702 ORTHOPEDICS | ORTHOSuperSite.

com
Review Article
abstract
T
he use of surgical drains have a long
history in thoracic and abdominal
surgery, but indications for their
use in orthopedic surgery have been less
fully described. Nevertheless, orthope-
dic surgeons have used surgical drains to
avoid hematomas and seromas, to provide
egress for infected wounds with the goal
of minimizing the risk of such infections
and other wound problems (eg, necrosis of
ap in calcaneus fractures, compartment
syndrome, compression of nerves, etc).
Drains have been used in a variety of elec-
tive orthopedic cases such as total joint
replacement, sports medicine, and spine
procedures. Drains have also been used in
the treatment of open fractures. Common
to all of these cases is the matter of wound
healing postoperatively, with the role that
these surgical drains play remaining un-
certain. Specically, the efcacy of these
drains to decrease wound complications
remains controversial.
HISTORY
The concept of surgical drainage is
rooted in antiquity, with the earliest re-
corded use of drains to treat empyema
credited to Hippocrates (460-377 BC).
1,2

Physicians in ancient Rome, including
Claudius Galen (. 1st century AD), were
known to have used surgical drains to
treat ascites and deep abscesses. Ambrose
Pare (1510-1590), considered by many a
key pioneer of surgical drainage, used his
tentes (cannulated lead tubes) not only
for drainage, but also for wound care and
debridement. He may have been the rst
to use drains widely for orthopedic proce-
dures.
2
While early drains relied on over-
ow or gravity, Johann Schultes (1595-
1645) took advantage of capillary action
and improved drain function by inserting
wicks into the core of the drain.
3

The later works of pioneers such as Jo-
seph Lister (1827-1912), Claude Bernard
(1813-1878), and Robert Koch (1843-
1910) brought to the forefront the impor-
tance of microbes and wound debridement.
While greater appreciation for the status
of the wound itself and the importance of
appropriate debridement was developing,
certain advances in drainage occurred.
From the late 19th until the mid 20th cen-
tury, gravity-type open systems continued to
be used with little other progress in drain
technology. Then, advances in material en-
gineering led to the development of tubing
that was better able to resist occlusion when
suction was applied. This spurred the evolu-
tion of closed drainage systems that helped
to decrease the potential for environmental
wound contamination while actively de-
compressing wound hematoma and seroma.
Continuous suction closed drain systems
were shown to reduce wound complications
The Use of Surgical Drains in Orthopedics
ROBERT J. GAINES, MD; ROBERT P. DUNBAR, MD
Dr Gaines is from the Department of Ortho-
pedic Surgery, Bone and Joint/Sports Medicine
Institute, Naval Medical Center Portsmouth,
Virginia; and Dr Dunbar is from Harborview
Medical Center, University of Washington, Seattle
Washington.
Drs Gaines and Dunbar have no relevant -
nancial relationships to disclose.
The views expressed in this article are those of
the authors and do not reect the ofcial policy or
position of the Department of the Navy, Depart-
ment of Defense, or the United States Government.
Correspondence should be addressed to: Rob-
ert J. Gaines, MD, 27 Efngham St, Portsmouth,
VA 23708.
The use of postsurgical drains have a long history in thoracic and abdominal
surgery. In orthopedics these devices have been used to decrease local edema,
lessen the potential for hematoma or seroma formation, and to aid in the ef-
ux of infection. However, the role of postoperative surgical drains in clean,
elective cases has not been rmly established. In fact, most studies fail to show
a statistical difference in outcome between drained and undrained patients.
Despite the paucity of clinical evidence demonstrating any benet supporting
their use, drains continue to be placed after elective orthopedic procedures.
JULY 2008 | Volume 31 Number 7 703
SURGICAL DRAINS IN ORTHOPEDICS |GAINES & DUNBAR
compared with open or non-self-suctioning
drain systems. Modern drainage systems
have evolved toward a self contained, mo-
bile, continuous suction device.
BASIC SCIENCE
Intuitively, the use of drains in infec-
tion has value. Facilitating the egress of
infected material helps prevent abscess
formation and decreases the microorgan-
ism load, which may improve the local
environment (decreased local edema, less
localized immunosuppression) enough
that healing may ensue.
Extending the use of drains to clean
procedures as prophylaxis against infec-
tion or other wound problems is less intui-
tive and perhaps requires a leap of faith.
Concern exists that the drain may serve
as a conduit for organisms, predisposing
a clean wound to infection.
Cerise et al
4
demonstrated that bacte-
ria can directly contaminate deep surgical
sites by migrating over a drain. They dem-
onstrated a statistically signicant increase
of infection with the use of simple con-
duit drains in splenectomized New Zea-
land White rabbits. Rabbits treated with
a drain showed an increased migration of
type specic streptococcus from the skin
to the splenectomy bed compared with
controls (P.01).
4
Baker and Borchardt,
5

using an in vitro model proved that sump
drains can potentially infect wounds with
contaminants from the air. They demon-
strated 100% contamination rate in their
experimental model when wall suction was
applied to an uncapped sump drain.
Waugh and Stincheld
6
published the
rst article describing the use of closed
suction drainage for orthopedic proce-
dures. In a prospective controlled series
they found a 1% incidence of postop-
erative infection in patients with a closed
drain system versus a 3% infection rate
in matched cases without a drain. While
this result did not reach statistical signi-
cance, due to sample size, the potential to
decrease wound infections with prophy-
lactic drains was deemed encouraging.
Alexander et al
7
helped differentiate
important factors in wound healing and
the early postoperative soft tissue envi-
ronment that the use of drains may affect
directly. Specically, they investigated the
infection ghting capacity of dilutions of
post-surgical exudates. Using a canine
model, they compared the opsonization
of Escherichia coli in wound exudate and
similar dilutions of the dogs serum. The
pilot study demonstrated a decrease in the
opsonizing capacity of wound exudates 24
hours postoperatively compared to serum.
Opsonizing activity steadily decreased
until it was virtually absent 14 days post-
operatively. In a separate study, these au-
thors then performed a similar protocol in
a human model, aspirating wound exudate
samples at different time intervals from
the retroperitoneal space of patients who
had undergone nephrectomy. These data
were consistent with their previous nd-
ings, leading them to conclude that uids
collecting in wounds have a progressive
reduction in their ability to support opso-
nization of bacteria for phagocytosis.
7
The increased risk for infection of
open draining systems combined with
the decrease in infection ghting capac-
ity of wound exudates over time called
into question the use of drains for postop-
erative prophylaxis against wound com-
plications. Further labwork by Raves et
al
8
established the superiority of closed
drainage systems over open ones in terms
of infectious risk. They studied 60 New
Zealand White rabbits split into 3 groups
of 20. Each rabbit underwent splenecto-
my. The control group had no drain post-
splenectomy, in the second group a simple
latex conduit (open drainage system) was
used, while in the third group a closed
bulb suction device was used. The skin
around the drain site was then inoculated
with a type-specic Streptococcus spe-
cies. Of the animals treated with a simple
open latex drain, 18 of 20 (90%) demon-
strated Streptococcus in the surgical bed
at 72 hours. Splenectomized animals in
the closed drain limb of the study only
demonstrated positive cultures in 4 of 20
(20%) (P.001). There were no positive
cultures in control animals closed with-
out a drain.
8
This study underscored the
postoperative infectious potential of open
drain systems.
CLINICAL RELEVANCE
Several prospective randomized trials
investigated wound complications and
postoperative drain use in total joint re-
placement.
9-12
Ovadia et al
11
performed a
prospective study of 88 patients undergo-
ing either primary total hip replacement
(THR) or primary total knee replacement
(TKR). Drains were left in place for 48
hours for 32 of 58 patients undergoing
TKR and 18 of 30 patients undergoing
THR. Use of a drain did not affect the
infection rate. However, signicantly
(P.02) more transient serous wound
drainage was noted from patients who
were not drained. Further, in the TKR
population, when a drain was used, sta-
tistically signicant increase was noted in
blood transfusion requirement (P.005).
The signicant increase in postop-
erative transfusion requirement was not
unique to the Ovadia study and had been
previously addressed by other authors.
In a retrospective review of nearly 300
TKR patients, Reilly et al
13
found no dif-
ference in wound problems or postopera-
tive range of motion whether a drain was
used or not. However, these authors noted
that patients who had closed suction drains
required blood transfusion at twice the rate
of patients who were not drained (P.01).
Similarly, in a retrospective review of THR
patients, Hadden and McFarlane
14
found
no difference in their short term compli-
cations and documented a trend (but no
statistical signicance) toward increased
requirements for blood transfusions in pa-
tients who received drains.
Beer et al
15
compared matched pairs of
patients undergoing THR and TKR to in-
vestigate suction drainage and short term
outcomes. In this study a drain was used on
one side and not used on the other. There
704 ORTHOPEDICS | ORTHOSuperSite.com
Review Article
was no statistical difference in clinically
noted edema or wound drainage. None
of the patients in this study demonstrated
clinical signs of postoperative infection.
When analyzing only the primary TKR, no
difference was noted in the range of motion
or return of active quadriceps function be-
tween the two sides.
15
Niskanen et al
12
and
Ashraf et al,
16
reporting on both primary
and revision arthroplasties of the knee and
hip have also found no difference in wound
healing, hematoma formation, or postop-
erative range of motion.
Prospective randomized trials after
THR echo the ndings after TKR. Kim
et al
10
published a prospective analysis
of patients undergoing bilateral THR.
Similarly, they found no difference in
early complications, or outcome in terms
of postoperative range of motion or Har-
ris hip score. In this study the only sta-
tistically signicant benets of postop-
erative drain use was a decrease in the
requirement for dressing reinforcement
(P.001) and a decrease in erythema
and ecchymosis around the incision site
(P.05).
10
However, they found, as did
others, that undrained hips required more
dressing reinforcements and sheet chang-
es during the patients hospital stay.
11,17

Additionally, a cost analysis demonstrat-
ed that these dressing and linen changes
were less expensive than the disposable
drain system. Of note, Kim et al
10
sug-
gested that the decreased dressing chang-
es may be psychologically benecial to
the patient.
Gunnar et al,
18
in a prospective study
evaluated drain usage in 90 primary TKR
patients. The rst group of 30 received an
autotransfusion drain, the second group a
disposable closed suction system, and the
third group served as a control, not using
a drain. No difference was noted between
groups in regard to hospital stay, knee
swelling, knee range of motion, or post-
operative hemoglobin or hematocrit lev-
els. Also, no difference was found in the
number of required blood transfusions be-
tween the groups. Gunnar et al
17
conclud-
ed that drains offered no added benet to
the patient after total joint arthroplasty.
In fracture surgery the degree of soft
tissue injury, including tissue necrosis,
edema, and internal degloving and inam-
mation may be signicantly different than
in the elective total joint replacement pop-
ulation.
17,19,20
Nevertheless, the ndings
were similar to those established in the
total joint literature, ie, no effect on hema-
toma or seroma formation nor a decrease
in wound complications. Specically,
Cobb
19
found no statistically signicant
difference in wound swelling, erythema,
or infection postoperatively in 70 consecu-
tive patients treated for femoral neck frac-
tures when surgical drains were used. In
fact, wound complications like tenderness
and swelling around the incision were less
common in the undrained group.
19
One
patient required a return to the operating
room for removal of a surgical drain that
had been sewn into the closure. Although
uncommon, this preventable complication
is only seen when drains are used.
Lang et al
20
examined 202 patients
in a randomized study evaluating drains
in the treatment of nonemergent, closed,
fractures of the extremities and the pel-
vis. Open fractures were excluded, so that
contamination would not be a confound-
ing variable. Again no benet to the use of
a drain was noted. Specically, there was
no increase in wound drainage, edema,
hematoma, infection, or need for addi-
tional surgery or readmission in the rst 6
postoperative weeks.
Iliac crest bone graft donor sites, with
large exposed areas of cancellous bone,
are at signicant risk for postoperative
hematoma formation. Even when drains
were used in this scenario they showed no
clinical benet. Sasso et al
21
placed drains
in the bed of iliac crest bone graft donor
sites used for xation of spine fractures.
They noted no difference in graft site mor-
bidity between the drained and undrained
groups throughout follow-up.
In contrast to the wealth of studies that
show little or no the benet of the use
of postoperative drains, one prospective
study has provided some objective data
in support of them. Varley and Milner
17

evaluated 177 consecutive patients under-
going operative treatment for proximal
femur fractures with either a hemiarthro-
plasty or a dynamic hip screw. Thy used
ultrasound to monitor the surgical site for
hematoma accumulation and they were
able to demonstrate that drains were ef-
fective in reducing hematoma formation.
Using a wound scoring system, they noted
a statistically signicant improvement in
those scores when wounds were drained
when compared with wounds that were
not drained (P.01). Correspondingly,
they found that poor postoperative scores
were predictive of infection.
22
Another unresolved issue in the use of
drains is deciding when to remove them.
There is little guidance in the literature.
It has been demonstrated that intravenous
antibiotics penetrate the postoperative he-
matoma and can be found in the uids in
the wound for several days.
23,24
Addition-
ally, in many cases the majority of wound
drainage occurs within the rst 24 hours
postoperative.
9,25

Drinkwater and Neil
9
performed a dual
center prospective trial with patients un-
dergoing total joint arthroplasty. Although
they were not able to demonstrate statisti-
cal signicance, they showed an increased
in bacterial contamination of drain tips af-
ter 24 hours, in patients covered with pro-
phylactic antibiotics.
9
These studies help to
dene quantiable changes in the wound
bed over time, but there is an absence of
a prospective randomized trial that demon-
strates the optimal duration of drain use.
There is a lack of large, well-designed
randomized clinical trials in the orthope-
dic literature evaluating the necessity to
support the use of antibiotic prophylaxis
for surgical drains. While this remains a
contentious issue for some, no objective
data supports the extended use of antibiot-
ics for the sole purpose of prophylaxing
against drain induced wound complica-
tions. It would be expected that many
JULY 2008 | Volume 31 Number 7 705
SURGICAL DRAINS IN ORTHOPEDICS |GAINES & DUNBAR
wounds require no drain or would have
the drain removed prior to the last dose of
prophylactic perioperative antibiotics.
Use of perioperative antibiotics exclu-
sive of drain use have been proven to be
of benet.
26-28
Grossly infected wounds
that require serial debridements and that
use drains typically are treated with an-
tibiotics for the infection, not the drain.
Thus, the question of antibiotic prophy-
laxis of drains then only arises in the case
in which a presumably clean wound is
drained for an extended period beyond the
typical need for perioperative antibiotics.
Currently, we are aware of no data that
supports this practice.
SUMMARY
The role of postoperative surgical drains
in clean, elective cases has not been rmly
established. In fact, most studies examin-
ing closed drainage for elective cases fail
to show a statistical difference in outcome
between drained and undrained patients.
Despite the paucity of clinical evidence
demonstrating any benet supporting their
use, drains continue to be placed after
elective orthopedic procedures. Chandra-
treya et al
29
offers an interesting perspec-
tive on the use of postoperative surgical
drains. They performed two separate sur-
veys of British orthopedic surgeons. In the
rst survey, they established the incidence
of drain use. In the second survey they
questioned surgeons about their reasons
for drain use. Finally, they presented the
literature regarding drain usage to the sur-
geons surveyed. After being presented
with the data that demonstrated no benet
from drain use, they found that the major-
ity of surgeons did not change their prac-
tice.
29
This study underscored the reality
that drains continue to be used in various
surgical scenarios often without clear clin-
ical evidence that they improve outcomes
or offer any benet. There appears to be
limited objective support for the use of
closed suction drainage of elective ortho-
pedic procedures. In open, contaminated,
infected or degloved wounds drain use
may have a role, the specics of which re-
quires further study.
REFERENCES
1. Robb H. The management of the drainage
tube in abdominal surgery. Johns Hopkins
Hospital Report. 1891; 2:184.
2. Moss JP. Historical and current prospectives
on surgical drainage. Surgery, Gynecology,
and Obstetrics. 1981; 152:517-527.
3. Golovsky D, Conolly WB. Observation on
wound drainage with review of the literature.
Med J Aust. 1976; 1(10):289-291.
4. Cerise EJ, Pierce WA, Diamond DL. Abdom-
inal drains: their role as a source of infec-
tion following splenectomy. Ann Surg. 1970;
171(5):764-769.
5. Baker BH, Borchardt KA. Sump drains and
airborne bacteria as a cause of wound infec-
tions. J Surg Res. 1974; 17(6): 407-410.
6. Waugh TR, Stincheld FE. Suction drainage
of orthopedic wounds. J Bone Joint Surg Am.
1961; 43:939-946.
7. Alexander JW, Korelitz J, Alexander NS.
Prevention of wound infections. A case for
closed suction drainage to remove wound u-
ids decient in opsonic proteins. Am J Surg.
1976; 132(1):59-63.
8. Raves JJ, Slifkin M, Diamond DL. A bacte-
riologic study comparing closed suction and
simple conduit drainage. Am J Surg. 1984;
148(5):618-620.
9. Drinkwater CJ, Neil MJ. Optimal timing of
wound drain removal following total joint ar-
throplasty. J Arthroplasty. 1995; 10(2):185-
189.
10. Kim YH, Cho SH, Kim RS. Drainage ver-
sus nondrainage in simultaneous bilateral
total hip arthroplasties. J Arthroplasty. 1998;
13(2):156-161.
11. Ovadia D, Luger E, Bickels J, Menachem
A, Dekel S. Efcacy of closed wound drain-
age after total joint arthroplasty. A prospec-
tive randomized study. J Arthroplasty. 1997;
12(3):317-321.
12. Niskanen RO, Korkala OL, Haapala J, Kuok-
kanen HO, Kaukonen JP, Salo SA. Drainage
is of no use in primary uncomplicated ce-
mented hip and knee arthroplasty for osteo-
arthritis: a prospective randomized study. J
Arthroplasty. 2000; 15(5):567-569.
13. Reilly TJ, Gradisar IA, Pakan W, Reil-
ly M. The use of postoperative suction drain-
age in total knee arthroplasty. Clin Orthop
Relat Res. 1986; (208):238-242.
14. Hadden WA, McFarlane AG. A comparison
study of closed-wound suction drainage vs
no drainage in total hip arthroplasty. J Ar-
throplasty. 1990; 5(suppl):S21-S24.
15. Beer KJ, Lombardi AV, Mallory TH, Vaughn
BK. The efcacy of suction drains after rou-
tine total joint arthroplasty. J Bone Joint Surg
Am. 1991; 73(4):584-587.
16. Ashraf T, Darmanis S, Krikler SJ. Effective-
ness of suction drainage after primary or re-
vision total hip and total knee arthroplasty.
Orthopedics. 2001; 24(12):1158-1160.
17. Varley GW, Milner SA. Wound drains in
proximal femoral fracture surgery: a random-
ized prospective trial of 177 patients. J R Coll
Surg Edinb. 1995; 40(6):416-418.
18. Gunnar A, Bystrom S, Kolstad K, Mallmin
H, Milbrink J. Postoperative drainage of knee
arthroplasty is not necessary. Acta Orhop
Scandanav. 1998; 69:475-478.
19. Cobb JP. Why use drains? J Bone Joint Surg
Br. 1990; 72(6):993-995.
20. Lang GJ, Richardson M, Bosse MJ, et al.
Efcacy of surgical wound drainage in or-
thopaedic trauma patients: a randomized
prospective trial. J Orthop Trauma. 1998;
12(5):348-350.
21. Sasso RC, Williams JI, Dimasi N, Meyer
PR. Postoperative drains at the donor sites
of iliac-crest bone grafts. A prospective,
randomized study of morbidity at the donor
site in patients who had a traumatic injury
of the spine. J Bone Joint Surg Am. 1998;
80(5):631-635.
22. Wilson AP, Treasure T, Sturridge MF,
Grunenberg RN. A scoring method (ASEP-
SIS) for postoperative wound infections for
use in clinical trials of antibiotic prophylaxis.
Lancet. 1986; 1(8476):311-313.
23. Wilson FC, Worcester JN, Coleman PD,
Byrd WE. Antibiotic penetration of experi-
mental bone hematomas. J Bone Joint Surg
Am. 1971; 53(8):1622-1628.
24. Nelson CL, Berfeld JA, Schwartz J, Kolc-
zun M. Antibiotics in human hematoma and
wound uid. Clin Orthop Relat Res. 1975;
(108):138-144.
25. Willett KM, Simmons CD, Bentley G. The
effect of suction drains after total hip replace-
ment. J Bone Joint Surg Br. 1988; 70(4):607-
610.
26. Williams DN, Gustilo RB. The use of preven-
tive antibiotics in orthopaedic surgery. Clin
Orthop Relat Res. 1984; (190):83-88.
27. Oishi CS, Carrion WV, Hoagland FT. Use of
parenteral prophylactic antibiotics in clean
orthopaedic surgery. Clinl Orthop Relat Res.
1993; (296):249-255.
28. Hanssen AD, Osmon DR. The use of pro-
phylactic antimicrobial agents during and
after hip arthroplasty. Clin Orthop Relat Res.
1999; (369):124-138.
29. Chandratreya A, Giannikas K, Livesly P. To
drain or not to drain: literature versus prac-
tice. The Journal of the Royal College of Sur-
geons of Edinburgh. 1998; 43:404-406.
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