ortho journal club 5 by dr saumya agarwal

Outcome In Primary Cemented Total knee Arthroplasty With or Without

Drain A prospective comparative study

Rafał Kęska, T Przemysław Paradowski, Dariusz WitońskiDepartment of Reconstructive Surgery and Arthroscopy of the Knee

Joint, Medical University of Łódź, Drewnowska , Poland.

INDIAN JOURNAL OF ORTHOPAEDICSJuly 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

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 .

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.

• 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 noclear advantage of using suction drains, apart from reduced need for change of dressing after total knee arthroplasty (TKA).

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.

• 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.

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.

• 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.

• 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.

• 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.

Assessment

Primary outcome factors were pain intensity and analgesic intake.

Pain intensity was measured with the help of a visual analog scale.

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.

Dressing reinforcement

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

Radiographic Examination

• All patients were clinically and radiologicallyevaluated preoperatively, during hospitalization, then at follow up, approximately 6 and 12 months after surgery.

• Radiographs in anteroposterior and lateralview were performed using.

• Range of movements were assessed.

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).

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.

RESULTS

Primary outcome factors

• On day of surgery, intake of analgesics was comparable between both groups.

• From 1st postoperative day to discharge, lowerdemand for opioids in study group compared with control group was noted.

• Patients in study group required approximately 3times less opioids than patients in control group.

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.

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.

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.

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.

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).

Questionnaires

• Both groups were comparable in terms of preoperative KOOS and SF-36 outcomes.

• Average functional outcome in both groups improved during follow up.

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.

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

• 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 hypersensivityand persistent decrease in pain threshold at the site of injured as well as surrounding uninjured tissues.

• 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.

• 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.

Limitations

• Number of subjects were small but comparable to other studies.

• Difference in opinions on transfusion criteria between orthopedic surgeons and anesthetists .

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.