There are a lot for and against drainage of a wound after THR. What's your experience in this field.. Are there any rationales for the dainage ?
We use routinely 2 closed suction drains (suprafascial and subfascial) for 48-72 hours after THR. I am aware of the trend to leave a THR without any drainage, but I am sure that those colleaques have problems with intraoperative hematomas. This is the more so because of the use of cementless prostheses (postoperative bleeding is higher than in cemented prostheses) today, and especially for the routine use of pharmacological DVT prophylaxis. A deep hematoma is a serious complication which needs evacuation, that is to say - a second operation with all possible inconvenience and risks.
A very important issue is to study a possible relationship of unevacuated deep hematomas(no drains) and late deep infection with loosening of the prosthesis ?
Dear Wieslaw, we routinely used one drain (sub facial) after hip surgery. I prefer to evacuate bleeding after this procedure and avoid a deep hematoma that could bring to a deep infection. I am not so worried about supra facial bleeding so we don't use superficial drain.
Dear Wieslaw : We always use 2 drain supra and subfascial after THR for 48 hours , we consider it is very important to avoid deep hematomas
Very good question, we also use routinely two suction drainage for 48 h after surgery.
we believe this will reduce hematomas, but as far as i know there is no good evidence for that.
I have mostly given up hip surgery, but the evidence is aginst it and none of my colleagues here as far as I am aware, use them in primary surgery. Although wounds may be a little more bruised, once you inlude drainage from the drain site, the drained wounds, don't dry up any more quickly than those that have no drain at all. Also, unless you are using the re-transfusion drains, transfusion trates will be higher.
Use of drains in THR allows a portal for bacteria to enter the hip wound. It allows prevents the tamponade effect and leads to an increase in blood loss and trandfusion requirements.
We have not used drains for a nearly 10 years and have no increased deep infection rate, as long as careful haemostasis is performed with a meticulous closure of all the layers. Allows early mobilisation, early discharge and doesnt run the risk of accidentally catching the drain in one of the sutures.
Recent use of Tranexamic acid may also reduce the risk of haematoma and therefore makes the use drains after THR unnecessary.
Meticulous haemostatsis and a secure layered closure negates the need for a drain
How could we perform a meticulous hemostasis in cases of wide surface of bleeding cancellous bone , i.e. in cementless arthroplasty ? The more so that bleeding is usually increased in the early postoperative period through the routine pharmacological antithrombotic prophylaxis. Bleeding from open cancellous bone surfaces is in fact a problem with orthopedic surgery as a whole. In case of cemented arthroplasty bleeding is less because of the bone cement applied.
Always a careful haemostasis is performed with a meticulous closure of all the layers in spite of this , there is a clear blending about all in cementless arthroplasties and therefore we use drains, it located in the deep layers without suction the early hours. We always check the drains are free without entrapment by sutures . Ww have a postoperative infection rate of less than 1%. We believe that postoperative drainage is beneficial in this surgery
Dear Dr. Herera, I agree with you entirely. Our infection rate is also under 1% and I do not see any reason to change our drainage regimen. Some colleagues use transexamic acid to reduce bleeding, blood loss and hematomas in arthroplasty. But I find the combination of antifibrinolytic with anticoagulants somewhat confusing. There are a lot of papers on tranexamic acid in arthroplasty but good quality RCT's as far as increase in DVT and PE is concerned are still lacking.
Dear Panayot : thank you for your answer , We have a limited experienece with the use of Tranexamic acid .I've only used in patients with a large perioperative bleeding or in cases of revision surgery, the result has been satisfactory
In my expérience I use drainage for all THR.Actually I dont think I will change.
My point of vue is to use drainage in every kind of hip arthroplasty!
I use aspirative (suction) drenage but shortly, because prolonged drainage is associated with a higher rate of postop. morbidity.
JBJS Am 2007.Jan 89 (1) 33-8.
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