**5.2 Drainages and non-infectious complications**

The use of drainages in orthopedic surgery is a matter of tradition. Its use prevents postoperative hematomas and diminishes postoperative pain, but its use is still controversial (Corpe et al., 2000). Despite several evidence-based medical studies, British orthopedists were not following their recommendations in 2003 (Canty et al., 2003).

Drains have been related to the transfusion necessity and infection rate, among others. But some studies, such as Seyfert's et al (Seyfert et al., 2002), prove that placing drainages with suction does not increase transfusion requirements or postoperative course.

On the other hand, there are studies whose results highlight that not using drainages does not avoid transfusions nor does it reduce blood loss. Padala et al. find questionable the use of drainages in primary knee surgery as it increases transfusions (Padala et al., 2004). Some studies hold on to the fact that it is not necessary their use in primary knee arthroplasty (Adalberth et al., 1998; Corpe et al., 2000; Jenny et al., 2001), nor hip or knee (Crevoisier et al., 1998; Niskanen et al., 2000), nor primary hip (Acus, III et al., 1992; Beer et al., 1991; Hadden & McFarlane, 1990; Kumar et al., 2006). Della Valle et al found out in their study

Blood Transfusion in Knee Arthroplasty 119

abovementioned is that from Schmitt et al. (Schmitt & Weyand, 1997), in which a greater number of hours maintaining the drainage increases bacterial contamination of the drainage tip. Therefore, Willemen (Willemen et al., 1991), Drinkwater et al. (Drinkwater & Neil, 1995) and Rowe's et al. (Rowe et al., 1993) groups recommend use of drainages up to 24 hours, owing to the relationship between use of drains, microbial contamination in the catheter's

Regarding superficial infections, authors such as Saleh et al. (Saleh et al., 2002) and Ovadia et al. (Ovadia et al., 1997), find in their studies that superficial infection is significantly

Within the options in saving blood we can use intraoperative and postoperative blood retrieval. Regarding the use of blood retrieval in total knee ( Dalen et al., 1996; Gannon et al., 1991; Groh et al., 1990; Handel et al., 2006; Heddle et al., 1992; Hendrych, 2006; Kristensen et al., 1992; Majkowski et al., 1991; Martin et al., 1992; Munoz et al., 2005a; Noain et al., 2005; Simpson et al., 1994; Strumper et al., 2004; Thomas et al., 2001; Wojan et al., 2005; Xenakis et al., 1997) and hip (Gannon et al., 1991;Kristensen et al., 1992) arthroplasty, it is considered to be useful as it decreases blood transfusion necessity, reaching a 48% decrease transfusion

The use of postoperative retrieval in knee or hip primary surgery, analyzed from a costbenefit point of view, is a profitable procedure ( Dramis & Plewes, 2006; Jones et al., 2004; Thomas et al., 2001; Wojan et al., 2005). However, some authors like Umlas et al. show that the use of a retrieving instrument is not profitable due to its high cost and the small amount of blood retrieved (Umlas et al., 1994). Slagis' group (Slagis et al., 1991) find that using a retrieval is actually associated to a diminishment in costs, but it is not recommended as a systematic manner in all patients undergoing total knee arthroplasty as the amount of blood

The amount of blood salvaged in hip arthroplasty surgery is 350-700 mL and 500-800 mL in knee arthroplasty (Dutka et al., 2002), although other groups state that the average transfused amount is around 1000 mL in knee arthroplasty (Breakwell et al., 2000). The study by Han et al. (Han & Shin, 1997) shows that using a retrieval is useful as it is possible to reinfuse 437 mL in hip, 883 mL in knee arthroplasty and 1713 mL in bilateral knee surgery without patients having any air embolism problem, coagulopathy, renal failure or sepsis. The followed protocol in blood retrieval is the reinfusion of the collected blood within 6 first hours (Dalen et al., 1995). Using blood from postoperative drainage (blood retrieval) in knee arthroplasty does not show important complications (Groh et al., 1990; Sinardi et al., 2005; Wojan et al., 2005), neither inflammatory cell response increase ( Altinel et al., 2006; Munoz et al., 2005b; Munoz et al., 2006)**.** According to different studies there are no statistically significant differences within the studied parameters, except for IL-6, which could increase febrile reactions ( Handel et al., 2006; Kristiansson et al., 1995). In the study by Bengtson et al. (Bengtson et al., 1990) they found a decrease of anaphylactic toxin and complement activation with no clinical impact. Woda et al. (Woda & Tetzlaff, 1992) describe a case with

The recovered blood culture may be positive in some cases, for this reason Wollinsky et al. recommend antibiotic prophylaxis with cefuroxime to reduce contamination of suction tips and collection bags (Wollinsky et al., 1997). This same study shows that the use of

prophylactic cefuroxime limits the transfer of autologous blood products.

tip, risk of prosthetic infection and comfort in early rehabilitation.

related to use and duration of drainages.

**5.4 Use of postoperative blood retrieval** 

salvaged is low and they still need blood transfusions.

tracheal edema post-reinfusion of salvaged blood.

requirements.

more complications in the group with drainages in comparison to the non-drainages group in primary hip arthroplasty (Gonzalez, V et al., 2004). Ovadia et al (Ovadia et al., 1997), as well as other work-groups (Hallstrom & Steele, 1992; Walmsley et al., 2005), find significant the premise that the use of drainages increases transfusion requirements (0.7 units per patient with drainage, in comparison to 0.2 unit per patient without, p = 0.005).

Widman et al.(Widman et al., 2002) reveal in their study that the use of drainages in hip surgery does not decrease postsurgical hematoma, analyzed with SPECT, but it does increase transfusion requirements.

Esler et al. (Esler et al., 2003) state that they cannot support the use of suction drainages as the group with suction drainages shows a greater blood loss than the non-drainages group. Nevertheless, they do give support to the use of drainages for reusing blood.

Some authors assert that the use of drainage is not harmful but it is of no use at all (Ashraf et al., 2001; Johansson et al., 2005a). Other authors do not see that using drainages in unicompartmental knee surgery has an adequate cost/benefit ratio, since it increases the cost of the procedure both in labor and equipment expenditure; and furthermore, avoiding postoperative drainage in this kind of procedures does not influence the outcome (Confalonieri et al., 2004).

In their meta-analysis, Parker et al. (Parker et al., 2004) find out that suction drainage increases transfusion requirements after a hip or knee arthroplasty, with no benefits contributed.

A mechanical complication that may occur with Redon-drains is that this can break, thus staying intra-articular. In the knee's joint we may keep an expectant management or else require surgical maneuvers such as arthrotomy (Marmor, 1990) or either arthroscopy surgery to remove the drainage (Kao et al., 2002).

### **5.3 Relation between drainage and infection**

Once we reach the infectious complications, the debate remains open. On the one hand, the fact that drains decrease hematoma, knowing that hematoma is an enabling factor for infection, is an argument for its use. But on the other hand, drainages can increase retrograde infection (Mengal et al., 2001).

Regarding deep infections, studies are controversial. Some authors, e.g. Kim et al., defend that using drainages does not increase infections rate or it even decreases it. These associate drains' use with a non-significant decrease in deep infections (Kim et al., 1998).

On the other hand, many authors present results where drains' use has a positive relation to infection. Minnema et al. (Minnema et al., 2004)have linked the use of suction drains with an increasing rate of surgical wound infection after total knee arthroplasty.

Cultivating the drain's end is not a favorable practice in cost-benefit studies, according to the study published by Weinrauch et al. (Weinrauch, 2005). In spite of Weinrauch's study, several groups have cultivated the drain's tip. Zamora-Navas et al. (Zamora-Navas et al., 1999) analyze the drain's tip observing that drainages removed before 12 hours do not have any contamination, those retired at 24 hours show contamination in 2 out of 12 patients for *Staphylococcus epidermidis*, and those drains removed at 48 hours also present contamination for *S. epidermidis* in 2 out of 12 patients. Clinical evaluations of wound healing were similar in both groups. A different group of study, Willemen's et al. (Willemen et al., 1991), cultivated the catheter's tip of all groups and concluded that culture of the catheter's end that had been removed at 24 hours time, were all-negative cultures. A related study to the

more complications in the group with drainages in comparison to the non-drainages group in primary hip arthroplasty (Gonzalez, V et al., 2004). Ovadia et al (Ovadia et al., 1997), as well as other work-groups (Hallstrom & Steele, 1992; Walmsley et al., 2005), find significant the premise that the use of drainages increases transfusion requirements (0.7 units per

Widman et al.(Widman et al., 2002) reveal in their study that the use of drainages in hip surgery does not decrease postsurgical hematoma, analyzed with SPECT, but it does

Esler et al. (Esler et al., 2003) state that they cannot support the use of suction drainages as the group with suction drainages shows a greater blood loss than the non-drainages group.

Some authors assert that the use of drainage is not harmful but it is of no use at all (Ashraf et al., 2001; Johansson et al., 2005a). Other authors do not see that using drainages in unicompartmental knee surgery has an adequate cost/benefit ratio, since it increases the cost of the procedure both in labor and equipment expenditure; and furthermore, avoiding postoperative drainage in this kind of procedures does not influence the outcome

In their meta-analysis, Parker et al. (Parker et al., 2004) find out that suction drainage increases transfusion requirements after a hip or knee arthroplasty, with no benefits

A mechanical complication that may occur with Redon-drains is that this can break, thus staying intra-articular. In the knee's joint we may keep an expectant management or else require surgical maneuvers such as arthrotomy (Marmor, 1990) or either arthroscopy

Once we reach the infectious complications, the debate remains open. On the one hand, the fact that drains decrease hematoma, knowing that hematoma is an enabling factor for infection, is an argument for its use. But on the other hand, drainages can increase

Regarding deep infections, studies are controversial. Some authors, e.g. Kim et al., defend that using drainages does not increase infections rate or it even decreases it. These associate

On the other hand, many authors present results where drains' use has a positive relation to infection. Minnema et al. (Minnema et al., 2004)have linked the use of suction drains with an

Cultivating the drain's end is not a favorable practice in cost-benefit studies, according to the study published by Weinrauch et al. (Weinrauch, 2005). In spite of Weinrauch's study, several groups have cultivated the drain's tip. Zamora-Navas et al. (Zamora-Navas et al., 1999) analyze the drain's tip observing that drainages removed before 12 hours do not have any contamination, those retired at 24 hours show contamination in 2 out of 12 patients for *Staphylococcus epidermidis*, and those drains removed at 48 hours also present contamination for *S. epidermidis* in 2 out of 12 patients. Clinical evaluations of wound healing were similar in both groups. A different group of study, Willemen's et al. (Willemen et al., 1991), cultivated the catheter's tip of all groups and concluded that culture of the catheter's end that had been removed at 24 hours time, were all-negative cultures. A related study to the

drains' use with a non-significant decrease in deep infections (Kim et al., 1998).

increasing rate of surgical wound infection after total knee arthroplasty.

patient with drainage, in comparison to 0.2 unit per patient without, p = 0.005).

Nevertheless, they do give support to the use of drainages for reusing blood.

increase transfusion requirements.

(Confalonieri et al., 2004).

surgery to remove the drainage (Kao et al., 2002).

**5.3 Relation between drainage and infection** 

retrograde infection (Mengal et al., 2001).

contributed.

abovementioned is that from Schmitt et al. (Schmitt & Weyand, 1997), in which a greater number of hours maintaining the drainage increases bacterial contamination of the drainage tip. Therefore, Willemen (Willemen et al., 1991), Drinkwater et al. (Drinkwater & Neil, 1995) and Rowe's et al. (Rowe et al., 1993) groups recommend use of drainages up to 24 hours, owing to the relationship between use of drains, microbial contamination in the catheter's tip, risk of prosthetic infection and comfort in early rehabilitation.

Regarding superficial infections, authors such as Saleh et al. (Saleh et al., 2002) and Ovadia et al. (Ovadia et al., 1997), find in their studies that superficial infection is significantly related to use and duration of drainages.

### **5.4 Use of postoperative blood retrieval**

Within the options in saving blood we can use intraoperative and postoperative blood retrieval. Regarding the use of blood retrieval in total knee ( Dalen et al., 1996; Gannon et al., 1991; Groh et al., 1990; Handel et al., 2006; Heddle et al., 1992; Hendrych, 2006; Kristensen et al., 1992; Majkowski et al., 1991; Martin et al., 1992; Munoz et al., 2005a; Noain et al., 2005; Simpson et al., 1994; Strumper et al., 2004; Thomas et al., 2001; Wojan et al., 2005; Xenakis et al., 1997) and hip (Gannon et al., 1991;Kristensen et al., 1992) arthroplasty, it is considered to be useful as it decreases blood transfusion necessity, reaching a 48% decrease transfusion requirements.

The use of postoperative retrieval in knee or hip primary surgery, analyzed from a costbenefit point of view, is a profitable procedure ( Dramis & Plewes, 2006; Jones et al., 2004; Thomas et al., 2001; Wojan et al., 2005). However, some authors like Umlas et al. show that the use of a retrieving instrument is not profitable due to its high cost and the small amount of blood retrieved (Umlas et al., 1994). Slagis' group (Slagis et al., 1991) find that using a retrieval is actually associated to a diminishment in costs, but it is not recommended as a systematic manner in all patients undergoing total knee arthroplasty as the amount of blood salvaged is low and they still need blood transfusions.

The amount of blood salvaged in hip arthroplasty surgery is 350-700 mL and 500-800 mL in knee arthroplasty (Dutka et al., 2002), although other groups state that the average transfused amount is around 1000 mL in knee arthroplasty (Breakwell et al., 2000). The study by Han et al. (Han & Shin, 1997) shows that using a retrieval is useful as it is possible to reinfuse 437 mL in hip, 883 mL in knee arthroplasty and 1713 mL in bilateral knee surgery without patients having any air embolism problem, coagulopathy, renal failure or sepsis.

The followed protocol in blood retrieval is the reinfusion of the collected blood within 6 first hours (Dalen et al., 1995). Using blood from postoperative drainage (blood retrieval) in knee arthroplasty does not show important complications (Groh et al., 1990; Sinardi et al., 2005; Wojan et al., 2005), neither inflammatory cell response increase ( Altinel et al., 2006; Munoz et al., 2005b; Munoz et al., 2006)**.** According to different studies there are no statistically significant differences within the studied parameters, except for IL-6, which could increase febrile reactions ( Handel et al., 2006; Kristiansson et al., 1995). In the study by Bengtson et al. (Bengtson et al., 1990) they found a decrease of anaphylactic toxin and complement activation with no clinical impact. Woda et al. (Woda & Tetzlaff, 1992) describe a case with tracheal edema post-reinfusion of salvaged blood.

The recovered blood culture may be positive in some cases, for this reason Wollinsky et al. recommend antibiotic prophylaxis with cefuroxime to reduce contamination of suction tips and collection bags (Wollinsky et al., 1997). This same study shows that the use of prophylactic cefuroxime limits the transfer of autologous blood products.

Blood Transfusion in Knee Arthroplasty 121

528 mL, whereas in the non-suction 436 mL. However, difference between both averages

If the opening-up of drainage is delayed, the obtained amount through drainage diminishes in a statistically significant manner (Roy et al., 2006; Tsumara et al., 2006). Along the same lines, another study states that delaying the opening-up of drainages 4 hours; drainage

On the other hand, some authors conclude that clamping drains during first 2 postoperative hours does not influence within drained quantity, nor transfusion number, or mobility, or surgical wound complications (Kiely et al., 2001). Study by Leemann et al. affirms that after 6 hours drainage can be removed as 78% of bleeding has been already

Senthil et al. (Senthil et al., 2005) state in their study that 84% of total drain was collected during first 12 hours, and 94% during first 24 hours. The study's conclusion is that articular

The Spanish group headed by Zamora-Navas (Zamora-Navas et al., 1999) study bleeding features in three groups in which drainage is maintained 12, 24 and 48 hours. They observed that the group maintaining drainage for 24 hours had already drained 87% of the total amount at 12 hours time. In the last group (with drainage 48 hours), bleeding at 12 hours corresponded to 91% of the total amount, and bleeding at 24 hours was 97% of the total

Regarding when to remove drainage, in the study by Benoni et al. (Benoni & Fredin, 1997) we can observe how the drained amount between 24 and 48 hours is only 215 mL in the high-pressure aspiration drainages, and 105 mL in those with low-pressure aspiration. In conclusion, we can see that aspiration pressure is not more than a variable, as previously seen, and that drained volume between 24 and 48 hours is not as far as important as the

In the study by Slagis et al., the conclusion of greater volume collected during first operative hours repeats (Slagis et al., 1991). The average collected volume was 493 mL, great part of it

Another study showing that prosthetic bleeding is produced during first postsurgical hours is that from Willemen et al. (Willemen et al., 1991), in which they keep drains 48 hours and they observe that 85% of total volume was drained after 24 hours. Between 24 and 48 hours

In our own study (Ares-Rodriguez et al., 2008), we observed that mean of the survival curve for postoperative bleeding time was 16 hours for total knee arthroplasty, and we therefore concluded that drainage in total knee arthroplasty can be safely removed after 18

A first study shows that releasing the tourniquet intraoperative (before wound closure) and a correct hemostasis does not reduce total amount of blood lost in total knee arthroplasty (Hersekli et al., 2004). Barwell et al. (Barwell et al., 1997) present in their study that using tourniquet has some side effects and that these can be minimized if removal of tourniquet is done prematurely, together with a thoroughly hemostasis prior to surgical wound closing.

was not statistically significant.

drained (Leeman et al., 2006).

amount collected after 48 hours.

bleeding that occurs during first 24 hours.

postoperative hours, with a safety margin.

being collected during first 4 hours.

the drain was of only 50 mL.

**5.8 Tourniquet** 

**5.7 Start/opening-up/end of drainage** 

decreases in a statistically significant way (Shen et al., 2005).

drainages can be safely removed after first 12 postoperative hours.

Several studies compare the different blood retrievals, finding out that whereas some are easier to use, others have a better suction and that side effects do not present statistically significant differences (Trammell et al., 1991).

Another point of view to look at is that from Mauerhan et al. (Mauerhan et al., 1993) and other authors (Mac et al., 1993; Reize et al., 2006), who find that the use of a recovered blood is not necessary in hip and knee arthroplasty. Faraj et al. show in their study that cost/profit ratio is not profitable when using a blood retrieval (Evans et al., 1993; Faraj & Raghuvanshi, 2006; Jackson et al., 2000).
