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Arthroscopically assisted ACL reconstruction. Is a drain necessary?
The Knee 10 (2003) 283–285
Arthroscopically assisted ACL reconstruction. Is a drain necessary? Robert Straw, Karen Colclough, Guido G. Geutjens* Department of Orthopaedic Surgery, Derbyshire Royal Infirmary, Derby, UK Received 26 September 2002; received in revised form 3 October 2002; accepted 4 November 2002
Abstract We report on the results of a prospective randomised controlled trial to evaluate the use of an intra-articular drain following arthroscopically assisted ACL reconstruction using patellar tendon autograft. Forty-nine patients were recruited for the trial and randomised into receiving or not receiving a drain following surgery. An independent observer who was blinded for the use of the drain assessed the knees for swelling, range of movement (ROM) and pain at 2, 4 and 6 weeks postoperatively. Muscle strength was assessed at 12 weeks following surgery using the KIN COM III isometric dynamometer. We found that the knees that were drained following surgery initially had less swelling and a better ROM. However, at 4 weeks this difference had disappeared. At 3 and 6 months, there was no functional difference between the two groups. We recommend that no drain be used following ACL reconstruction as removal of the drain is uncomfortable and carries theoretical and avoidable risks. 䊚 2002 Elsevier Science B.V. All rights reserved. Keywords: ACL reconstruction; Drain
1. Introduction Arthroscopically assisted ACL reconstruction has become an established and reproducible procedure in the past 15 years w1,2x. However, its reliability remains an issue since 100% effectiveness is not reproduced. Opinions are divided about the routine use of an intraarticular drain following this procedure. Some surgeons advocate the use of a drain as they feel that all cavities must be drained following surgery to decrease the theoretical risk of intra-articular adhesions and joint stiffness w3x. However, others feel that the use of a drain might increase the risk of infection or cause damage to the graft and articular surfaces of the knee. Furthermore, patients dislike the pain associated with removal of the drain.
study. Informed consent was taken from all patients who were then randomly allocated to either receiving or not receiving a drain. Randomisation was performed by means of the last digit of the patients’ hospital number. Patients with chronic knee instability due to ACL laxity undergoing arthroscopically assisted ACL reconstruction using the middle third of the patellar tendon as a graft were recruited into the study. Patients who underwent reconstruction using hamstring grafts or revision ACL reconstruction were excluded. There were no differences between the two groups concerning age, sex, activity levels and time between rupture and reconstruction and all patients had a full range of movement (ROM) (as compared to the opposite knee) prior to surgery. 3. Operative procedure
2. Subjects and methods Approval from our Hospital Trust Ethics Committee was requested and obtained prior to commencing the *Corresponding author. Department of Trauma and Orthopaedics, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK. Tel.: q44-1332-347141x4192; fax: q44-1332-254950. E-mail address: [email protected] (G.G. Geutjens).
All procedures were performed by the senior surgeon (G. G). A tourniquet was used routinely and the leg was exsanguinated by simple elevation for a minimum of 2 min. A Rhys–Davies exsanguinator was not used. A notchplasty was performed if necessary. The middle third of the patellar tendon was harvested as a 10-mm bone–tendon–bone graft. A single incision endoscopic technique with the femoral tunnel drilled through the
0968-0160/03/$ - see front matter 䊚 2002 Elsevier Science B.V. All rights reserved. PII: S 0 9 6 8 - 0 1 6 0 Ž 0 2 . 0 0 1 5 0 - 3
R. Straw et al. / The Knee 10 (2003) 283–285
284
Table 1 Difference in circumference (cm) between the operated and contralateral knee Follow up
Drain
No drain
2 week 4 week 6 week
1.3 (0.97) 1.2 (0.18) 1.0 (0.40)
1.9 (0.16) 1.1 (0.14) 1.1 (0.34)
P-0.002 Ps0.47 Ps0.47
Table 2 ROM (8) Follow up
Drain
No drain
2 week 4 week 6 week
108 (1.80) 124 (1.15) 133 (1.24)
99 (2.60) 120 (1.86) 134 (1.36)
P-0.002 Ps0.14 Ps0.57
Figures for standard errors are shown in brackets.
Figures for standard error are shown in brackets.
tibial tunnel was used. The graft was secured in the tunnels using a metal interference screw 1 mm smaller than the diameter of the tunnel. A suction drain was inserted via the fluid drainage portal in those patients randomised into receiving a drain and left for 16–20 h before removal. The amount of blood collected by each drain was documented. All procedures were done as inpatient procedures with an average postoperative hospital stay of 26 h. 4. Postoperative regimen Postoperatively, a compression bandage and cryocuff were routinely used. CPM was commenced on the day of surgery and continued on the first postoperative day. Patients were then enrolled in an accelerated ACL rehabilitation program as described by Shelbourne w4x. ACL braces were not used. 5. Follow up evaluation All patients were evaluated at 2, 4 and 6 weeks postoperatively for pain, swelling and ROM by an experienced physiotherapist (K. C) who was blinded to the use of a drain. Muscle strength was assessed using the KIN COM III isometric dynamometer at 12 weeks following surgery. Pain was assessed using a 10-cm visual analogue scale and the ability to perform a straight leg raise. Knee swelling was demonstrated by the presence of an effusion and compared to the contralateral knee by measuring the circumference at the level of the base of the patella. ROM was documented. Patient satisfaction and knee function were recorded at 6 months. 6. Results Forty-nine patients were enrolled into the study. Two patients decided not to continue their physiotherapy rehabilitation protocol and therefore 47 patients were available for follow up. Twenty-four patients received a drain and 23 patients had no drain inserted at the time of surgery. In the drain group the mean age of the patients was 27.2 years (range 16–49) with 15 male patients and 9 female. The demographics of those patients not receiving a drain were not dissimilar with a
mean age of 26.4 years (range 18–43) with 15 male patients and 8 female. The mean drainage was 120 ml (range 10–300 ml). There were no post-operative complications; no knee required an aspiration and all grafts were functional at 6-month follow up. There was little difference in pain between the groups at the 2-week follow up. The mean visual analogue score for the drain group was 2.2 compared to 2.4 in those patients without a drain and all patients were able to perform a straight leg raise. Patients receiving a drain following surgery showed slightly less swelling (Table 1) and a marginally better ROM at the 2-week follow up (Table 2). Two patients exhibited extension deficits in the drain group compared to 5 patients in those without a drain at the 2-week follow up. However, only 1 patient had an extension deficit at the subsequent review 2 weeks later. Muscle strength testing was conducted in all patients 3 months after surgery using the KIN COM III isometric dynamometer. Eccentric and concentric measurements were recorded for both quadriceps and hamstrings. Both groups showed similar results with hamstrings having the least dysfunction post operatively compared to quadriceps (Table 3). In testing for a difference between the two groups, the 2-week data for both knee swelling and ROM both gave a P-value of 0.002 using the t-test. Therefore, there is strong evidence to reject the null hypothesis of no difference between the groups at this time. However, at the 4- and 6-week follow up the P-values were 0.14, 0.47, 0.47 and 0.57, which are not significant. In addition, no significant difference was found between the two groups when comparing muscle strength. 7. Discussion Arthroscopically assisted ACL reconstruction has become an established and reproducible procedure in Table 3 Isometric dynamometer testing (% operated vs. unoperated side) Muscle test
Drain
Concentric quadriceps Concentric hamstrings Eccentric quadriceps Eccentric hamstrings
69.7 89.3 67.7 83.7
(3.43) (4.20) (3.38) (3.84)
Figures for standard errors are shown in brackets.
No drain 72.4 92.6 70.5 88.1
(3.09) (6.22) (3.78) (5.83)
R. Straw et al. / The Knee 10 (2003) 283–285
the past 15 years w1,2x. However, its reliability remains an issue since 100% effectiveness is not reproduced and an abundance of papers continue to be published commenting on the short term and long term results of ACL reconstruction. However, relatively few papers appear commenting on those operative specifics, which although perhaps not important in the eye of the surgeon are important in the eyes of the patient. In particular, the senior surgeon had noticed prior to embarking on this study that several of his patients commented that removal of the drain was the aspect they disliked the most following surgery. Opinions are divided about the routine use of an intra-articular drain following this procedure. Some surgeons advocate the use of a drain as they feel that all cavities must be drained following surgery to decrease the theoretical risk of intra-articular adhesions and joint stiffness w3x. However, others feel that the use of a drain might increase the risk of infection or cause damage to the graft or articular surfaces of the knee. The aim of this study was to compare the use of an intra-articular drain to no drainage following arthroscopically assisted ACL reconstruction. We used an independent observer to assess outcome measures. Our study found that the use of a drain does not appear to make any difference beyond 2 weeks following surgery. Although there was a significant difference in postoperative swelling and ROM at the 2-week follow up, this difference had settled within 4 weeks of surgery. Furthermore, several patients in the study reported that removal of the drain was the part of the operation they disliked the most. Drain removal was perceived painful. The strength of this study was that the patients were operated on in a prospective randomised manner. A blinded observer who was unaware whether or not a drain had been used following surgery assessed outcome measures.
285
Follow up is relatively short but as there was no discernible difference between the two groups at 4 weeks, we felt that the 6-month follow up was an appropriate time for us to report our findings. In terms of function, there was no difference between the two groups. Studies evaluating the use of closed suction drains following hip and knee replacements have reported similar findings with no difference in outcome between patients treated with or without a drain w5,6x. As the use of a drain carries the disadvantage of pain with removal as well as potential and theoretical risks of damage to the graft and infection, we recommend that no drains be used following routine arthroscopically assisted ACL reconstruction. In addition, demonstrating safety of ACL reconstruction without a drain is important if the procedure is to be performed as a day case. The senior author has therefore omitted the use of a drain from his current practice. References w1x Noyes FR, Barber-Westin SD. A comparison of results in acute and chronic ligament ruptures of arthroscopically assisted autogenous patella tendon reconstruction. Am J Sports Med 1997;25(4):460 –471. w2x Dandy DJ, Hobby JL. Anterior cruciate ligament reconstruction. J Bone Joint Surg Part B 1998;80:189 –190. w3x O’Driscoll SW, Kumar A, Salter RB. The effect of continuous passive motion on the clearance of a haemarthrosis from a synovial joint. An experimental investigation in the rabbit. Clin Orth 1983;176:305 –311. w4x Shelbourne KD, Wilcklins JH. Current concepts in anterior cruciate ligament rehabilitation. Orth Rev 1990;19(11):957 – 964. w5x Ritter MA, Keating EM, Faris PM. Closed wound drainage in total hip or total knee replacement. A prospective, randomized study. J Bone Joint Surg Part A 1994;76:35 –38. w6x Niskanen RO, Korkala OL, Haapala J, Kuokkanen HO, Kaukonen JP, Sala SA. Drainage is of no use in primary uncomplicated hip and knee arthroplasty for osteoarthritis: a prospective randomized study. J Arthroplasty 2000;15(5):567 – 569.
Arthroscopically assisted ACL reconstruction. Is a drain necessary? Robert Straw, Karen Colclough, Guido G. Geutjens* Department of Orthopaedic Surgery, Derbyshire Royal Infirmary, Derby, UK Received 26 September 2002; received in revised form 3 October 2002; accepted 4 November 2002
Abstract We report on the results of a prospective randomised controlled trial to evaluate the use of an intra-articular drain following arthroscopically assisted ACL reconstruction using patellar tendon autograft. Forty-nine patients were recruited for the trial and randomised into receiving or not receiving a drain following surgery. An independent observer who was blinded for the use of the drain assessed the knees for swelling, range of movement (ROM) and pain at 2, 4 and 6 weeks postoperatively. Muscle strength was assessed at 12 weeks following surgery using the KIN COM III isometric dynamometer. We found that the knees that were drained following surgery initially had less swelling and a better ROM. However, at 4 weeks this difference had disappeared. At 3 and 6 months, there was no functional difference between the two groups. We recommend that no drain be used following ACL reconstruction as removal of the drain is uncomfortable and carries theoretical and avoidable risks. 䊚 2002 Elsevier Science B.V. All rights reserved. Keywords: ACL reconstruction; Drain
1. Introduction Arthroscopically assisted ACL reconstruction has become an established and reproducible procedure in the past 15 years w1,2x. However, its reliability remains an issue since 100% effectiveness is not reproduced. Opinions are divided about the routine use of an intraarticular drain following this procedure. Some surgeons advocate the use of a drain as they feel that all cavities must be drained following surgery to decrease the theoretical risk of intra-articular adhesions and joint stiffness w3x. However, others feel that the use of a drain might increase the risk of infection or cause damage to the graft and articular surfaces of the knee. Furthermore, patients dislike the pain associated with removal of the drain.
study. Informed consent was taken from all patients who were then randomly allocated to either receiving or not receiving a drain. Randomisation was performed by means of the last digit of the patients’ hospital number. Patients with chronic knee instability due to ACL laxity undergoing arthroscopically assisted ACL reconstruction using the middle third of the patellar tendon as a graft were recruited into the study. Patients who underwent reconstruction using hamstring grafts or revision ACL reconstruction were excluded. There were no differences between the two groups concerning age, sex, activity levels and time between rupture and reconstruction and all patients had a full range of movement (ROM) (as compared to the opposite knee) prior to surgery. 3. Operative procedure
2. Subjects and methods Approval from our Hospital Trust Ethics Committee was requested and obtained prior to commencing the *Corresponding author. Department of Trauma and Orthopaedics, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK. Tel.: q44-1332-347141x4192; fax: q44-1332-254950. E-mail address: [email protected] (G.G. Geutjens).
All procedures were performed by the senior surgeon (G. G). A tourniquet was used routinely and the leg was exsanguinated by simple elevation for a minimum of 2 min. A Rhys–Davies exsanguinator was not used. A notchplasty was performed if necessary. The middle third of the patellar tendon was harvested as a 10-mm bone–tendon–bone graft. A single incision endoscopic technique with the femoral tunnel drilled through the
0968-0160/03/$ - see front matter 䊚 2002 Elsevier Science B.V. All rights reserved. PII: S 0 9 6 8 - 0 1 6 0 Ž 0 2 . 0 0 1 5 0 - 3
R. Straw et al. / The Knee 10 (2003) 283–285
284
Table 1 Difference in circumference (cm) between the operated and contralateral knee Follow up
Drain
No drain
2 week 4 week 6 week
1.3 (0.97) 1.2 (0.18) 1.0 (0.40)
1.9 (0.16) 1.1 (0.14) 1.1 (0.34)
P-0.002 Ps0.47 Ps0.47
Table 2 ROM (8) Follow up
Drain
No drain
2 week 4 week 6 week
108 (1.80) 124 (1.15) 133 (1.24)
99 (2.60) 120 (1.86) 134 (1.36)
P-0.002 Ps0.14 Ps0.57
Figures for standard errors are shown in brackets.
Figures for standard error are shown in brackets.
tibial tunnel was used. The graft was secured in the tunnels using a metal interference screw 1 mm smaller than the diameter of the tunnel. A suction drain was inserted via the fluid drainage portal in those patients randomised into receiving a drain and left for 16–20 h before removal. The amount of blood collected by each drain was documented. All procedures were done as inpatient procedures with an average postoperative hospital stay of 26 h. 4. Postoperative regimen Postoperatively, a compression bandage and cryocuff were routinely used. CPM was commenced on the day of surgery and continued on the first postoperative day. Patients were then enrolled in an accelerated ACL rehabilitation program as described by Shelbourne w4x. ACL braces were not used. 5. Follow up evaluation All patients were evaluated at 2, 4 and 6 weeks postoperatively for pain, swelling and ROM by an experienced physiotherapist (K. C) who was blinded to the use of a drain. Muscle strength was assessed using the KIN COM III isometric dynamometer at 12 weeks following surgery. Pain was assessed using a 10-cm visual analogue scale and the ability to perform a straight leg raise. Knee swelling was demonstrated by the presence of an effusion and compared to the contralateral knee by measuring the circumference at the level of the base of the patella. ROM was documented. Patient satisfaction and knee function were recorded at 6 months. 6. Results Forty-nine patients were enrolled into the study. Two patients decided not to continue their physiotherapy rehabilitation protocol and therefore 47 patients were available for follow up. Twenty-four patients received a drain and 23 patients had no drain inserted at the time of surgery. In the drain group the mean age of the patients was 27.2 years (range 16–49) with 15 male patients and 9 female. The demographics of those patients not receiving a drain were not dissimilar with a
mean age of 26.4 years (range 18–43) with 15 male patients and 8 female. The mean drainage was 120 ml (range 10–300 ml). There were no post-operative complications; no knee required an aspiration and all grafts were functional at 6-month follow up. There was little difference in pain between the groups at the 2-week follow up. The mean visual analogue score for the drain group was 2.2 compared to 2.4 in those patients without a drain and all patients were able to perform a straight leg raise. Patients receiving a drain following surgery showed slightly less swelling (Table 1) and a marginally better ROM at the 2-week follow up (Table 2). Two patients exhibited extension deficits in the drain group compared to 5 patients in those without a drain at the 2-week follow up. However, only 1 patient had an extension deficit at the subsequent review 2 weeks later. Muscle strength testing was conducted in all patients 3 months after surgery using the KIN COM III isometric dynamometer. Eccentric and concentric measurements were recorded for both quadriceps and hamstrings. Both groups showed similar results with hamstrings having the least dysfunction post operatively compared to quadriceps (Table 3). In testing for a difference between the two groups, the 2-week data for both knee swelling and ROM both gave a P-value of 0.002 using the t-test. Therefore, there is strong evidence to reject the null hypothesis of no difference between the groups at this time. However, at the 4- and 6-week follow up the P-values were 0.14, 0.47, 0.47 and 0.57, which are not significant. In addition, no significant difference was found between the two groups when comparing muscle strength. 7. Discussion Arthroscopically assisted ACL reconstruction has become an established and reproducible procedure in Table 3 Isometric dynamometer testing (% operated vs. unoperated side) Muscle test
Drain
Concentric quadriceps Concentric hamstrings Eccentric quadriceps Eccentric hamstrings
69.7 89.3 67.7 83.7
(3.43) (4.20) (3.38) (3.84)
Figures for standard errors are shown in brackets.
No drain 72.4 92.6 70.5 88.1
(3.09) (6.22) (3.78) (5.83)
R. Straw et al. / The Knee 10 (2003) 283–285
the past 15 years w1,2x. However, its reliability remains an issue since 100% effectiveness is not reproduced and an abundance of papers continue to be published commenting on the short term and long term results of ACL reconstruction. However, relatively few papers appear commenting on those operative specifics, which although perhaps not important in the eye of the surgeon are important in the eyes of the patient. In particular, the senior surgeon had noticed prior to embarking on this study that several of his patients commented that removal of the drain was the aspect they disliked the most following surgery. Opinions are divided about the routine use of an intra-articular drain following this procedure. Some surgeons advocate the use of a drain as they feel that all cavities must be drained following surgery to decrease the theoretical risk of intra-articular adhesions and joint stiffness w3x. However, others feel that the use of a drain might increase the risk of infection or cause damage to the graft or articular surfaces of the knee. The aim of this study was to compare the use of an intra-articular drain to no drainage following arthroscopically assisted ACL reconstruction. We used an independent observer to assess outcome measures. Our study found that the use of a drain does not appear to make any difference beyond 2 weeks following surgery. Although there was a significant difference in postoperative swelling and ROM at the 2-week follow up, this difference had settled within 4 weeks of surgery. Furthermore, several patients in the study reported that removal of the drain was the part of the operation they disliked the most. Drain removal was perceived painful. The strength of this study was that the patients were operated on in a prospective randomised manner. A blinded observer who was unaware whether or not a drain had been used following surgery assessed outcome measures.
285
Follow up is relatively short but as there was no discernible difference between the two groups at 4 weeks, we felt that the 6-month follow up was an appropriate time for us to report our findings. In terms of function, there was no difference between the two groups. Studies evaluating the use of closed suction drains following hip and knee replacements have reported similar findings with no difference in outcome between patients treated with or without a drain w5,6x. As the use of a drain carries the disadvantage of pain with removal as well as potential and theoretical risks of damage to the graft and infection, we recommend that no drains be used following routine arthroscopically assisted ACL reconstruction. In addition, demonstrating safety of ACL reconstruction without a drain is important if the procedure is to be performed as a day case. The senior author has therefore omitted the use of a drain from his current practice. References w1x Noyes FR, Barber-Westin SD. A comparison of results in acute and chronic ligament ruptures of arthroscopically assisted autogenous patella tendon reconstruction. Am J Sports Med 1997;25(4):460 –471. w2x Dandy DJ, Hobby JL. Anterior cruciate ligament reconstruction. J Bone Joint Surg Part B 1998;80:189 –190. w3x O’Driscoll SW, Kumar A, Salter RB. The effect of continuous passive motion on the clearance of a haemarthrosis from a synovial joint. An experimental investigation in the rabbit. Clin Orth 1983;176:305 –311. w4x Shelbourne KD, Wilcklins JH. Current concepts in anterior cruciate ligament rehabilitation. Orth Rev 1990;19(11):957 – 964. w5x Ritter MA, Keating EM, Faris PM. Closed wound drainage in total hip or total knee replacement. A prospective, randomized study. J Bone Joint Surg Part A 1994;76:35 –38. w6x Niskanen RO, Korkala OL, Haapala J, Kuokkanen HO, Kaukonen JP, Sala SA. Drainage is of no use in primary uncomplicated hip and knee arthroplasty for osteoarthritis: a prospective randomized study. J Arthroplasty 2000;15(5):567 – 569.