The Jury’s Still Out on These Intraoperative Measures in TJA
Is it time to abandon the time-honored traditions of using drains and tourniquets in total knee arthroplasty (TKA) patients?
Maybe for one and not the other, maybe for both, or maybe for neither of them: Surgeons can find studies that support and refute both practices, said Michael J. Taunton, MD, from Mayo Clinic in Rochester, Minnesota, at ICJR’s annual Winter Hip & Knee Course. His presentation was part of a series of lectures on urban legends in total joint arthroplasty.
Surgeons who use drains do so because, they say, the drains decrease hematoma formation, infection risk, and stiffness. But there are potential downsides as well, including increased pain, infection risk, stiffness, and blood transfusion.
Dr. Taunton quoted a prospective, randomized study from 1994 that looked at the use of drains in 415 total joint arthroplasty patients.  The study authors found no statistical difference in wound drainage, transfusion rate, hemoglobin, or range of motion with or without the use of drains.
Another study – a Cochrane database systematic review from 2007 – similarly found no statistically significant difference in wound infection, hematoma, dehiscence, or reoperations across 36 studies that included 5464 orthopaedic surgery patients . However, Dr. Taunton said this study found an increased transfusion rate in TKA patients who had a drain, as well as increased drainage and bruising in TKA patients who did not have a drain. 
Dr. Taunton had a final word of advice about the use of drains: A 2008 study found the 2-year risk of infection increased from 0.6% to 12.3% following early return to surgery for evacuation of hematomas in primary TKA patients. To avoid this issue, he said, the use of a drain may be warranted if a TKA patient’s wound seems to ooze or bleed more than usual and the patient is at risk for a hematoma.
Surgeons continue to use a tourniquet during TKA to decrease intraoperative blood loss and improve efficiency of the procedure through better visualization and easier and better cementing technique. The downsides to using a tourniquet include thigh pain, limb swelling as a result of reactive hyperperfusion, and potentially increased risk of blood clots and quadriceps atrophy.
As with drains, there are studies to support both sides of the argument, Dr. Taunton said. A Cochrane study by Wang et al  reviewed the effect of tourniquets in 689 TKAs and found less blood loss with the use of the tourniquet, but no change in transfusion rates. The rate of thrombotic events, however, went up with tourniquet use, from 1.31 to 19.10.
Rama et al  compared the effects of early tourniquet release with those of late tourniquet release. They found that early release leads to higher overall blood loss, whereas late release leads to an increased reoperation rate.
In his own practice, Dr. Taunton uses no drains. He looks for bleeders throughout the case and is careful to achieve good hemostasis. A tourniquet is used only during the cementation phase to prevent bleeding from compromising cementation.
Click the image above to watch the presentation by Dr. Taunton, who also discusses blood conservation and blood transfusions.
Dr. Taunton has no disclosures relevant to this presentation.
- Ritter MA, Keating ME, Faris PM. Closed wound drainage in total hip or total knee replacement. A prospective, randomized study. J Bone Joint Surg Am. 1994;76(1):35-8.
- Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev. 2007;18;(3):CD001825.
- Galat DD, McGovern SC, Hanssen AD, Larson DR, Harrington JR, Clarke HD. Early return to surgery for evacuation of a postoperative hematoma after primary total knee arthroplasty. J Bone Joint Surg Am. 2008;90(11):2331-6.
- Zhang W, Ning Li, Chen S, Yang Tan, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2014;6:9-13.
- Rama KR, Apsingi S, Poovali S, Jetti A. Timing of tourniquet release in knee arthroplasty. Meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007;89(4):699-705