The use of postoperative suction drainage in total knee arthroplasty

A retrospective review of 299 total knee arthroplasties performed between 1973 and 1983 revealed 170 knees in which postoperative suction drainage was used and 129 knees in which drains were not used. Comparison between these two groups revealed no statistically significant difference in wound problems, postoperative temperatures, or resulting range of motion. However, blood transfusions were given more than twice as often to the patients whose knees were drained (39% compared to 16%, p less than .01). The drained group also had a greater decrease in hemoglobin than the nondrained group (3.1 gm compared to 2.6 gm, p less than .01). In a review of these patients, no advantage was found for the use of postoperative suction drainage in the uncomplicated total knee arthroplasty.     

Effectiveness of suction drainage after primary or revision total hip and total knee arthroplasty.

Postoperative suction drainage of a surgical wound is aimed at evacuation of wound hematoma. This study evaluated the effectiveness of suction drainage in joint replacement surgery. Surgical wounds in 206 patients with primary or revision hip and knee arthroplasty were assessed according to a set criteria. Forty-eight hours postoperatively, wound hematoma and exudate formation were not related to the use of suction drains. A greater tendency of wound oozing was seen in revision hip arthroplasty performed with postoperative suction drainage. Therefore, postoperative suction drainage did not affect hematoma formation or wound oozing and is thus considered an unnecessary practice.     

Closed suction drainage for hip and knee arthroplasty. A meta-analysis

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.     

Closed suction drainage has no benefits in revision total hip arthroplasty: a randomized controlled trial

Purpose

Several studies have failed to show significant benefits of closed suction drainage (CSD) in routine primary total hip arthroplasty (THA). However, blood loss, haematoma formation and wound complications are generally much greater in revision THA as compared to primary THA. The purpose of this study was to determine if CSD is beneficial for revision THA patients.

Methods

We conducted a prospective, randomized, controlled trial at our institution between July 2013 and July 2014. Eighty-eight patients undergoing revision THA were enrolled and randomly assigned to receive a CSD (n?=?44) or to not receive a CSD (n?=?44). All first-stage revision surgeries for infection were excluded. Primary outcomes were haemoglobin loss and number of patients transfused. Secondary outcomes included functional outcome evaluated with Harris hip score (HHS), pain evaluated with visual analogue scale (VAS), and length of hospital stay.

Results

There were significantly more patients in the CSD group that required blood transfusions (20/44 as compared to 11/44, p?=?0.04). Patients in the no CSD group were discharged earlier than patients in the CSD group (4.3 days as compared to 5.4 days, p?=?0.002). No statistical significant difference was found in the HHS or pain VAS between the groups.

Conclusions

This study did not demonstrate any benefit with the use of CSD for revision THA with regard to wound related complications, infection or early functional outcome. Post-operative blood loss, transfusion rate, and length of hospital stay may be higher with CSD.

     

Is suction drainage necessary after total joint arthroplasty?

A prospective evaluation of 98 patients who had undergone a total hip or knee arthroplasty was conducted to assess the effect of postoperative suction drainage. Sixty-six patients undergoing elective total hip arthroplasty and 32 patients undergoing total knee replacement were randomly allocated to undergo either suction drainage or no drainage of the wound. Statistical analysis of the results showed no difference in wound healing, severity of wound haematoma, postoperative blood transfusion requirement, range of motion and duration of the hospitalization between the two groups. We conclude that the use of closed suction drainage provides no apparent advantage after uncomplicated total hip or knee arthroplasty. Received: 19 December 1996     

The use of constrained components in total hip arthroplasty

The use of a constrained component may be appropriate for the surgical treatment of recurrent dislocation due to soft-tissue insufficiency following a total hip arthroplasty. Constrained components usually include a locking mechanism incorporated into the polyethylene acetabular liner to keep the prosthetic femoral head in place. Two different prosthetic designs are available and have been approved by the U.S. Food and Drug Administration. The S-ROM constrained component uses additional polyethylene in the rim, which deforms to more fully capture the femoral head and then is held in place by a metal locking ring. The Howmedica Osteonics constrained component is a tripolar device; its bipolar component articulates with another polyethylene liner. These constrained components transfer hip forces that would otherwise lead to dislocation to the locking mechanism, the liner-shell interface, or the bone-prosthesis interface. These forces may eventually contribute to failure of the component due to loosening, dissociation, breakage, or recurrent dislocation. Studies of these components show a failure rate of 4% to 29% at relatively short-term follow-up.     

The use of dual-mobility components in total hip arthroplasty

Dual-mobility hip components provide for an additional articular surface, with the goal of improving range of motion, jump distance (ie, vertical or inferior head displacement required for dislocation), and stability of the total hip arthroplasty. A large polyethylene head articulates with a polished metal acetabular component, and an additional smaller metal head is snap-fit within the polyethylene. New components have recently been released for use in North America. Although these devices are routinely used in some European centers for primary hip arthroplasty, their greatest utility may be to manage recurrent dislocation in the setting of revision hip arthroplasty. Several small retrospective series have shown satisfactory results for this indication at short- to midterm follow-up. Polyethylene wear and intraprosthetic dislocation are concerns, as is the lack of long-term data. Caution is thus advised in the routine use of dual-mobility components in primary and revision total hip arthroplasty.     

初次全髋关节置换术两种负压引流放置方式的比较

[目的]探讨初次全髋关节置换术中两种负压引流放置方式对患者术后失血量及红细胞沉降率(ESR)、C反应蛋白(CRP)的影响。[方法]对2014年3月～2019年5月在本科行初次全髋关节置换术的200例患者进行回顾性分析。其中,囊内组患者65例,将引流管置于关节囊内;囊外组患者135例,紧密缝合关节囊并将引流管置于关节囊外。比较两组患者临床失血相关指标和实验室检查结果。[结果]两组患者均顺利手术,无血管、神经损伤等严重并发症。术后均无局部感染、血肿形成和输血病例。两组患者术中失血量的差异无统计学意义(P>0.05),但是,囊内组患者术后1 d总失血量、术后3 d总失血量、术后引流量和显性失血量明显多于囊外组,差异有统计学意义(P<0.05):而囊内组患者隐性失血量少于囊外组,差异有统计学意义(P<0.05)。两组患者Hb随时间推移而降低,不同时间点间的差异均有统计学意义(P<0.05)。两组患者术前Hb水平差异无统计学意义(P>0.05):囊内组患者术后1 d Hb水平低于囊外组,差异有统计学意义(P<0.05),囊内组患者术后3 d HB水平仍低于囊外组,但差异无统计学意义(P>0.05)。术后两组患者的CRP和ESR均较术前显著升高,差异有统计学意义(P<0.05)。术前囊内组与囊外组CRP和ESR的差异无统计学意义(P>0.05),但术后囊内组CRP和ESR显著低于囊外组,差异有统计学意义(P<0.05)。[结论]初次全髋关节置换术中紧密缝合关节囊并将引流管置于关节囊外,相对于常规的关节囊内引流,术后总失血量明显少,但隐性失血量增加,术后炎症指标水平升高。     

非骨水泥型人工全髋关节置换术后两种引流方式的比较

[目的]比较非骨水泥型人工全髋关节术后普通引流和低负压引流两种引流方式的引流效果。[方法]根据术后所采取的不同引流方式,将本院2008年6月～2011年12月实施的符合研究标准的95例非骨水泥型单侧人工全髋关节置换术病人,分成普通引流组和低负压引流组,分别对两组患者的失血总量、术后显性失血量、隐性失血量、输血量、输血总人数、相关并发症和髋关节术后3、6、12个月Harris评分进行回顾性分析。[结果]普通引流组的失血总量、术后显性失血量、输血量、输血总人数明显少于低负压引流组(P<0.05),但其隐性失血量稍多于低负压引流组(P<0.05)。两组术后髋关节Harris评分逐步增加,术后3、6、12个月两组Harris评分无统计学差异(P>0.05)。两组术后均无切口内血肿、裂开、深部感染及下肢深静脉血栓等并发症发生。切口浅表感染普通引流组2例,低负压引流组1例,无统计学差异(P>0.05)。异位骨化普通引流组6例,低负压引流组5例,无统计学差异(P>0.05)。[结论]非骨水泥型人工全髋关节置换术后普通引流失血总量、术后显性失血量、输血量及输血总人数均明显少于低负压引流,但两种引流术后髋关节功能恢复及并发症的发生率相当,提示非骨水泥型人工全髋关节置换术后宜采用普通引流。     

Stem/progenitor cells in closed suction drainage fluid after hip arthroplasty

Background and purpose

Drainage after surgery is commonly used, and the contents are generally discarded as clinical waste. We analyzed closed suction drainage fluid from hip arthroplasty patients to determine whether any multipotent stem cells were present that could be used as a source of cells for tissue regeneration.

Methods

Drainage fluid was obtained from 14 patients after hip arthroplasty on the day of surgery, the next day, and 2 days after surgery. Peripheral blood and bone marrow from the iliac crest were also obtained from the same patients during surgery. These samples were examined using regular flow cytometric profiling, and we performed quantitative immunoassays of stromal-derived factor-1 (SDF1) levels in the plasma. Mononuclear cells (MNCs) from these samples were also isolated and cultured. Fibroblastic adherent cells from MNC fractions were cultured in an osteogenic and a chondrogenic differentiation medium and were then evaluated for multipotentency.

Results and interpretation

Fibroblastic adherent cells were isolated from the mononuclear cell fraction of bone marrow and drainage fluid on the day of surgery, but they were not present in either the mononuclear cell fraction of the peripheral blood or the drainage fluid on the next day and 2 days after surgery. The cells from the drainage fluid on the day of surgery could differentiate in vitro into osteogenic and chondrogenic cells. SDF1 was elevated on the day of surgery, while CXCR4 was elevated on that day and the next day. This suggests that locally-induced SDF1 contributes to the mobilization of circulating CXCR4-positive cells. These results show that the drainage fluid collected on the day of surgery contains stem/progenitor cells that could be used for autologous cell-based therapy.Stem cells are vitally involved in tissue regeneration and homeostasis. Mesenchymal stem cells (MSCs) have the potential to differentiate into lineages of mesenchymal tissues, including cartilage, bone, fat, and muscle. Isolation and characterization of MSCs from bone marrow, muscle, adipose tissue, or synovial tissue have been reported (Pittenger et al. 1999, Lee et al. 2000, De Bari et al. 2001, Jones et al. 2002, Gimble et al. 2007).The clinical use of MSCs is increasing, with profound implications for regenerative medicine. Several animal studies have demonstrated the efficacy of using stem cells in the treatment of bone defects (Ohgushi et al. 1989, Bruder et al. 1994, Ranieri et al. 2007, Veronique et al. 2007). Local injection of ex vivo expanded autologous bone marrow stem cells has been used successfully for the treatment of large bone defects in 3 patients (Quarto et al. 2001). Furthermore, with tissue engineering, a titanium-mesh scaffold filled with bone mineral blocks infiltrated with BMP7 and a bone marrow mixture were found to produce a large amount of bone tissue needed for reconstructing a mandibular defect in a patient (Warnke et al. 2004).Drainage fluid connected to a cell-collecting device has been used for salvage of red blood cells to re-infuse after arthroplasty (Semkiw et al. 1989). White blood cells, including the MSC fraction, were usually discarded as clinical waste.Stromal-derived factor-1 (SDF1) controls many aspects of stem cell function (Aiuti et al. 1997, Peled et al. 1999). The SDF1/CXCR4 axis plays an essential role in the mobilization and homing of stem/progenitor cells (Ceradini et al. 2004, Kucia et al. 2005). Furthermore, the expression of SDF1 is upregulated following irradiation and hypoxia, and SDF1 can induce the recruitment of endothelial progenitor cells in a regeneration model for myocardial infarction (Ceradini et al. 2004).Thus, it is of interest to investigate the mechanism underlying stem cell recruitment to injured tissues by evaluating the level of SDF1 or the frequency of CXCR4-positive cells in various samples.We investigated whether the mononuclear cells (MNCs) in closed suction drainage fluid after hip arthroplasty could produce MSCs, and determined the level of SDF1 and frequency of CXCR4-positive cells in the drainage fluid to investigate the mechanism underlying stem cell recruitment to the injured tissue.     

Ultimate outcome in immediate postoperative total hip arthroplasty instability

The objective of this study was to determine the ultimate outcome of patients who experienced immediate postoperative instability after primary total hip arthroplasty using regional anesthesia. Thirty-one patients whose radiographs demonstrated dislocation or subluxation immediately after total hip arthroplasty were evaluated as to the ultimate outcome of hip function and stability. Once a dislocation has occurred, the risk of redislocation is high. In this study, of the 29 patients who did not have revisions immediately after surgery, 3 (10.3%) have had recurrent dislocation and 1 (3.5%) has had a subluxation event. Recurrent instability or the need for revision surgery is significantly greater when compared with those patients who have no evidence of postoperative instability.     

Early postoperative acetabular discontinuity after total hip arthroplasty

Periprosthetic acetabular fracture is a rare complication after total hip arthroplasty (THA). However, we have treated 2 patients with acute postoperative acetabular discontinuity that occurred 2 and 3 weeks after primary THA. Both fractures were in elderly osteoporotic female patients with minimal trauma and may have developed from unrecognized intraoperative fractures. Pelvic stability was restored with acetabular revision using medial morselized bone grafting and a cemented reconstruction cage. This report demonstrates that early postoperative periprosthetic acetabular discontinuity after THA is a risk in elderly patients with severe osteoporosis and that salvage of acetabular fixation can be achieved with cemented cage reconstruction and medial morselized bone grafting.     

The use of allograft bone in revision of total hip arthroplasty

Fifty-two frozen bone allografts have been used on 44 patients undergoing revision hip arthroplasties. The average follow-up time on these patients has been 17 months, with a range of six to 72 months. Both proximal femoral allografts and the allografts for the reconstruction of acetabular deficiencies have been used. To date, most patients experience marked pain relief and improvement in function. Though the results attained to date are short-term, the use of allografts in the revision hip arthroplasties represents a natural progression of the tumor work. However, while the early results are encouraging, it remains to be seen how the proximal femur allografts and the large acetabular allografts will behave over a long period of time.     

The use of a high-hip center in revision total hip arthroplasty

In certain cases, primary and revision total hip arthroplasty is complicated by insufficient bone stock and distorted acetabular anatomy such that the craniocaudal dimension of the acetabular recess is greater than the anteroposterior dimension. Acetabular reconstruction in such cases can be carried out by placing the acetabular component more proximally than normal (high-hip center). Recent biomechanical and clinical data suggest that placement of the acetabular component at a higher than normal hip center does not adversely effect the longevity of the component fixation. Proximal placement of the hip center also facilitates the contact between the host bone and the porous coating when uncemented porous coated components are used, and minimizes the need for structural bone grafts. However, femoral components with longer neck lengths and removal of impinging bone are needed when the acetabular components are placed more proximally in order to restore the limb lengths and minimize the chances for dislocation.     

Revision total hip arthroplasty: The use of solid allograft

Intract solid allografts was used to augment severe bone loss in 8 acetabula and 15 femora in 22 patients who underwent revision total hip arthroplasty with noncemented implants. The average follow-up period was 4 years. The average time to radiographic union of whole acetabular allografts was 11 months. Superior migration of the allografts occurred in four patients. Varus tilt of the acetabular component within the allografts was noted in three patients. Eleven patients underwent entire proximal femoral allograft reconstruction, and four patients had femoral head allograft reconstruction. Nine patients with entire proximal femoral allografts achieved radiographic union at an average of 13 months and two failed by nonunion. Only one of the four patients with femoral head, allograft reconstruction achieved union. Femoral component subsidence was noted in seven whole proximal femoral allografts (64%). Entire proximal femoral allograft reconstruction was complicated by at least one episode of postoperative dislocation in 6 of 11 procedures. The authors recommend that femoral head allografts should be used with caution to reconstruct proximal femoral deficiencies in which structural, support is required for stability of the implant. Successful use of acetabular allografts requires that the majority of the allograft be contiguous to host bone and not to soft tissue. With entire proximal femoral reconstruction, the tip of the femoral, component should not reside at the host-graft junction. All components should be cemented into allograft bone; and revision surgery should be performed before osteolytic destruction of bone advances to the point where allograft reconstruction is required.     

The effects of preoperative chronic opioid use in total hip arthroplasty

BackgroundPerioperative opioid use is becoming an increasingly concerning topic in total joint arthroplasty (TJA). The current study aims to add to the paucity of prior studies that have detailed perioperative opioid use patterns and the effects of preoperative chronic opioid use among a cohort of total hip arthroplasty (THA) patients.MethodsA retrospective analysis of 256 consecutive patients who underwent a THA at our institution between February 2016 and June 2016 was performed. Two cohorts were compared: patients deemed 1) preoperative chronic opioid users, and 2) non-chronic users. Variables compared included baseline characteristics, quality metrics, and patients’ opioid use histories 3 months prior to surgery and 6 months following surgery.ResultsOf the 256 patients, 54 (21.1%) patients were identified as preoperative chronic opioid users. Baseline characteristics including age, gender, BMI, and ASA scores were similar between both cohorts. Discharge disposition, value-based purchasing (VBP) costs, length of stay (LOS), emergency room visits, and postoperative office visits were similar between the two cohorts. Readmission rates (30-day, 90-day, and 6-month) were significantly higher (p < 0.05) in the chronic opioid users cohort. By the 6-month postoperative time period, chronic opioid users were consuming approximately 100-times the morphine equivalents than non-chronic users.ConclusionsThe current study demonstrates that a substantial proportion of preoperative chronic opioid users continue to consume large amounts of opioids up to 6-months following THA surgery. Furthermore, preoperative chronic use is significantly associated with poorer quality outcomes, specifically with respect to readmission rates.Level of evidenceLevel II, Prognostic Study.