Primary total knee replacement without drain: A good and safe practice to inculcate

Abstract

BACKGROUND: The use of drain in primary total knee replacement (TKR) started with the belief that it prevents hematoma formation and infection. The fear of infection made this practice an essential step that enjoyed a long journey. However, in recent years, majority of evidence-based studies have not only been failed to provide substantial benefits of the drain but also have proven this a counterproductive step. OBJECTIVE: The purpose of our study is to assess the outcome of performing primary TKR without the use of a drain. METHODOLOGY: After meeting inclusion and exclusion criteria, a prospective observational study was conducted on 186 patients (191 knees) who underwent primary cemented total knee arthroplasty without the use of drain from September 2018 to March 2020 and were followed up for one year. Surgery was performed under tourniquet, bleeders were electro cauterized, and injection tranexamic acid was used to control bleeding. A good preoperative screening for foci of infection, tight glycemic control for diabetics, part preparation, prophylactic antibiotics, and gentle handling of soft tissue was ensured to control infection. Deep vein thrombosis prophylaxis was instituted after risk stratification. Ambulation and physiotherapy were started as per protocol. The clinical parameters such as pain score and range of motion (ROM) were measured by a physiotherapist. Postoperative hemoglobin (Post Op Hb) and requirement of dressing change/reinforcement were monitored by the ward nurse. Aspiration of the knee if required was done by the treating surgeon. RESULTS: Post Op Hb drop was insignificant and none of the patients required blood transfusion. Tense arthrocoele, requiring rescue analgesia, were found in 5(2.6%) patients which responded well with knee aspiration. There was significant improvement (P < 00001) in pain score and the targeted ROM were achieved in 3 weeks' postoperative. Although ecchymosis was a common finding (20.4%), it did not require special attention. Blisters developed in six patients which were managed by antibiotic-impregnated paraffin dressing. Wound healing was not delayed in any patient. None of the patients acquired infection. CONCLUSION: Performing primary TKR without drain is a safe practice to exercise as it neither increases the risk of infection nor poses a significant threat of blood loss and blood transfusion. The presence of arthrocoele in postoperative period does not compromise short term clinical and functional outcomes. The incidence of developing tense hemarthrosis is very less and if aspirated, relieves patient's discomfort and aborts the surgeon's fear of infection. Moreover, not only the cost of drain and utilization of workforce is saved but the question of caring for the drain and its complications also ends.