INTRODUCTION:

Since the time of Hippocrates, the usage of a closed suction drain [CSD] has been present¹. Most of the CSD usage is because of training prior methods rather than scientific evidence². It is believed that post-op CSD decrease secchymosis³ and prevents hematoma formation, thereby promoting the healing of wound by decreasing tension around the wound and increased tissue blood perfusion in the nearby vicinity⁴. Following bacterial colonisation, the hematoma can lead to either superficial or deep-seatedinfection⁵. Despite this, total hip arthroplasty [THA] is being performed without CSD for enhanced recovery after surgery [ERAS] programs. On the other side of the spectrum, it is believed that CSD is associated with higher levels of blood loss, due to absence of tamponade effect⁶ and there is also the chance of a higher risk of infection due to retrograde bacterial migration⁷. Furthermore, it was indicated in studies that postop rehabilitation and nursing care is hindered by CSDs^8,9. In THA, when compared to TKA, surgeons believes that there is more dead space. However meticulous closure with proper cauterisation of bleeders enhances early mobilization and reduces the length of hospital stay.

MATERIALS AND METHODS:

Study design: Prospective study.

Study area: Tertiary care Medical College and Hospital

Study population: Patients who need primary total hip arthroplasty.

Duration of study: 6 months

Institutional Ethical Committee Remark: Approved

Inclusion criteria:

· Age 18 -75 years

· Primary hip arthroplasty due to any cause

· Cemented and uncemented hip arthroplasty

Exclusion criteria:

· Paediatric age group,

· patients with significant systemic illness

· revision surgery

· and organ failure

SURGICAL PROCEDURE:

Consent is taken from the patient selected for the study. Total hip replacements were performed under general or regional anaesthesia by surgeons of consultant grade. All cases were done using a posterior approach. Drains were placed beneath the Ilio Tibial band.

Postoperatively, compressive bandages were applied and patients were provided mobilisation with the guidance of a PMR physician. All patients were mobilised the day after surgery and weight-bearing was permitted as tolerated. Thromboprophylaxis was uniformly provided with LMWH.

Drains were removed after 48hrs and dressing was checked on postoperative day 2 for signs of infection. Any soakage of dressing warranted a change in dressing, anti-biotics (Cefeperazone and Sulbactum) were administered appropriately. Intraoperative and postoperative complications like fall in haemoglobin and blood transfusions were documented. Discharge from the hospital after achieving satisfactory goals such as straight leg raising and stair climbing. Blood transfusion was provided for those patients who were symptomatic. Post-operative hospital stay was also calculated. All the data was tabulated and compared. P-value was found using the chi-square test.

RESULTS:

In the study conducted 100 participants were involved with 70 for the group with drains fixed and 30 for the group without drains. There were 52 males and 48 females. The range of their ages was between 36 and 77 years with a mean age of 57 years. Infection was noted in 5 patients with 4 being from the drain group and the other from the group without the drain. Blood transfusion was done for 18 patients in total due to blood loss with 14 being from the drain group and 4 from the group without the drain. Serum markers for infection were elevated in all 3 cases with infection. Wound swabs were taken for all cases and appropriate antibiotics were started. The infection was resolved and all eight cases were recovered. In the clinical assessments done at post-op, after 1 month and 3 months, it was found that except for one patient, all the others had a fair to good functional score [Harris hip score]. The case with a poor functional outcome already had a very low pre-op score. post-op hospital stay was also noted, and the mean postop stay was 8.6 days for patients in the group with the CSDs and 7.1 days in the group without the drain. P-value was found to be significant at less than 0.05.

Figure 1. Images of a THA case done without CSD

Figure 2. Images of a THA case done with CSD

Figure 3. Xray Images of THA case done with CSD

DISCUSSION:

The study was done to evaluate CSD effects in patients who’ve undergone primary hip arthroplasty. The finding was that in patients with CSD was associated with a higher transfusion rate in patients undergoing routine primary total hip arthroplasty. Their period of stay was also longer than the patients without CSDs.

For patients with end-stage hip diseases, total hip arthroplasty is not only a common procedure but also a successful treatment option too because of the significant pain relief and improvement of the patient’s quality and function of life¹⁰. Efforts have been made to reduce the blood loss in the perioperative period, despite which a loss of 1000-1500 ml remains a challenge yet to be solved¹¹. Furthermore, complications such as infection, anaphylactic reactions, haemolytic reactions, deep vein thrombosis, post-op stay, high hospitalisation costs and higher in-hospital mortality^12,13,14. Blood donors are often insufficient, therefore reducing the transfusion rates is necessary for patients undergoing THA.

There are previous studies, where it was found that continuous suction drain was not linked with a higher blood transfusion rate in primary total hip arthroplasty^15,16,17. A study done by Bjerke-Kroll et al showed that CSD was associated with increased blood transfusion rates¹⁸, probably due to blood loss in the drain group. The other previous studies done which showed CSDs had higher transfusion rates^19,20. According to studies^21,22, most of the hidden blood loss was early post-operative and hidden blood loss itself accounts for 60% of total blood loss.Hidden blood loss is mostly because the blood gets collected in the joint space and the muscle compartments. When we place a drain the tamponade effect is lost and the blood in these spaces continues to drain and leads to inadequate filling up of the dead spaces present²³.

Post-op stay is a marker of excellence which can't be substituted²⁴. In many countries, a reduced postop stay would mean increased hospital efficiency and productivity. A shorter post-op stay would have obvious benefits such as lower use of medical resources, reduction of cost, and patient satisfaction^25,26. With the development of ERAS programs, postop stay shortening is very important to shortening the length of stay (LOS). Despite some previous studieswhich have shown that CSDs were not associated with longer post-op stays, they also haven’t recommended utilising CSDs since the benefits were not significant enough for patients undergoing total hip arthroplasty. In the study done by Sharma et al and Bjerke’s-Kroll et al, post-op stay was found to be comparatively higher in the group with drains when compared with the ones without drains, after total hip arthroplasty. The results which we obtained also showed that the postoperative stay was higher. There is also the possibility that, since drains interfere with mobilization of the patient earlier on and provides some complications in nursing care, it contributes to a longer postoperative stay.

Wound complications both infectious and the non-infectious ones (which may lead on to secondary infection) can progress to prosthetic joint infection (PJI)^27,28. In our study, we were unable to see a difference significant enough between the two groups. Therefore, future studies would be needed to give us a proper estimation of the association of infections with CSDs.

CSD usage is something which should be done based on the advantages and disadvantages which it provides. ERAS programs being developed more recently, CSDs are being reconsidered by orthopaedists worldwide. For the patients undergoing THA, a CSD cost is relatively low but when you factor in the longer postop stay and higher transfusion rates the rise in cost does become significant. Although CSDs require fewer dressings, it does interfere with early mobilization and nursing care²⁹. In addition to the complications such as hematoma formation, excessive blood loss, longer incisions, etc., revision arthroplasty are more complex than primary total hip arthroplasty³⁰. Fichman et al.³¹ have also reported a higher blood transfusion rate and a longer postop stay among patients with CSDs with revision arthroplasties. Despite that, future studies of higher quality would be needed to make a definitive conclusion with regards to CSD in revision THA.

The results of the current study would be beneficial for orthopaedic surgeons in deciding with regards to CSD usage in total hip arthroplasties.

Table.1: Comparision of parameters with various studies

		With CSD	Without CSD
Infection	Our study	5.7 %	3.3 %
Infection	Gaurav M Sharma et al.	1.69 %	1.63%
Transfusion rate	Our study	20 %	13%
Transfusion rate	Hong Xu et al.	20.53 %	13.5%
Post op stay	Our study	8.6 days	7.1 days
Post op stay	Hong Xu et al.	7 days	6.07 days

CONCLUSION:

At the end of this study, we have concluded that CSDs are associated with a higher blood transfusion rate and longer postop stay in patients who've undergone unilateral primary total hip arthroplasty. The routine use of CSD is not recommended in unilateral primary total hip arthroplasty.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

The authors would like to thank the Department of Orthopaedics and Saveetha Medical College Hospital for their kind support during the study period.

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Received on 10.09.2023 Revised on 08.04.2024

Accepted on 03.09.2024 Published on 24.12.2024

Available online from December 27, 2024

Research J. Pharmacy and Technology. 2024;17(12):5738-5742.

DOI: 10.52711/0974-360X.2024.00873