The findings of this study should be viewed after considering the following limitations. First, we did not include a group without closed-suction drainage, and therefore, we cannot conclude from this study whether intraarticular or subcutaneous closed drainage offers advantages or disadvantages in comparison to no drain. Furthermore, despite the lack of definitive proof regarding the advantages of vacuum drainage [1, 3, 10, 15, 20, 23, 28, 30, 35, 36], many surgeons continue to use vacuum drainage after TKA to reduce the possibility of wound problems and the need for dressing reinforcement [7, 18, 22, 29, 30]. Our data showed that a subcutaneous closed suction drain resulted in outcomes equivalent to those of an intraarticular closed suction drain but, having no control group without a drain, could not address the value of either drainage method versus no drain. Second, we clamped our intraarticular drains for 2 hours after surgery and then kept drains open until 24 hours after surgery (at which time the drains were removed). Several studies have determined optimal drain clamping times, but recommendations varied and included no clamping , clamping for 1 hour [37, 47], 10-minute clamp releases every 2 hours , clamping for 4 hours [41, 43], and clamping for 20 hours . We cannot comment on the effects of clamping time on the intraarticular indwelling method, but mean drained volume in our study (352 mL) compares with those (253-843 mL) reported previously [21, 33, 37, 38, 41, 43, 47]. Third, as mentioned above, our cohort size was sufficient to detect differences in drained volumes, hemoglobin level, and functional outcomes, but not differences in allogenic transfusion requirements, hypotension episodes, and wound problems. Finally, we did not measure intraoperative blood loss. We believed the amount of intraoperative blood loss would be negligible because all surgical procedures were performed with a pneumatic tourniquet inflated except when checking the presence of arterial bleeders before capsule closure.
Our findings suggest, compared with intraarticular closed-suction drainage, subcutaneous closed-suction drainage involves equivalent blood loss with comparable wound problems and functional outcomes. The mean drained volume was lower in the subcutaneous indwelling group, but hemoglobin decreases at 2 and 5 days postoperatively were similar (Table 2). No difference was found in allogenic transfusion requirements. Furthermore, although we had expected faster hemoglobin recovery in the subcutaneous indwelling group, because some components required for hematopoiesis could be recruited from extravasated blood , no group differences were found in terms of hemoglobin recovery variables. Our finding of similar blood loss in the subcutaneous indwelling group indicates whether the subcutaneous indwelling method exploits the joint tamponade effect of the no suction drainage method to a clinically meaningful extent remains to be answered. Nonetheless, the observation of smaller blood drainage in the subcutaneous group suggests, after TKA, more free blood is available for drain removal intraarticularly than is available subcutaneously. Subsequently, this finding of small blood drainage in the subcutaneous indwelling group indicates clinical values of a subcutaneous indwelling autotransfusion drain would be limited.
Our observations also suggest the two approaches have similar incidences of wound problems and similar functional outcomes. There were no differences in any of the parameters representing wound problems and functional outcomes (Tables 3, 4). We cannot draw a solid conclusion regarding wound complications because of the insufficient power, but our experience during the past 3 years using this method has supported its safety in terms of wound complications. Several studies have concluded closed-suction drainage offers advantages over no drainage in terms of wound problems and dressing reinforcement requirements (Table 5) [18, 22, 29, 30]. Nonetheless, our study indicates removal of either intraarticular or subcutaneous blood by a postoperative drain does not create a clinical difference regarding transfusion rate, motion arc, or functional outcomes.
Our data suggest subcutaneous indwelling closed-suction drainage is similar to that for intraarticular indwelling closed-suction drainage with equivalent blood loss and no adverse effects on functional outcomes. Based on our findings, we propose subcutaneous closed suction drainage offers a reasonable alternative to intraarticular closed suction drainage after TKA.
We thank Yeon Gwi Kang for help with motion arc measurements and maintenance of the database.
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