Question: In patients having primary total knee arthroplasty, how
effective is a deep closed-suction drain compared with no
drain?
Design: Randomized (unclear allocation concealment), unblinded,
controlled trial with 10-day follow-up.
Setting: A university hospital in Leicester, United Kingdom.
Patients: 100 patients (mean age, 73 years; 55% women) who were
having primary total knee replacement. Follow-up was complete.
Intervention: Patients were allocated to insertion of 1 deep drain
(Medinorm 600 System, 1/8, Quierschied, Germany) (n = 50) or no drain (n = 50)
immediately before closure of the wound. All other operative procedures were
the same in the 2 groups: a cemented posterior-cruciate-retaining prosthesis
(PFC; Johnson and Johnson, Bracknell, UK) was implanted, and a tourniquet was
used until the dressings were in place. Above-the-knee graduated compression
stockings and aspirin (300 mg, once daily) were used for antithrombotic
prophylaxis. The dressings were left for 48 hours unless they became saturated
with blood or caused discomfort or constriction. Patients were mobilized after
24 hours, and the drain was removed after 48 hours.
Main outcome measures: Postoperative blood loss, change in
hemoglobin level, increase in knee circumference, time to regain flexion, and
time to straight-leg raising.
Main results: Patients with the drain lost more blood than did
patients with no drain (P < 0.01) (Table), although patients with no drain
lost more blood into the dressings (P < 0.01). The groups did not differ
with regard to a decrease in hemoglobin level (P = 0.6), increase in knee
circumference (P = 0.15), or time to regain preoperative flexion (P = 0.14).
Patients with a drain took 1 day longer to perform active straight-leg raising
(P = 0.02) (Table).
Conclusion: In patients having primary total knee arthroplasty, the
use of a deep, closed-suction drain did not reduce blood loss or improve any
postoperative outcomes compared with no use of a drain.
Whether or not to use drains after total knee arthroplasty is
controversial. Surgeons who use drains argue that they decrease the risk of
hematoma (which would lead to limited motion and potentially more
postoperative manipulations) and wound infections. In contrast, surgeons who
do not use drains argue that they serve as a portal for bacteria, increase
postoperative blood loss, and do not improve overall range of motion.
Esler and colleagues found no difference with respect to postoperative
hemoglobin level, postoperative knee circumference, or time to regain
postoperative flexion whether the knee did or did not receive a drain.
However, all of the patients received aspirin as prophylaxis to prevent deep
venous thrombosis (DVT). The results might have differed if prophylactic
agents associated with higher bleeding rates were used. Furthermore, the study
may have had insufficient power to determine true differences between the
groups. For example, a trend toward increased knee manipulations had been seen
in the no-drain group that might have reached significance with more patients.
Finally, the orthopaedic follow-up period was only 10 days, so it is not
possible to determine the potential influences of draining the knee with
respect to final range of motion and function. The assessment of the efficacy
of drains in the literature is
mixed1-5.
The study by Esler and colleagues suggests that there are limited
advantages associated with the use of a drain after total knee arthroplasty,
particularly when aspirin is used for DVT prophylaxis. However, these findings
need to be verified by a larger randomized trial with a longer follow-up
period.
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