Wound drainage versus non-drainage for proximal femoral fractures. A prospective randomised study

OBJECTIVES: The purpose of this prospective randomised study was to examine whether routine drainage in surgery for traumatic hip fractures is useful. BASIC PROCEDURES: At the end of surgery for hip fractures, 200 consecutive patients (51 men, 149 women) were randomised to receive suction drainage or not. The status of wound healing was evaluated, with specific reference to haematoma formation or wound infection. Indices of blood loss were the average blood loss during operation, a decrease in the haemoglobin level, fluid collected by the drain, and blood transfusion. MAIN FINDINGS: The severity of wound haematoma and the number of wound infections was not significantly different between the two groups. The average blood loss during operation was 172 ml in the drainage group and 179 ml in the non-drainage group. The volume of drainage fluid was 146 ml. The haemoglobin concentration decreased by 1.4 mg/dl in the drainage group and by 1.3 mg/dl in the non-drainage group (P = 0.83). During admission, 55 patients in the drainage group received 2.5 units of blood and 50 patients in the non-drainage group received 2.7 units. CONCLUSIONS: The severity of wound haematoma does not lead to statistically significant differences in wound infection rate. The routine use of suction drains may not prevent wound infections.     

皮下引流持续冲洗负压吸引术在肠造口还纳术后预防切口感染的前瞻性研究

目的探讨皮下引流持续冲洗负压吸引术在结直肠癌手术并肠造口患者行还纳术后预防切口感染的应用价值。 方法前瞻性选择2017年2月至2018年12月佛山市第一人民医院收治的100例肠造口患者,按照随机数字表法分成两组,在肠造口还纳术中关闭切口时采用不同措施,每组50例,试验组采用皮下引流持续冲洗负压吸引装置,对照组采用传统关闭切口方法。比较两组患者的围手术期资料以及术后切口感染率。 结果两组患者均采取开腹手术,无一例围手术期死亡。两组造口类型、初次造口时机、造口时间、手术时间、术中出血量比较,差异均无统计学意义。试验组患者术后住院时间为（7.0±5.7）d,术后切口感染率为2.0%（1/50）,显著低于对照组的（9.5±5.6）d、16.0%（8/50）,差异有统计学意义（t=-2.193,P=0.031;χ²=4.396,P=0.036）。 结论皮下引流持续冲洗负压吸引术能有效降低结直肠癌肠造口还纳术患者的切口感染发生率,缩短住院时间,临床应用价值较高。     

Simplified wound care and earlier wound recovery without closed suction drainage in elective total hip arthroplasty. A prospective randomized trial in 100 operations

Introduction Evidence to support or refute closed suction drainage (CSD) in primary total hip replacement (THR) is not conclusive. Our anecdotical experience was that persistent ooze from the drainage hole often delayed wound recovery. We hypothesized that, without CSD, wound care would be simplified without short or long term disadvantage. Materials and methods Hundred patients scheduled for primary THR were randomly assigned for CSD or non-drainage. Drains were withdrawn at day 2. Pain, wound hematoma, number of dressing changes, time of persistent discharge from the operation site (skin incision and drain hole), total blood loss and number of blood transfusions were prospectively recorded. Hip function, presence of heterotopic ossifications (HTO) and complications were recorded at a follow visit 1 year after surgery. Results Wound sites managed without CSD needed significantly less wound dressings (P < 0.001) and were dry at an earlier time (P < 001). Despite a significant bigger subfascial hematoma in the non-drained group (P < 0.05), in terms of pain, thigh swelling, total blood loss, number of transfusions needed, hip function and HTO no difference was recorded between the groups (P = 0.2–0.82). Conclusion To omit CSD in primary THR results in simplified and more rapid wound management without any disadvantage at short and long term.     

腹部手术后是否需预防性引流

Abdominal drainage is the most common technique applied in the abdominal surgery. According to the aim of drainage, it can be divided into curative drainage and preventive drainage, but there is no obvious difference between the 2 drainages. Abdominal drainage is not necessary after parenchymal viscera operation, but necessary after spleenectomy in preventing infection. For cavity viscera operation, abdominal drainage is applied according to the infectious condition, but scholars at home and abroad have different opinions on this point. Surgeons should pay attention to the placement of the drainage tube in patients who received preventive drainage.     

Suction/irrigation for deep wound infection after spinal instrumentation: a case study

Deep wound infection after spinal instrumentation is a serious complication that is difficult to treat without removing the instruments and bone graft. Debridement and suction/irrigation is an effective method of treatment in these cases. It was performed on six patients in our department who developed this complication between 1985 and 1994. Four patients with early post-operative infection were cured by this method without removing the instruments and bone graft, and two patients with delayed post-operative infection were cured by this method with instrument removal. Debridement and suction/irrigation is a useful method of treatment for both groups of deep wound infection and gives good results when performed soon after infection onset together with additional antibiotic therapy.     

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

Background:

Total knee arthroplasty (TKA) is widely accepted treatment for moderate or severe osteoarthritis and rheumatoid arthritis. Significant blood loss can be seen during the early postoperative period where a blood transfusion may be necessary. Closed suction drainage is known to prevent the formation of hematomas in the operative field, decrease tension on incisions, diminish delayed wound healing and reduce the risk of infection. Subcutaneous indwelling closed suction drainage method has been known to be beneficial and an alternative to the intraarticular indwelling method. This prospective randomized study was to compare the visible, hidden, total blood loss and postoperative hemodynamic change of subcutaneous and intraarticular indwelling closed suction drainage method after TKA.

Materials and Methods:

One hundred and sixty patients with primary osteoarthritis who underwent unilateral TKA were enrolled; group A with subcutaneous (n = 78) and group B with intraarticular (n = 79) indwelling closed suction drainage method. Total blood loss, visible blood loss, internal blood loss, postoperative day 1, 5^th, 10^th day hemoglobin, hematocrit levels were compared. Allogeneic blood transfusion rate and complications related to soft tissue hematoma formation were additionally compared.

Results:

Allogenic transfusion requirements between subcutaneous drainage group and intraarticular drainage groups (6.4% vs. 24.1%) were significantly different (P = 0.002). Although the minor complications such as the incidence of bullae formation and the ecchymosis were higher in the subcutaneous indwelling group, the functional outcome at postoperative 2 year did not demonstrate the difference from intraarticular drainage group.

Conclusion:

Subcutaneous indwelling closed suction drainage method is a reasonable option after TKA for reduction of postoperative bleeding and transfusion rate.     

Closed suction drainages in Lower Limb Joint Arthroplasty: A level I evidence based meta-analysis

IntroductionThe role of closed suction drainage during elective total joint arthroplasty is still unclear. The present study compared the use of closed suction drains to no drainage for elective total knee arthroplasty (TKA) and in total hip arthroplasty (THA) through a meta-analysis of randomized clinical trials (RCTs).MethodsFollowing the PRISMA guidelines, a meta-analysis of randomized controlled trials identified in December 2021. All randomized clinical trials comparing the use of closed suction drains to no drainage for elective THA or TKA were considered.ResultsTwenty-five RCTs were included in the final analysis. 49% (1722 of 3505) of patients received no-drainage, and 51% (1783 of 3505) received closed suction drainage. There was no evidence of a statistically significant evidence between the two groups in occurrence of postoperative infections (P = 0.4), mean total postoperative hemoglobin (P = 0.2) or length of hospital stay (P = 0.1). The no-drainage group showed a lower rate of blood transfusion (P < 0.0001).ConclusionThere is no evidence to support the routine use of closed suction drainage in THA or TKA patients.Level of evidenceLevel I, meta-analysis of randomized clinical trials.     

粘贴式负压冲吸器在治疗结直肠术后切口感染中的应用研究

目的 探讨应用粘贴式负压冲吸器治疗结直肠术后切口感染的效果.方法 将2010年1月-2011年11月南京军区福州总医院普通外科收治的48例结直肠手术后出现切口感染的患者,按照抽签随机分组的方法,随机分为实验组和对照组,实验组24例,采用粘贴式负压冲吸器治疗;对照组24例,采用传统处理方法治疗.对比2种方法的人均伤口处理时间、换药次数和换药总费用.结果 实验组自开始处理感染切口至二期缝合所需要的人均伤口处理时间(6.12±1.19)d短于对照组(8.54 ±2.98)d,差异有统计学意义(P＜0.05),人均换药次数[(1.44±0.51)次]明显少于对照组[(9.42±2.92)次],差异有统计学意义(P＜0.01),人均换药总费用也少于对照组,差异有统计学意义(P＜0.05).结论 应用粘贴式负压冲吸器治疗结直肠术后切口感染,能缩短伤口处理时间,减少了换药次数和换药总费用,具有较高的临床应用价值.     

负压封闭引流术在脊柱后路内固定术后深部感染治疗中的应用

目的探讨负压封闭引流（vacuum sealing drainage,VSD）在治疗脊柱后路内固定术术后感染中的应用价值。方法回顾性分析2006年1月～2009年12月应用VSD治疗11例脊柱内固定术术后深部感染患者的治疗经过,以总结出合理的诊疗方法。结果11例患者应用VSD技术处理创面1～3次,每次引流7—10d。10例患者保留椎间植骨融合器、椎弓根钉、连接棒,仅取出横连。1例患者术中发现内固定已松动,取出所有内固定。随访6～36个月,所有患者均获得临床治愈。结论VSD技术可以充分引流脊柱后路内固定术术后深部感染伤口的脓液并消灭其死腔;同时增加了取出横连保留其他内固定的安全性,有利于切口早习愈合及尽早进行功能锻炼。     

Evidence in orthopaedics: patellar resurfacing in total knee arthroplasty

Abstract Four good quality randomized clinical trials comparing patellar resurfacing versus noresurfacing in knee arthroplasty are analyzed. The outcomes evaluated were anterior knee pain, scores on the Knee Societys rating system and reoperation.No relevant differences were found in knee scores, but anterior knee pain was less frequent in patients with patellar resurfacing. Few patients had severe anterior knee pain. Still, patients with anterior knee pain were less satisfied with the clinical result. Studies with longer follow-up showed that anterior knee pain increased with time in both groups. A clinically relevant increase in reoperation rate in the nonresurfaced group could not be excluded with the numbers available.Anterior knee pain seems to be influenced by the decision of resurfacing the patella during knee arthoplasty. Although it is not associated with important changes in knee scores, patients perceive it as a cause of insatisfaction. Influence of patellar resurfacing on implant supervivence is not clear.     

Closed suction surgical wound drainage after hip fracture surgery: a systematic review and meta-analysis of randomised controlled trials

There is still debate over the use of drains following hip fracture surgery. We have performed a systematic review and meta-analysis of the literature for randomised trials that related to the use of closed suction drains following hip fracture surgery. Six studies involving 664 patients were identified. There was no statistically significant difference in the occurrence of wound healing complications, re-operations or requirement for blood transfusion between drained and un-drained wounds. All other outcomes reported failed to show any benefit from the use of drains. Further randomised trials are required and until they have been undertaken the efficacy of closed surgical drainage systems in hip fracture surgery is unknown.

---

Résumé  Il existe toujours un débat sur l’utilisation de drains après traitement chirurgical d’une fracture de la hanche. Nous avons réalisé une méta analyse de la littérature à partir d’essais randomisés relatant l’usage de drains aspiratifs après fracture de la hanche opérée. Six études regroupant 664 patients ont été analysées. Il n’y a pas de différences significatives sur le taux de complications (hématome). Le nombre des réinterventions, ni la nécessité de transfusions entre les plaies drainées et non drainées. De nouveaux essais randomisés seront utiles pour déterminer l’efficacité du drainage chirurgical après fracture de la hanche.

     

全膝关节置换术后引流管短期夹闭与持续开放相比较的Meta分析

[目的]应用Meta分析的方法,评价全膝关节置换术(total knee arthroplasty,TKA)后短期夹闭引流管对术后失血量及手术并发症的影响.[方法]计算机检索Pubmed、EMBASE、Ovid和Cochrane图书馆关于TKA术后对引流管短期夹闭和持续开放进行比较的随机对照试验,按照文中所述纳入标准收集后进行比较,利用RevMan 5.0软件进行异质性分析及Meta分析,绘制森林图.[结果]本文检索了1979～2009年间发表的1688篇关于TKA术后比较引流管短期夹闭和持续开放影响的文献,经过筛选和评价,最后收集到已发表的6篇(共603例患者)随机对照试验,符合本次Meta分析所纳入的试验标准.结果发现夹闭组患者术后引流量显著减少,两组在血红蛋白下降值、患者输血率、患膝活动度和术后并发症上差异无统计学意义(95%显著区间有重叠).[结论]现有临床研究结果尚不支持在TKA术后短期夹闭引流管方法疗效优于持续开放引流管方法.     

自制皮下引流管持续冲洗负压吸引预防腹部切口感染的双中心随机对照研究

目的探讨自制皮下引流管持续冲洗负压吸引预防腹部Ⅳ类切口感染的价值。 方法将2012年1月至2017年1月在佛山市第一人民医院普外科和伽师县人民医院普外科行Ⅳ类切口开腹手术的220例患者随机分为试验组和对照组。试验组患者关腹时放置自制皮下引流管,术后持续负压冲洗3 d后拔除;对照组采用传统不放置皮下引流管的关腹方法。观察并比较两组患者术后伤口恢复情况及围手术期临床资料。 结果试验组平均术后住院时间、术后治疗费用、总治疗费用显著低于对照组,差异均有统计学意义（P<0.01）。两组腹腔液细菌培养结果差异无统计学意义（χ²=0.017,P=0.992）,试验组的切口愈合程度显著优于对照组（χ²=8.208,P=0.017）,切口感染发生率显著低于对照组（χ²=8.206,P=0.004）。多因素分析结果显示,是否放置皮下引流管（P=0.008）、原发疾病部位（P=0.004）、术前降钙素原水平（P=0.008）、合并糖尿病（P=0.006）是术后伤口感染的危险因素。 结论Ⅳ类切口手术放置自制皮下引流管持续冲洗和负压吸引,能有效预防术后切口感染,减少住院时间,降低住院费用。     

Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee

IntroductionPeriprosthetic fractures (PPFXs) are becoming increasingly common following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients sustaining PPFXs face considerable perioperative morbidity, with relatively increased rates of surgical site infection. We sought to evaluate the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing perioperative wound complications following lower extremity periprosthetic fracture surgery.MethodsWe performed a retrospective review of 69 consecutive patients who underwent surgery to address lower extremity periprosthetic fractures around hip or knee implants performed over a 6.5-year period. The population was divided into two groups based on the surgical dressing used at the conclusion of the procedure: (1) a sterile, antimicrobial hydrofiber dressing, or (2) ciNPT. There were no baseline demographic differences between the two groups. Rates of wound complications, surgical site infection, and reoperation related to the surgical site were compared between groups. Continuous variables were analyzed using a student’s t-test, and categorical variables using either chi-square or fisher’s exact test.ResultsPatients treated with ciNPT developed fewer wound complications (4% vs. 35%; p = 0.002), fewer deep infections (0% vs. 25%; p = 0.004), and underwent fewer reoperations related to the surgical site (4% vs. 25%; p = 0.021) compared to patients treated with standard of care.ConclusionsOur findings suggest that ciNPT may reduce wound complications, SSIs, and reoperations in patients undergoing lower extremity periprosthetic fracture surgery. This is the first study to investigate ciNPT as a treatment for periprosthetic fracture surgery, and has the potential to change the postoperative management of these patients.     

Non-continuous versus continuous wound drainage after total knee arthroplasty: a meta-analysis

Purpose

So far, controversy still exists regarding the use of non-continuous or continuous wound drainage after total knee arthroplasty. The aim of this study was to assess the efficacy and safety of these two drainage techniques after total knee arthroplasty.

Methods

We searched the established electronic literature databases of Pubmed, Embase, Cochrane Library, CNKI, VIP and WANFANG. Nine RCTs including a total of 761 patients involving 811 knees were eligible for this meta-analysis.

Results

Our results showed that non-continuous drainage was associated with less haemoglobin loss (WMD,  −0.43, 95 % CI −0.62 to −0.24; P < 0.00001) and postoperative visible blood loss (WMD,  −305.09, 95 % CI −408.10 to −202.08; P < 0.00001) compared with continuous drainage. No significant difference was found between the two groups in terms of range of motion (WMD, 0.99, 95 % CI −1.01 to 2.98; P = 0.33), incidence of blood transfusion (OR, 0.63, 95 % CI 0.38 to 1.06; P = 0.80) or postoperative complications (OR, 1.09, 95 % CI 0.35 to 3.40; P = 0.89).

Conclusion

The existing evidence indicates that non-continuous drainage can achieve less haemoglobin loss (especially the four- to six-hour drain clamping) and postoperative visible blood loss with no increased risk of postoperative complications compared with continuous drainage.     

Research in spinal surgery: Evaluation and practice of evidence-based medicine

Evidence-based medicine (EBM) is a common concept among medical practitioners, yet unique challenges arise when EBM is applied to spinal surgery. Due to the relative rarity of certain spinal disorders, and a lack of management equipoise, randomized controlled trials may be difficult to execute. Despite this, responsibility rests with spinal surgeons to design high quality studies in order to justify certain treatment modalities. The authors therefore review the tenets of implementing evidence-based research, through the lens of spinal disorders. The process of EBM begins with asking the correct question. An appropriate study is then designed based on the research question. Understanding study designs allows the spinal surgeon to assess the level of evidence provided. Validated outcome measurements allow clinicians to communicate the success of treatment strategies, and will increase the quality of a given study design. Importantly, one must recognize that the randomized controlled trial is not always the optimal study design for a given research question. Rather, prospective observational cohort studies may be more appropriate in certain circumstances, and would provide superior generalizability. Despite the challenges involved with EBM, it is the future of medicine. These issues surrounding EBM are important for spinal surgeons, as well as health policy makers and editorial boards, to have familiarity.     

Antithrombotic prophylaxis in major orthopaedic surgery: an historical overview and update of current recommendations

The risk of venous thromboembolism following major orthopaedic procedures, such as joint arthroplasty and hip fracture surgery, are well recognised and represent one of the major challenges in orthopaedic practice, having in mind the increasing number of arthroplasties of the hip and knee done worldwide per year and their successful outcome. This potentially fatal complication remains a challenge in orthopaedic practice. The percentage of patients in whom antithrombotic prophylaxis has not been administrated or has been inadequate may reach 50 %. Until recently, anticoagulant prophylaxis with low molecular weight heparins (LMWHs) has been a “gold standard”. LMWHs are indirect inhibitors of the clotting factors Xa and thrombin and are administered by daily subcutaneous injection. Their efficacy has been proven in numerous clinical trials and the rate of complications with their use is relatively low. However these compounds are associated with a failure rate and are inconvenient to administer, requiring subcutaneous injection, leading to inadequate compliance. For these reasons postoperative thrombembolism continues to occur in up to 10 % of this patient population. Recently, novel oral anticoagulants have been introduced into practice for thromboprophylaxis after joint arthroplasy and hip fracture surgery. These drugs are direct thrombin inhibitors (dabigatran) or direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban). These oral drugs have the same efficacy as the LMWHs with the same or slightly more clinically significant haemorrhage as their main side effect. Their ease of administration and favourable clinical profile makes them an important addition to the therapeutic armamentarium available for venous thromboprophylaxis. In this paper we review the aetiology and pathogenesis of venous thromboembolism and present the various alternatives for its prevention after major orthopaedic surgical procedures with emphasis on the new oral drugs.     

Surgical versus conservative treatment for acute first-time anterior shoulder dislocation: the evidence

Acute anterior dislocation of the shoulder is a common injury associated with a high rate of recurrence in young active men. Management of traumatic anterior shoulder dislocation aims to restore range of motion, to reduce the risk of recurrence and to assure an improved quality of life with a stable and painless shoulder. It includes conservative and surgical-open or arthroscopic treatment, followed by rehabilitation. No clear consensus has been reached on the best management, surgical or conservative, to adopt in first-time anterior shoulder dislocation. The aim of this review was to collect and evaluate the scientific evidence supporting the effectiveness of immediate surgical treatment versus immobilization and rehabilitation for first-time traumatic anterior shoulder dislocation. There is some evidence to support primary surgery in young active patients with an acute first traumatic shoulder dislocation, in order to reduce the risk of recurrence, but there is no evidence for the best surgical technique or best conservative approach, nor is there information regarding the best treatment in other categories of patients.