Differentiating and identifying cause of tethering can avoid unwarranted 2nd surgery for drain removal after TKR

Suction drain after total knee arthroplasty, even though constantly debated, is commonly used for its advantages of reducing haematoma, postoperative pain and swelling. Drain tethering, although less commonly reported if happens, increase the stress for both patient and surgeon, may warrant second surgery and increase the risk of infection. The most common cause of tethering is unintended suture fixation during wound closure, the other reasons include folding, local compression, soft tissue incarceration, etc.

N. Ragunanthan & Ibad Sha reported two case scenarios of tethered drain after total knee replacement.

The first patient was a 58-year-old female in whom the drain was caught by the fascial sutures. As per the standard hospital protocol, drain removal was attempted after 24 hrs on the first post-operative day. The registrar tried to pull the drain out, but was unable to do so even with moderate force. It was noted that the drain was tethered and on applying excessive force the patient had severe pain at the wound site. The drain was presumed to be caught on the sutures, and the situation was explained to the patient. The suture bite on the drain was visualized and the entirety of the drain was confirmed under direct visual examination in re-surgery as well as post-operative knee radiographic evaluation.

In the second patient who was a 63-year-old female in whom the drain was caught between the joints and crushed. The drain removal as planned was attempted after 24 hours by the registrar. It was noted that the drain was tethered and was not coming, even on considerable force. The drain removal was again attempted by the operating surgeon and failed. It was noted that with both the attempts, even with considerable force, the patient didn't have any exaggeration of pain. Even though it was presumed to be caught on the sutures, the absence of pain exaggeration created doubt to suspect other possibilities. Considering the possibility of the drain tip getting jammed between the knee components, the decision to attempt drain removal with knee flexion and extension was taken and the same was attempted. The drain came out easily once the knee was flexed to 50 degrees. On visual evaluation, the drain tip was noted to be crushed by getting jammed between the joints. The entirety of the drain is confirmed under direct visual examination and knee radiographs.

Tethered drains after a total knee replacement and subsequent drain retention are likely to be underreported because of the concern of legal implications. Although proper precautions can reduce the risk of this complication, cases still do occur and proper identification of cause of tethering may avoid a second surgery and gave peace of mind to the operating surgeon and the patient.

the authors mentions the below learning points:

1. Follow techniques to avoid drain entrapment meticulously

2. Always check for suture entrapment of drain before skin closure

3. Remove the drain before 48 hrs as it avoids retrograde infection

4. Not all drain tethering's are due to suture entrapment

5. Drain tethering between joints may be released with joint movements

The authors concluded that - although underreported, the drain tethering after total knee replacement is a completely preventable complication and should not occur. They can affect recovery and increase anxiety, often leading to second surgery. Following proper preventive techniques and extra vigilance intraoperatively can avoid this complication. Differentiation of the cause of tethering from suture entrapment and getting trapped by the knee components will help in avoiding a second surgery.

Further reading:

Tethered drain after total knee replacement - Two different case scenarios and review of literature.

N. Ragunanthan , Ibad Sha

Journal of Orthopaedic Reports 1 (2022) 100048

https://doi.org/10.1016/j.jorep.2022.100048