The Effect of Drainage After Hip Arthroplasty

Closed suction drainage is a routinely used method in all fields of surgery. The idea to drain a wound is quite old. Supposedly, Hippocrates had already used a wooden tube to drain the operative wound (Levy, 1984). In orthopaedic surgery, Waugh and Stinchfield were the first who popularized the method of draining. Their preference to draining was based on their retrospective study, where they observed the incidence of wound infection after various orthopaedic procedures (Waugh & Stinchfield, 1961). The group of 100 patients with closed suction drainage was compared with a similar group (identical procedure, same comorbidities and the same surgeon) of 100 patients without the drainage. Wound infection occurred in 1% of patients with closed suction drainage and in 3% of patients without the drainage. They also noted that the post-operative rehabilitation was quicker if they drained the operated joint after an arthroplasty. Even though the difference in incidence of wound infection was not statistically significant, they concluded that a more benign postoperative course can be expected if the drains are used. After that, the use of drains quickly spread in all areas of orthopaedic surgery. It seemed logical to drain the operative wound. Exposed intramedullary canal and trabecular bone make it difficult to create a perfect hemostasis. A hematoma inevitably forms which increases the pressure on the surrounding tissues. Increased pressure impairs blood flow and healing of the operative wound. Additionally, a hematoma is also a good culture medium for bacteria (Cheung et al., 2008; Parvizi et al., 2007). The function of phagocytic cells to eliminate these bacteria in hematoma is weakened. The first reason for this weakened elimination is that phagocytic cells have a hardened access to the bacteria in the hematoma. Secondly, due to the low level of opsonic proteins in hematoma, the destruction capacity of phagocytic cells is damaged (Alexander et al., 1976). Therefore, in order to prevent the infection of the surgical wound, it appears logical to drain the wound to avoid or at least reduce the formation of hematoma. New studies have emerged at the end of the 20th century. These studies have questioned the logical mechanism of drainage and the use of drainage in hip arthroplasty. There are several potential adverse effects from draining. Drain tubes may become contaminated and allow a retrograde migration of the skin bacteria around the wound. In addition, drains may be inadvertently sutured to surrounding tissues and are difficult to remove post-operatively. Furthermore, drains may increase the amount of blood loss and increase the need for