DRAINS (Recommendation Against)

This recommendation has been downgraded due to potential benefits to patients. Four high quality studies (Zhou 2017, Li 2011, Esler 2003, and Omonbude 2010) and two moderate quality studies (Maniar 2019, Jenny 2001) were reviewed. There is no difference in composite functional score between two groups. Zhou (2017) showed that despite an increase in range of motion by 7.1 degrees at discharge and 5.2 degrees at six months in patents with drain, patients without drain after tourniquet-free TKA were associated with less decrease in Hb, less use of hematopoietic medication, earlier time to ambulation, and shorter length of stay in the early postoperative period. Maniar (2019) demonstrated reduced opioid consumption in the first 6 hours but no difference in opioid consumption at 6-24 hours and no difference in patient outcome at 1 year. Elser (2003) showed increased blood loss in patients with drain however there was no statistical difference in the swelling, pain score, time at which flexion was regained, the need for manipulation, or in the incidence of infection. Omonbude (2010) demonstrated that there was increased hematoma in no-drain group which was clinically not significant because it did not result in difference in post-operative hemoglobin. Overall, the studies have been unable to provide evidence to support the routine use of a closed suction drain in TKA.

Benefits/ Harms of Implementation

Drains may benefit a slight decrease in swelling and increase in range of motion, but it can interfere with early mobilization. There is a possibility of increased manipulation in patients without drains. Patients with drains could result in a longer length of stay leading to increased cost of care.

Outcome Importance

Placement of drains does not improve functional outcome. The overall benefit does not appear sufficient to advise use.

Cost Effectiveness/ Resource Utilization

Drain utilization may increase the cost of care due to the possibility of increased length of stay.

Acceptability

Literature supports that use of drains does not improve outcome or decrease complications. This recommendation should be acceptable to medical providers. It is important to emphasize that this recommendation applies to primary knee arthroplasty. Physicians should use their judgment in patients with revision knee arthroplasty.

Feasibility

There are no significant barriers to implementation of recommendation. Eliminating drain use will decrease cost and improved patient experience.

Future Research

There is a possibility that slightly better range of motion in patients with drains could decrease manipulation under anesthesia. A well-designed prospective study would be helpful to see if the use of drains could decrease the incidence of arthrofibrosis. Tranexamic acid has been very effective in reducing blood loss after knee arthroplasty. Further research is needed to see if tranexamic acid use alone can reduce the hematoma formation and increase range of motion which will completely eliminate the perceived need for use of the drain.