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| ORIGINAL ARTICLE |
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| Year : 2016 | Volume
: 16
| Issue : 2 | Page : 139-146 |
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Effect of drainage tube on knee function after arthroscopically assisted anterior cruciate ligament reconstruction
Atul Mahajan, Himanshu Kataria
Sports Injury Centre, Safdarjang Hospital, New Delhi, India
| Date of Web Publication | 13-Apr-2016 |
Correspondence Address:
Dr. Atul Mahajan
Lady Hardinge Medical College, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1319-6308.180182
Background: There is a paucity of literature evaluating the use of intra-articular drains after arthroscopically assisted anterior cruciate ligament (ACL) reconstruction and their effects on knee function. Objective: The aim of this study is to determine the effect of postoperative drain use on knee function after ACL reconstruction with quadrupled hamstring graft. Materials and Methods: In this study, 44 arthroscopic ACL reconstruction patients were randomized for either intra-articular suction drain group or nondrain group. Outcome assessment was done on postoperative day 4, day 10, 1 month, 3, 6, and 12 months after the surgery in which patients were asked to complete a visual analog pain scale. They were assessed for a range of motion (ROM) in flexion and extension with a universal goniometer, knee effusion, and knee stability by Lachman's test. Results: Both treatment and control groups showed no statistical significant difference in flexion of the knee through the ROM (P = 0.116). The percentage reduction in knee effusion was found to be statistically significant at 4 th (P < 0.001), 10 th (P < 0.001) 16, and 1 month (P = 0.012) in between treatment and control group. The overall pain difference between the two groups was not found to be statistically significant (P = 0.198). Conclusion: Clinically, the drain group showed faster pain relief, lesser effusion, and early return to motion compared to the no-drain group but was not statistically significant. تأثير أنبوب التصريف على وظائف الركبة بعد عمليات مناظيرلإعادة إعمار الرباط الصليبي الأمامي
خلفية البحث: هنال العديد من الدراسات لتقييم استخدام أنبوب التصريف داخل المفصل بعد مناظير المفاصل لمساندة بناء الرباط الصليبي الأمامي (ACL) وتأثيراته على وظيفة الركبة.
الهدف: الهدف من هذه الدراسة هو تحديد تأثير استخدام أنبوب التصريف بعد العملية الجراحية على وظيفة في الركبة بعد إعادة الإعمار ACL مع ترقيع اوتار الركبة.
المواد والطرق: في هذه الدراسة، تم اختيار44 مريضا بصورة عشوائية خضعوا لمنظار مفصلي لبناء الرباط الضليبي الأمامي إما للتصريف يالشفط و التصريف داخل المفصل أو مجموعة عدم التصريف وقد تم تقييم النتائج في اليوم الرابع للجراحة واليوم العاشر، وبعد شهرو بعد 3 و 6 و 12 شهرا بعد الجراحة حيث طلب من المرضى إكمال مماثل لمقياس الألم البصري. وتم تقييمهم ايضا لمدى الحركة (ROM) في الثني و التمدد مع مقياس الزوايا العالمي، و سوائل الركبة، و ثبات الركبة خلال اختبار لاشمان.
النتائج: جميع المجموعات المعالجة و الضابطة لم تظهر ذات دلالة إحصائية في ثني الركبة ROM (P = 0.116). وتم العثور على خفض نسبة في السوائل في الركبة لتكون ذات دلالة إحصائية في 4 (P<0.001)، 10 (P<0.001) 16، و 1 الشهر (P = 0.012) بين العلاج والمجموعة الضابطة. لم يتم العثور على فرق في الألم الشامل بين المجموعتين لتكون ذات دلالة إحصائية (P = 0.198).
الخلاصة: سريريا، أظهرت مجموعة التصريف سرعة أكبر في تسكين الألم، وسوائل أقل، وا ستعادة مبكرة للحركة مقارنة بالمجموعة عدم التصريف ولكن لم تكن ذات دلالة إحصائية. Keywords: Anterior cruciate ligament, arthroscopy, drains, hamstring graft, knee effusion, visual analog scale
How to cite this article:
Mahajan A, Kataria H. Effect of drainage tube on knee function after arthroscopically assisted anterior cruciate ligament reconstruction. Saudi J Sports Med 2016;16:139-46 |
How to cite this URL:
Mahajan A, Kataria H. Effect of drainage tube on knee function after arthroscopically assisted anterior cruciate ligament reconstruction. Saudi J Sports Med [serial online] 2016 [cited 2023 May 31];16:139-46. Available from: https://www.sjosm.org/text.asp?2016/16/2/139/180182 |
| Introduction | |  |
The anterior cruciate ligament (ACL) is the primary restraint to anterior translation of tibia in all degrees of flexion. [1] Edwards et al. [2],[3] have divided the ACL into two functional bundles. The ACL originates on the medial aspect of the lateral femoral condyle and inserts onto the tibia in the anterior intercondylar area in a triangular pattern roughly described as a "duck's foot." [4] The ACL plays an important role in the stability of the knee primarily through its passive constraint to anterior tibial translation and tibial rotation.
Drains have been used commonly in orthopedics to evacuate hematomas under the presumption that this will decrease pain and swelling, hasten the return of motion, shorten the hospital stay, speed rehabilitation, and potentially decrease the risk of infection. [5],[6],[7] Over the years, the necessity of intra-articular drains has been questioned in the literature. [8],[9],[10] Other methods to reduce postoperative swelling and hemarthrosis, especially in arthroscopic procedures, have included compression type dressings and the use of tourniquets. [11] Despite the use of these dressings, tourniquets, and drains, hemarthrosis after an arthroscopic procedure continues to be the most commonly reported complication. [11] There is a paucity of literature evaluating the use of intra-articular drains after arthroscopic procedures. We conducted a prospective randomized clinical trial to determine the effect of postoperative drain use in arthroscopically assisted ACL reconstruction with quadrupled hamstring graft following the surgery. The null hypothesis was that use of a drain would not result in improvement in knee function for patients who had drains compared with those who did not.
| Materials and Methods | | |
A prospective randomized evaluation was performed on the effect of drain use in the postoperative period after arthroscopically assisted ACL reconstruction with quadrupled hamstring graft in ACL deficient patients.
Subjects of study
All patients undergoing primary ACL tear reconstruction, using quadrupled hamstring graft between August 2013 and August 2014 were included in the study. They were then followed up for the duration of 1 year postoperatively.
Study design
The design of the study was prospective and randomized. Block randomization was done to divide the patients into two groups: One in which closed wound drains were used for 24 h postoperatively and another in which no drains were used.
Study group
The participants of this study were divided into two groups; first group with patients undergoing ACL reconstruction with insertion of drainage tube (DT) postoperatively for a period of 24 h and second group having patients undergoing ACL reconstruction without insertion of DT postoperatively.
Study period
August 2013 to August 2014.
Inclusion criteria
Patients with ACL deficient knee requiring isolated ACL reconstruction, patients with ACL tear presenting after 6 weeks but before 6 months from the date of injury and patients with ACL tear who had a minimum of 120° of flexion possible at the knee before surgery and had no pain in the affected knee.
Exclusion criteria
Patients with multiligament injuries, presence of fractures or deformities in the lower limb, revision ACL reconstruction, patients with Grade 3/4 cartilage injury, and patients with irreparable Grade 3 meniscus injury at meniscocapsular junction.
Assessment was done based on following criteria:
- Range of motion (ROM) using standard goniometer: With the patient lying supine on a firm mattress, flexion was measured when the patient maximally flexed the knee without any external support
- Assessment of pain by visual analog scale: A visual analog scale (VAS) is a psychometric response scale which was used in our study. It is a measurement instrument for assessing the pain that cannot be directly measured
- Knee effusion: Classification of Coupens and Yates (graded subjectively from 0 to 4) was used for Clinical Grading of Hemarthrosis
Grade description:
- 0: No detectable fluid
- 1: Fluid present with fluid wave
- 2: Palpable fluid in suprapatellar space
- 3: Ballotable patella
- 4: Tense hemarthrosis.
- Knee stability: The Lachman's test has surpassed the anterior drawer test as a basic screening examination for abnormal anterior knee laxity. One of the differences that make the Lachman's test easier to assess than the anterior drawer test is that in most normal patients, there is little or no excursion of the tibia when the Lachman's test is performed. Either no translation at all or 1-2 mm of translation with a very firm endpoint is appreciated. In the presence of ACL tear, the translation is increased and the endpoint indefinite.
Methodology
Preoperative
Random allocation was made in blocks in order to keep the sizes of treatment and control groups similar. Block randomization was used to divide the patients into two groups: One in which closed wound drains were used for 24 h postoperatively and another in which no drains were used. It was not a blinded study, and there were 22 patients in each of the groups.
Surgical technique
The type of anesthetic (regional or general) was not controlled and was selected at the discretion of the anesthesiologist. All patients received prophylactic intravenous antibiotics preoperatively. A pneumatic tourniquet was used following exsanguination to produce a relatively bloodless operative field. The same team of surgeons performed all of the ligament reconstructions in the patients in this study. The ACL was reconstructed with quadrupled hamstring graft, harvested from the ipsilateral knee under tourniquet. Trans-tibial technique was used in graft placement. Anchorage of the graft was done using bio-absorbable interference screws at the tibial side and either crosses pins, tightrope, or Endobutton for the femoral side.
Postoperative drainage tube protocol
After arthroscopic ACL reconstruction, two mini-vac drains were inserted, one at the extra-articular site deep to the sartorial fascia and one at the intra-articular site. For patients in the control group, the knee was closed primarily, without the drain placement. In the operating room, a three-layered compressive dressing was placed on the knee of all patients. A knee immobilizer was applied for all the patients for first 2 weeks at rest. Patients were allowed partial weight bearing from the next day after gait training with bilateral axillary crutches. All patients were encouraged to elevate the extremity when not performing therapy. Postoperative rehabilitation was performed in accordance with the accelerated ACL protocol and was identical in both the treatment and control group. The drain was pulled out from the patients in the treatment group 24 h after the operation. No drain malfunctions were noted. After removing the drain, three-layered compression dressing was continued until the 4 th postoperative day. On the 4 th day, three-layered compression dressing was removed, and lower limb compression stocking was applied. In all the patients, similar postoperative analgesia regimen was followed.
Postoperative knee assessment
Assessment was done on postoperative day 4, day 10, 1 month, 3, 6, and 12 months after the surgery based on the same criteria considered preoperatively. All patients were asked to complete a visual analog pain scale (range: 0-10, with 10 being the worst pain). They were assessed for ROM in flexion and extension with a universal double-armed goniometer, knee effusion, and knee stability.
Statistical analysis
The statistical analysis was done using Software "Statistical Package for social sciences version 16 (SPSS Inc., Chicago, II)." The analysis of the data was carried out by the investigator in consultation with the statistics department.
Results were expressed as a mean ± standard deviation. Statistical analysis was performed by using repeated-measures analysis of variance. Independent sample t-test was used to compare the treatment group and control group over a period of time. Post hoc test was used in finding patterns and/or relationships between subgroups of samples under study. The difference between the two groups was considered significant if the P value was <0.05.
Ethical considerations
The personal details of the subjects were kept confidential, informed consent was taken prior to the randomization, and the operative procedure and the study did not involve additional physical, emotional, or financial burden to the subjects. The subjects were free to leave the study when they wanted.
| Results | | |
A prospective randomized evaluation was performed on the effect of drain use in the postoperative period after arthroscopically assisted ACL reconstruction with quadrupled hamstring graft in 44 patients. Reconstructions were performed on the left knee in 18 patients and on the right knee in 26 patients.
Sample size
As per the criteria set forth in the methodology, 44 cases were recorded during the period, August 2013 to August 2014. The cases were included in the study as and when they were posted for ACL reconstruction and randomized into two groups, the DT group and the no-DT group were followed up regularly.
Age
The age of the patients treated was ranged between 18 and 50 years, average being 30 years. This group represents the active working class. Those <25 years of age were comprised mainly of students.
Gender
The gender distribution of cases was eccentric, with 94.5% (n = 42) males, and a mere 4.5% (n = 2) females in the study. This can be explained on the basis of lower rates of road traffic accidents among females and lesser participation in sports activities.
Pain
Multivariate analysis demonstrated that both the treatment and the control groups showed the same decreasing trend in pain over time [Table 1]. The mean decrease in the pain, as measured was found to be statistically significant for both the treatment group (P < 0.001) and control group (P < 0.001). With the no-DT group, pain trend showed an increase on the 4 th postoperative day (mean 5.86) compared to preoperative value (mean 2.4) following which pain trend showed a continuous decline over a period of time. With the DT group, a continuous decline in pain trend was observed over a period of time [Figure 1]. Post hoc test analysis also substantiated that pain was the most preoperatively and showed a decrease over a period of time sequentially. The overall pain differences between the control group and the treatment group from day 1 to 12 months from the date of surgery were not found to be statistically significant (P = 0.198) as calculated by independent sample t-test. | Figure 1: Mean VAS scores in both the DT and no DT groups over a period of 12 months
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 | Table 1: Independent sample t-test for comparing range of motion and visual analog scale scores between drainage tube group and no drainage tube group
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Range of motion
Both treatment and control groups showed similar trends showing a decline in flexion on the 10 th postoperative day (mean DT group 94.09; mean no-DT group 83.64) from preoperative values (mean DT group 118.27; mean no-DT group 122.36). However, the recovery in the knee ROM was found to be faster and more in the patients with DT compared to the patients without DT [Figure 2]. Post hoc test analysis also showed progressive increment in knee ROM over time in both treatment and control groups. | Figure 2: Mean degrees of knee flexion in the DT group and no DT group over a period of 12 months
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No statistical significant difference between the treatment and control groups could be seen when comparing flexion of the knee through the ROM (P = 0.116) as measured by independent sample t-test [Table 1].
Knee effusion
Hemarthrosis causes joint distension leading to increased pain and subsequent decreased ROM. In our study, we used classification of Coupens and Yates (graded subjectively from 0 to 4) for Clinical Grading of Hemarthrosis.
At the 4 th postoperative day, [Figure 3] the percentage reduction in knee effusion was found to be statistically significant (P < 0.001) in between treatment and control group. Of 22 patients in DT group, 15 patients had Grade 1 effusion and 4 patients had no effusion compared to no-DT group in which 13 patients had evidence of Grade 2 effusion while only 6 patients had Grade 1 effusion. Three patients from no-DT group had Grade 3 effusion while no patients in DT group had Grade 3 effusion. | Figure 3: Distribution of patients according to the grades of effusion on 4 th postop day
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At the 10 th postoperative day, [Figure 4] percent reduction in knee effusion was found to be statistically significant between the treatment and control group (P < 0.001) 16 patients in the treatment group showed no effusion while 6 patients had Grade 1 effusion. On the other hand, 10 patients without DT had Grade 2 effusion, and 8 patients showed Grade 1 effusion. At 1 month postoperatively, percent reduction in knee effusion was found to be statistically significant (P = 0.012). Eighteen patients in DT group had no effusion at the end of 1 month while four patients showed Grade 1 effusion [Figure 5]. The control group, on the other, had 12 patients showing Grade 1 effusion while 10 patients had no effusion [Table 2]. | Figure 4: Distribution of patients according to the grades of effusion on 10 th postop day
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 | Figure 5: Distribution of patients according to the grades of effusion at 1 month
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 | Table 2: Grades of hemarthrosis in both the drainage tube and no drainage tube groups
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Knee stability
The instability of the knee was assessed using Lachman's test. Lachman's test was performed at 30° of knee flexion to check abnormal anterior knee laxity. The preoperative assessment showed of 44 patients who underwent ACL reconstruction, 30 patients were having Grade 2 instability while 14 patients showed Grade 3 instability as per Lachman's test. Patients were assessed for stability at regular follow-up, and all the patients had stable knees postoperatively. The following graph shows that. After the procedure, knee was stable and had no features of instability as evident at follow-up at 1 year which showed negative Lachman's test in 41 patients and Grade 1 instability in three patients [Figure 6].
| Discussion | | |
Use of drains
Drains have been used commonly in orthopedics to evacuate hematomas under the presumption that this will decrease pain and swelling, hasten the return of motion, shorten the hospital stay, speed rehabilitation, and potentially decrease the risk of infection. [5],[6],[7] Over the years, the necessity of intra-articular drains has been questioned in the literature. [8],[9],[10] However, drains have not been abandoned for fear of local complications. Several prospective, randomized studies have evaluated the use of drains in joint arthroplasty and orthopedic trauma, and the most of these studies show no benefit to using drains. [5],[6],[7]
Willett et al. [12] in their assessment of drain usage after total hip arthroplasty, found that drains removed at 24 h were as effective as those left in for longer periods. There are little data in the literature with reference to drain use after arthroscopic procedures on the knee or ACL reconstruction. Williams et al. [13] described their management of infected arthroscopic ACL reconstructions, including the use of constant suction drains that were placed in all patients and removed after 1 or 2 days. In one of the few reports supporting the use of drains, Coupens and Yates [11] examined the effects of drain use in a variety of arthroscopic procedures on knees that included meniscectomies, retinacular releases, and chondroplasties. These authors found that patients who had drains placed after surgery averaged a 15° greater ROM and statistically significantly less hemarthrosis 1 week after surgery.
A prospective but nonrandomized review of 60 arthroscopic knee surgeries showed that patients with a drain and no tourniquet had fewer hemarthroses develop and had a quicker return of motion. [14] However, this study did not include ACL patients. These patients may be different than other orthopedic patients because they tend to be younger, with high functional demands. Therefore, small deficits in ROM may have a greater effect on function and are a greater concern. In addition, with the desire to perform these as outpatient procedures, any beneficial effect from a drain in reducing postoperative pain would be of value. Karahan et al. [15],[16] showed decreased swelling and increased ROM in the second postoperative week following the use of drains in arthroscopically assisted ACL reconstruction.
Raves et al. [17] demonstrated decreased incidence of infection in the surgical wound bed in specimens with a closed-suction drain compared with those with a simple conduit system in an in vivo rabbit model. The necessity to evacuate wound hematomas is not supported in the literature; however, in their study of trauma patients, Lang et al. [8] found more hematomas in the group without drains. They found no statistical difference between the drain and no-drain groups in the development of infection, regardless of the presence of hematomas. Although our study was not designed to address the issue of wound infection, there were no wound complications in either group. Willett et al. [12] recommended removal of drains after 24 h. In our study, both the drains were removed 24 h after the surgery so that it could not act as a conduit of infection to the knee joint.
The other disadvantages of the use of surgical drains include hernias, breakdown of anastomoses, fistula formation, erosion into adjacent structures, and discomfort during the presence of and removal of the drain. [18] Reilly et al. [19] in their review of 299 knee replacements, found a 5.8% incidence of wound problems with drains and 3% without the use of a prophylactic postoperative drain. However, we encountered no such problems in our study. This can be attributed to the fact that drains were retained only for 24 h after the surgery. In our study, pain was measured on VAS. Multivariate analysis demonstrated that both the treatment and the control groups showed the same decreasing trend in pain over time. The mean decrease in the pain, as measured was found to be statistically significant for both the treatment group (P < 0.001) and control group (P < 0.001) over a period of follow-up of 12 months. With the no-DT group, pain trend showed an increase on the 4 th postoperative day (mean 5.86) compared to preoperative value (mean 2.4) following which pain trend showed a continuous decline over a period of time. With the DT group a continuous decline in pain trend was observed over a period of time. Post hoc test analysis also substantiated that pain was the most preoperatively and showed a decrease over a period of time sequentially. The overall pain differences between the control group and the treatment group from day 1 to 12 months from the date of surgery were not found to be statistically significant (P = 0.198) as calculated by independent sample t-test.
The decreased amount of pain seen in the group with a drain is an interesting finding and may be related to the decreased hemarthrosis which causes joint distension and increased pain. All patients followed a postoperative regimen of acetaminophen (100 mg) with paracetamol (500 mg), one tablet every 12 h with an intramuscular injection of diclofenac as needed, with the goals of pain relief and ability to participate in physical therapy. Multivariate analysis demonstrated that both groups showed a significant decrease in pain over time. This result suggests that pain management was similar, at least in effect, for both groups.
Both treatment and control groups showed similar trends showing a decline in flexion on the 4 th postoperative day from the preoperative values. However, the recovery in the knee ROM was found to be faster and more in the patients with DT compared to the patients without DT. Post hoc test analysis also showed progressive increment in knee ROM over time in both treatment and control groups. This clinically significant improvement in ROM in DT group can be attributed to lesser knee effusion and faster pain relief compared to the no-DT group. However, no statistical significant difference between the treatment and control groups could be seen when comparing flexion of the knee through the ROM (P = 0.116) as measured by independent sample t-test.
Preoperative assessment showed of 44 patients who underwent ACL reconstruction, 30 patients were having Grade 2 instability while 14 patients showed Grade 3 instability as per Lachman's test. After the procedure, knee was stable and had no features of instability as evident at follow-up at 1 year which showed negative Lachman's test in 41 patients and Grade 1 instability in 3 patients.
Hemarthrosis causes joint distension leading to increased pain and subsequent decreased ROM. The formation of hematomas is thought to lead to an increased risk of tissue compression. Our study showed that patients with DT had lesser knee effusion compared to the patients without DT. On the 4 th postoperative day, the percent reduction in knee effusion was found to be statistically significant (P < 0.001) in between treatment and control group. Of 22 patients in DT group, 15 patients had Grade 1 effusion and four patients had no effusion compared to no-DT group in which 13 patients had evidence of Grade 2 effusion while only six patients had Grade 1 effusion. At the 10 th postoperative day, percent reduction in knee effusion was found to be statistically significant between the treatment and control group (P < 0.001) 16 patients in the treatment group showed no effusion while six patients had Grade 1 effusion. At 6 months following surgery, no statistically significant difference was found in between treatment and control group. Twenty-one patients in the treatment group and 20 patients in the control group had no evidence of effusion.
| Conclusion | | |
- One of the purported advantages of using a drain is to reduce the incidence of wound problems and the risk of deep infection. Although this study was not designed to address the issue of wound infection, there were no wound complications in either group
- This study showed that for the primary outcomes of pain and ROM, clinically the drain group showed faster pain relief and early return to motion compared to the no-drain group as evidenced by comparing means. However, the results showed no statistical significant difference between the groups at the end of 12 months. The decreased amount of pain seen in the group with a drain is an interesting finding and may be related to the decreased hemarthrosis which causes joint distension and increased pain. Similarly, the recovery in knee ROM was faster and more in the patients with DT, and this can be explained by lesser effusion in the knee and faster pain relief in DT group compared to the no-DT group
- There was statistically smaller hemarthrosis in the drain group. The significance of the difference in hemarthrosis between the drain and no-drain groups was (P = 0.001) at 4 th and 10 th postoperative days.
Limitations
- Short-term study. The duration of the study was too short to predict the influence of many variables which manifest their effects over a long duration of time
- Variation in outcome was also influenced by factors like lack of adherence to rehabilitation protocol, avoidance of physical activity due to fear of re-injury, and social and financial issues
- Inadequate sample size which was influenced by short duration of the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]
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