AAOS Discourages It Yet Drains Used in 24% of TKAs. Why?

Despite American Academy of Orthopaedic Surgeons (AAOS) guidelines discouraging the use of surgical drains, the practice stubbornly continues. How widespread is the use of surgical drains? A team of researchers from the Icahn School of Medicine reviewed 1,130,124 total knee arthroplasties (TKAs) from the claims-based Premier Healthcare Database to find that answer. In the process, they also teased out possible reasons for its continued use.

Their study, “Utilization of Drains and Association With Outcomes: A Population-Based Study Using National Data on Knee Arthroplasties,” was published in the October 15, 2019 Journal of American Academy of Orthopaedic Surgery.

Co-author Jashvant Poeran, M.D., Ph.D., assistant professor in the Department of Population Health Science & Policy, the Department of Orthopaedic Surgery at the Icahn School of Medicine at Mount Sinai in New York, explained the genesis of this study to OTW, “Our study started more from the point of penetration of clinical guidelines into daily clinical practice, i.e., the difference between studies performed in highly controlled trials that are unlikely to be representative of the overall surgical population and how the results from such studies are (not) incorporated into daily practice.

Calin S. Moucha, M.D., senior orthopedic surgeon on the paper with the Leni and Peter W. May Department of Orthopaedic Surgery at Icahn, expanded on the topic of surgical drains to OTW, “In the case of surgical drains in lower extremity joint arthroplasty surgery various trials have been conducted and to date there is still no sufficient evidence to support their routine use.”

“Therefore, importantly, the American Academy of Orthopaedic Surgeons also does not recommend the use of surgical drains, particularly in total knee arthroplasty. Given the clear guideline and lack of evidence of benefit we were wondering how often drains are still used and how their use in a non-controlled (real world) setting was associated with outcomes such as length of hospital stay, cost of hospitalization, need for blood transfusion, risk of infection and risk of 30-day readmission after surgery.”

“To address these study objectives, we used a national claims dataset that included information on more than 1 million total knee arthroplasties over the period from 2006 to 2016.”

Dr. Poeran summarized the study’s results to OTW, “Surgical drains are still being used in patients undergoing total knee arthroplasty. Between 2006 and 2016 we found an overall drain utilization of 24.2% (274,016 of 1,130,124 patients undergoing total knee arthroplasty) which seems to be decreasing over time.”

“We also found that drains are particularly used more often in large and non-teaching hospitals. The strongest finding from our main analysis was that the use of drains in patients undergoing total knee arthroplasty was associated with up to 42% increased odds of needing a blood transfusion. This falls in line with other smaller studies that have identified greater blood loss and increased need for blood transfusions among patients receiving drains, possibly because of the absence of the so-called ‘tamponade effect,’ i.e., bleeding in the surgical wound will continue until the pressure in the wound increases. Placing a drain may relieve that pressure which can lead to more blood loss.”

“Our study also provided some signs that the use of drains may be associated with higher odds of being readmitted within 30 days to the hospital after surgery.”

“Although the use of drains is discouraged in guidelines, this practice still occurs. Practical recommendations may be more geared towards professional organizations such as the AAOS and AAHKS [American Academy of Hip and Knee Surgeons] regarding dissemination (and perhaps refinement) of guidelines and identifying mechanisms behind suboptimal uptake of these guidelines in daily clinical practice.”

“While there indeed may be some cases in which the use of surgical drains is justified, a more thorough look at this issue should clarify what proportion is due to suboptimal adherence to current evidence. A broader recommendation is to continuously monitor practice patterns, particularly practices that are generally not supported by evidence.”

“Even though not supported by current evidence, surgical drains are still used in a significant proportion of total knee arthroplasties and there is a potential for harm.