Dr. Vellu¹, Dr. Pavithra

Postgraduate, Professor & HOD

Department of Orthopaedics

Meenakshi Medical College Hospital and Research Institute, Enathur, Kanchipuram.

Email ID: drvellu@yahoo.com

Submission Date: 26.05.2023

Accepted Date: 21.06.2023

Published Date: 30.06.2023

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Introduction: Since its introduction, total knee replacement procedures have incorporated the use of a tourniquet.

However, this practice is associated with various complications, including limb ischemia, blood vessel

calcification, and nerve palsy, along with increased postoperative drainage. To address the risk of hematoma

formation and excessive fluid buildup in the knee joint, suction drains were traditionally inserted. Despite this

precaution, the primary concern with drain usage remains an elevated risk of infection.

Materials & Methods: This study documents 100 instances of knee replacement surgery conducted without the

use of tourniquets or drains. In cases of single knee replacements, blood loss averaged around 300 ml, eliminating

the need for blood transfusions or drain insertion as a crepe bandage was utilized to create a tamponade effect.

The absence of a tourniquet prevented any associated complications. Patients experienced excellent post-

operative recovery, and the intra-operative antibiotic prophylaxis proved effective.

Results: On the first day after surgery, patients were encouraged to mobilize according to their pain tolerance.

They noted reduced pain levels and enhanced functionality. Most patients described tolerable post-surgical

discomfort and increased joint mobility. Additionally, all study participants recovered without complications or

adverse events.

Conclusions: The use of a Romovac suction drain is not essential for total knee replacement procedures.

Keywords: Evaluation, Drain, Total Knee Replacement Surgery

Introduction

The introduction of total knee replacement surgery in the early 1970s marked a significant

advancement in orthopedic procedures, with the tourniquet being routinely employed to create a

bloodless surgical field and improve visibility for the surgeon [1]. Despite its benefits, the use of a

tourniquet has been linked to several adverse effects, including ischemic limb injury, venous

thromboembolism, calcified vessels, and nerve palsy. Additionally, patients undergoing surgeries with

tourniquets often experience increased postoperative drainage and discomfort [2][3]. Severe knee

arthritis is commonly treated through total knee arthroplasty (TKA), a surgical intervention designed to

alleviate pain and restore joint function [4]. Although TKA has proven to be an effective procedure

with favorable long-term outcomes, there remains considerable debate regarding the use of drains

during the operation [5][6].

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This controversy persists even with the advent of modern surgical techniques that aim to minimize

blood loss, reduce complications, and promote faster recovery [7]. The use of drains in TKA is

associated with potential risks, such as an increased chance of retrograde infection, greater

postoperative blood loss, delayed rehabilitation, and, in some cases, accidental drain dislocation [8][9].

If a drain breaks during or after surgery, it may require wound revision for removal, posing an

additional surgical burden. Although the primary purpose of drains is to prevent hematoma formation

and remove excess fluid through suction at the surgical site, their use can inadvertently elevate the risk

of postoperative infections [10,11].

Materials & Methods

This study documents 100 cases of total knee replacement surgeries conducted without tourniquet use.

During the surgical incision and subsequent bleeding, blood vessels are sealed through cauterization,

enabling the completion of the procedure without inflating a tourniquet or using a drain. A crepe

bandage is applied post-dressing, creating a tamponade effect that minimizes blood accumulation and

serves as an alternative to a drain. The typical blood loss for a single knee replacement is around 300 ml,

with no need for blood transfusions. By eliminating tourniquet-related complications such as venous

thromboembolism and fat necrosis, postoperative recovery is enhanced, and intraoperative antibiotic

prophylaxis is effective.

The study data was input into Microsoft Excel and variables were coded. Analysis was conducted using

SPSS software (Version 27, IBM), employing descriptive statistics. Associations between categorical

variables were examined. A statistical test was used to compare treatment group outcomes and test the

hypothesis, with a P value below 0.5 considered significant.

Results

This study included a total of 100 participants. On the first day after their operation, patients were

encouraged to become mobile based on their individual comfort levels. Most participants experienced

tolerable post-surgery pain and improved joint mobility. Additionally, all study subjects recovered

successfully without any complications or adverse events.

Table 1: Age distribution among the study participants

Age

Percentage (%)

< 40 years

41 – 60 years

>60 years

Total

100

The age distribution of the study participants revealed that 21% were below 40 years of age, 34% were

between 41 and 60 years, and 45% were above 60 years. This indicates that the majority of the

participants, accounting for 79%, were over 40 years old, with the largest proportion belonging to the

age group above 60 years. This trend suggests that the study population was predominantly composed of

middle-aged and elderly individuals, reflecting a higher prevalence of the studied condition or surgical

intervention among older adults.

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Chart 1: Gender distribution among the study participants

Among the study participants, the gender distribution was 60% female and 40% males who underwent

the total knee replacement.

Table 2: Postoperative mobilization on day 1

Postoperative mobilization D1

Percentage (%)

Yes

Total

100

A study examining the mobility of 100 patients on the first day after surgery revealed that 80% were

able to move around, while 20% remained immobile. This data suggests that a substantial proportion of

the group achieved early mobilization post-operation, which is considered a favorable outcome. The

ability of four-fifths of the patients to become mobile so soon after their procedure indicates a positive

trend in post-surgical recovery.

Table 3: Details on Pain tolerance among the study participants

Pain tolerance

Percentage (%)

Mild pain

Moderate pain

Severe pain

Total

100

Of the total sample, 40 individuals (40%) experience mild pain, making this the second most common

category. The majority, 45 individuals (45%), report moderate pain, indicating that half of the sample

population has a moderate pain tolerance. The smallest group, consisting of 15 individuals (15%),

experiences severe pain.

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Chart 2: Details on the increased range of motion

Among the study patients, 80% patients had an increased range of motion

Table 4: Details of Complications among the study Participants

Complication

Percentage (%)

Present

Absent

100

The study findings indicate that complications were absent among all 100 participants. This is

demonstrated by the complete lack of cases in the "Present" category for complications, with a 0%

frequency and percentage. Conversely, the entire cohort of 100 individuals (100%) fell into the "Absent"

category, signifying no complications whatsoever. This clear-cut distribution demonstrates a total lack

of complications within this particular sample, implying that every patient in the group recovered

without experiencing any negative outcomes.

Discussion

According to Jeon et al. [11], the practice of using closed suction drainage is becoming increasingly

controversial among surgeons worldwide, leading to a gradual reduction in its routine application. The

primary justification for drain usage has traditionally been concern over hematoma formation and

subsequent infection. Surgeons historically believed that wound drainage prevented the accumulation

of blood in postoperative wound compartments, thereby reducing hematoma formation. Hematomas

are considered an ideal medium for bacterial proliferation due to low concentrations of opsonic

proteins, which impair phagocytic activity and delay wound healing. Additionally, it has been

theorized that the use of drains prevents the tamponade effect, which is essential for obliterating dead

space within the surgical wound.

Various techniques have been employed to assess postoperative hematoma formation, including

measurement of dressing weight, ultrasonographic evaluation of the wound, and single-photon

emission computed tomography. However, none of these methods have conclusively demonstrated a

significant role for drains in preventing hematoma formation. Evidence suggests that a certain degree

of hematoma persists irrespective of drain usage. Consequently, there appears to be no strong

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physiological or clinical rationale supporting the routine use of drains solely for hematoma prevention,

as also suggested by Crevoisier et al. [9].

Postoperative infection remains a major concern following total knee arthroplasty and requires prompt

management. In the present study, one patient in each group developed an early superficial infection,

both of which were successfully treated with oral antibiotics. A recent meta-analysis reported infection

rates of 0.5% in patients with drains and 1.2% in those without drains, findings comparable to a

randomized trial that reported superficial infection rates of 2.9% in drained and 4.8% in non-drained

groups. However, similar to observations by Drinkwater et al. [10] and Crevoisier et al. [9], our study

did not demonstrate any statistically significant difference in superficial wound infection rates between

the two groups. Notably, no cases of deep wound infection were observed in either group.

Several studies have reported a statistically significant association between the absence of drains and

increased rates of persistent wound discharge and ecchymosis. In the present study, although a greater

number of patients in the experimental (non-drain) group required dressing changes within the first 24

hours and exhibited ecchymosis compared to the control group, these differences were not statistically

significant. One patient (1.69%) in the experimental group experienced persistent wound discharge

lasting until the seventh postoperative day. Initially, the discharge was bloody and fluid in nature,

likely secondary to hematoma formation, and became serous after 3–4 days. In contrast, two patients

(3.2%) in the control group experienced serous discharge from the drain insertion site, persisting until

the eighth and tenth postoperative days, respectively. Similar findings have been reported by

Stucinskas et al. [5] and Tsumara et al. [6]. It is noteworthy that prolonged wound discharge or

drainage from insertion sites contributes to increased patient discomfort, prolonged hospital stay, and

higher overall treatment costs.

Conclusion

Generally, a suction drain for removal is not necessary during total knee replacement procedures.

Appreciation: We express our gratitude to all study participants for their involvement and complete

cooperation. We also recognize the faculty members of the Orthopedics Department for their

encouragement and support.

Financial backing and sponsorship: None

Conflict of Interest: Nil

Reference

1. Gascon P, Zoumbos NC, Young NS. Immunologic abnormalities in patients receiving multiple blood

transfusions. Ann Intern Med. 1984;100:173–7.

2. Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion-transmitted viral

infections. The retrovirus epidemiology donor study. N Engl J Med. 1996;334:1685–90.

doi:10.1056/NEJM199606273342601.

3. Charoencholvanich K, Siriwattanasakul P. Tranexamic acid reduces blood loss and blood transfusion

after TKA: a prospective randomized controlled trial. Clin Orthop Relat Res. 2011;469:2874–80.

doi:10.1007/s11999-011-1874-2.

4. Orpen NM, Little C, Walker G, Crawfurd EJ. Tranexamic acid reduces early post-operative blood loss

after total knee arthroplasty: a prospective randomised controlled trial of 29 patients. Knee.

2006;13:106–10. doi:10.1016/j.knee.2005.11.001.

5. Stucinskas J, Tarasevicius S, Cebatorius A, Robertsson O, Smailys A, Wingstrand H. Conventional

drainage versus four hour clamping drainage after total knee arthroplasty in severe osteoarthritis: a

prospective, randomised trial. Int Orthop. 2009;33:1275–8. doi:10.1007/s00264-008-0662-4.

Page 6

6. Tsumara N, Yoshiya S, Chin T, Shiba R, Kohso K, Doita M. A prospective comparison of clamping the

drain or post-operative salvage of blood in reducing blood loss after total knee arthroplasty. J Bone Joint

Surg Br. 2006;88:49–53. doi:10.1302/0301-620X.88B1.16653.

7. Banerjee S, Kapadia BH, Issa K, et al. Postoperative blood loss prevention in total knee arthroplasty. J

Knee Surg. 2013;26:395–400

8. Molloy DO, Archbold HA, Ogonda L, McConway J, Wilson RK, Beverland DE. Comparison of topical

fibrin spray and tranexamic acid on blood loss after total knee replacement: a prospective, randomised

controlled trial. J Bone Joint Surg Br. 2007;89:306–9. doi:10.1302/0301-620X.89B3.17565.

9. Crevoisier XM, Reber P, Noesberger B. Is suction drainage necessary after total joint arthroplasty? A

prospective study. Arch Orthop Trauma Surg. 1998;117:121–4.

10. Drinkwater CJ, Neil MJ. Optimal timing of wound drain removal following total joint arthroplasty. J

Arthroplasty. 1995;10:185–9.

11. Jeon, Y.S., Park, J.S. & Kim, M.K. Optimal release timing of temporary drain clamping after total knee

arthroplasty. J Orthop Surg Res 12, 47 (2017).