Drain tip fracture, a rare complication
of knee arthroplasty:
a case report

T. VANNIASINGHAM, S. GUPTA, L.A.K. KHAN, M. KΟIZIS, S. JAYABALAN
Department οf Οrthοpaedic Surgery, Watfοrd General Hοspital, West Herts NHS Trust,
Watfοrd, UK

 

ABSTRACT
We describe a rare complication of suction drain placement after knee arthroplasty. A retained drain tip fragment was found after suction drain removal caused fracture of the drain tip. The drain tip fragment was extracted arthroscopically and the patient made a good recovery.
The use of drains after knee arthroplasty is common practice. A recent survey showed that 89.5% of surgeons routinely use drains after total knee replacement surgery[1]. Well recognised complications associated with drains include poor wound healing and increased blood transfusion requirements[2]. Here we describe a case of a retained drain tip after a uni-compartmental knee replacement and its subsequent arthroscopic retrieval.

Key words: drain tip fracture, knee arthroplasty, arthroscopic extraction.

CASE REPORT
A 54 year-old man underwent a uni-compartmental knee replacement for medial compartment osteoarthritis. The procedure was uncomplicated and the knee was drained using a closed suction (20 kilopascals) Redivac Drainage system (16CH/5.3mm). The drain was not sutured. At 48 hours the drain was removed by the ward nursing staff, who had reported some initial difficulty at removing the drain but eventually managed to remove it and no further complication was noted. The patient experienced pain, a mechanical block to full extension and a crunching sensation deep within the joint on mobilising the knee. Plain x-rays were arranged, which on close scrutiny revealed a retained drain tip within the knee joint adjacent to the intertubercular eminence (tibial spine) (figure 1).
The drain tip was identified only because our drains are lined with a radioopaque marker line that allows visualisation on plain film X rays.
The drain tip was removed arthroscopically using a 30 degree arthroscope. The drain tip was visualised through an anterolateral portal to be lying deep within the joint behind the anterior cruciate ligament. Using a grasper introduced via the anteromedial portal the drain tip was removed in entirety. The patient was subsequently discharged and made a complete uneventful recovery.

Figure 1. Plain radiograph showing drain tip (arrow).

DISCUSSION
Drain placement is common practice after knee arthroplasty to prevent haemarthrosis[1].
It has been recommended that drains be removed at 24 hours[3]. The complications include increased rates of infection[2,3] and increased transfusion requirements[2].
We encountered a relatively rare complication, in our case the drain tip was inadvertently fractured during removal and the tip retained in the knee joint. Retained drain tips have previously been reported in a number of orthopaedic procedures[4] and were previously extracted by surgically re-exploring the wound or were left in situ. The open method of surgical exploration was associated with longer hospitalisation and an increased risk of infection and wound complications. Apart from pain, mechanical blockage and polyethylene wear, a further complication of leaving a fractured drain tip in the joint includes the risk of inducing a foreign body reaction[4]. We chose to remove the drain tip arthroscopically as opposed to an open procedure and were fortunately successful.

CONCLUSION
This case highlights an unusual complication of using drains after knee joint arthroplasty. We suggest that unexpected pain coupled with a mechanical block on mobilizing should arouse the suspicion of a retained drain tip. Close scrutiny of plain film X-rays may confirm this complication. In addition, careful wound closure giving due regard to the placement of the drain together with accurate measurements and recordings of drain length at insertion and removal will help early recognition of this rare complication.
In the event of a retained drain tip, we recommend arthroscopic retrieval as the preferred method of removal.

REFERENCES
1. Canty SJ, Shepard GJ, Ryan WG, Banks AJ. Do we practise evidence based medicine with regard to drain usage in knee arthroplasty? J Bone Joint Surg. (Br) 2003;85-B:suppl II,95.
2. Roberts CP, Parker MJ. Closed suction drainage after orthopaedic surgery: Is it necessary? J Bone Joint Surg. (Br) 2003;85-B:suppl II,102.
3. Drinkwater CJ, Neil MJ. Optimal timing of wound drain removal following total joint arthroplasty. J Arthroplasty 1995;10(2):185-189.
4. Zeide MS, Robbins H. Retained wound suction-drain fragment. Report of 7 cases. Bull Hosp Joint Dis. 1975;36(2):163-169.