To drain or not to drain in orthopedics?

Perhaps anyone who has ever been a patient undergoing fracture surgery, hip replacement, knee replacement, or even arthroscopy has wondered what the tube sticking out of their incision is for. In this article, the doctor will explain what a drain is, why it is used, and why it is not used.

The story begins with a conversation with my American colleagues 3 years ago. While operating together, I discussed this and asked if they wanted to use a postoperative drain for this case. In my mind, I already assumed they would place one, but their "No" response came as quite a surprise to me. They added that in the US, they no longer use drains because there is no difference whether they are used or not. Postoperative monitoring truly showed that patients recovered well and nothing happened. My subsequent trip to the US lasting over a month in 2023 allowed me to follow them and find the answer.

A surgical drain is a technique of placing a tube into the wound to remove blood, secretions, etc., after surgery. The main purpose is to prevent infection, reduce pressure, eliminate dead space in the body, thereby promoting rapid wound healing and monitoring complications. If it is so beneficial, why abandon it?

Everything has a reason. As medicine evolves, minimally invasive surgical approaches that do not cut through fascia and muscles, featuring increasingly smaller incisions, are being adopted. A minimally invasive approach means minimizing soft tissue damage, reducing bleeding, and decreasing inflammation, thereby minimizing the risk of fluid accumulation. And when there is no risk of fluid accumulation, naturally, you do not need a drain. Without a drain, patients can begin early mobilization right after surgery.

Returning to Vietnam, I gradually eliminated drains in almost all orthopedic trauma and sports medicine surgeries. Initially, it was for upper and lower extremity fracture fixation cases, followed by larger surgeries such as hip and knee replacements. (As for arthroscopy, I haven't used drains for a long time). And subsequently, this was combined with cosmetic suturing and biological tissue glue. I often joke that my motto is the 3 NEs: NO DRAIN, NO DRESSING CHANGE, AND NO STITCH REMOVAL.

This helps patients mobilize earlier, reduces inconveniences regarding wound and personal care, and brings satisfaction to both the patients and their families.

Broken arm 10 days after glue application

So does omitting the drain expose the patient to an increased risk of infection? The answer, as mentioned above: Studies have shown that there is no significant difference in the surgical site infection (SSI) rate between using and not using surgical drains in most orthopedic surgeries [1,2]. However, the ultimate decision still rests with the surgeon. If I feel that the surgery was prolonged, with extensive soft tissue damage and a high risk of fluid accumulation, placing a drain may still be a safe and easily monitored solution. Conversely, if it is a minimally invasive surgery with a smooth intraoperative course, omitting the drain, using cosmetic suturing, and applying biological glue is a perfect choice.

With the experience of operating on thousands of cases, I find that not using drains is the trend of modern medicine, bringing many benefits to patients in a social context that increasingly values convenience and aesthetics.

Image: No drain, cosmetic suturing, and biological glue in Orthopedic and Traumatology surgery - Source: Dr. Vu Anh

References

1. Albasha A, Salman LA, Elramadi A, et al. Outcomes of drain versus no drain in total knee arthroplasty: a retrospective cohort study. Int Orthop. 2023;47(12):2985-2989. doi:10.1007/s00264-023-05946-z

2. Goel, Aditya; Singh, Shivendra; Shukla, Navin K.. Role of Surgical Drains in Orthopedics. Journal of Orthopaedic Diseases and Traumatology 6(3):p 234-236, Sep–Dec 2023. | DOI: 10.4103/jodp.jodp_32_23

P/S: I would like to add a note that this article is limited to elective orthopedic and traumatology surgeries; open fractures are not discussed in this article.