Subcutaneous versus intraarticular closed suction indwelling drainage after total knee arthroplasty: A randomised control trial

Optimised fast-track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications

PURPOSE

This literature review aims to present evidence-based clinical recommendations for the eight most debated topics related to perioperative management in total knee arthroplasty: counselling, prehabilitation, transfusion risk, tranexamic acid, drainage, analgesia, urinary catheter and compression stockings.

METHODS

A multidisciplinary team conducted a systematic review on these topics. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the literature review and result presentation. The research encompassed articles from 1 January 2009 to 28 February 2023, retrieved through the MEDLINE database via PubMed, Embase database and Cochrane Library.

RESULTS

Forty-five articles were selected. Preoperative counselling has limited evidence for its impact on postoperative outcomes; yet, it can help alleviate surgery-related anxiety and manage postoperative symptoms. Prehabilitation can also prepare patients for surgery, reducing hospital stays and improving postsurgery functionality. Numerous studies suggest that preoperative Hb levels are independently linked to transfusion risk, with a recommended level of 13 g/dL. Combining intravenous and local tranexamic acid administration is strongly advised to reduce perioperative blood loss, while drainage after primary total knee arthroplasty offers no functional advantages. Employing a multimodal analgesia approach yields better results with reduced opioid usage. Indwelling urinary catheters provide no benefit and avoiding them can lower the risk of urinary tract infections. As for compression stockings, there is insufficient evidence in the literature to support their efficacy in preventing venous thromboembolism.

CONCLUSION

The best-track protocol has demonstrated its efficacy in reducing hospitalisation time and perioperative/postoperative complications. It is success relies on a collaborative, resource-adaptive approach led by a multidisciplinary team. Both patients and hospitals benefit from this approach, as it enhances care quality and lowers costs. Several studies have highlighted the significance of a patient-centred approach in achieving high-quality care. Creating a novel treatment protocol could be a prospective goal in the near future.

LEVEL OF EVIDENCE

Level III.

Does drainage affect development of heterotopic ossification after total hip arthroplasty?

OBJECTIVE

To investigate the effect of drainage on heterotopic ossification (HO) after total hip arthroplasty (THA) and to evaluate other postoperative complications and joint dysfunction between patients with and without drainage.

METHODS

In this retrospective cohort study, the medical records of patients who underwent THA from 2017 to 2019 were reviewed. The patients were divided into a drainage group and non-drainage group. Standard preoperative anteroposterior and lateral radiographs were assessed by senior radiologists for HO analysis. Clinical indicators included the hemoglobin concentration, superficial infection, blood transfusion, hematoma formation, hip range of motion (ROM), erythrocyte sedimentation rate, C-reactive protein concentration, dressing changes, visual analogue scale score, and Harris Hip Score (HHS).

RESULTS

The incidence of HO was significantly higher in the drainage than non-drainage group (32.0% vs. 16.3%). The presence of severe HO (Brooker grade III or IV) was also different between the groups. Patients in the non-drainage group had smaller ROM early after surgery, but the final ROM and HHS did not differ significantly between the groups.

CONCLUSIONS

The rate and degree of HO after THA were significantly different between patients with and without drainage. There is no added advantage of closed suction drainage over no drainage in primary THA.

Effect of an Elevated Preoperative International Normalized Ratio on Transfusion and Complications in Primary Total Hip Arthroplasty with the Enhanced Recovery after Surgery Protocol

Objective

To verify whether an elevated preoperative international normalized ratio (INR) increases transfusion and complications independently in primary total hip arthroplasty (THA) with the management of an enhanced recovery after surgery (EARS) protocol.

Methods

We retrospectively reviewed the database of adults who underwent primary THA between 2014 and 2018 by the same surgeon. A total of 552 patients were assigned into three groups by preoperative INR class: INR ≤ 0.9, 0.9 < INR < 1.0, and INR ≥ 1.0. We regarded transfusion within 90 days during the same hospitalization as the primary outcome. We also included perioperative blood loss, maximum Hb drop, postoperative anaemia requiring medicine, and length of hospital stay (LOS) during the same hospitalization in the study. Complications and reoperation at 90 days and mortality at 90 days and 12 months were also included in the study. Univariable analyses were utilized to compare baselines and outcomes among the three groups. Multivariate logistic regressions were used to adjust for differences at baseline among the groups.

Results

All patients had an INR < 1.5 preoperatively and were managed with the ERAS protocol. Among them, 93 (16.8%) patients had INR ≤ 0.9, 268 (48.6%) patients had 0.9 < INR < 1.0, and 191 (34.6%) patients had INR ≥ 1.0. In the univariable analyses, as the INR increased, the transfusion rates increased from 1.08% for INR ≤ 0.9, to 1.12% for 0.9 < INR < 1.0 and to 5.76% for INR ≥ 1.0 (P < 0.05). The overall complication rate increased from 10.8% for INR ≤ 0.9, to 16.4% for 0.9 < INR < 1.0, and to 22.5% for INR ≥ 1.0 (P < 0.05). The length of stay (LOS) in the INR ≥ 1.0 group was 5.7 ± 2.2 days, which was significantly longer than that in the INR ≤ 0.9 group (4.7 ± 1.6 days, P = 0.000) and 0.9 < INR < 1.0 group (5.1 ± 2.0 days, P = 0.007). No statistical significance was detected among the groups regarding blood loss, maximum Hb drop, or the incidence of postoperative anaemia that required medicine. There was no significant difference in reoperation or mortality among the groups. When controlling for demographic and comorbidity characteristics, there was no statistically significant difference in the odds of transfusion during the same hospitalization or overall complications at 90 days among the groups (P > 0.05).

Conclusions

Elevated preoperative INR cannot increase transfusion or complication rates independently in primary THA with the management of the ERAS protocol. With the improvement in the ERAS protocol and the use of tranexamic acid (TXA), an INR < 1.5 is still a conventional safe threshold for THA surgery.

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

A Comparison of the Postoperative Complications between Two Drainage Methods after Total Knee Arthroplasty

BACKGROUND

The role of wound drainage after total knee arthroplasty is still considered controversial as although closed drainage systems have been believed to be effective in decreasing the post-operative complications, they could also facilitate the bleeding and increase the rate of transfusion and infection. We have conducted the current study to compare the outcomes superficial subcutaneous, one deep, and two deep drain techniques after total knee arthroplasty.

METHODS

Between 2014 and 2015 sixty consecutive patients were prospectively selected and underwent primary total knee arthroplasty. Patients randomized to receive one superficial, one deep and two deep drains at the end of operation. Tourniquet was used and opened at the end of the surgery after dressing. Patients were studied for volume of blood loss, hemoglobin drop, number of transfusion, and any complications. Knee range of motion and diameter were measured and compared with contralateral side in all cases at the end of the third day.

RESULTS

There was no statistical difference regarding red blood cell volume loss, Hb drop, and transfusion rate between groups. Patients in one superficial group had the most sever post-operative ecchymosis. Knee flexion and swelling were the same in all groups. Patients in one superficial drain group had the worst VAS for the pain. Need for early blood transfusion was significantly higher in two deep drain group. In one deep drain group returned back to operating room for sever hemarthrosis and wound dehiscence was occurred in a patient. One patient in one deep group had also developed mild thrombo-emboli.

CONCLUSION

Regarding the blood volume loss after total knee arthroplasty there is no difference between superficial drainage and even more effective intra-articular techniques. Outcome and complication rates are the same.Level of evidence: II.