J Knee Surg
DOI: 10.1055/a-2045-8211
Original Article

Closed Suction Drainage after Total Knee Arthroplasty with Concomitant Intravenous Tranexamic Acid Administration

Slaton Case
1   Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
1   Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
2   Northwestern Memorial Hospital, Chicago, Illinois
Jonathan Edgington
3   Community Healthcare System, Munster, Indiana
David Manning
1   Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
2   Northwestern Memorial Hospital, Chicago, Illinois
Kevin Hardt
1   Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
2   Northwestern Memorial Hospital, Chicago, Illinois
› Author Affiliations


Drain use in total knee arthroplasty (TKA) remains controversial. Use has been associated with increased complications, particularly postoperative transfusion, infection, increased cost, and longer hospital stays. However, studies examining drain use were performed before widespread adoption of tranexamic acid (TXA), which markedly reduces transfusion without increasing venous thromboembolism events. We aim to investigate incidence of postoperative transfusion and 90-day return to the operating room (ROR) for hemarthrosis in TKA with use of drains and concomitant intravenous (IV) TXA. Primary TKAs from a single institution were identified from August 2012 to December 2018. Inclusion criteria were primary TKA, age 18 years and over where use of TXA, drains, anticoagulant, and pre- and postsurgical hemoglobin (Hb) were documented during the patient's admission. Primary outcomes were 90-day ROR specifically for hemarthrosis and rate of postoperative transfusion. A total of 2,008 patients were included. Sixteen patients required ROR, three of which were due to hemarthrosis. Drain output was statistically higher in the ROR group (269.3 vs. 152.4 mL, p = 0.05). Five patients required transfusion within 14 days (0.25%). Patients requiring transfusion had significantly lower presurgical Hb (10.2 g/dL, p = 0.01) and 24-hour postoperative Hb (7.7 g/dL, p < 0.001). Drain output between the transfusion and no transfusion groups varied significantly (p = 0.03), with transfusion patients having higher postoperative day 1 drain output of 362.6 mL and total drain output of 376.6 mL. In this series, postoperative drain use with concomitant weight-based IV TXA is shown to be safe and efficacious. We observed exceedingly low risk of postoperative transfusion compared with prior reports of drain use alone as well as preserved low rate of hemarthrosis that has previously been positively linked to drain use.

Publication History

Received: 07 December 2022

Accepted: 24 February 2023

Accepted Manuscript online:
02 March 2023

Article published online:
06 April 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Delanois RE, Mistry JB, Gwam CU, Mohamed NS, Choksi US, Mont MA. Current epidemiology of revision total knee arthroplasty in the United States. J Arthroplasty 2017; 32 (09) 2663-2668
  • 2 Ranawat AS, Ranawat CS. The history of total knee arthroplasty. In: The Knee Joint: Surgical Techniques and Strategies; 2012. Springer; DOI: 10.1007/978-2-287-99353-4_63
  • 3 Poeran J, Ippolito K, Brochin R. et al. Utilization of drains and association with outcomes: a population-based study using national data on knee arthroplasties. J Am Acad Orthop Surg 2019; 27 (20) e913-e919
  • 4 Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty: a meta-analysis. J Bone Joint Surg Am 2004; 86 (06) 1146-1152
  • 5 Wind TC, Barfield WR, Moskal JT. The effect of tranexamic acid on blood loss and transfusion rate in primary total knee arthroplasty. J Arthroplasty 2013; 28 (07) 1080-1083
  • 6 Mont MA, Jacobs JJ, Boggio LN. et al; AAOS. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg 2011; 19 (12) 768-776
  • 7 Edelstein AI, Terzaghi C, Nudelman B, Qin C, Kwasny M, Manning DW. Early response to warfarin initiation and the risk of venous thromboembolism after total joint arthroplasty. J Am Acad Orthop Surg 2018; 26 (04) e90-e97
  • 8 Faour M, Piuzzi NS, Brigati DP. et al. Low-dose aspirin is safe and effective for venous thromboembolism prophylaxis following total knee arthroplasty. J Arthroplasty 2018; 33 (7S): S131-S135
  • 9 Bini SA, Darbinian JA, Brox WT, Khatod M. Risk factors for reaching the post-operative transfusion trigger in a community primary total knee arthroplasty population. J Arthroplasty 2018; 33 (03) 711-717
  • 10 Lindman IS, Carlsson LV. Extremely low transfusion rates: contemporary primary total hip and knee arthroplasties. J Arthroplasty 2018; 33 (01) 51-54
  • 11 Frisch NB, Wessell NM, Charters MA, Yu S, Jeffries JJ, Silverton CD. Predictors and complications of blood transfusion in total hip and knee arthroplasty. J Arthroplasty 2014; 29 (9, Suppl) 189-192
  • 12 Fitzgerald J, Spiro TE, Trowbridge AA. et al. Prevention of venous thromboembolic disease following primary total knee arthroplasty: a randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin. J Bone Joint Surg Am 2001; 83 (06) 900-906
  • 13 Mismetti P, Laporte S, Zufferey P, Epinat M, Decousus H, Cucherat M. Prevention of venous thromboembolism in orthopedic surgery with vitamin K antagonists: a meta-analysis. J Thromb Haemost 2004; 2 (07) 1058-1070
  • 14 Leclerc JR, Geerts WH, Desjardins L. et al. Prevention of venous thromboembolism after knee arthroplasty. A randomized, double-blind trial comparing enoxaparin with warfarin. Ann Intern Med 1996; 124 (07) 619-626
  • 15 Urish KL, Qin Y, Salka B. et al. Comparison of readmission and early revision rates as a quality metric in total knee arthroplasty using the Nationwide Readmission Database. Ann Transl Med 2020; 8 (11) 687 DOI: 10.21037/atm-19-3463.
  • 16 Koh CK, Zeng I, Ravi S, Zhu M, Vince KG, Young SW. Periprosthetic Joint infection is the main cause of failure for modern knee arthroplasty: an analysis of 11,134 knees. Clin Orthop Relat Res 2017; 475 (09) 2194-2201
  • 17 Heck DA, Melfi CA, Mamlin LA. et al. Revision rates after knee replacement in the United States. Med Care 1998; 36 (05) 661-669
  • 18 Patterson JT, Sing D, Hansen EN, Tay B, Zhang AL. The James A. Rand Young Investigator's Award: administrative claims vs surgical registry: capturing outcomes in total joint arthroplasty. J Arthroplasty 2017; 32 (9S): S11-S17
  • 19 Manley M, Ong K, Lau E, Kurtz SM. Total knee arthroplasty survivorship in the United States Medicare population: effect of hospital and surgeon procedure volume. J Arthroplasty 2009; 24 (07) 1061-1067
  • 20 Held MB, Grosso MJ, Sarpong NO, Hamilton WG, Sista AK, Macaulay W. Recurrent hemarthrosis following total knee arthroplasty. JBJS Rev 2019; 7 (10) e2
  • 21 Klika AK, Small TJ, Saleh A, Szubski CR, Chandran Pillai ALP, Barsoum WK. Primary total knee arthroplasty allogenic transfusion trends, length of stay, and complications: nationwide inpatient sample 2000-2009. J Arthroplasty 2014; 29 (11) 2070-2077
  • 22 Pedersen AB, Mehnert F, Overgaard S, Johnsen SP. Allogeneic blood transfusion and prognosis following total hip replacement: a population-based follow up study. BMC Musculoskelet Disord 2009; 10: 167
  • 23 Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology 2010; 113 (02) 482-495
  • 24 Clair AJ, Evangelista PJ, Lajam CM, Slover JD, Bosco JA, Iorio R. Cost analysis of total joint arthroplasty readmissions in a bundled payment care improvement initiative. J Arthroplasty 2016; 31 (09) 1862-1865
  • 25 Ravi B, Jenkinson R, O'Heireamhoin S. et al. Surgical duration is associated with an increased risk of periprosthetic infection following total knee arthroplasty: a population-based retrospective cohort study. EClinicalMedicine 2019; 16: 74-80
  • 26 Curtis GL, Jawad M, Samuel LT. et al. Incidence, causes, and timing of 30-day readmission following total knee arthroplasty. J Arthroplasty 2019; 34 (11) 2632-2636