Prophylactic Wound Drainage in Orthopaedics: A Comparative Evaluation of Closed Suction Drainage versus No-Drainage in a Nigerian Teaching Hospital

Ikpeme A. Ikpeme, Ngim E. Ngim, Iniabasi U. Ilori, Enembe Oku, Anthony M. Udosen

Departments of Anaesthesiology, University of Calabar Teaching Hospital, Calabar, Nigeria.
Departments of Community Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria.
Departments of Orthopaedics & Traumatology, University of Calabar Teaching Hospital, Calabar, Nigeria.

DOI: 10.4236/ss.2013.45054                

Abstract

Background: Surgical wound drainage is practiced routinely by many orthopaedic surgeons despite studies that challenge the practice. Among proponents, the advantages of drainage include prevention of haematoma and/or seroma formation which potentially reduces the chances for infection, prevention of wound swelling, prevention of compartment syndrome and improvement of the local wound environment. Opponents argue that prophylactic wound drainage confers no significant advantages, increases the risk of infection and the need for blood transfusion with the attendant risks of this therapy. Aim: To ascertain if prophylactic drainage of clean orthopaedic wounds confer any significant advantages by evaluating wound and systemic factors in two treatment groups. Patients and Methods: A prospective analysis of 62 patients was undergoing clean orthopaedic procedures. The patients were randomly assigned to a “No drain” (study) group and a “drain” (control) group. Each group had 31 patients. Surgeons were blinded to the randomization process and the evaluation of clinical outcomes. The parameters assessed included pain, superficial wound infection, the need for post-operative transfusion, wound leakage, dressing changes and the surgery-discharge interval. Data was analysed using SPSS statistics version 20 (IBM Corp., New York). Results: There were no significant differences in the demographic data. Femoral fractures were the commonest indication for surgery (43.55%), and plate and screw osteosynthesis was the commonest procedure (48.4% in the drain group and 67.7% in the no-drain group). There was a significantly higher need for post-operative transfusion in the drain group (22.6% against 0%) as well as a significantly prolonged capillary refill time (2.39 + 0.56 secs versus 2.03 + 0.41 secs). Although not statistically significant, there were four cases (12.8%) of superficial wound infection in the drain group and 1 case (3.2%) in the no-drain group. Conclusion: Prophylactic wound drainage confers no significant advantages over no drainage and may contribute to increased treatment costs through an increased post-operative transfusion requirements.

Keywords

Wound Drain; No-Drain; Complications; Orthopaedics

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	R. J. Gaines, “The Use of Surgical Drains in Orthopaedics,” Orthopaedics, Vol. 3, No. 31, 2008, pp. 702-705. doi:10.3928/01477447-20110505-06
[2]	J. P. Moss, “Historical and Current Perspectives on Surgical Drainage,” Surgery, Gynecology, and Obstetrics, Vol. 152, No. 4, 1981, pp. 517-527.
[3]	P. S. Barie, “Are We Draining the Life from Our Patients?” Surgical Infections, Vol. 3, No. 3, 2002, pp. 159-160. doi:10.1089/109629602761624162
[4]	R. Clifton, S. Haleem, A. Mckee and M. J. Parker, “Closed Suction Surgical Wound Drainage after Hip Fracture Surgery; a Systematic Review and Meta-Analysis of Randomized Controlled Trials,” International Orthopaedics (SICOT), Vol. 32, No. 6, 2008, pp. 723-727. doi:10.1007/s00264-007-0420-z
[5]	Q. D. Zhang, W. S. Guo, Q. Zhang, Z. H. Liu, L. M. Cheng and Z. R. Li, “Comparison between Closed Suction Drainage and Non-Drainage in Total Knee Arthoplastry: A Meta-Analysis,” Journal of Arthroplasty, Vol. 26, No. 8, 2011, pp. 1265-1272.
[6]	G. Tucci, V. Amorese and E. Romanini, “Closed Suction Drainage after Orthopaedic Surgery: Evidence versus Practice,” Journal of Orthopaedics and Traumatology, Vol. 7, No. 1, 2006, pp. 29-32. doi:10.1007/s10195-006-0118-9
[7]	A. Chandratreya, K. Giannikas and P. Livesky, “To Drain or Not to Drain; Literature versus Practice,” Journal of the Royal College of Surgeons of Edinburgh, Vol. 43, No. 6, 1998, pp. 404-406.
[8]	T. R. Waugh and F. E. Stinchfield, “Suction Drainage of Orthopaedic Wounds,” Journal of Bone and Joint Surgery (American), Vol. 43A, No. 7, 1961, pp. 939-946.
[9]	G. W. Varley and S. A. Milner, “Wound Drains in Proximal Femoral Fracture Surgery: A Randomized Prospective Trial of 177 Patients,” Journal of the Royal College of Surgeons of Edinburgh, Vol. 40, No. 6, 1995, pp. 416-418.
[10]	M. J. Parker, V. Livingstone, R. Clifton and A. Mckee, “Closed Suction Surgical Wound Drainage after Orthopaedic Surgery,” Cochrane Database of Systemic Reviews, No. 3, 2007, Article ID: CD001825.
[11]	A. Loh and P. A. Jones, “Evisceration and Other Complications of Abdominal Drains,” Postgraduate Medical Journal, Vol. 67, No. 789, 1991, pp. 687-688. doi:10.1136/pgmj.67.789.687
[12]	R. R. Durai, A. A. Mownah and P. C. H. Ng, “Use of Drains in Surgery: A Review,” Journal of Perioperative Practice, Vol. 19, No. 6, 2009, pp 180-186.
[13]	S. G. Smith and M. S. Shapiro, “The Use of Drains for Outpatient Orthopaedic Surgeries: Safety and Efficacy,” Ambulatory Surgery, Vol. 5, No. 4, 1997, pp. 145-147. doi:10.1016/S0966-6532(97)00042-5
[14]	G. P. Khanal, R. Rijal, B. P. Shresthra, N. K. Karn and P. Chaudhary, “A Study to Evaluate the Role of Suction Drains in Orthopaedic Surgery,” Health Renaissance, Vol. 9, No. 2, 2011, pp. 91-94. doi:10.3126/hren.v9i2.4980
[15]	J. Walker, “Patient Preparation for Safe Removal of Surgical Drains,” Nursing Standard, Vol. 21, No. 49, 2007, pp. 39-41.
[16]	M. A. Ritter, E. M. Keating and P. M. Faris, “Closed Wound Drainage in Total Hip or Total Knee Replacement,” Journal of Bone and Joint Surgery (American), Vol. 76, No. 1, 1994, pp. 35-38.
[17]	P. J. Walmsley, M. B. Kelly, R. M. F. Hill and I. B. Renkel, “A Prospective, Randomized, Controlled Trial of the Use of Drains in Total Hip Arthroplady,” Journal of Bone and Joint Surgery (British), Vol. 87B, No. 10, 2005, pp. 1397-1401. doi:10.1302/0301-620X.87B10.16221
[18]	T.-W. Tai, C.-Y. Yang and C.-W. Chang, “The Role of Drainage after Total Knee Arthroplastry,” In: S. Forkter, Ed., Recent Advances in Hip and Knee Arthroplastry, In Tech, Shanghai, 2012, pp. 267-274. doi:10.5772/26519
[19]	J. J. Callaghan, “Patient Specific Transfusion Options in Total Hip and Knee Surgery,” Orthopaedics, Vol. 23, No. 9, 2000, pp. 925-926.
[20]	R. H. G. P. Van Erve and A. C. Wiekenkamp, “Transfusion Reduction in Orthopaedic Surgery,” In: P. Kochnar Ed., Blood Transfusion in Clinical Practice, In Tech, Shanghai, 2012, pp. 61-82. doi:10.5772/33920
[21]	D. Ovadia, E. Luger, J. Bickels, A. Menachem and S. Dekel, “Efficacy of Closed Wound Drainage after Total Joint Arthroplasty: A Prospective Randomized Study,” Journal of Arthroplasty, Vol. 12, No. 3, 1997, pp. 317-321. doi:10.1016/S0883-5403(97)90029-2
[22]	J. A. Razzak and A. L. Kellermann, “Emergency Medical Care in Developing Countries: Is It Worthwhile?” Bulletin of the World Health Organization, Vol. 80, No. 11, 2002, pp. 900-905.
[23]	Y. H. Kim, S. H. Cho and R. S. Kim, “Drainage versus Non-Drainage in Simultaneous Bilateral Total Hip Arthroplasties,” Journal of Arthroplasty, Vol. 13, No. 2, 1998, pp. 156-161. doi:10.1016/S0883-5403(98)90093-6
[24]	K. W. Cheung and K. H. Chiu, “Effect of Drain Pressure in Total Knee Arthroplasty,” Journal of Orthopaedic Surgery, Vol. 14, No. 2, 2006, pp. 163-166.
[25]	A. Karbalaeikhani and A. Saied, “Postoperative Drains at the Donor Sites of Iliac-Crest Bone Grafts in Patients Who Had a Single Comminuted Long Bone fracture,” Surgical Science, Vol. 2, No. 9, 2011, pp. 437-441.
[26]	T. W. Tai, I. M. Jou, C. W. Chang, K. A. Lai, C. J. Jin and C. Y. Yang, “Non-Drainage Is Better than 4-Hour Clamping Drainage in Total Knee Arthroplasty,” Orthopaedics, Vol. 33, No. 3, 2010, pp. 156-160.
[27]	C. Li, A. Nijat and M. Askar, “No Clear Advantage to Use of Wound Drains after Unilateral Total Knee Arthroplasty,” The Journal of Arthroplasty, Vol. 26, No. 4, 2011, pp. 519-522.
[28]	K. Panonsis, P. Grigoris and A. E. Strover, “Suction DressIngs in Total Knee Arthroplasty—An Alternative to Deep Suction Drainage,” Acta Orthopaedica Belgica, Vol. 70, No. 4, 2004, pp. 349-354.