The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 6

Scientific Articles | June 01, 2004

Closed Suction Drainage for Hip and Knee Arthroplasty: A Meta-Analysis

Martyn J. Parker, MD, FRCS¹; Chris P. Roberts, FRCS¹; Douglas Hay, FRCS¹

¹ Department of Orthopaedics and Trauma, Peterborough District Hospital, Thorpe Road, Peterborough, Cambridgeshire PE3 6DA, England. E-mail address for M.J. Parker: mjparker@doctors.org.uk

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Investigation performed at the Department of Orthopaedics and Trauma, Peterborough District Hospital, Cambridgeshire, England

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Abstract

Background: The use of closed-suction drainage systems after total joint replacement is a common practice. The theoretical advantages for the use of drains is a reduction in the occurrence of wound hematomas and infection. The aim of this meta-analysis was to determine, on the basis of the evidence from randomized controlled trials, the advantages and adverse effects of surgical drains.

Methods: All randomized trials, as far as we know, that compared patients managed with closed-suction drainage systems and those managed without a drain following elective hip and knee arthroplasty were considered. The trials were identified with use of searches of the Cochrane Collaboration with no restriction on languages or source. Two authors independently extracted the data, and the methods of all identified trials were assessed.

Results: Eighteen studies involving 3495 patients with 3689 wounds were included in the analysis. The pooled results indicated that there was no significant difference between the wounds treated with a drain and those treated without a drain with respect to the occurrence of wound infection (relative risk, 0.73; 95% confidence interval, 0.47 to 1.14), wound hematoma (relative risk, 1.73; 95% confidence interval, 0.74 to 4.07), or reoperations for wound complications (relative risk, 0.52; 95% confidence interval, 0.13 to 1.99). A drained wound was associated with a significantly greater need for transfusion (relative risk, 1.43; 95% confidence interval, 1.19 to 1.72). Reinforcement of wound dressings was required more frequently in the group managed without drains. No difference between the groups was seen with respect to limb-swelling, venous thrombosis, or hospital stay.

Conclusions: Studies to date have indicated that closed suction drainage increases the transfusion requirements after elective hip and knee arthroplasty and has no major benefits. Further randomized trials with use of larger numbers of patients with full reporting of outcomes are indicated before the absence of any benefit, particularly for the outcome of wound infection, can be proved.

Level of Evidence: Therapeutic study, Level I-2 (systematic review of Level-I randomized controlled trials [studies were homogeneous]). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Hippocrates is believed to have used a wooden tube to drain an operative wound around 400 b.c.¹. Orthopaedic wounds are particularly vulnerable to the development of hematomas owing to the difficulty in securing absolute hemostasis in operations involving medullary bone. Many approaches to this problem had been advocated prior to the widespread use of closed-suction drainage systems².

In theory, a perforated plastic tube attached to low-pressure suction will evacuate a developing hematoma from the operative field and promote wound-healing³. A hematoma is thought to impair wound-healing by increasing wound tension and reducing tissue perfusion. In addition, a hematoma provides an excellent culture medium for infection, as it is low in opsonic proteins⁴. Drains may, however, act as a conduit for the introduction of infection^5,6 and may also enhance infection by impairing host resistance⁷. Observational studies on the use of closed-suction drainage systems for wounds following orthopaedic procedures are conflicting, such that the use of drains has been associated with both an increased⁸ and a decreased⁹ rate of wound infection.

We chose to undertake a meta-analysis of prospective, randomized studies in order to provide a more powerful rationale for the use of drains in hip and knee arthroplasty.

Materials and Methods

All randomized trials involving elective hip and knee arthroplasty that were identified by our search strategy of all literature sources and all languages were considered for inclusion. Quasi-randomized trials, in which treatment allocation was inadequately concealed, such as those based on alternation of the even-odd patient record number were also considered. Trials involving other types of surgery of the hip and knee and fracture fixation or arthroplasty for fracture treatment were excluded. Randomized trials were identified with use of a search strategy of the Cochrane Collaboration¹⁰. This included hand-searching of journals, computer-aided searching of Medline, EMBASE, CINAHL, CENTRAL, and Current Contents. In Medline, the following specific search terms were used: "suction"/all subheadings, "orthopedics"/all subheadings, (wound* or suction) all subheadings, "surgical-wound-infection"/all subheadings, explode "joint-prosthesis"/all subheadings, explode "fractures"/surgery, explode "fracture-fixation"/all subheadings, orthopaedic* or orthopedic*, #2 or #5 or #6 or #7 or #8, #1 or #3 or #4, #9, and #10. Reference lists of trials and review articles were searched. All databases were searched from the earliest studies to the most recent search of March 2003. Articles in all languages were included and translated if necessary.

For each randomized trial identified, the average patient age, gender ratio, and type of operation were recorded. The outcome measures sought, within the follow-up period of each individual study (or one year from surgery for the studies with a follow-up of longer than one year), were wound infection (superficial or deep), hematoma, wound dehiscence, limb-swelling, ecchymosis, bleeding from the wound, reoperation because of a wound-healing complication, complications specific to the use of drains such as difficulty with drain removal, postoperative blood transfusion, decrease in hemoglobin or hematocrit, thromboembolic complications, patient discomfort, costs, and functional outcome such as time to regain mobility. Any other outcomes as mentioned in individual studies were considered for inclusion. In studies in which data were incomplete or unclear, attempts were made to contact investigators for clarification.

Two reviewers independently extracted data for the outcomes listed above, and each trial was assessed independently for the quality of its methodology, with use of the quality scale shown in the Appendix, a scale similar to that described by Detsky et al.¹¹. Differences were resolved by discussion. Where studies had been published first as conference abstracts and then as journal articles, the articles were used as the primary reference. For each study, relative risks and 95% confidence limits were calculated for dichotomous outcomes, and mean differences and 95% confidence limits were used for continuous outcomes. Where appropriate, the results of comparable groups of trials were pooled with use of a fixed-effects model. Heterogeneity between comparable trials was tested with use of a standard chi-square test.

Results

Trials Identified

Eighteen studies involving 3495 patients and 3689 wounds were included in the analysis^12-29 (Table I). In the studies by Beer et al.¹³ and Kim et al.^19,20, all patients had a bilateral procedure. Two patients in the study by Ravikumar et al.²⁷ had bilateral surgery. Methodology scores ranged from 1 (poor methodology) to 10 (excellent methodology). In some cases, the low score may represent underreporting of data, such as a trial that was reported as a conference abstract, rather than a poor trial design. The duration of wound drainage for the wounds allocated to receive the drains was twenty-four to forty-eight hours, and all studies used a closed-suction drainage system.

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TABLE I Characteristics of the Studies*

Study	Procedure	No. of Patients	No. of Wounds	Mean Age (Range)	Male Patients (%)	Length of Follow-up	Methodology Score
Adalberth et al.¹² (1998)	Knee arthroplasty	49	49	72 (56-86)	46	4 months	8
Beer et al.¹³ (1991)	Bilateral hip and knee arthroplasty	50	100	NA	NA	3 months	5
Crevoisier et al.¹⁴ (1998)	Hip and knee arthroplasty	98	98	72 (36-87)	41	Discharge	6
Esler et al.¹⁵ (2003)	Knee arthroplasty	100	100	72 (50-88)	45	60 months	6
Hill and Brenkel¹⁶ (2003)	Hip arthroplasty	552	577	68 (NA)	NA	6 months	4
Holt et al.¹⁷ (1997)	Knee arthroplasty	136	136	69 (46-93)	32	6 weeks	5
Jenny et al.¹⁸ (2001)	Knee arthroplasty	60	60	70 (62-84)	32	2 weeks	6
Kim et al.¹⁹ (1998)	Bilateral knee arthroplasty	69	138	64 (37-80)	10	12 months	9
Kim et al.²⁰ (1998)	Bilateral hip arthroplasty	48	96	48 (22-76)	21	12 months	10
Leb et al.²¹ (1995)	Knee arthroplasty	100	100	NA	NA	3 months	2
Mengal et al.²² (2001)	Hip and knee arthroplasty	256	256	69 (44-89)	38	NA	6
Murphy and Scott²³ (1993)	Hip arthroplasty	40	40	NA	NA	10 days	5
Niskanen et al.²⁴ (2000)	Hip and knee arthroplasty	97	97	70 (44-88)	32	2 months	5
Nixon²⁵ (2000)	Hip and knee arthroplasty	1292	1292	NA	NA	48 months	2
Ovadia et al.²⁶ (1997)	Hip and knee arthroplasty	88	88	71 (63-79)	32	Discharge	8
Ravikumar et al.²⁷ (2001)	Hip arthroplasty	23	25	77 (39-47)	48	6 weeks	6
Ritter et al.²⁸ (1994)	Hip and knee arthroplasty	415	415	NA	NA	Discharge	4
Widman et al.²⁹ (2002)	Hip arthroplasty	22	22	71 (49-78)	41	NA	3

NA = not available.

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TABLE I Characteristics of the Studies*

Study	Procedure	No. of Patients	No. of Wounds	Mean Age (Range)	Male Patients (%)	Length of Follow-up	Methodology Score
Adalberth et al.¹² (1998)	Knee arthroplasty	49	49	72 (56-86)	46	4 months	8
Beer et al.¹³ (1991)	Bilateral hip and knee arthroplasty	50	100	NA	NA	3 months	5
Crevoisier et al.¹⁴ (1998)	Hip and knee arthroplasty	98	98	72 (36-87)	41	Discharge	6
Esler et al.¹⁵ (2003)	Knee arthroplasty	100	100	72 (50-88)	45	60 months	6
Hill and Brenkel¹⁶ (2003)	Hip arthroplasty	552	577	68 (NA)	NA	6 months	4
Holt et al.¹⁷ (1997)	Knee arthroplasty	136	136	69 (46-93)	32	6 weeks	5
Jenny et al.¹⁸ (2001)	Knee arthroplasty	60	60	70 (62-84)	32	2 weeks	6
Kim et al.¹⁹ (1998)	Bilateral knee arthroplasty	69	138	64 (37-80)	10	12 months	9
Kim et al.²⁰ (1998)	Bilateral hip arthroplasty	48	96	48 (22-76)	21	12 months	10
Leb et al.²¹ (1995)	Knee arthroplasty	100	100	NA	NA	3 months	2
Mengal et al.²² (2001)	Hip and knee arthroplasty	256	256	69 (44-89)	38	NA	6
Murphy and Scott²³ (1993)	Hip arthroplasty	40	40	NA	NA	10 days	5
Niskanen et al.²⁴ (2000)	Hip and knee arthroplasty	97	97	70 (44-88)	32	2 months	5
Nixon²⁵ (2000)	Hip and knee arthroplasty	1292	1292	NA	NA	48 months	2
Ovadia et al.²⁶ (1997)	Hip and knee arthroplasty	88	88	71 (63-79)	32	Discharge	8
Ravikumar et al.²⁷ (2001)	Hip arthroplasty	23	25	77 (39-47)	48	6 weeks	6
Ritter et al.²⁸ (1994)	Hip and knee arthroplasty	415	415	NA	NA	Discharge	4
Widman et al.²⁹ (2002)	Hip arthroplasty	22	22	71 (49-78)	41	NA	3

NA = not available.

Twelve studies were excluded from the analysis because, although they were randomized trials of drains, they involved a variety of other surgical procedures^3,30-40. Thirteen additional studies were excluded for different reasons^41-53. Two studies were reported only as a conference abstract and provided insufficient information^41,42. Hill and Brenkel⁴¹, in a study of 529 knee arthroplasties treated with or without a drain and followed for six months, reported that the rates of superficial wound infection were 2.9% and 4.8%, respectively, and the rates of deep infection were 1.2% and 0.4%, respectively; however, the study could not be included because of the failure to present the number of patients in each group. In a study of drainage after 111 knee arthroplasties, Pomeroy et al.⁴² reported that no significant difference was found in the rates of infection, swelling, or hemoglobin levels; however, as no data were provided, the article was not included. One study was excluded as the treatment allocation was not random⁴³. Four randomized trials compared different types of suction vacuums, but they did not include a group managed without drains and so were excluded^44-47. Two excluded trials compared different designs of drains but did not include a group managed without drains^48,49. One study compared different numbers of drains, but again it did not include a group treated without drains⁵⁰. One randomized study considered reinfusion drains against conventional drains⁵¹. Two randomized studies considered only the timing of drain removal^52,53.

Wound Infections

The occurrence of wound infection was reported in seventeen studies and is summarized in Figure 1. None of the studies, either individually or as pooled results, demonstrated a significant difference between the groups managed with a drain and those managed without a drain. Pooled results for all studies also showed a wound infection rate of 1.6% (twenty-nine) of 1775 wounds treated with a drain compared with 2.4% (forty-two) of 1765 wounds treated without a drain (relative risk, 0.73; 95% confidence interval, 0.47 to 1.14). The chi-square test for heterogeneity between the studies was 6.43, with 10 degrees of freedom. The p value was 0.78, indicating no significant heterogeneity between the studies. The analysis was undertaken for the fourteen studies in which the occurrence of deep wound infection was reported. Again, no significant difference between groups was shown (see Appendix). The rate of deep infection after hip and knee arthroplasty was 0.2% (four) of 1725 wounds treated with drains compared with 0.5% (nine) of 1715 wounds treated without drains (relative risk, 0.50; 95% confidence interval, 0.17 to 1.49, chi-square test for heterogeneity, 0.78; 4 degrees of freedom; p = 0.94).

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Fig. 1: The prevalence of all wound infections associated with the different surgical procedures with respect to the use of drains. The values are given as the number of patients with a wound infection/number of patients in group, with a summation of the totals and the relative risk (RR) and 95% confidence intervals (CI).

Wound Hematomas and Healing

The occurrence of wound hematomas was reported in seven studies. The pooled results (see Appendix) indicated that the rate of wound hematomas was 1.7% (twelve) of 707 wounds treated with a drain compared with 0.8% (six) of 707 wounds treated without a drain (relative risk, 1.73; 95% confidence interval, 0.74 to 4.07; chi-square test for heterogeneity, 3.1; 4 degrees of freedom; p = 0.54). Nine cases of wound dehiscence were reported in two studies^14,18; six of seventy-nine wounds treated with a drain had a wound dehiscence compared with three of fifty treated without a drain (relative risk, 1.23; 95% confidence interval, 0.46 to 3.33). Leb et al.²¹ stated that no patient in either group had "major wound healing complications."

Reinforcement of the Dressing and Persistent Oozing or Bleeding from the Wound

The number of patients who needed reinforcement of the dressing was documented in five studies^{15,17,19,20,24}. Pooling of the results demonstrated that significantly more patients who were not managed with a drain needed reinforcement (35.2% [100 of 284]) than did those who were managed with a drain (7.8% [twenty-two of 283]) (relative risk, 0.23; 95% confidence interval, 0.15 to 0.35; chi-square test for heterogeneity, 16.6; 5 degrees of freedom; p = 0.005). Four studies indicated the number of patients who had persistent discharge from the wound^19,24,26,27; the pooled results showed that 7% (twelve) of 178 patients managed with a drain had persistent discharge from the wound compared with 19% (thirty-two) of 170 who were not managed with a drain (relative risk, 0.35; 95% confidence interval, 0.19 to 0.65; chi-square test for heterogeneity, 3.1; 5 degrees of freedom; p = 0.69). Leb et al.²¹ reported that drainage persisted from the wound for a mean of 5.5 days in the group treated with a drain compared with 4.7 days for the group treated without a drain; the difference was not significant. Kim et al.²⁰ reported a significant increase in the amount of drainage from the wound site for the wounds treated without a drain, as assessed by the weight of the dressings at twelve and twenty-four hours after surgery.

Bruising and Swelling of the Limb

Both Holt et al.¹⁷ and Kim et al.²⁰ reported that wounds that were not drained had a significant increase in the area of ecchymosis in comparison with those that were drained. Adalberth et al.¹², Beer et al.¹³, Holt et al.¹⁷, and Ovadia et al.²⁶ all reported no significant difference between those managed with or without a drain with respect to swelling of the limb whereas Mengal et al.²² reported an increase in the limb-swelling for patients managed without a drain, but it was not significant.

Reoperations for the Treatment of Wound-Healing Complications

A summary of the numbers of patients in studies that included data on reoperations for wound-healing complications is provided in the Appendix. These operations included drainage of a hematoma, wound débridement, revision because of infection, and removal of a broken drain. The overall pooled rate of reoperation was 0.5% (two) of 387 patients managed with a drain compared with 1.4% (five) of 359 patients managed without a drain (relative risk, 0.52; 95% confidence interval, 0.13 to 1.99; chi-square test for heterogeneity, 1.7; 2 degrees of freedom; p = 0.44).

Transfusion Requirements, Blood Loss, and Change in Hemoglobin

The number of patients requiring transfusion after surgery was provided in six studies (see Appendix). The pooled results demonstrated that transfusion was required for 40.0% (179) of 447 patients managed with a drain compared with 28.1% (126) of 449 managed without a drain (relative risk, 1.43; 95% confidence interval, 1.19 to 1.72; chi-square test for heterogeneity between studies, 6.6; 6 degrees of freedom; p = 0.36).

Other studies indicated the mean number of units transfused or the mean volume of blood transfused, but it was not possible to combine the data because standard deviations were not provided. The data from each of the individual studies are summarized in the Appendix. In addition, Nixon²⁵ reported an increased requirement for transfusion in patients managed with a drain, but data were not provided. Crevoisier et al.¹⁴ and Niskanen et al.²⁴ reported no difference in the decrease in hematocrit between the groups. Leb et al.²¹, however, also used the change in hematocrit as an estimation of blood loss, which suggested a significant increase for the group managed with a drain (p = 0.02). Adalberth et al.¹², Hill and Brenkel¹⁶, Mengal et al.²², Holt et al.¹⁷, Ovadia et al.²⁶, and Ravikumar et al.²⁷ reported no significant difference in the decrease in hemoglobin between the two groups. Mengal et al.²² estimated that the total blood loss for the patients managed with a drain and those managed without a drain was 1942 and 1766 mL, respectively, after total hip replacement and 1590 and 1983 mL, respectively, after total knee replacement. The increased blood loss for patients managed without a drain after total knee replacement was found to be significant (p < 0.01).

Range of Movement and Functional Assessment

Thirteen studies all found no difference between patients managed with a drain and those managed without a drain with respect to the range of movement of the joint after surgery^{12-21,24,26,28}. Kim et al.²⁰ reported no differences in the hip scores between the groups. Leb et al.²¹ also reported no difference in the Insall knee scores between the groups, and Mengal et al.²² found no difference in the functional recovery between the groups. Two studies^15,17 found no significant difference with respect to the time taken to achieve straight-leg raising.

Pain

Six studies^13,15,18-21 found no significant difference between the groups with regard to pain. Ravikumar et al.²⁷ stated that the pain scores were higher for the group managed with a drain. Holt et al.¹⁷ reported no significant difference between the groups with respect to the mean amount of opiate analgesia used postoperatively. Meta-analysis of the data for the outcome of pain was not possible because of the variable outcome measures used.

Other Outcomes

The occurrence of deep-vein thrombosis was mentioned in seven studies^{12,13,16,17,22,24,28}. The pooled results indicated that the prevalence of deep-vein thrombosis was 1.6% (thirteen) of 816 patients managed with a drain compared with 1.1% (nine) of 814 managed without a drain (relative risk, 1.38; 95% confidence interval, 0.63 to 3.05; chi-square test for heterogeneity, 3.5; 4 degrees of freedom; p = 0.44). Seven studies^12,14-18,26 found no significant difference in the length of hospital stay between the groups. Summation of these data in the meta-analysis was not possible because standard deviations were not provided. Cost analysis was mentioned in only two studies. Kim et al.²⁰ stated that the cost of the drains was $135 per patient, and the extra cost of dressings required for patients treated without drains was $50 per patient (in 1998 US dollars). Holt et al.¹⁷ reported that the mean cost of treatment for the group treated with a drain was $17,269 compared with $17,428 (in 1997 US dollars) for the group treated without a drain.

Discussion

The use of closed suction drains in orthopaedic surgery is common practice. In the last decade, this practice has been questioned, leading to a considerable number of randomized trials on the topic. Many of the studies involved too few patients to provide definite conclusions, particularly for outcomes with a low prevalence, such as wound infection. Therefore, we conducted a systematic review of the literature and subsequent meta-analysis of the results. The methodology ratings of many of the studies included in the present study were often poor, perhaps because of poor reporting in the study. A number of the studies were small and were reported only as a conference abstract, rather than as a full publication. We believe that it is still appropriate to include these studies within the analysis, to minimize any bias against smaller studies that were not published in full. The follow-up of patients was often limited, with many of the patients followed only until hospital discharge. This may have resulted in an underreporting of some outcomes, such as wound infection and reoperation. Although the use of blinding, which would involve obscuring any possible drain site by the dressing, would be preferable and has been achieved in one study on the use of drains³⁶, no study in the present review included a blinded assessment of outcome. Despite the differences in trial methodology, the results of the studies were generally homogeneous.

We believe that the primary outcome measure for an investigation of drains should be the occurrence of wound infection. The results of this analysis indicated no significant difference in the occurrence of this complication related to wound drains in any of the operative subgroups or overall. Figure 1 suggests a tendency to a lower infection rate in the group treated with drains, but the difference was a total of only thirteen patients. One small study had a markedly higher infection rate²⁷, with development of a wound infection in eight of twenty-seven patients, suggesting that factors other than the presence of a drain were responsible for the infections. The majority of the studies had a wound infection rate of <2%. Additional studies with larger numbers of patients are needed before definite conclusions may be made about the absence of any benefit related to the use of drains, particularly in terms of the outcome of wound infection. Other outcome measures, such as reoperation, wound hematoma, dehiscence, later drainage from the wound, swelling of the limb, deep-vein thrombosis, range of movement, pain, function, return to work, strength, and hospital stay, showed no difference between the groups managed with a drain and those managed without a drain.

A definite advantage for patients managed without a drain was the reduced transfusion requirements. This seemed particularly relevant for total knee arthroplasty, as the number of patients who needed a transfusion was reduced from sixty-eight (50%) of 137 patients managed with a drain to forty (31%) of 130 patients managed without a drain (see Appendix). With increasing concerns about the risk of transmission of infection and possible immune suppression with blood transfusion, this finding should provide an important argument against the use of drains.

The only definite advantage of the use of drains demonstrated by this analysis was the reduction in the amount of blood leaking through the wound, as demonstrated by the reduced number of dressing reinforcements in the group treated with a drain. In addition, a number of the studies suggested that the use of drains reduced the degree of bruising at the operation site.

In conclusion, the randomized studies to date have indicated that the routine use of closed suction for elective hip and knee arthroplasty may be of more harm than benefit as it results in an increase in the number of patients requiring blood transfusion. The only proven benefit of drains is a reduced need for a change of the dressing. However, because of the poor trial methodology of many of the studies and the inadequate reporting of outcomes, further randomized trials on this topic are justified. Such studies should use a larger number of patients, a longer follow-up period, blinded assessment of outcome, and full reporting of results.

Appendix

Figures showing the prevalence of deep wound infection, wound hematoma, reoperation, and the number of patients requiring transfusion, as well as tables presenting the methodology scoring system, the methodological scores for each of the studies, and data on the transfusions are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Acknowledgements

Note: The authors thank the members of the Cochrane Musculoskeletal and Cochrane Wounds Groups for their valuable assistance in the identification of studies and comments on the analysis.

References

Levy M. Intraperitoneal drainage. Am J Surg.1984;147: 309-14.147309 1984 [PubMed][CrossRef]

Chandler FA. Closed drainage of the knee joint following arthrotomy. J Bone Joint Surg Am.1949;31: 580-1.31580 1949

Cobb JP. Why use drains? J Bone Joint Surg Br.1990;72: 993-5.72993 1990 [PubMed]

Alexander JW, Korelitz J, Alexander NS. Prevention of wound infections. A case for closed suction drainage to remove wound fluids deficient in opsonic proteins. Am J Surg.1976;132: 59-63.13259 1976 [CrossRef]

Casey BH. Bacterial spread in polyethylene tubing. A possible source of surgical wound contamination. Med J Aust.1971;2: 718-9.2718 1971 [PubMed]

Willett KM, Simmons CD, Bentley G. The effect of suction drains after total hip replacement. J Bone Joint Surg Br.1988;70: 607-10.70607 1988

Magee C, Rodeheaver GT, Golden GT, Fox J, Edgerton MT, Edlich RF. Potentiation of wound infection by surgical drains. Am J Surg.1976;131: 547-9.131547 1976 [PubMed][CrossRef]

Acus RW 3rd, Clark JM, Gradisar IA Jr, Kovacik MW. The use of postoperative suction drainage in total hip arthroplasty. Orthopedics.1992;15: 1325-8.151325 1992 [PubMed]

Waugh TR, Stinchfield FE. Suction drainage of orthopaedic wounds. Am J Orthop.1961;43: 939-46.43939 1961

Optimal search strategy for RCTs. Cochrane Reviewers Handbook 4.1.2. In: Clarke M, Oxman AD, editors. The Cochrane Library, Issue 1. Oxford: Update Software; 2003. Appendix 5c. 2003

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbe K. Incorporating variations in the quality of individual randomized trials into meta-analysis. J Clin Epidemiol.1992;45: 255-65.45255 1992 [CrossRef]

Adalberth G, Bystrom S, Kolstad K, Mallmin H, Milbrink J. Postoperative drainage of knee arthroplasty is not necessary: a randomized study of 90 patients. Acta Orthop Scand.1998;69: 475-8.69475 1998 [CrossRef]

Beer KJ, Lombardi AV Jr, Mallory TH, Vaughn BK. The efficacy of suction drains after routine total joint arthroplasty. J Bone Joint Surg Am.1991; 73: 584-7.73584 1991 [PubMed]

Crevoisier XM, Reber P, Noesberger B. Is suction drainage necessary after total joint arthroplasty? A prospective study. Arch Orthop Trauma Surg.1998; 117: 121-4.117121 1998 [PubMed][CrossRef]

Esler CNA, Blakeway C, Fiddian NJ. The use of a closed-suction drain in total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg Br.2003;85: 215-7.85215 2003 [PubMed][CrossRef]

Hill RMF, Brenkel I. Drain vs no drain in unilateral total hip arthroplasty: a randomised prospective trial. J Bone Joint Surg Br.2003;85(Suppl II): 104.85104 2003

Holt BT, Parks NL, Engh GA, Lawrence JM. Comparison of closed-suction drainage and no drainage after primary total knee arthroplasty. Orthopedics.1997;20: 1121-5.201121 1997 [PubMed]

Jenny JY, Boeri C, Lafare S. No drainage does not increase complication risk after total knee prosthesis implantation: a prospective, comparative, randomized study. Knee Surg Sports Traumatol Arthrosc.2001;9: 299-301.9299 2001 [CrossRef]

Kim YH, Cho SH, Kim RS. Drainage versus nondrainage in simultaneous bilateral total knee arthroplasties. Clin Orthop.1998;347: 188-93.347188 1998 [PubMed]

Kim YH, Cho SH, Kim RS. Drainage versus nondrainage in simultaneous bilateral total hip arthroplasties. J Arthroplasty.1998;13: 156-61.13156 1998 [PubMed][CrossRef]

Leb RB, Parker RD, Cohn BT, Fabian V. The efficacy of closed suction drainage in total knee arthroplasty. Orthop Trans.1995;19: 332-3.19332 1995

Mengal B, Aebi J, Rodriquez A, Lemaire R. [A prospective randomized study of wound drainage versus non-drainage in primary total hip or knee arthroplasty]. Rev Chir Orthop Reparatrice Appar Mot.2001;87: 29-39. French.8729 2001

Murphy JP, Scott JE. The effectiveness of suction drainage in total hip arthroplasty. J R Soc Med.1993;86: 388-9.86388 1993

Niskanen RO, Korkala OL, Haapala J, Kuokkanen HO, Kaukonen JP, Salo SA. Drainage is of no use in primary uncomplicated cemented hip and knee arthroplasty for osteoarthritis: a prospective randomized study. J Arthroplasty.2000;15: 567-9.15567 2000 [PubMed][CrossRef]

Nixon J. Wound drainage the long term results after primary hip and knee arthroplasty. J Bone Joint Surg Br.2000;82(Suppl II): 125.82125 2000

Ovadia D, Luger E, Bickels J, Menachem A, Dekel S. Efficacy of closed wound drainage after total joint arthroplasty. A prospective randomized study. J Arthroplasty.1997;12: 317-21.12317 1997 [CrossRef]

Ravikumar KJ, Alwan T, Fordyce MJF, Tuson KWR. Drainage versus nondrainage in total hip arthroplasty. A prospective randomised study. Hip International.2001;11: 49-54.1149 2001

Ritter MA, Keating EM, Faris PM. Closed wound drainage in total hip or total knee replacement. A prospective, randomized study. J Bone Joint Surg Am.1994;76: 35-8.7635 1994 [PubMed]

Widman J, Jacobsson H, Larsson SA, Isacson J. No effect of drains on the postoperative hematoma volume in hip replacement surgery: a randomized study using scintigraphy. Acta Orthop Scand.2002;73: 625-9.73625 2002 [CrossRef]

Duranthon LD, Grimberg J, Vandenbussche E, Mondoloni B, Augereau P. [Effectiveness of postoperative drainage after bipolar sealed endoprosthetic arthroplasty for femur neck fracture. Results of a prospective randomized study of 86 cases]. Rev Chir Orthop Reparatrice Appar Mot.2000;86: 370-2. French.86370 2000 [PubMed]

Lautenbach EEG, Tiemessen CH, Cunningham S, Farah A. How effective is suction drainage? South Africian Bone Joint Surg2000;10: 14-7.1014 2000

Nicolajsen K, Kramhoft M, Hansen D. The use of closed suction drains in femoral neck and intertrochanteric fractures [Abstract]. Acta Orthop Scand.1996;67(Suppl 267): 30.6730 1996

Varley GW, Milner SA. Wound drains in proximal femoral fracture surgery: a randomized prospective trial of 177 patients. J R Coll Surg Edinb.1995; 40: 416-8.40416 1995 [PubMed]

Gartsman GM, Milne JC, Russell JA. Closed wound drainage in shoulder surgery. J Shoulder Elbow Surg.1997;6: 288-90.6288 1997 [CrossRef]

Payne DH, Fischgrund JS, Herkowitz HN, Barry RL, Kurz LT, Montgomery DM. Efficacy of closed wound suction drainage after single-level lumbar laminectomy. J Spinal Disord.1996;9: 401-3.9401 1996

Dhawan A, Doukas WC, Papazis JA, Scoville CR. Effect of drain use in the early postoperative period after arthroscopically assisted anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. Am J Sports Med.2003;31: 419-24.31419 2003 [PubMed]

Paessler HH, Buchgraber A. Is wound drainage in ACL reconstructive surgery necessary? A prospective and randomized study. Orthop Trans.1997; 21: 1233-4.211233 1997

Browett JP, Gibbs AN, Copeland SA, Deliss LJ. The use of suction drainage in the operation of meniscectomy. J Bone Joint Surg Br.1978;60: 516-9.60516 1978 [PubMed]

Sasso RC, Williams JI, Dimasi N, Meyer PR Jr. Postoperative drains at the donor sites of iliac-crest bone grafts. A prospective, randomized study of morbidity at the donor site in patients who had a traumatic injury of the spine. J Bone Joint Surg Am.1998;80: 631-5.80631 1998 [CrossRef]

Lang GJ, Richardson M, Bosse MI, Greene K, Meyer RA Jr, Sims SH, Kellam JF. Efficacy of surgical wound drainage in orthopaedic trauma patients: a randomized prospective trial. J Orthop Trauma.1998;12: 348-50.12348 1998 [PubMed][CrossRef]

Hill RMF, Brenkel I. Drain vs no drain in unilateral and bilateral knee arthroplasty: a randomised prospective trial. J Bone Joint Surg Br.2000; 82(Suppl I): 68.8268 2000 [PubMed][CrossRef]

Pomeroy DL, Campbell MJ, Empson JA, Stovall D, Davis J.Evaluation of postoperative suction drainage in primary total knee arthroplasty. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons; 1995 Feb 16-21; Orlando, FL. 1995

Reilly TJ, Gradisar IA Jr, Pakan W, Reilly M. The use of postoperative suction drainage in total knee arthroplasty. Clin Orthop.1986;280: 238-42.280238 1986

Berman AT, Fabiano D, Bosacco SJ, Weiss AA. Comparison between intermittent (spring-loaded) and continuous closed suction drainage of orthopedic wounds: a controlled clinical trial. Orthopedics.1990;13: 309-14.13309 1990 [PubMed]

Gerngross H, Marquardt KJ. [What suction drainage is optimal for drainage of wound secretion? A clinico-experimental study exemplified by the knee joint]. Chirurg.1992;63: 447-53. German.63447 1992 [PubMed]

Kohler S, Awiszus F, Neumann W, Ratayski H. Gravital drainage is best suited as care after total hip end prosthetic operations. Results of a prospective randomised controlled study [abstract]. Hefte zur der Unfallchirurg.2000;275: 415-416.275415 2000

Seyfert C, Schulz K, Pap G. [The influence of the drain suction in knee arthroplasty]. Zentralbl Chir.2002;127: 886-9. German.127886 2002 [CrossRef]

Graupe F, Eyssel M, Stock W. [Slit drainage in hip endoprosthesis—also an alternative in trauma surgery? A prospective follow-up study]. Unfallchirurgie.1996;22: 223-7. German.22223 1996 [PubMed][CrossRef]

Trammell TR, Fisher D, Brueckmann FR, Haines N. Closed-wound drainage systems. The Solcotrans Plus versus the Stryker-CBC ConstaVAC. Orthop Rev.1991;20: 536-42.20536 1991 [PubMed]

Labek G, Bohler N. [Blood transfusion in total hip endoprosthesis operations in relation to Redon drainage and pressure bandages. An innovation in surgical method]. Z Orthop Ihre Grenzgeb.1998;136: 433-8. German.136433 1998 [PubMed][CrossRef]

Mac HL, Reynolds MA, Treston-Aurand J, Henke JA. Comparison of autoreinfusion and standard drainage systems in total joint arthroplasty patients. Orthop Nurs.1993;12: 19-25.1219 1993 [PubMed][CrossRef]

Willemen D, Paul J, White SH, Crook DW. Closed suction drainage following knee arthroplasty. Effectiveness and risks. Clin Orthop.1991; 264: 232-4.264232 1991 [PubMed]

Zamora-Navas P, Collado-Torres F, de la Torre-Solis F. Closed suction drainage after knee arthroplasty. A prospective study of the effectiveness of the operation and of bacterial contamination. Acta Orthop Belg.1999; 65: 44-7.6544 1999 [PubMed]

Topics

edema ; hemorrhage ; hematoma ; limb ; hip region ; hip joint ; repeat surgery ; suction drainage ; wound infection ; wounds and injuries

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Martyn J. Parker, Chris P. Roberts, Douglas Hay; Closed Suction Drainage for Hip and Knee ArthroplastyA Meta-Analysis. The Journal of Bone & Joint Surgery. 2004 Jun;86(6):1146-1152.

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