Closed wound drainage systems are commonly used in total joint arthroplasty. However, multiple studies in the hip and knee arthroplasty literature have failed to identify a benefit with closed drainage systems in postoperative range of motion, wound infection, hematoma, or reoperation rates.1–4 Previous studies of shoulder arthroplasty have reported a correlation between hematoma formation and the development of deep postoperative infection requiring additional surgery.5 This would suggest that by preventing hematoma formation in shoulder arthroplasty, closed drainage systems could prevent postoperative complications. Although a single study examined closed drainage in all types of shoulder surgeries (including rotator cuff repair, anterior reconstruction for instability, and arthroplasty),6 no study to date has investigated the effectiveness of closed wound drainage solely in total shoulder replacement in preventing postoperative complications.
The purpose of this study was to determine if any significant differences exist between closed drainage use in primary shoulder arthroplasty and the postoperative complications of infection and hematoma within 1 year. Also, the authors sought to identify any significant correlation between chronic medical conditions, such as bleeding disorders, anticoagulation therapy, diabetes mellitus, autoimmune/proinflammatory conditions, or immunosuppressive medication, and postoperative complications.
Materials and Methods
The authors retrospectively identified all primary total shoulder arthroplasty (TSA) and primary reverse total shoulder arthroplasty (rTSA) procedures performed by fellowship-trained upper extremity surgeons at their institution during a 2-year period (February 2013 to February 2015). Institutional review board approval was obtained. Using their institutional electronic medical record system, the authors excluded all cases of nonprimary shoulder arthroplasty; cases with insufficient medical records, including those lacking detailed operative reports; cases without documented minimum 12-month follow-up; and cases involving surgeries for tumor. The authors inspected the medical records of all included patients and identified potential risk factors in their past medical history, including bleeding disorders, anticoagulation therapy, diabetes mellitus, autoimmune/proinflammatory conditions (such as lupus, rheumatoid arthritis, or psoriasis), or use of immunosuppressive medication. All operative notes were identified, and the authors recorded whether a closed drainage system was used. Finally, the authors reviewed medical records for postoperative complications, such as wound dehiscence, hematoma, seroma, infection, or reoperation for such complications. The authors used Fisher's exact test to determine if a significant association existed among drain use in shoulder arthroplasty surgeries, risk factors, and postoperative complications.
Of the 636 TSAs and rTSAs performed between February 2013 and February 2015, 378 cases met inclusion criteria (136 TSAs and 242 rTSAs). Drains were used in 111 (29.4%) of all included cases (Figure 1). Complications occurred in 11 (2.9%; 8 rTSA and 3 TSA patients) of the 378 cases, with deep infection (n=5), superficial infection (n=4), and hematoma formation (n=2) being identified. In 1 of the 11 cases, a drain was used, for an overall complication rate with drain use of 0.9% (1 of 111). Ten complications occurred in those patients who did not receive a drain, for a complication rate of 3.7%. The authors did not identify a statistically significant relationship between drain use (Figure 1) and postoperative complications (P=.186).
Arthroplasty patients and complications identified as a function of drain use postoperatively. Abbreviations: RF, risk factors; rTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty; +, positive; −, negative.
After reviewing the medical records, the authors identified 218 patients with potential risk factors; of these, 58 had drains placed and 160 did not. Leading risk factors included aspirin use (n=119), diabetes mellitus (n=67), and rheumatoid arthritis (n=38), and some patients had multiple risk factors (Figure 2). Complication rate was not related to the presence (1 of 58 patients [1.7%]) or absence (0 of 53 patients [0.0%]) of risk factors in those patients receiving drains (P=1.00) (Figure 1). Complication rate was not related to the presence (8 of 160 patients [5.0%]) or absence (2 of 107 patients [1.9%]) of risk factors in those patients who did not receive a drain postoperatively (P=.324). When complications were stratified just by the presence or absence of risk factors, irrespective of whether a drain was used, no significant relationship was identified (4.1% vs 1.3%, P=.340) (Figure 3).
Number of risk factors identified in arthroplasty patients. Some patients had multiple risk factors.
Complication rate in arthroplasty patients with preidentified risk factors, including a history of bleeding disorders, anticoagulation therapy, diabetes, autoimmune/proinflammatory conditions, or use of immunosuppressive medication. Abbreviations: RF, risk factors; rTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty; +, positive; −, negative.
Although previous studies of knee and hip arthroplasty reported no benefit of closed drainage in preventing wound infection, hematoma formation, or reoperation,1–4 no study has investigated whether closed drainage prevents these complications in primary shoulder arthroplasty surgeries. The current study confirmed that in the setting of primary reverse and anatomical shoulder replacement, there are no correlations between closed drainage use and the postoperative complications of infection and hematoma formation.
Preventing postoperative hematoma has been associated with a decreased risk of deep infection in total joint arthroplasty. Saleh et al7 examined preoperative, intraoperative, and postoperative factors of knee and hip arthroplasty and reported only hematoma and days of postoperative drainage as being predictive indicators of superficial and deep infections. Cheung et al5 also found an association between hematoma formation and deep infection in shoulder arthroplasty. Although the current data did not support closed drain use for preventing postoperative hematoma or infection, using tranexamic acid may be a more effective measure for doing so. In a prospective randomized trial, Gillespie et al8 found a significant reduction in postoperative blood loss with the use of tranexamic acid in 88 primary TSA patients. Whether tranexamic acid reduces postoperative hematoma formation, and subsequently infection, needs to be further investigated.
Bohsali et al9 reported that the overall prevalence of infection of total shoulders, over multiple studies, was 0.7%. In contrast, 9 (2.4%) of 378 shoulder arthroplasties at the authors' institution developed superficial and deep infection. Wirth and Rockwood10 found infections after shoulder arthroplasty to be associated with rheumatoid arthritis, diabetes mellitus, advanced age, remote sites of infection, malnutrition, and immunosuppressive medication. The current study did not find any correlation between most of these risk factors and the complications of infection and hematoma formation.
The main limitations of this study were the small number of patients and its retrospective nature. Although the authors found an increased number of complications in patients with risk factors and no drain use compared with the other group, this was not significant. Far fewer surgeons at the authors' institution routinely place drains in primary shoulder arthroplasties; thus, there is a much smaller pool of patients to compare with no drain use. Also, 258 (40.6%) of 636 primary shoulder arthroplasty cases in the 2-year study period were excluded from this study, with most due to insufficient medical records, including lacking a detailed operative report and/or 12 months of documented postoperative follow-up.
Indications for drain use may include arthroplasty for fracture, revision surgery, or infection. The routine use of closed drainage systems in primary TSA is not supported by this study. This includes patients with risks factors for potentially developing hematoma or infection.
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