|Year : 2023 | Volume
| Issue : 1 | Page : 147-152
Primary total knee replacement without drain: A good and safe practice to inculcate
Sunil Kumar Thakur1, Suresh Kumar Choudhary1, Mukesh Kumar2, Ravishekar N Hiremath3, KP Jaidev1, Rohini VK4, Monika Sharma4, Sisir Kumar Raut5, Hardewa Ram5
1 Department of Orthopedics, AFMS, New Delhi, India
2 Department of Anaesthesia, Punjab Institute of Medical Sciences, Jalandhar, Punjab, India
3 Department of Community Medicine, AFMS, New Delhi, India
4 Department of Nursing, AFMS, New Delhi, India
5 Department of Physiotherapy, AFMS, New Delhi, India
|Date of Submission||06-May-2022|
|Date of Acceptance||14-Jun-2022|
|Date of Web Publication||21-Jan-2023|
Dr. Suresh Kumar Choudhary
Department of Orthopedics, AFMS, New Delhi
Source of Support: None, Conflict of Interest: None
BACKGROUND: The use of drain in primary total knee replacement (TKR) started with the belief that it prevents hematoma formation and infection. The fear of infection made this practice an essential step that enjoyed a long journey. However, in recent years, majority of evidence-based studies have not only been failed to provide substantial benefits of the drain but also have proven this a counterproductive step.
OBJECTIVE: The purpose of our study is to assess the outcome of performing primary TKR without the use of a drain.
METHODOLOGY: After meeting inclusion and exclusion criteria, a prospective observational study was conducted on 186 patients (191 knees) who underwent primary cemented total knee arthroplasty without the use of drain from September 2018 to March 2020 and were followed up for one year. Surgery was performed under tourniquet, bleeders were electro cauterized, and injection tranexamic acid was used to control bleeding. A good preoperative screening for foci of infection, tight glycemic control for diabetics, part preparation, prophylactic antibiotics, and gentle handling of soft tissue was ensured to control infection. Deep vein thrombosis prophylaxis was instituted after risk stratification. Ambulation and physiotherapy were started as per protocol. The clinical parameters such as pain score and range of motion (ROM) were measured by a physiotherapist. Postoperative hemoglobin (Post Op Hb) and requirement of dressing change/reinforcement were monitored by the ward nurse. Aspiration of the knee if required was done by the treating surgeon.
RESULTS: Post Op Hb drop was insignificant and none of the patients required blood transfusion. Tense arthrocoele, requiring rescue analgesia, were found in 5(2.6%) patients which responded well with knee aspiration. There was significant improvement (P < 00001) in pain score and the targeted ROM were achieved in 3 weeks' postoperative. Although ecchymosis was a common finding (20.4%), it did not require special attention. Blisters developed in six patients which were managed by antibiotic-impregnated paraffin dressing. Wound healing was not delayed in any patient. None of the patients acquired infection.
CONCLUSION: Performing primary TKR without drain is a safe practice to exercise as it neither increases the risk of infection nor poses a significant threat of blood loss and blood transfusion. The presence of arthrocoele in postoperative period does not compromise short term clinical and functional outcomes. The incidence of developing tense hemarthrosis is very less and if aspirated, relieves patient's discomfort and aborts the surgeon's fear of infection. Moreover, not only the cost of drain and utilization of workforce is saved but the question of caring for the drain and its complications also ends.
Keywords: Complications, hematoma, infection, no drain, primary total knee replacement, tourniquet, tranexamic acid
|How to cite this article:|
Thakur SK, Choudhary SK, Kumar M, Hiremath RN, Jaidev K P, Rohini VK, Sharma M, Raut SK, Ram H. Primary total knee replacement without drain: A good and safe practice to inculcate. Indian J Health Sci Biomed Res 2023;16:147-52
|How to cite this URL:|
Thakur SK, Choudhary SK, Kumar M, Hiremath RN, Jaidev K P, Rohini VK, Sharma M, Raut SK, Ram H. Primary total knee replacement without drain: A good and safe practice to inculcate. Indian J Health Sci Biomed Res [serial online] 2023 [cited 2023 Jan 28];16:147-52. Available from: https://www.ijournalhs.org/text.asp?2023/16/1/147/368321
| Introduction|| |
The incidence of knee arthritis among Indians is more than double of China and surprisingly up to 15 times higher than that found in Western nations. Total knee replacement (TKR) has long been a globally accepted mainstay of treatment in advanced knee osteoarthritis when nonsurgical treatments are exhausted. The high success rate of this procedure is evident by the exponential rise in the numbers of TKR performed these days. The risk of bleeding and infection is a key concern and cannot be hidden under the carpet of long-lasting clinical and functional improvements following TKR. Significant bleeding whether overt or concealed in the subcutaneous and intra-articular space can lead to higher transfusion rates with their potential complications and prolonged hospital stay. To reduce and control the bleeding, various physical and chemical methods have been suggested, including the use of a tourniquet, coagulation diathermy, knee position, infiltration with vasoconstrictor solutions, tranexamic acid, temporary drain clamping, and the use of a fibrin agent. Among these options, the use of drain has been highly debated.
Drains have been used in medical practice since the age of Hippocrates and its use in orthopedic surgery was initiated by Waugh and Stinchfield. The fear of infection among surgeons had been grounded to such a level that the utility of drain in primary TKR used to be a routine and the same practice can be seen in few among us nowadays also. The benefits expected from its use could not be tasted uniformly as many evidence-based studies have come to light with equivocal results over the last few decades. Furthermore, the counterproductive results on bleeding, hematoma formation, rate of infection, and clinico-functional outcome have questioned the prophylactic use of drain in primary TKR.
A review of the literature suggests that drainage helps to prevent hematoma and reduces pain and edema,,, infection,, wound dehiscence, requirement for reinforcement of dressings, and occurrence of bruising,. Those who do not use drainage argue that it can serve as a portal for bacteria and increase the infection rate, postoperative blood loss, need for blood transfusion,,,, and total costs. It has also been realized over a period of time that draining of hematoma has its own benefits and drawbacks so a way of middle path existed in the form of clamping of the drain,, reduction in the drainage duration, and suction pressure and auto-transfusion of drained blood to tackle perioperative blood loss and infection. Controversy does not end here as there are studies that speaks different tongue that there is no clear benefit or drawback to the use of closed drainage after primary total knee arthroplasty.,,,,,,
Hence, in this ambience of unending debate, it is wise to introspect and shift our focus from mere bloodletting to some precautionary measures which prevent hematoma formation and its consequences and thereby cancel the need for a conduit to egress the blood. In view of the above, we conducted the study to assess the outcome of performing primary TKR without the use of a drain.
| Methodology|| |
A prospective observational study was carried out at one of the tertiary care centers in north India, between September 2018 and March 2020 on 186 consecutive patients (191 knees) who underwent primary cemented total knee arthroplasty without the use of a drain. After meeting inclusion and exclusion criteria [Table 1], prior written informed consent was obtained from each patient for the proposed study and postoperative rehabilitation. Each subject was assessed clinically as well as functionally at postoperative day 1, day 7, and day 21 and followed up for 1 year. Data was collected using pretested institutional proforma which consisted of detailed history about knee pain, associated swelling, deformity, difficulty in activities of daily living and ambulatory status. History of any inflammatory arthritis, bony injury to the lower limb, and other associated comorbidities were also enquired. Both the knees were examined for any scar, swelling, fixed deformities, lateral collateral ligament laxity, knee subluxation, distal neurovascular status, and varicose vein. Radiographs of both knees standing AP, lateral, and skyline views were obtained. Patients were explained about operative procedures, possible risks, and postoperative rehabilitation plans by the operating surgeon. Written and verbal consents for anesthesia and surgery, for blood transfusion, and for cemented TKR were obtained separately. Risk stratification for deep vein thrombosis (DVT) prophylaxis was done.
Surgeries were performed in the same modular operation theatre with laminar air flow, by two orthopedic surgeons, well trained in arthroplasty with equal years of experience with standard protocols. The choice of SA/CSEA was left on to the anesthetist. cefazolin 2 g, amikacin 500 mg, and injection tranexamic acid 500 mg given 20 min before incision. The tourniquet was inflated after exsanguination of the lower limb with a sterile crepe bandage. Surgical exposure and technique were identical in all patients. The midline longitudinal incision and standard medial parapatellar approach with patellar eversion were employed. Patelloplasty was done in all cases with cauterization. Soft tissue release was carried out as per requirement. Bleeders were electro-cauterized judiciously during the procedure. Implants (Zimmer/Smith and Nephew/DePuy/DJO) were cemented using Simplex/Palacos cement with an antibiotic. Knee flexed to 90° and closed in layers without drain, injection tranexamic 500 mg injected into the knee, and compression dressing applied. Tourniquet was released and time was noted. Knee brace was applied, and the patient was shifted to the joint replacement ward.
Both limbs were placed in Bohler-Braun position and ensured neutral rotation to avoid pressure over the fibular head. Cold packs were placed around the surgical sites. Postoperative pain was taken care of by tablet paracetamol (PCM) 1 g three times a day (TDS) and capsule pregabalin 75 mg HS. Injection diclofenac 75 mg IM/tramadol 50 mg IM/PCM 1 g IV was kept as rescue pain relief. Injection dexamethasone 8 mg and Injection ondansetron 4 mg at 0600 h morning given for 48 h. Injection tranexamic acid 500 mg IV TDS given for 48 h. Injection cefuroxime 1.5 g/cefazolin 2 g IV BD was given for 3 days. DVT prophylaxis was initiated after risk stratification. Injection low-molecular-weight heparin (LMWH) 40 IU (<60 kg)/60 IU (>60 kg) was started after 24 h postsurgery and continued for 1 week and thereafter tablet Aspirin 75 mg (<60 Kg)/150 mg (>60 Kg) was advised for 1 month. Weight-bearing ambulation with support and physiotherapy was started after 24 h as per protocol. The dressing was reinforced in case of soakage and was changed in case of oozing or the patient developing pain out of proportion otherwise routinely after 72 h. Staples were removed at 3 weeks.
The pain was measured using visual analog scale (VAS) scale and rescue pain relief was started for any score >6 and documented. Range of motion (ROM) was measured using a goniometer. Postoperative hemoglobin (Post Op Hb) was investigated and blood transfusion was planned for any value <9 g/dl. The number of dressing changed within 48 h was counted. Knee effusion and the need for aspiration were documented. Other complications such as blisters, ecchymosis, edema, oozing, infection, and DVT were also searched for. As per our protocol, we discharged the patients after suture removal. However, patients requiring any active intervention after the 7th postoperative day for surgical consequences were noted under prolonged hospital stay. All the demographic data, clinical data, and complications were tabulated and analyzed. Ethical Clearance was obtained from Hospital Institutional Ethical Committee with Ref no EC/ORTHO/JRC/INST/2018/01 dated 03 Sep 2018.
| Results|| |
The mean surgical duration was 98 min for B/L and 64.8 min for U/L cases. The mean tourniquet duration was 65.84 min. The demographic details such as age, gender, BMI, pre and post Op Hb level, and laterality are shown in [Table 2].
The pre op means VAS score was 7.76 which became 3.86, 0.85, and 0.25 on postoperative day 1, day 7, and day 21, respectively, which was significant. The mean pre op ROM was 98.04 which became 44.09, 79.15, and 107.57 on postoperative day 1, day 7, and day 21 respectively, which was also significant [Table 2]. ROM in patients with tense hematoma was although lower than the desired value on postoperative day 1, the targeted ROM was indifferent in all patients at 3 weeks' postoperative. The postoperative complications are summarized in [Table 3]. Ecchymosis was the most common finding (20.43%) in the postoperative period. Oozing was encountered in 3.66% of cases which were managed by a change of dressing. Blisters were noted in 4.84% of cases and responded with antibiotic-impregnated paraffin dressing. 2.69% of patients developed tense hemarthrosis which were aspirated. Although a minimal amount of hematoma was found in most of the cases, however, none of the patients developed an infection. The mean drop in hemoglobin was 1.46 g dl in U/L cases and 3.32 g/dl in B/L cases, which is insignificant statistically and none of them required blood transfusion. No case of DVT was reported.
| Discussion|| |
Swelling and hematoma are known findings in post-TKR patients. Various intraoperative and postoperative methods (viz., the use of tourniquet, coagulation diathermy, tranexamic acid, temporary drain clamping) have been suggested to curb hematoma formation, perioperative blood loss, and hence the requirement of blood transfusions. Among them, the use of drains has been highly debated and the same can be vividly observed in the variability among surgeons for its parameters such as the number of the drain, location (superficial or deep), intermittent clamping, rate of drainage, gravity or suction drainage, the pressure of drain, and time of its removal. The studies which second the notion that drain prevents hematoma formation, have been questioned by many as there is always some amount of hematoma left unevacuated even if the drain is being used. The possible explanation could be the loss of tamponade effect which is necessary to stop bleeding. As a result, patients bleed more and more into the drain, requiring transfusions.,,
Minimal knee effusion was encountered in most of the patients in our study and was resolved with the application of ice and compression bandage. Five patients developed tense hemarthrosis with discomfort in terms of pain during ROM, which were aspirated with a wide bore (16 gauge) needle on a post of day 3. Dressings were required to be reinforced in 11 pts and changed within 48 h in 7 (3.66%) patients. The mean drop in hemoglobin in postoperative day 3 as compared to preoperative value was 1.46 gmdl in U/L cases and 3.32 g/dl in B/L cases, which is insignificant statistically. None of the patients required a blood transfusion. We are of the opinion that, apart from the body's own most effective procurative coagulation system, a higher level of preoperative hemoglobin, use of tourniquet, judicious use of electro-cautery, local and systemic use of tranexamic acid, and tight closure of subcutaneous tissue have reduced the amount of hematoma and blood loss and canceled any need for blood transfusion. A tense hematoma causing discomfort to the patient in terms of painful and limited ROM and requiring more analgesia should be aspirated.
Infection is one of the catastrophic complications post TKR, although rare but fears every surgeon and demands urgent attention. Speculations about draining the wound to prevent hematoma formation and abort any incidence of infection sounds healthy, but the literature that support these finding, are weak and still struggling to find its place in the era of evidence-based practice. Wang et al., Si et al., Sharma et al., Liu et al. and Niskanen et al. have concluded in their studies that there are no significant differences in wound complications between the drain and no-drain groups after routine primary TKA whereas Willemen et al. and Märdian et al. concluded that CSD may be a source of retrograde infection and its risk increases if the indwelling time exceeds 24 h.
In our study, 38 pts (20.43%) developed ecchymosis which subsided with ice application within a week. 09 pts developed blisters for which dermatological consultation was sought for. Blisters and rashes in 3 pts were because of adhesive dressing (localized under and around the dressing), which responded well with anti-allergic and change of dressing to dry gauge piece dressing. The remaining 06 pts were managed with antibiotic-impregnated paraffin gauge dressing. These six patients also had tense hemarthrosis which was aspirated on postoperative day 3. Tight compression dressing or tense knee effusion might have resulted in blisters in these patients. Oozing of blood was found in 7 cases, which was managed by the ice pack, knee brace application and restriction of movement, and reducing the dose of LMWH for 2–3 days. The cause of oozing could be high intra-articular pressure, leakage of tight closure of the wound, or the use of anticoagulants. Wound healing was not delayed in any patient. None of the patients acquired deep infection. We believe that a good preoperative screening for foci of infection, tight glycemic control for diabetics, part preparation, and gentle handling of soft tissue might have restricted any infection to settle in spite of the presence of hematoma in postoperative period. Swelling of the index leg was noticed in 26 pts (13.98%), which subsided with limb elevation, ice application, and with ankle exercises. None of the pts developed DVT.
There was significant improvement in pain on the VAS scale in postoperative as compared to pre operative VAS score. However, 29 patients (15.18%) required rescue analgesia out of which 05 had tense hemarthrosis and 09 had blisters. Hence, hematoma cannot be blamed solely for such pain, but the use of tourniquet and electro-cautery should also be questioned for. Moreover, unlike others, Pts with tense hematoma responded well after aspiration and did not require further rescue pain relief. ROM in post of day 1 was lower than the desired value in patients with tense hematoma as compared to others, but no significant difference was noted on day 7 and day 21. This finding was in concordance with the literature. Although the ROM at the knee was lower at postoperative day 1, the targeted ROM was achieved in 3 weeks' postoperative and had no implication in long term. None of the patients developed arthrofibrosis.
Strengths and limitations
It could have been a better study if we would have a direct comparison group. Further follow-up is required to assess the long-term results such as chronic deep joint infection and implant loosening.
| Conclusion|| |
Performing primary TKR without drain is a safe practice to inculcate as it neither increases the risk of infection nor poses a significant threat of blood loss and blood transfusion. The presence of minimal knee effusion is common in postoperative period but it neither demands special attention nor compromises short-term clinical and functional outcomes. The incidence of developing tense hemarthrosis is very less and if aspirated, relieves patients' discomfort and aborts the surgeon's fear of infection. It is further added that a higher level of preoperative Hemoglobin, use of tourniquet, judicious use of electro-cautery, local and systemic use of tranexamic acid, and tight closure of subcutaneous tissue is of capital importance in reducing the amount of hematoma and blood loss, and thus canceling any need for blood transfusion. Needless to say, a good preoperative screening for foci of infection, tight glycemic control for diabetics, part preparation, prophylactic use of antibiotics, and gentle handling of soft tissue is of paramount significance to shut the door for infection. However, future research is required to support the objective set forth in this article and assess its long-term effect.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]