Review Question - QID 213939

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TKA Postoperative Inpatient Management Inpatient Management Drain Placement QID: 213939 (OBQ19.37)

QID 213939 (Type "213939" in App Search)

You are currently evaluating a 68-year-old woman who has met indications for a total knee arthroplasty. You finally have finished documenting the patient’s extensively detailed social and family history. As you finish, the patient tells you that she has spoken with her friends regarding her knee and tells you that she wants a prescription for preoperative physical therapy, would like a drain placed, an order for a cryotherapy device and use of a patient-controlled analgesia (PCA), in addition to being mobilized with physical therapy on the day of surgery. As an astute resident you inform the patient that based on the current AAOS clinical practice guidelines (CPG), there is strong evidence against using which of the patient’s request?

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Preoperative physical therapy

63/1765

Drain placement

61%

1073/1765

Cryotherapy device

101/1765

Postoperative day 0 mobilization

44/1765

Patient-controlled analgesia

27%

473/1765

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Based on the most recently published AAOS CPG, there is strong evidence to support not using a drain with total knee arthroplasty (TKA) because there is not any difference in complications or outcomes.

The use of a drain was postulated to aid in decreasing postoperative infection, swelling, blood transfusions, hematoma formation, pain, length of hospital stay, and re-operation rates. In addition, their use was meant to improve postoperative range of motion. However, after review of the high- and moderate-quality studies and with input from the multiple orthopaedic and medical societies, there has not been any clear advantage to the use of drains after unilateral total knee arthroplasty when comparing complication profiles and outcomes.

McGrory et al. published a systematic review on the surgical management of osteoarthritis of the knee. In an effort to improve the surgical management of patients with osteoarthritis, the authors provide 38 evidence-based recommendations on topics specific to the preoperative, perioperative and postoperative treatment of such patients. Additionally, each topic was further classified based on the level of evidence available (limited, moderate, and strong) to support or not support a give recommendation.

MacDonald et al. completed a prospective randomized clinical trial using continuous passive motion (CPM) following TKA. The patients were separated into two separate treatment groups plus a control group. The patients were followed over the course of one year from surgery. Similar to postoperative drain placement following TKA, MacDonald et al. were unable to demonstrate any significant difference in outcomes for CPM versus no CPM.

Incorrect Answers:
Answer 1: There is limited evidence to support that supervised exercise before TKA might improve pain and physical function after surgery.
Answer 3: There is moderate evidence to support that the use of cryotherapy devices after TKA does not improve outcomes.
Answer 4: There is strong evidence to support that rehabilitation started on the day of TKA reduces the length of hospital stay. Also, there is moderate evidence to support that when rehabilitation is started on the day of TKA there is a reduction in pain and an improvement in function it comparison to starting on postoperative day 1.
Answer 5: There are not any current recommendations regarding PCA use.