CSD have long been utilized in orthopedic surgery to prevent hematoma formation, mitigate infection risks, and alleviate compartment pressure[2]. However, the efficacy of this practice, along with its potential adverse effects, has come under scrutiny over time[8]. TKA is recognized as a procedure often associated with substantial bleeding and frequent transfusion requirements. Numerous studies have documented the efficacy of TA in reducing bleeding and transfusion needs[12].
In this study, we compared patients who underwent TKA with the use of CSD along with the administration of TA to patients who underwent TKA without the use of CSD. We demonstrated that in TKA surgeries where TA was used without CSD, blood loss, transfusion requirements, LOS, and the number of dressing changes could be reduced. These findings may impact the widespread use of this practice.
The inclusion of a patient series treated by a single primary surgeon in our study is crucial for accurately assessing the outcomes
In unilateral total knee arthroplasty, blood loss of up to 2000 ml has been reported[13]. In our study, the total blood loss in group A was found to be mean 1155 ± 88 ml, and in group B it was 716 ± 78 ml (P = 0.0001). A significant decrease in total blood loss was observed when TA and CSD were used. The mean blood loss in group A patients was lower than the previously reported blood loss in literature[13]. We believe this could be attributed to measures taken to reduce bleeding. It has been reported that using the tourniquet only during cementation allows for more effective hemostasis during surgery[14]. Additionally, in posterior cruciate retaining (PCR) procedures, the femoral medullary cavity was closed with cancellous bone. Clamping the drains for 2 hours in patients where drains were used was also used as a method to reduce bleeding[15].
There are several studies either suggesting local, systemic or both local and systemic application of TA in TKA[9, 16, 17]. In our study, we preferred both systemic and local application in group B patients. The decrease in total blood loss in group B patients, along with not using CSD, demonstrates the combined effect of local and systemic TA application. The study design is not suitable for distinguishing the effects of tranexamic acid and absence of CSD use. Along with the decrease in total blood loss, a significant reduction in transfusion requirements was observed between the groups. The need for transfusion in group B was significantly lower than in group A (P = 0.0001). However, in other studies, the decrease in transfusion requirement is not consistently reported alongside the decrease in total blood loss[18]. This variability in reporting may be attributed to differences in the size of the study groups.
We observed the necessity for dressing changes in our study, particularly noting a significantly increased requirement in patients where CSD were utilized. This need was particularly prominent after the removal of the drain. In patients where CSD were not used and TA was administered, a notable reduction in the requirement for dressing changes was observed. The excessive requirement for dressing changes is significant in terms of increasing the risk of infection, disrupting wound healing, impacting patient comfort, and also in terms of cost implications[19]. Contrary to our findings, meta-analyses on the abstention from CSD in TKA surgery have reported an increase in the requirement for dressing changes. Especially, the absence of TA application in these studies should be emphasized [18, 20, 21].
In our study, patients with CSD exhibited leakage-type bleeding from the drain exit site after the drain was removed. Dressing contamination from the drain exit point occurred when the patient walked or used continuous passive motion. However, dressing changes were not observed in non-CSD patients
There is no consensus regarding the effect of CSD usage on LOS. While several studies have reported no significant difference, some large-scale studies have indicated that not using CSD can reduce LOS[22]. In our study, we observed a significant reduction in LOS in patients where CSD were not used, along with the combined use of local and systemic TA (P = 0.005). We believe the shorter LOS is related to the discharge criteria we applied. Patients were scheduled for discharge once they achieved a 90-degree range of motion, could walk approximately 30 meters, and did not require dressing changes for at least two consecutive days. The increased need for dressing changes in group A, where CSD were used, directly impacted the LOS.
In our study, we compared TKA surgeries performed without CSD application but with the administration of both intravenous and local TA to surgeries performed with CSD using a clamping technique. We observed that the absence of CSD in TKA surgery, coupled with the use of intravenous and local TA, led to reductions in postoperative blood loss and transfusion requirements. Specifically, we found that patients in the study group experienced an average reduction of 439 ml in blood loss and required approximately 1 unit less blood transfusion.
Meta-analyses examining the impact of CSD on bleeding and transfusion have consistently reported that abstaining from CSD reduces both bleeding and the need for transfusion [23–25]. We evaluated the total effect of TA use and non-CSD use in our study, and our findings support the data obtained separately with tranexamic acid and non-CSD use[16, 26]. However, we did not come across a study comparing the combined use of these two. Another significant discovery in our study is the diminished requirement for dressing changes in patients without CSD. We consider this observation crucial to emphasize, as it contradicts existing reports suggesting that abstaining from CSD in TKA may actually lead to an increased need for dressing changes. In these studies reporting the association of increased dressing changes with the absence of CSD, it is noteworthy that TA was not utilized[18, 20, 21].
We evaluated the combined effects of local and intravenous tranexamic acid administration along with the non-CSD use. Our study presents the collective outcome of these practices. Our results cannot be attributed separately to the omission of CSD or the use of local or intravenous tranexamic acid. This limitation emerges as a restricted aspect of our study.