Drainage versus nondrainage in simultaneous bilateral total hip arthroplasties

The Journal of Arthroplasty Vol. 13 No. 2 1998

Drainage Versus Nondrainage in Simultaneous Bilateral Total Hip Arthroplasties Young-Hoo Kim, MD,* Soon-Ho Cho, MD,* and Ryuh-Sup Kim, MD~-

Abstract: A prospective study of 48 patients (96 hips) who had undergone primary

simultaneous bilateral total hip arthroplasty was conducted to assess the effect of postoperative suction drainage on wound healing and infection. A suction drain was placed by randomization of the drained versus undrained side. The same surgical technique was used in alI total hip arthroplasty wounds. Statistical analysis of the results showed significant differences with respect to drainage from the wound, soaked dressings requiring reinforcements, ecchymosis, and erythema about the wound in the group without drainage. There was no specific correlation between the incidence of wound complications and infection after total hip arthroplasty and the use or nonuse of closed-suction drainage. The hip score and range of motion of the hip were unaffected by the use or nonuse of the drains. The cost of 1 set of hemovac drains is $135 and the cost for 4-5 dressings and bed sheet changes is about $50. Although the hemovac is more expensive, the authors recommend the routine use of suction drains for wounds after primary total hip arthroplasty to reduce drainage, soaked dressings requiring reinforcement, ecchymosis and erythema around the wound, and psychological impact on the patient's fear of bleeding. K e y w o r d s : total hip arthroplasty, suction drains, hip score, wound drainage, ecchymosis, erythema.

A postoperative h e m a t o m a after total hip arthroplasty (THA) m a y be an i m p o r t a n t factor contributing to the d e v e l o p m e n t of prolonged drainage, delayed w o u n d healing, and infection of the w o u n d . Closed d e e p - s u c t i o n drainage of w o u n d s after m a n y o r t h o p a e d i c p r o c e d u r e s has b e c o m e a n established routine procedure, w i t h the a i m of p r e v e n t i n g w o u n d h e m a t o m a s and t h e r e b y reducing w o u n d complications a n d infection; however, a literature r e v i e w failed to provide a n y firm basis for

the widespread use of this m e t h o d . Some authors h a v e reported that closed deep-suction drainage is effective in reducing w o u n d complications a n d results in a less c o m p l i c a t e d p o s t o p e r a t i v e course [1--4], yet others h a v e failed to support the p e r c e i v e d b e n e f i t of suction d r a i n a g e of w o u n d s {5-17]. To clarify the role of closed deep-suction drainage after THA, the results of a prospective study of 48 patients w h o u n d e r w e n t s i m u l t a n e o u s bilateral prim a r y THA are described. A drain was placed b y r a n d o m i z a t i o n of the drained versus u n d r a i n e d side. All r a n d o m i z a t i o n procedures w e r e done with the assistance of the staff of the University Biomedical C o m p u t a t i o n Facilities. The site of insertion of drainage was d e t e r m i n e d in accordance with the instructions in a sealed, n u m b e r e d envelope. This e n v e l o p e was chosen f r o m a sequential pool m a i n tained by the statisticians, based on a table of r a n d o m i z e d n u m b e r s . All r a n d o m i z a t i o n procedures w e r e p e r f o r m e d before the surgeon started

From the *Joint Replacement Center of Korea at Cha General Hospital affiliated with Pochon Cha University College of Medicine, SeouL Korea, and the ~Department of Orthopedic Surgery, InHa University College of Medicine, InChon, Korea. Read in part at the 63rd annual meeting of the American Academy of Orthopaedic Surgeons, Atlanta, Geor~a, February 1996. Reprint requests: Young-FIoo Kim, MD, Joint Replacement Center of Korea at Cha General Hospital, affiliated with Pochon Cha University College of Medicine, YeokSam-1 Dong 650-9, KangNam-Gu, Seoul, Korea. Copyright © 1998 Churchill Livingstone. 0883- 5403/1302-000555.00/0

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operating. A drain was placed on the right side in 24 patients and on the left side in 24 patients.

Materials and Methods We investigated 51 consecutive patients w h o u n d e r w e n t primary simultaneous bilateral THA at the Joint Replacement Center of Korea. All patients were analyzed on an intention-to-treat basis. Of 51 patients w h o u n d e r w e n t THA, 48 patients (96 hips) were included in the study. Three patients w h o had b e e n included initially were disqualified for the study because a drain was r e m o v e d accidentally and therefore were excluded. All surgeries were p e r f o r m e d by the senior a u t h o r (Y.H.K.). The majority of patients had a preoperative history of using nonsteroidal antiinflammatory drugs. Some patients had also used corticosteroids before surgery. Therefore, an extensive study was made of coagulation factors including platelet count, p r o t h r o m b i n time, partial thromboplastin time, antithrombin III level, and m o r n i n g and afternoon cortisol levels. All patients were asked to discontinue all nonsteroidal and steroidal medications 2 weeks before the operation. Abnormal findings were corrected before the operation. To eliminate the possible influence of age, sex, systemic disease, reaction to medication, and effort and differences in rehabilitation, the patients served as their o w n control subjects. The same surgical technique was used in all wounds. H e m o v a c drains were r e m o v e d 24 hours after the operation. Patients' sex, age, body weight, height, diagnosis, and follow-up period are listed in Table 1. The THA procedure was p e r f o r m e d with the patients u n d e r general or epidural normotensive anesthesia using a modified Gibson approach in all patients. In all patients, an epidural catheter was left

Table 1. Data o n t h e 48 Patients W h o U n d e r w e n t Total Hip Arthroplasty Variable No. of cases (no. of hips) Sex (M/F) Age Diagnosis (%) Avascular necrosis Osteoarthritis Spondyloepiphyseal dysplasia Rheumatoid arthritis Ankylosing spondylitis Legg-Perthes disease Weight (kg) Height (cm) Follow-up period (mo)

Patients 48 (96) 38/10 48.2 (range, 22-76) 30 (62.5) 8 (16.7) 3 (6.2) 3 (6.2) 2 (4.2) 2 (42) 59.9 (range, 36-78) I59.1 (range, 141-178) 15 (range, 14-27)

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in place for 48 hours to control postoperative pain. Hemostasis was done with electrocautery. All 48 patients (96 hips) received cementless Duraloc 100 or 1,200 series acetabular c o m p o n e n t s (DePuy, Warsaw, IN) on both sides. All patients (96 hips) received a cementless Profile femoral stem (DePuy) on both sides. The Barovac closed-wound drainage system (Sewon Medical, Sewon, Korea) with an external diameter of 3.2 m m was used. Two drains were used in each case, both placed deeply beneath the fascia lata. After surgery, the patients remained in bed for 36 hours, and t h e n progressive gait and strengthening exercises were instituted. No patient received prophylactic medication for deep vein thrombosis on the basis of the low incidence of deep vein thrombosis in Korean patients after THA [18]. The w o u n d s were assessed by all authors for the absence or presence of drainage and soaked dressings requiring reinforcement, 12, 24, and 36 hours after the operation, and subjective pain and ecchymosis and erythema a r o u n d the w o u n d on the second, fifth, and seventh days and sixth week after surgery. To compare the amounts of drainage and soaked dressings quantitatively on each side, 20 layers of preweighed sterile gauze were applied on each side in the operating room. W h e n the dressing was changed, usually b e t w e e n 12 and 36 hours after the operation, the gauze soaked with blood from each side was weighed to assess the a m o u n t of drainage quantitatively. The degree of e r y t h e m a on each side was compared by measuring the reddened area a r o u n d the wound. Also, the degree of ecchymosis on each side was c o m p a r e d by measuring the area of bluish discoloration a r o u n d the w o u n d site. Subjective pain was assessed by asking the patient w h e t h e r 1 side was more painful. The a m o u n t of swelling was assessed on the second, fifth, and seventh days and sixth week after surgery by measuring the circumference of the extremity at the middle of the thigh. W o u n d h e m a t o m a was assessed by ultrasound scanning on the sixth or seventh day [19,20]. The hip region was examined on the sixth or seventh day after the operation by removing the dressing and spraying the w o u n d with a plastic sealant. A film of lubricating jelly was applied to act as a coupling agent, and, with a 3.5- or 5-MHz transducer, ultrasound scans were made in transverse and longitudinal planes along the region of the w o u n d . After surgery, an echo-free or echo-poor area indicates a h e m a t o m a . A m o u n t of h e m a t o m a in the sonogram was classified arbitrarily as none,

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small, and large. Absence of h e m a t o m a was classified as none. If the h y p o e c h o g e n i c density was b e t w e e n 1 and 9 m m thick, it was classified as a small h e m a t o m a . If it was m o r e t h a n 10 m m thick, it was classified as a large h e m a t o m a . The location of the h e m a t o m a was assessed as superficial or deep to the fascia lata. The status of w o u n d healing and infection was assessed at follow-up examinations at 6 weeks, 3 months, 6 months, and 1 year. Hip scores as described by Harris [21] were recorded before surgery and at 6 weeks, 3 months, 6 months, and t h e n yearly after surgery. Statistical evaluation was p e r f o r m e d by chisquare analysis and unpaired t-tests.

Results In 3 of 48 w o u n d s (6.3%) with suction drains and 11 of 48 w o u n d s (22.9%) w i t h o u t suction drains, there was drainage from the w o u n d site and soaked dressings requiring r e i n f o r c e m e n t at 12, 24, or 36 hours after surgery (Table 2). No hips with suction drains had drainage or soaked dressings on the seventh day. In contrast, 6 hips (I2.5%) w i t h o u t suction drains had drainage and soaked dressings on the second postoperative day and 1 hip (2.1%) had drainage and soaked dressings on the seventh postoperative day. Amounts of drainage in the drained and n o n d r a i n e d groups were compared (Table 2). In 3 hips (6.3%) with suction drains and 11 hips (22.9%) w i t h o u t suction drains, there were ecchymosis and e r y t h e m a a r o u n d the w o u n d site on the second, fifth, and seventh postoperative days (Tables 3, 4); the difference b e t w e e n sides was statistically significant. The average a m o u n t of drainage was 653 mL (range, 230-940 mL) and the average n u m b e r of units transfused was 4.9 units (range, 2-8 units). In the sixth postoperative week, w o u n d s in neither group had drainage, soaked dressings

Table 3. A r e a o f E r y t h e m a (cm z) A f t e r Total H i p Replacement

Postoperative Day

2 5 7

Drained Group

Nondrained Group

3 hips (6.3%): 10.5 (5-12) 3 hips (6.3%): 11.8 (7-4) 3 hips (6.3%): 8.6 (5-11)

11 hips (22.9%}: 12.7 (8-4) 11 hips (22.9%): 15.9 (8-17) 11 hips (22.9%): 10.7 (9-15)

P

< .05 < .05 < .05

ecchymosis, or erythema. The drainage persisted (from the drain hole) after the seventh day in 32 w o u n d s (66.7 % ) in which drains had been inserted. No w o u n d s had persistent serious drainage from the drain hole site on the f o u r t e e n t h postoperative day. No w o u n d had clinical signs of infection, and incision and drainage were not needed. At the 6-week and 3 - m o n t h postoperative examinations, both w o u n d s in all 48 patients were well healed. This j u d g m e n t was substantiated by a continued observation of the patient during the follow-up period. The results of ultrasound examination for hematoma 6 or 7 days after THA are summarized in Table 5. All h e m a t o m a s were located deep to the fascia lata (Fig. 1). Thirteen of the 48 w o u n d s (27.1%) in which suction drainage was used and 4 of the 48 n o n d r a i n e d w o u n d s (8.3%) did not have hematomas; this difference was statistically significant. This finding suggests 2 possibilities: ( 1 ) the use of suction drains m a y not evacuate h e m a t o m a s completely in the hip joint; (2) small h e m a t o m a s reaccumulated in the hip joint after the drain was r e m o v e d 24 hours after surgery. Twenty-two drained w o u n d s (45.8%) and 18 n o n d r a i n e d w o u n d s (37.5%) had small hematomas; this difference was not statistically different. Thirteen drained w o u n d s (27.1%) and 26 n o n d r a i n e d w o u n d s (54.2%) had large hematomas; this difference was statistically significant. During the 5-day interval from the second to the seventh postoperative days, the w o u n d s s h o w e d an

Table 2. Amount of Drainage (cm2) (Weight of Gauze

[g] ) After Total Hip Replacement Postoperative Hour

Drained Group

Nondrained Group

At operating time 42.3-45.6 42.5-46.2 (average, 43.5) (average, 43.7) 12 124-150.8 258-270.2 (136.5) (269.8) 24 100.3-138.2 202.5-278.4 (112.8) (226.2) 36 50.8-100.2 102.3-198.2 (70.8) (167.2)

Table 4. Area of Ecchymosis (cm2)

After Total Hip Arthroplasty P > .05

Postoperative Day

< .001

2

> .001

5

< .05.

7

Drained Group

Nondrained Group

3 hips (6.3%): 26.3 (18-28) 3 hips (6.3%): 32.3 (24-34) 3 hips (6.3%): 32.6 (25-35)

11 hips (22.9%): 29.7 (22-32) 1i hips (22.9%): 35.7 (33-44) 11 hip (22.9%): 36.8 (34-45)

P < .05 < .05 < .05

Drain Versus NondrainAfterTHA

Table 5. Results of Ultrasound Examination for Hematoma Hematoma Size

Nondrained Group

Drained Group

P

None Small Large

4 hips (8.3%) 18 hips (37.5%) 26 hips (54.2%)

13 hips (27.1%) 22 hips (45.8%) 13 hips (27.1%)

< .05 > .05 < .05

average decrease in swelling of 2.2 cm on the drain side and 2.0 cm on the n o n d r a i n e d side. This difference was not statistically significant. The preoperative hip score on the drained side averaged 40 points, and that on the n o n d r a i n e d side, 44 points. At the 6-week, 3-months, 6-month, and 1-year follow-up examinations, hip scores averaged 79, 86, 97, and 99 points on the drained side and 79, 89, 96, and 98 points on the n o n d r a i n e d side, respectively. There were no significant differences in the symptoms of pain w h e n the drained and n o n d r a i n e d sides were compared. Preoperative total arc of m o t i o n averaged 154 ° and 159 ° on the drained and n o n d r a i n e d sides. At the 6-week, 3-month, 6-month, and 1-year follow-up examinations, the total arc of motion e,n the drained side averaged 169 °, 190 °, 234 °, and 240 °, respectively, and on the n o n d r a i n e d side, 159 °, 176 °, 191 °, and 240 °, respectively. There were no statistical differences b e t w e e n the two groups with respect to the parameters measured.

Discussion Questions have arisen as to w h e t h e r suction drainage systems for w o u n d s after total joint arthroplasty have any benefit. In theory, a perforated plastic tube with suction applied will evacuate any developing h e m a t o m a from the operative field and p r o m o t e w o u n d healing; however, few studies have b e e n done providing a firm basis for the widespread use of this m e t h o d after THA or total knee arthroplasty. Waugh and Stinchfield support the use of suction drainage after various orthopaedic procedures and state that it prevents h e m a t o m a s in w o u n d s and decreases the rate of infection [4]. In contrast, other investigators have f o u n d that insertion of a drain after THA does not significantly affect the incidence of w o u n d complications [5,10,17]. In this series, the THA w o u n d s w i t h o u t drains had higher incidences of drainage from the w o u n d site,

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soaked dressings requiring reinforcement, and ecchymosis and e r y t h e m a t h a n did the w o u n d s with drains on the second, fifth, and seventh postoperative days. In the sixth postoperative week, no w o u n d s in either group had drainage, soaked dressings, ecchymosis, or erythema; however, persistent drainage from the drain site after the seventh day occurred only in the w o u n d s with drains (66.7%). No w o u n d s h o w e d clinical signs of infection. All w o u n d s were judged to be well healed during the follow-up period. This study supports the view that a w o u n d drain reduces drainage, soaked dressings requiring r e i n f o r c e m e n t , eccyhmosis, and e r y t h e m a by decreasing the a m o u n t of blood escaping t h r o u g h the w o u n d or leaking into the surrounding soft tissues. Also, the result of this study supports the view that the use or n o n u s e of closed suction drainage does not affect the incidence of w o u n d complications or infection after THA. Substantial evidence exists for the migration of skin microorganisms into a w o u n d along a drain. After laboratory experiments, it was postulated that organisms spread in a retrograde m a n n e r in static serum columns in polyethylene drainage tubing [8]. Nora et al. reaffirmed this concept [15]. More recently, Raves et al. showed that, with simple conduit drains, retrograde migration of bacteria occurs with relatively high frequency (75-90%) by 72 hours; with closed-suction drainage, the freq u e n c y is m u c h lower (20%) [16]. The results of this study do not affirm the risk of ingress of skin microorganisms into the w o u n d by way of either the drain or the drain track with an increased rate of w o u n d sepsis. Early removal of the h e m o v a c drain in this series appears to be a cause of the absence of retrograde infection. Magnussen et al. reported that ultrasound scanning is a useful tool for detecting hematomas. They showed a significant correlation b e t w e e n the presence of a large h e m a t o m a and the d e v e l o p m e n t of an unsatisfactory w o u n d [ 19, 20]. In this study with ultrasound examination, nondrained w o u n d s had higher incidence of deep, large h e m a t o m a s ( 54.2 % ) than drained w o u n d s (27.1% ). There was no correlation b e t w e e n the presence of a large h e m a t o m a and the d e v e l o p m e n t of an unsatisfactory w o u n d . Some authors have reported that there are no differences in hip scores and range of m o t i o n of the hip b e t w e e n THAs in which suction drains are placed and those in which drains are not used [5,9]. This study confirms the reports that the presence or

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Fig. 1. Results of ultrasound examination for h e m a t o m a in both hips of a 48-year-old m a n with avascular necrosis of both [emoral heads. (A) A 1.6 × 0.5 × 1.5-cm echo-poor area (small a m o u n t of hematoma) in the right hip with drainage. (B) A 10 × 2.8 x 1.2-cm echo-poor area in the left hip without drainage.

a b s e n c e of a d r a i n h a s n o effect o n h i p score a n d r a n g e of m o t i o n of t h e hip. This s t u d y also s h o w s t h a t s t a t i s t i c a l l y s i g n i f i c a n t differences included drainage from the wound, soaked dressings requiring reinforcement, ecchymos i s , a n d e r y t h e m a in t h e g r o u p w i t h o u t d r a i n s

a f t e r THA. T h e r e w a s n o specific c o r r e l a t i o n b e t w e e n t h e i n c i d e n c e of w o u n d c o m p l i c a t i o n s a n d i n f e c t i o n a f t e r T H A a n d t h e u s e o r n o n u s e of c l o s e d - s u c t i o n d r a i n a g e . I n s e r t i o n of a d r a i n a f t e r THA d i d n o t i n f l u e n c e t h e p o s t o p e r a t i v e c o u r s e o r r e h a b i l i t a t i o n of t h e p a t i e n t .

Drain Versus NondrainAfterTHA

T h e cost of 1 set of h e m o v a c d r a i n s is $135 a n d t h e cost for 4 - 5 d r e s s i n g s a n d b e d s h e e t c h a n g e s is a b o u t $50. A l t h o u g h t h e h e m o v a c is m o r e e x p e n sive, w e r e c o m m e n d t h e r o u t i n e u s e of s u c t i o n d r a i n s for w o u n d s a f t e r p r i m a r y T H A to r e d u c e drainage, soaked dressings requiring reinforcement, ecchymosis, erythema, and psychological impact on t h e p a t i e n t ' s fear of b l e e d i n g .

References 1. Alexander JW, Korelitz J, Alexander NS: Prevention of w o u n d infections: a case for closed suction drainage to remove w o u n d fluids deficient in opsonic proteins. Am J Surg 132:59, 1976 2. Cruse PJE, Foord R: A five-year prospective study of 23,649 surgical wounds. Arch Surg 107:206, 1973 3. Morris AM: A controlled trial of closed w o u n d s~action drainage in radical mastectomy. Br J Surg 60:357, 1973 4. Waugh TR, Stinchfield FE: Suction drainage of orthopaedic wounds. J Bone Joint Surg 43A:939, 1961 5. Beer K J, Lombardi AV Jr, Mallory TH, Vaughn BK: The efficacy of suction drains after routine total joint arthroplasty. J Bone Joint Surg 73A:584, 1991 6. Browett JE Gibbs AN, Copiland SA, Deliss LJ: The use of suction drainage in the operation of meniscectomy. J Bone Joint Surg 60B:516, 1978 7. Bryan RS, Dickson JH, Taylor WF: Recovery of the knee following meniscectomy: an evaluation of suction drainage and cast immobilization. J Bone Joint Surg 51A:973, 1969 8. Cerise E J, Pierce WA, Diamond DL: Abdominal drains: their role as a source of infection following splenectomy. Ann Surg 171:764, 1970 9. Cobb JP: W h y use drains? J Bone Joint Surg 72B:993, 1990

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10. Hadden WA, McFarlane AG: A comparative study of closed-wound suction drainage vs. no drainage in total hip arthroplasty. J Arthroplasty 5 (suppl):S2I, 1990 l i. Healy DA, Keyser J I I I , Halcomb GW III et ah Prophylactic closed suction drainage of femoral wounds in patients undergoing vascular reconstruction. JVasc Surg 10:166, 1989 12. Jepsen OB, Larsen SO, Thomsen VF: Post-operative w o u n d sepsis in general surgery: an assessment of factors influencing the frequency of w o u n d sepsis. Acta Chir Scand Suppl 396:80, 1969 13. Lidwell OM: Sepsis in surgical wounds: multiple regression analysis applied to records of postoperative hospital sepsis. J Hyg 59:259, 1961 i4. Magee C, Rodehearer GT, Golder GT et al: Potentiation of w o u n d infection by surgical drains. Am J Surg 131:547, 1976 15. Nora PF, Vanecko RM, Bransfield J J: Prophylactic abdominal drains. Arch Surg 105:173, 1972 16. Raves JJ, Slifkin M, Diamond DL: A bacteriologic study comparing closed suction and simple conduit drainage. Am J Surg 148:618, 1984 17. Willett KM, Simmons CD, Bentley G: The effect of suction drains after total hip replacement. J Bone Joint Surg 70B:607, I988 I8. Kim Y-H, Suh JS: Low incidence of deep vein thrombosis after cementless total hip replacement. J Bone Joint Surg 70A:878, i988 19. Magnussen PA, Crozier AE, Gregg PJ: Detecting hematomas by ultrasound: brief report. J Bone Joint Surg 70B:150, 1988 20. Magnussen PA, Jackman JSG, Iyer S, A d a m EJ: A study of w o u n d h e m a t o m a after hip surgery using ultrasound. J Bone Joint Surg 68B:497, 1986 21. Harris WH: Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty: an end-result study using a new method of result evaluation. J Bone Joint Surg 51A:737, 1969