Figure 2 - available via license: Creative Commons Attribution 4.0 International
Content may be subject to copyright.
Forest plot for complication rates with erythema and ecchymosis of bilateral TKA with and without drainage.
Source publication
PurposeThe aim of this meta-analysis was to compare the complication rates of one-stage bilateral total knee arthroplasty (TKA) with and without drainage in order to identify whether there was no clinical significance and the value of drainage.Methods
Randomized controlled trials (RCTs) based on bilateral TKA with and without drainage were identifi...
Similar publications
Background: Endovenous Radiofrequency Ablation (RFA) is gradually gaining widespread acceptance as a minimally invasive modality for treatment of varicose veins (VV). The objective of this study was to evaluate the efficacy based on Venous Doppler and Venous Clinical Severity Score (VCSS) and the safety of radiofrequency ablation for varicose veins...
Background: Wound complications and pain are major causes of morbidity after cesarean section (CS). Although medications are safe for use by mothers after CS, many females prefer non-pharmaceutical methods. An abdominal binder is a complementary therapy, commonly used post-major abdominal surgery. Objectives: There is limited evidence about the eff...
Citations
... In contrast, Erne et al. demonstrated an increased postoperative blood loss using suction drainage in primary TKA [19]. Nevertheless, several studies did not report significant outcome differences between a drainage and non-drainage approach [7,20,21]. Maniar et al. demonstrated how drainage employment, combined with TXA administration, does not influence the total blood loss and the average of swelling, range of motion, infection and deep vein thrombosis [22]. Our experience displays how suction drainage does not influence the general hemoglobin trend, knee swelling or blood transfusions needs both in TKA and UKA management (Tables 2 and 3). ...
Background
Suction drainage is commonly applied after total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) to reduce hematoma, swelling and to favor surgical wound healing. However, its efficacy remains controversial; thus, the purpose of this study is to evaluate drainage efficiency in the management of postoperative bleeding in TKA and UKA.
Methods
The cohort comprised 134 clinical records of patients affected by knee osteoarthritis (OA) who underwent either TKA or UKA. All the patients were subdivided into 2 groups: the first one with drainage and the second one without drainage (respectively 61 and 73 patients). For each group, hemoglobin levels in the preoperative, first, second and third postoperative day were collected. Postoperative complications such as swelling, bleeding from the surgical wound or the need for blood transfusion, were also recorded.
Results
Our results did not show any significant difference of hemoglobin levels in the first ( p = 0.715), second ( p = 0.203) and third post-operative day ( p = 0.467) between the two groups. Moreover, no significant correlation between knee swelling or transfusion rate and the drainage was observed ( p = 0.703 and p = 0.662 respectively). Besides, a significant correlation was found between bleeding from the surgical wound and the absence of drainage ( p = 0.006).
Conclusions
The study demonstrates how the routine use of suction drainage does not provide substantial benefits in the postoperative blood loss management after TKA or UKA.
Trial registration
ClinicalTrials.gov NCT04508101 , 09/08/2020, Retrospectively registered
Level of evidence
III
... Evidence-based medicine has obtained recognition and popularity with the purpose to provide best selection in clinical practice since last decade [5]. Although numerous meta-analyses or systematic reviews have been published to evaluate the necessity and benefit of the usage of drainage after primary total hip or knee arthroplasty [6][7][8][9][10][11][12][13][14][15][16][17], the pooled conclusions were still discordant and could not provide more potent evidence. Thus, it is difficult for clinical professionals to determine whether to use drainage after total hip or knee arthroplasty based on the conflicting conclusions of these systematic reviews. ...
... After duplicates were removed following the search strategy, a total of 132 titles and abstracts were preliminarily identified, of which 12 of the issued systematic reviews [6][7][8][9][10][11][12][13][14][15][16][17] met the inclusive criteria ultimately (Fig. 1). Table 1 showed the characteristics of included studies. ...
... Table 1 showed the characteristics of included studies. The number of primary original studies varied from 3 in the study published in 2015 [13] to 20 that published in 2013 [10] (Supplementary Table 1). All included systematic reviews conducted qualitatively data synthesis. ...
Background
Numerous systematic reviews investigating the benefit of the usage of drainage after primary total hip or knee arthroplasty have been published with divergent conclusions. We aim to determine the best available evidence and consider risk of bias of these articles and to provide recommendations.
Methods
A systematic search of systematic reviews published through to May 2020 was performed in MEDLINE, EMBASE and Cochrane library. Methodological quality, risk of bias and best evidence choice of included articles were evaluated by AMSTAR instrument, ROBIS tool and Jadad decision algorithm, respectively. We selected systematic reviews with high methodological quality and low risk of bias ultimately as best evidence.
Results
Twelve meta-analyses were included lastly. According to the ROBIS tool, seven of the included systematic reviews were with low risk of bias and five with high risk of bias. The Jadad decision algorithm suggested that two reviews conducted by Zan et al. for hip and Si et al. et al. for knee were selected as the best evidence, with highest AMSTAR score and low risk of bias.
Conclusions
Ten systematic reviews were included as low-quality with only two high-quality studies. Based on the current available evidence, we have insufficient confidence to draw conclusion that whether to use closed suction drainage for both total knee and hip arthroplasty. To verify the necessity and benefit of using closed suction drainage after primary total knee and hip arthroplasty, and develop exact recommendations, further studies are still required.
... 5,6 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. ...
... 12,13 However, they have been extensively criticized and their use in primary elective TJA has declined. 7,8,14 Drains reduce circulating blood volume, causing increased blood loss by reducing the tamponade effect, which tends to increase the need for blood transfusions. 15,16 Moreover, constant attention from healthcare personnel to monitor blood loss is required. ...
Introduction:
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).
Methods:
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.
Results:
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).
Conclusion:
There is no evidence to support the routine use of closed suction drainage in THA or TKA patients.
Level of evidence:
Level I, meta-analysis of randomized clinical trials.
... Our study performed non-drainage TKA because omitting closed suction drainage reduces the importance of monitoring fluid volume and becomes an acceptable procedure in modern TKA. The published systematic reviews showed no additional benefits of using a suction drain after TKA on patient outcomes and postoperative complications [14,23]. Another recent prospective study reported no significant differences in short-term and long-term clinical outcomes between drainage and non-drainage groups [13]. ...
Purpose
To investigate whether catheterization remains necessary in non-drainage total knee arthroplasty (TKA) using combined spinal epidural anesthesia (CSEA) with a short-acting opioid by comparing (1) incidences of postoperative urinary retention (POUR), and (2) postoperative clinical outcomes between retained urinary catheter (UC) and non-retained urinary catheter (non-UC) groups.
Methods
A total of 230 patients underwent non-drainage TKA using CSEA with fentanyl were randomized into UC and non-UC groups (115 patients each, 115 knees each). Incidences of POUR, clinical outcomes (intraoperative intravenous fluid, operative time, whole blood loss, urinary tract infection (UTI), and length of stay) were evaluated after the operation, while range of motion (ROM) and Knee society score (KSS) were evaluated 3- and 6-month postoperatively.
Results
Incidences of POUR and other perioperative and postoperative clinical outcomes between the two groups were not significantly different. ROM and KSS at 3- and 6-month postoperatively revealed no significant differences between the groups.
Conclusion
Given no significant difference in POUR incidence, clinical outcomes and knee scores and functions, catheterization in non-drainage TKA under CSEA with a short-acting opioid might not be necessary.
Clinical Trials
Clinical Trials gov (NCT03341819) (11/09/2017).
... 15 In reality, our analysis of the literature does not reveal this reported hematoma and swelling reduction indeed according with it, Confalonieri et al. noted that knee circumference seems to be smaller already in the early postoperative days in the nodrain group compared with drain group. [16][17][18] In support of this, the study performed by Varley et al. using ultrasound to assess postoperative drained and non-drained wounds after hip fractures demonstrated that drains can prevent haematoma formation only whilst they remain in situ, once the drain is removed the haematoma reforms as without drainage. 19 ...
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] Although lots of orthopedists still follow this practice empirically, debate over the benefits of closed suction drains has never stopped. [4][5][6][7] We performed a systematic review and metaanalysis with respect to this topic in 2011 [8] ; however, at that time, pooled analyses of several valuable outcome parameters were unavailable due to limited number of trials. Some highquality studies were published in recent years and for the purpose of better illustrating this issue, an updated metaanalysis is requisite. ...
Background:
Placement of closed suction drains after total knee arthroplasty is an age-old practice; however, benefits and disadvantages of this procedure remain disputable in various studies.
Methods:
We performed an electronic database search in Medline/PubMed, the Cochrane Library, and Embase to retrieve publications with respect to this issue and then screened reference lists of related articles manually to obtain any additional ones. Randomized controlled trials (RCTs) evaluating the use of closed suction drains after primary total knee arthroplasty were eligible for this study. Useful data were extracted to calculate the pooled risk ratios (RRs) or weighted mean differences (WMDs) as well as corresponding 95% confidence intervals (CIs) as summary estimates.
Results:
Nineteen RCTs were included in the quantitative analysis. Compared with patients in the nondrainage group, those in the drainage group were significantly correlated with a decreased need of dressing change (RR = 0.31, 95% CI 0.12 to 0.79, P = .015) but an increased risk of homologous transfusion (RR = 1.38, 95% CI: 1.04-1.83) and longer time to regain straight-leg raising (WMD = 0.97 d, 95% CI: 0.48-1.46). Two groups showed no significant difference in total blood loss, hemoglobin drop, superficial wound infection, prosthetic joint infection, formation of deep vein thrombosis, duration of hospital stay, and range of movement.
Conclusions:
Based on this analysis, the use of closed suction drains after total knee arthroplasty is probably not superior to no drains for most outcome measures and therefore surgeons may wish to reconsider the routine use of this empirical practice until there is further evidence.
... Použití odsavné drenáže se kritizuje zejména z důvodu zvyšování krevních ztrát a zvýšeného rizika infekce. Překvapivě však metaanalýzy studií nezjistily, že by se výsledek operace výrazněji měnil v závislosti na použití/nepoužití drénu (13,21,28). ...
PURPOSE OF THE STUDY Our study compared early outcomes of total knee arthroplasty performed in conventional and enhanced perioperative care regimes, i.e. without the use of Redon drain, with intensified perioperative analgesia and more frequent and intensive rehabilitation regime in the latter. MATERIAL AND METHODS The prospective study included 194 patients (76 men and 118 women) implanted with primary knee endoprosthesis. The mean age was 68.8 (44.7 - 88.0 years). The patients were divided into two groups - the "enhanced" and "conventional" procedures. In the first group, Redon suction drain was not inserted at the end of the surgery, and the patients commenced passive knee mobility exercise of the operated knee immediately after being brought back from the operating theatre. The general anaesthesia was supplemented by a combined femoral nerve block and wound infiltration with local anaesthetics. The second group comprised the patients who underwent conventional surgery, i.e. with the use of drain, without femoral nerve block, with no wound infiltration with local anaesthetics, and without immediate post-operative mobilization of the joint. The evaluation was carried out using regular clinical tools (subjective evaluation, objective examination, questionnaire and Knee Society Score (KSS)). Standard statistical methods were applied to data processing. RESULTS The patients under the "conventional regime" showed a significantly sharper drop in haemoglobin and haematocrit levels, higher consumption of blood transfusion and analgesics during the first three days after the surgery. The patients under the "enhanced regime" showed a better range of joint motion at hospital discharge, flexion in particular (p = 0.001). During the hospital stay no frequent swelling, secretion or wound reddening was reported in any of the monitored groups. In the "conventional" group, however, haematomas were more frequently present. The postoperative checks did not reveal any differences in satisfaction of the patients with the surgery. At the first follow-up examination at the outpatient department the "conventional" group patients more often reported knee pain and a feeling of a swollen knee. Nonetheless, their statements did not correspond with the VAS score. In the period between the 6th and 12th months following the surgery, the differences in the range of motion disappeared. The KSS showed a noticeable improvement in both the groups as against the preoperative values. In the "enhanced" group patients, the score increased dramatically at the beginning, whereas in the "conventional" group, the score was growing slowly and gradually until the last follow-up check after the surgery. The "conventional" group patients more frequently reported infectious complications (surface and deep wound infections: 4 vs. 2 patients) requiring a revision surgery (p = 0.024). DISCUSSION Recently, attention has been drawn to the rapid recovery approach, which eliminated postoperative immobilization and enabled the patient to start exercising already on the day of the surgery, with some patients even walking independently. The individual enhanced recovery regimes differ in details but mostly result in achieving the aim much sooner when compared to the conventional approaches. The patients under the enhanced recovery regimes can accomplish better functional outcomes in the first few months after the surgery than the patients undergoing the surgery under the conventional regime. The routine use of Redon drains in TKA is obviously unnecessary; it tends to be associated with a higher blood loss and a higher risk of prosthetic joint infection. CONCLUSIONS The TKA implant without suction drains combined with intensified perioperative analgesia and intensive postoperative rehabilitation is a safe way to earlier recovery of the function of the operated knee, or, by extension, the lower limb. The described approach is not associated with a higher risk of perioperative complications (bleeding, healing disorders or early infections). Patients also benefit from lower blood losses. Based on the results of our study, we recommend performing the TKA surgeries routinely without drains, with perioperative analgesia and immediate postoperative joint mobilization. Key words: total knee arthroplasty; perioperative care; rapid recovery; drainage; active movement; postoperative outcomes; pain; infection.
... However, suction drainage is believed to have some disadvantages, including increased blood loss as a consequence of the lack of tamponade effect [10], enhancing bacteria colonization via drainage tube [12] and needing supplementary nursing care and hindering physiotherapy in the presence of a drainage tube [13]. Based on previous studies, it is still disputable whether closed suction drainage after TKA is necessary [8][9][10][11][12]14,15]. A newly published systematic review demonstrated no added advantages of applying a suction drain after TKA related to patient outcome [15]. ...
... A newly published systematic review demonstrated no added advantages of applying a suction drain after TKA related to patient outcome [15]. Another metaanalysis discussing postoperative complications established similar clinical outcomes in knees operated with a drain and those operated without a drain [14]. However, preceding systematic reviews emphasized past reports concentrated on short-term clinical results and no study assessed long-term outcomes and that longer-term assessment of periprosthetic joint infection, implant loosening and range of motion should be performed [14,16,17]. ...
... Another metaanalysis discussing postoperative complications established similar clinical outcomes in knees operated with a drain and those operated without a drain [14]. However, preceding systematic reviews emphasized past reports concentrated on short-term clinical results and no study assessed long-term outcomes and that longer-term assessment of periprosthetic joint infection, implant loosening and range of motion should be performed [14,16,17]. We have studied clinical outcomes of the knees with suction drainage and those without drainage after TKA to make clear whether suction drainage is essential in haemophilic patients who underwent TKA. ...
Introduction:
Closed suction drainage has been extensively applied for orthopaedic procedures for the sake of avoiding fluid collections around the wound at the operated limb.
Aim:
We believed that without application of suction drainage after total knee arthroplasty (TKA), the risk of infection and haematoma formation will not increase while the need for blood transfusion because of decreased blood loss will be lesser.
Methods:
In a prospective randomized clinical trial from April 2010 to April 2014, 176 patients with haemophilia who underwent TKA were included. The study group consisted of 88 patients (108 knees), in which we did not insert suction drain and the control group included 88 patients (106 knees), in which drain was inserted at the end of the surgery. All patients underwent TKA via anterior knee incision and medial parapatellar approach.
Results:
The mean follow-up period of study group and control group was 21 ± 11 months vs. 20 ± 9 months consecutively (P = 0.54). The mean hospital stay was 13 ± 8 days vs. 14 ± 8 days in study and control group consecutively (P = 0.40). In both groups, the major part of improvement in clinical knee society score was due to increase in pain subset (mean increase of 42 vs. 39 points consecutively) and to a lesser extent to alleviation of flexion contracture (mean increase of 13 vs. 15 points consecutively). We observed no differences in the mean visual analogue scale (VAS) value between both groups. Average functional outcome in both groups improved during follow-up visits.
Conclusion:
We can conclude that there is no rationale for the use of drain after primary TKA.
... Several studies have suggested that drains are not required in an uncomplicated primary TKA [15][16][17][18] . However, some investigators advocate the continued use of drains in order to reduce tissue ecchymosis, minimize local hematoma and wound soakage and need for frequent change of dressing [19][20][21][22][23][24] . Our study did not show any significant difference in complication rates between drain and no-drain groups. ...
Purpose:
Simultaneous bilateral total knee arthroplasty (TKA) is associated with excessive blood loss and morbidity arising from postoperative reduction in hemoglobin (Hb). The purpose of this prospective randomized study was to determine if drains have any effect on blood loss, postoperative reduction in Hb levels and transfusion rates compared to no drainage in simultaneous bilateral TKAs.
Materials and methods:
Two hundred and thirty patients who underwent simultaneous bilateral TKA by a single surgeon were randomly allotted to drain or no-drain group (n=115 in each group). Postoperative Hb level, blood loss volume and transfusion rate were compared between the two groups.
Results:
The mean postoperative Hb level (p=0.38), blood loss volume (p=0.33) and transfusion rate (p=0.52) in the drain group were not significantly different compared to the no-drain group. No statistical difference was found in terms of complications, readmissions and mortality rates between the two groups.
Conclusions:
No significant difference was observed in the two groups with respect to blood loss and blood transfusion. Non-drainage does not offer an advantage over drainage with respect to conserving blood in simultaneous bilateral TKA.
... In a recent meta-analysis, Li at al. 26 concluded that, through the current evidence, the use or non-use of SDs has similar utility and clinical significance in primary TKR. However, due to some limitations (few patients involved in each study and only three randomized controlled trials), their findings should be interpreted with caution. ...
Objectives
To evaluate bleeding and the estimated blood loss in patients who underwent total knee replacement (TKR) with different closed suction drains (3.2-mm and 4.8-mm gauge).
Methods
This was a randomized controlled trial with 22 patients who underwent TKR and were divided into two groups: Group I, with 11 patients in whom the 3.2-mm suction drain was used, and Group II, with 11 patients in whom the 4.8-mm suction drain was used. The hematocrit was measured after 24, 48 and 72 h after surgery in order to calculate the estimated blood loss. The drained volume was measured 3, 6, 12, 24, and 48 h after TKR, and thereafter both groups were compared.
Results
Regarding the hematocrit, there were no differences between groups in measured periods (24, 48, and 72 h after surgery). The total bleeding measured at the suction drains within 48 h was higher in Group II, with a statistically significant difference (p = 0.005); in the first 24 h, there was major bleeding in Group II (mean 893 mL), with a significant difference (p = 0.004). Between 24 and 48 h, there was no statistically significant difference in both groups (p = 0.710). The total estimated bleeding was higher in Group I, with mean of 463 mL, versus 409 mL in Group II, with no statistical significance (p = 0.394).
Conclusions
Bleeding was higher in the group that used the 4.8 mm gauge suction drain, with no differences in hematocrit and estimated blood loss.
