Outcome In Primary Cemented Total knee Arthroplasty With or Without Drain

1. Outcome In Primary Cemented Total
knee Arthroplasty With or Without
Drain
A prospective comparative study
Rafał Kęska, T Przemysław Paradowski, Dariusz Witoński
Department of Reconstructive Surgery and Arthroscopy of the Knee
Joint, Medical University of Łódź, Drewnowska , Poland.
INDIAN JOURNAL OF ORTHOPAEDICS
July 2014 | Vol. 48 | Issue 4
PRESENTER : Dr SAUMYA AGARWAL
Junior resident Dept of Orthopaedics J.N. Medical College and Dr.
Prabhakar Kore Hospital and MRC, Belgaum

2. TOTAL KNEE ARTHROPLASTY
is a surgical procedure to replace weight
bearing surfaces of knee joint to relieve pain
and disability.
It is most commonly performed for
osteoarthritis, rheumatoid arthritis .

3. INTRODUCTION
• Use of drain in Arthroplasty - a controversy.
• Suction drains are used to prevent hematoma which may
decrease joint mobility, reduce local tissue perfusion and
increase infection .
• However, there is paucity of available studies supporting
these traditional beliefs.

4. • Some authors state ; drainage evacuates fluid
only from limited area and does not prevent
infection if retrograde migration of bacteria
occurs.
• It can also impair early postoperative
rehabilitation.
• Recently a meta-anaylsis concluded -there is no
clear advantage of using suction drains, apart
from reduced need for change of dressing after
total knee arthroplasty (TKA).

6. MATERIAL AND METHODS
• 121 patients - recruited in 2 groups:
• Study group - 59 knees - did not use drain
• Control group - 62 knees, drain was inserted
• Inclusion criteria - knee arthritis impeding daily
activities.
• Exclusion criteria - significant bone loss that
required augmentation, previous thromboembolism
and intake of opioids preoperatively.

7. • Follow up rates at 6 and 12 months were
100% and 96%, respectively.
• Indication for TKA was osteoarthritis in 105
and rheumatoid arthritis in 16 subjects.

8. Operative Procedure
II Prosthesis systems: a) Genesis II (Smith and Nephew,
Memphis, TN, USA)
b) Search Evolution (Aesculap, Tuttlingen, Germany).
• 100 posterior stabilized prosthesis and 21 cruciate
retaining (CR) prosthesis, all stabilized with cement.
• Pneumatic tourniquet was applied to each patient and
was deflated after applying compression dressings at end
of surgery.
• Knee arthrotomy was performed through midline skin
incision and medial parapatellar capsular incision.

9. • In control group, drainage placed
intraarticularly.
• Removed within first 24 h postoperatively.
• Apart from spinal anesthesia (119 patients) and
general anesthesia (2 patients), 0.25%
bupivacaine solution with epinephrine was
injected intraoperatively in all patients.
• Skin was closed with intracutaneous continuous
sutures.

10. • Patients - monitored for 24 h, and intravenous
morphine pump infusion used to alleviate pain.
• All patients received low molecular weight
heparin, 12 h before surgery.
• compression stockings from 2nd postoperative
day.
• Antibiotics (cefuroxime 1.5 g and amikacin 0.5 g)
were administered intravenously 30 min before
surgery.
• Proper knee alignment was restored.

11. • Rehabilitation protocol remains same in both
groups.
• Patients stood up with walker on 1st
postoperative day and performed active flexion
up to 90°.
• Exercises with continuous passive motion were
commenced.
• From 2nd postoperative day, patients were
allowed to walk on crutches with full weight
bearing as tolerable.

12. Assessment
Primary outcome factors were pain intensity
and analgesic intake.
Pain intensity was measured with the help of a
visual analog scale.

13. Blood loss and transfusions
• In early postoperative period, Hb and hematocrit
(HCT) levels (preoperatively, then 8 h, 1 day and 2
days after surgery) were recorded.
• Study assessed the calculated blood loss (CBL),
hidden blood loss (HBL), total measured blood
loss (TMBL), transfusion rates.

14. Dressing reinforcement
During hospitalization all patients had dressings
covering the site of drain exit in control group .

15. Radiographic Examination
• All patients were clinically and radiologically
evaluated preoperatively, during hospitalization,
then at follow up, approximately 6 and 12
months after surgery.
• Radiographs in anteroposterior and lateral
view were performed using.
• Range of movements were assessed.

16. Questionnaires
Patients were assessed with questionnaires,
such as Knee Injury and Osteoarthritis Outcome
Survey (KOOS) and SF-36 Health Survey version
2 (SF-36 v2) (preoperatively and at follow up
examinations).

17. Statistics
Statistical analysis was performed using the
Student’s t-test, Chi-squared test , depending on
nature of variables.
Results are expressed as mean and standard
deviation (SD).
P <0.05 was considered to be significant.

18. RESULTS
Primary outcome factors
• On day of surgery, intake of analgesics was
comparable between both groups.
• From 1st postoperative day to discharge, lower
demand for opioids in study group compared
with control group was noted.
• Patients in study group required approximately 3
times less opioids than patients in control group.

19. Blood Loss and Transfusions
• Mean of blood collection in postoperative drain in
control group was 229 mL .
• In both groups, values of Hb and HCT decreased
during 1st 2 postoperative days .
• On 1st postoperative day, statistcally significant
reduction in Hb and HCT levels noted in control
group .
• No significant differences between both groups in
CBL, HBL and transfusion rates.

20. Dressing reinforcement
• In study group dressing changed at an average
4.5 times compared with 5.0 times in control
group.
• Minimum 3 dressings were done.
• 7 patients from control group required regular
dressing changes due to prolonged oozing from
wound after drain removal.

21. Range of Motion
All patients achieved full extension of operated
knee at discharge.
Knee flexion was comparable between both
groups .
Patients from both groups were discharged after
10 days.

22. COMPLICATIONS
6 Patients of study group:
4 wound related: prolonged wound healing ( 3)
prolonged healing of injured
scar ( 1)
2 general: gastrointestinal hemorrhage and
respiratory tract infection.

23. 11 patients of control group :
4 wound-related : Superficial wound infection
(1),
prolonged wound healing demanding
secondary suture (1),
persistent leg edema (2)
7 general: Cerebrovascular accident (1),
myocardial infarction (1), erysipelas (1),
respiratory tract infection (1), and urinary tract
infection (3).

24. Questionnaires
• Both groups were comparable in terms of
preoperative KOOS and SF-36 outcomes.
• Average functional outcome in both groups
improved during follow up.

25. Discussion
• Waugh and Stinchfield ; first authors who
advocated use of drains in modern orthopaedics.
• According to Chandratreya, 94% of British
Orthopedic Association members use drains after
TKA .
• Many available reports concentrate on blood loss
in presence of drain, while few assess its
influence on pain and analgesics requirement.
• In this study, significantly higher need for
opioids in patients with drain was observed,
which is distinct from prior reports.

26. Figure 1: Bar diagram showing intake of opioids per patient during hospitalization

27. • Disruption of continuity of skin and deeper
tissues along with drain causes peripheral
sensitization, resulting in decrease of
nociceptors threshold.
• Local inflammatory mediators increases and
secondarily induces central sensitization.
• This 2 level action causes pain hypersensivity
and persistent decrease in pain threshold at
the site of injured as well as surrounding
uninjured tissues.

28. • Confalonieri et al. evaluated patients after uni -
compartmental knee arthroplasty and noted lower
analgesic requirements on 1st postoperative day in
patients without drain.
• Yiannakopoulos and Kanellopoulos emphasized the
often neglected fact, that drain tube removal causes
pain and discomfort.
• Significant average reduction of Hb and HCT in drained
patients was noted on first postoperative day.
• Decrease of Hb concentration can lead to a higher
probability of blood transfusion.

29. • More changes of dressing were made in drained
patients.
• Until date, most authors assessing this issue
reported that in absence of drain need for dressing
reinforcement was higher or at least did not differ
significantly.
• Minnema et al. revealed that drainage is an
independent risk factor for infection after TKA.
• On other hand, Ovadia et al. evaluated 58 patients
following TKA and found significantly higher serous
wound discharge when drain was not used.

30. Limitations
• Number of subjects were small but
comparable to other studies.
• Difference in opinions on transfusion criteria
between orthopedic surgeons and
anesthetists .

31. CONCLUSION
Authors conclude that there is no rationale for
use of drain after primary TKA.
There are benefits when drain is not used
lower opioid intake,
lower blood loss on 1st postoperative day and
lower need for dressing reinforcement during
hospitalization.