The Effect of Placing or not Placing Drainage after Primary Unilateral Total Knee Arthroplasty on Blood Loss and Knee Function: A Retrospective Study

The Effect of Placing or not Placing Drainage after Primary Unilateral Total Knee Arthroplasty on Blood Loss and Knee Function: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Placing or not Placing Drainage after Primary Unilateral Total Knee Arthroplasty on Blood Loss and Knee Function: A Retrospective Study Shuyin Tan, Dingyan Zhao, Xing Yu, Yukun Ma, Yang Xiong, Xinliang Yue, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4535094/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract OBJECTIVE To observe the impact of placing or not placing drainage on the changes in blood index and knee function recovery in patients undergoing initial unilateral total knee arthroplasty (TKA). METHODS A review was conducted on 115 cases of primary unilateral total knee arthroplasty (TKA) patients at our hospital. The patients were categorized into two groups: a drainage group (D group) and a non-drainage group (ND group) depending on the usage of a postoperative drainage tube. In Group D, there were 53 cases (10 males, 43 females) with an average age of 68.57 ± 5.34 years. The distribution of cases was 22 on the left knee and 31 on the right knee, with an average follow-up period of 15.57 ± 1.92 months. In Group ND, there were 62 cases (12 males, 50 females) with an average age of 67.15 ± 5.78 years. The distribution of cases was 26 on the left knee and 36 on the right knee, with an average follow-up period of 15.16 ± 2.04 months. Relevant data was collected for both groups of patients during hospitalization and follow-up periods, which included: pain assessment using the Visual Analogue Scale (VAS), evaluation of patient symptoms improvement using the Hospital for Special Surgery Knee Score (HSS), assessment of postoperative functional improvement based on knee swelling and knee range of motion, and evaluation of blood loss using hemoglobin (HGB), hematocrit (HCT), and total theoretical blood loss during surgery. RESULTS Both patient groups exhibited enhancements in postoperative VAS, HSS, and knee joint activity levels compared to pre-surgery values, all with statistically significant disparities (P 0.05). Following surgery, knee swelling progressed incrementally over 3 days, culminating at its peak one week postoperatively, and subsequently subsided gradually. No significant statistical differences in knee swelling were observed between the two groups at any time point post-surgery (P < 0.05). Additionally, there were no statistically significant variances in preoperative levels of HGB (134.11 ± 12.16 vs. 135.66 ± 12.26) and HCT (39.76 ± 3.32 vs. 40.44 ± 3.60) between the patient groups (P > 0.05). One day following the surgery, both groups exhibited decreased HGB levels compared to the preoperative readings (D group: 112.91 ± 10.19 vs. 134.11 ± 12.16; ND group: 119.23 ± 11.56 vs. 135.66 ± 12.26, P < 0.05), and HCT levels demonstrated similar decreases compared to preoperative levels (D group: 33.24 ± 2.89 vs. 39.76 ± 3.32; ND group: 35.32 ± 3.61 vs. 40.44 ± 3.60, P < 0.05). The decrease in HGB and HCT levels in the D group was significantly greater compared to the ND group, with a statistically significant difference observed (HGB: 112.91 ± 10.19 vs 119.23 ± 11.56; HCT: 33.24 ± 2.8 vs 35.32 ± 3.61, P < 0.05). On the third day post-surgery, both HGB (D group: 100.06 ± 9.16 vs 112.91 ± 10.19; ND group: 108.98 ± 11.70 vs 119.23 ± 11.56) and HCT (D group: 29.45 ± 2.54 vs 33.24 ± 2.89; ND group: 32.28 ± 3.61 vs 35.32 ± 3.61) continued to decrease compared to the first-day post-surgery, with group D exhibiting lower levels of HGB and HCT than group ND (HGB: 100.06 ± 9.16 vs 108.98 ± 11.70; 29.45 ± 2.54 vs 32.28 ± 3.61, P < 0.05). Following seven days post-surgery, both groups demonstrated recovery in HGB (D group: 103.83 ± 9.58 vs 100.06 ± 9.16; ND group: 112.66 ± 12.17 vs 108.98 ± 11.70) and HCT (D group: 30.57 ± 2.68 vs 29.45 ± 2.54; ND group: 33.37 ± 3.75 vs 32.28 ± 3.61) compared to three days post-surgery. However, levels in group D remained lower than in group ND, with statistical significance. Throughout the perioperative period, the total blood loss in group ND was significantly less than that in group D (910.70 ± 242.73 vs 809.44 ± 228.55, P < 0.05). CONCLUSION Drainage may not be necessary after initial unilateral total knee arthroplasty (TKA). Omitting drainage can reduce the total amount of blood loss in patients and does not affect the postoperative recovery of knee joint function. Knee osteoarthritis Total knee arthroplasty Blood management Drainage Postoperative blood loss 1. Introduction Knee osteoarthritis (KOA) is a common degenerative knee joint condition, mostly seen in middle-aged and elderly individuals, with a higher incidence in females than males. [ 1 ] The clinical manifestations include knee joint pain and restricted knee joint function. In the early stages of KOA, the pain is usually intermittent and of mild to moderate intensity, which can be relieved with rest, and joint movement restriction is not significant. Satisfactory clinical outcomes can be achieved through non-surgical treatment. In advanced stages of KOA, knee joint pain is severe, movement is significantly restricted, joint surface damage is complete, and deformities such as knee varus, knee valgus, and knee flexion contracture may occur. [ 2 ] TKA is an effective method for treating severe KOA, which can significantly reduce knee joint pain, restore knee joint function, and improve the patient’s quality of life. However, TKA involves a large incision, bone resection during the procedure, the opening of the femoral medullary canal, and extensive detachment of loose soft tissues, leading to significant perioperative blood loss. Since TKA patients are mostly elderly, with relatively weaker hematopoietic function, the demand for allogeneic blood transfusion significantly increases after TKA. [ 3 ] Therefore, perioperative blood management in TKA has always been a hot topic in TKA-related research. Placement of drainage after TKA has been the standard practice for many years. [ 4 ] In the past, most scholars believed that routine drainage placement in the joint cavity after TKA could be important clinically in reducing incision tension, and local tissue pain, preventing the formation of hematomas near the incision, and reducing the risk of infection. But placing drainage also brings some problems, such as the lack of tamponade effect leading to a significant increase in blood loss. Studies have shown that postoperative drainage bleeding in TKA is an important component of total blood loss, with drainage bleeding accounting for up to 50% of total blood loss. [ 5 ] In recent years, with the advancement of TKA technology and the increasing emphasis on rapid postoperative recovery, some scholars have started to attempt postoperative non-drainage, and have found that this can effectively reduce postoperative blood loss. There is currently a debate on whether drainage should be placed after TKA. Therefore, this study conducted a retrospective comparative study on patients undergoing primary unilateral total knee arthroplasty, evaluating the impact of postoperative drainage placement and non-placement on blood index and knee joint functional recovery. 2. Methods 2.1. Study subjects and inclusion/exclusion criteria Retrospective analysis of clinical data of patients who underwent primary unilateral total knee arthroplasty in our department due to KOA from January 2015 to October 2022, divided into a drainage group (D group) and a non-drainage group (ND group) according to whether drainage was placed after TKA. Diagnosis criteria for KOA: ①Repeated knee joint pain in the past month. ②X-ray (standing or weight-bearing) shows joint space narrowing, subchondral bone sclerosis, and/or cystic changes, as well as osteophyte formation at the joint margins. ③Age ≥ 50 years. ④Morning stiffness ≤ 30 minutes. ⑤Crepitus present during joint movement. Meeting the diagnostic criteria of ①+ any 2 of ②③④⑤ can lead to a diagnosis of knee osteoarthritis. [ 6 ] Inclusion criteria: ①Diagnosed as late-stage severe KOA, ineffective after conservative treatment for more than 3 months; ②First-time unilateral TKA; ③Ages between 60–80 years old. Exclusion criteria: ①Patients with coagulation disorders or those taking anticoagulants and antiplatelet drugs; ②Patients with bleeding disorders; ③Patients undergoing revision surgery; ④Patients undergoing TKA due to knee joint tumors, tuberculosis, traumatic infection, and other reasons. This study has been approved by the Medical Ethics Committee of Dongzhimen Hospital, Beijing University of Chinese Medicine. (Approval Number:2024DZMEC-109-02) 2.2. Surgical method In our study, all patients diagnosed with KOA underwent surgical intervention conducted by the principal orthopedic surgeon along with their surgical team, utilizing fixed-platform bone cement joint prostheses supplied by Aikang Company in China. The surgical procedure was carried out under combined spinal and epidural anesthesia, with the patients positioned supine. A tourniquet was applied from the commencement of bone resection until the completion of prosthesis implantation. A midline incision was performed anterior to the knee joint, followed by meticulous dissection of the inner aspect of the patella to expose the joint capsule and facilitate comprehensive visualization of the joint. Additionally, debridement of proliferative bone spurs and diseased joint surfaces was performed for each patient. The femoral component was positioned with intramedullary guidance, whereas the tibial component was positioned extramedullary. Subsequently, both femoral and tibial prostheses were implanted, followed by the execution of trial reduction and the adjustment of the flexion extension and medial-lateral gap balance. The patellar track was evaluated after trial reduction, and once satisfactory, the knee joint prosthesis was installed routinely. The patella was only de-nervein after removing proliferative bone spurs, and no patellar joint surface replacement was performed. The incision was closed layer by layer after washing. All patients had zero milliliters of intraoperative bleeding. Both groups were injected with tranexamic acid into the joint cavity. The entire surgical process involves careful and thorough hemostasis, with autologous bone strips used to fill the medullary cavity opening. Group D placed drainage before closing the incision, which was clamped for 6 hours before opening and left in place for 24 hours before removal, while Group ND closed the incision normally without placing drainage. Both groups loosen the tourniquet before closing the incision to perform electrocoagulation hemostasis on the active bleeding point, cover the wound with a thick sterile dressing after closing the incision, apply pressure bandaging from the distal end of the lower leg to the proximal end of the thigh with elastic bandages, elevate the affected limb postoperatively, and continue cold compress at the surgical site. Both lower limbs were equipped with pneumatic compression devices and a Continuous Passive Motion (CPM) machine to facilitate the restoration of knee joint function. Tranexamic acid was administered intravenously to control bleeding, while Rivaroxaban was orally consumed for the prevention of deep vein thrombosis in the lower limbs. 2.3. Clinical efficacy index Using VAS for pain assessment, HSS evaluates improvement in patient symptoms. Assess postoperative functional improvement in patients based on knee swelling and knee range of motion. During measurement, use a tape measure to measure the circumference of the thigh (10 cm above the upper edge of the patella) and the circumference of the calf (10 cm below the lower edge of the patella). Use a goniometer to measure the range of motion of both knee joints (align the upper end with the greater trochanter of the femur, align the axis with the middle of the patella, and align the lower end with the outer ankle). [ 7 ] To reduce the errors caused by individual differences, when measuring the degree of knee swelling, subtract the measurement values at each postoperative time point from the preoperative measurement value of the knee joint, using the difference to represent the degree of knee swelling on that side. Compare the changes in VAS, HSS, knee swelling, and knee range of motion of patients at various follow-up time points before and after surgery. All measurements were independently carried out by two trained orthopedic surgeons, with each value measured three times and the average taken as the measurement value. In cases where there are significant discrepancies in the results, a third senior orthopedic surgeon is to assist in completing the measurements. 2.4. Haematological index Use hemoglobin (HGB), hematocrit (HCT), as well as the total estimated blood loss based on surgical theory to evaluate the patient’s blood loss. Collect HGB and HCT values from patients before surgery, 1 day after surgery, 3 days after surgery, and 7 days after surgery. According to Gross equation [ 8 ] , calculate the total blood loss of two groups of patients: total blood loss = preoperative blood volume × [preoperative hematocrit - postoperative hematocrit (taking the lowest postoperative value)] / preoperative hematocrit. According to the Nadler equation [ 9 ] , calculate the preoperative blood volume of two groups of patients: blood volume = k1×height(m)³ + k2×body weight(kg) + k3. (For male patients, k1 = 0.3669, k2 = 0.03219, k3 = 0.6041; for female patients, k1 = 0.3561, k2 = 0.03308, k3 = 0.1833). Compare the differences in indicators between the two groups of patients at various follow-up time points before and after surgery. 2.5.Statistical analysis The statistical analysis was conducted using SPSS version 26.0 software. Measurement values were presented as mean ± standard deviation (M ± SD). Paired sample t-tests were used for within-group comparisons when the data followed a normal distribution, while independent sample t-tests were utilized for between-group comparisons. The Wilcoxon test was employed for non-normally distributed parameters. A significance level of p < 0.05 was applied to determine statistical significance. 3. Results This study included a total of 115 patients who met the criteria, with females accounting for 80.9% (93/115) and males accounting for 19.1% (22/115). The D group had 53 cases (46.1%), and the ND group had 62 cases (53.9%). There was no statistically significant difference in baseline data between the two groups (P > 0.05). ( Table 1) Table 1. Summary of the demographic data. D Group (n=53) ND Group (n=62) P-value Cases (n) 53 62 Sex (M/F) 10/43 12/50 0.947 Age (years) 68.57±5.34 67.15±5.78 0.127 BMI 27.80±3.36 27.55±3.75 0.71 Surgical Side (Left/Right,n) 22/31 26/36 0.963 Hypertension(n) 21 26 0.801 Diabetes(n) 9 11 0.915 Smoke(n) 8 9 0.897 Drink(n) 5 7 0.985 Tourniquet Time(minutes) 86.2±5.00 87.6±4.5 0.073 Surgery Time(minutes) 97.00±4.47 97.45±4.21 0.722 Follow-up (mouths) 15.57±1.92 15.16±2.04 0.302 Note: No significant difference was found between the two groups. 3.1.Clinical efficacy Compared with before surgery, both groups of patients showed improvement in knee range of motion ,VAS,and HSS after surgery. The differences were statistically significant (P0.05). (Table 2) Table 2. K nee range of motion 、 VAS 、 HSS D Group (n=53) ND Group (n=62) P-value Knee range of motion(°) Before Surgery 66.51±6.09 65.82±6.25 0.572 3 Days after Surgery 84.08±2.99* 84.84±3.05* 0.185 2 Weeks after Surgery 102.02±5.87* 102.58±4.97* 0.494 3 Months after Surgery 113.34±5.66* 114.08±5.29* 0.469 1 Year after Surgery 115.08±5.75* 116.42±5.27* 0.205 VAS Before Surgery 6.66±1.13 6.31±1.03 0.089 3 Days after Surgery 4.19±0.76* 4.00±0.79* 0.199 2 Weeks after Surgery 2.36±0.52* 2.33±0.76* 0.491 3 Months after Surgery 1.36±0.48* 1.42±0.53* 0.472 1 Year after Surgery 0.4±0.49* 0.42±0.50* 0.802 HSS Before Surgery 62.77±2.79 63.18±2.93 0.358 3 Days after Surgery 71.28±2.13* 71.47±2.34* 0.612 2 Weeks after Surgery 80.45±3.07* 81.00±3.1* 0.375 3 Months after Surgery 87.83±1.65* 87.92±1.66* 0.738 1 Year after Surgery 88.19±1.79* 88.27±1.72* 0.851 Note: * P <0.05 compared with the preoperative period. In terms of the degree of knee swelling, no significant statistical difference was observed between the two groups at each postoperative time point (P<0.05). The knee swelling increased gradually three days after the operation, peaked at one week postoperatively, and then decreased gradually. (Table 3) Table 3. knee swelling D Group (n=53) ND Group (n=62) P-value 3 Days after Surgery(cm) thigh circumference 1.30±0.50 1.24±0.41 0.388 calf circumference 1.30±0.43 1.16±0.47 0.099 1 Week after Surgery(cm) thigh circumference 2.88±0.66 2.82±0.66 0.727 calf circumference 2.62±0.76 2.68±0.73 0.651 2 Weeks after Surgery(cm) thigh circumference 1.59±0.52 1.69±0.52 0.518 calf circumference 1.74±0.50 1.65±0.53 0.355 3 Months after Surgery(cm) thigh circumference 0.44±0.29 0.49±0.33 0.376 calf circumference 0.50±0.31 0.53±0.32 0.533 3.2.Blood index Both groups of patients showed no significant statistical difference in preoperative HGB and HCT (P>0.05). One day after surgery, the HGB and HCT in both groups of patients decreased compared to preoperative levels (P<0.05), but the decrease was more significant in Group D compared to Group ND (P<0.05). Three days after surgery, the HGB and HCT in both groups of patients continued to decrease, with Group D having lower values than Group ND (P<0.05). Seven days after surgery, the HGB and HCT in both groups of patients showed some recovery compared to three days postoperatively, but the levels in Group D remained lower than in Group ND (P<0.05). The total amount of blood loss in Group D was significantly higher than in Group ND, with a statistically significant difference (P<0.05). (Table 4) Table 4. HGB 、 HCT 、 Total blood loss D Group (n=53) ND Group (n=62) P-value HGB （ g/L ） Before Surgery 134.11±12.16 135.66±12.26 0.500 1 Day after Surgery 112.91±10.19* 119.23±11.56* 0.003 3 Days after Surgery 100.06±9.16* 108.98±11.70* 0.000 7 Days after Surgery 103.83±9.58* 112.66±12.17* 0.000 HCT （ % ） Before Surgery 39.76±3.32 40.44±3.60 0.301 1 Day after Surgery 33.24±2.89* 35.32±3.61* 0.001 3 Days after Surgery 29.45±2.54* 32.28±3.61* 0.000 7 Days after Surgery 30.57±2.68* 33.37±3.75* 0.000 Drainage Blood Loss(mL) 489.25±106.97 / / Total Blood Loss(mL) 910.70±242.73 809.44±228.55 0.000 Note: * P <0.05 compared with the preoperative period. 4. Discussion TKA is currently the standard procedure for clinical treatment of advanced severe KOA. [10] For patients with advanced severe KOA, TKA can effectively alleviate knee joint pain symptoms, and enable them to achieve better knee function and higher quality of life. [11] Although current research on KOA shows that non-surgical treatments such as physical therapy, injection therapy, and other surgical treatments can benefit patients in improving symptoms and delaying disease progression, TKA remains the ultimate effective treatment for severe KOA. [12] Although TKA technology is very mature, the issues of preoperative anemia and high rates of allogeneic blood transfusion in TKA patients are still difficult problems in need of urgent clinical resolution.The research shows that the average blood transfusion rate for TKA patients can reach 12.7% . [13] Therefore, perioperative blood management is of great clinical significance for patients undergoing total knee arthroplasty. With the continuous development of the Enhanced Recovery After Surgery (ERAS) related concepts in modern orthopedics, some scholars have applied the ERAS concept to the perioperative blood management of TKA. Several findings indicate that efficient blood management can significantly decrease perioperative blood loss and decrease the need for transfusions. [14] Blood management throughout the perioperative phase encompasses three key elements: preoperative, intraoperative, and postoperative strategies. The management of postoperative drainage stands as a crucial aspect of blood management following TKA. There is currently no consensus on whether drainage should be placed after TKA and how long the drainage should be placed.Since the concept of placing drainage was first proposed by Waugh et al [15] in the 1960s, the postoperative placement of drainage after TKA has undergone long-term practice in clinical settings. This method can effectively reduce the formation of local hematomas at the wound site, thereby lowering the incidence of secondary infections. [16] However, with the widespread use of drainage, some scholars believe that it may increase apparent blood loss, and the presence of drainage can provide a gateway for bacterial invasion, increasing the risk of infection. [17] There is insufficient evidence to suggest that placing drainage helps reduce postoperative infection rates, and prolonged drainage placement is instead highly prone to retrograde infection. [18] Continuous negative pressure drainage can help to drain the blood in the joint cavity, reduce incision tension and local tissue pain, assist in eliminating inflammatory exudate, and prevent intra-articular adhesions. However, it may lead to an increased risk of bleeding and related complications, significantly raise the rate of allogeneic blood transfusion, and hinder early rehabilitation training for patients. Since the 1990s, scholars have debated the placement of drainage following TKA. Watanabe et al. [19] argue that there is no significant difference in patients’ blood management and prognosis whether drainage is used or not. However, Albasha et al. [20] and Xu H et al. [21] found that patients who undergo TKA with drainage experience longer hospital stays, increased blood loss, and higher transfusion rates. Quinn et al. [22] conducted a meta-analysis of 594 TKA cases from six studies. The results revealed that in 83% of the studies, the placement of drains did not confer a significant advantage in immediate postoperative knee flexion function or periarticular edema. Additionally, 66% of the studies confirmed that drain placement did not significantly affect changes in hemoglobin levels. Another meta-analysis of 19 RCTs showed that for 945 patients undergoing TKA with drain placement and 920 patients without drain placement, the placement of a drain effectively reduced the incidence of hematoma but increased the transfusion rate [23] . So much so that in 2016 Sharma et al. [24] concluded: for patients undergoing primary TKA, drainage offers no benefits and can be safely omitted. Based on the above research findings, Mainard et al. [25] believe that the placement of drainage is no longer a necessary procedure for primary TKA. In addition, the study by Yin D et al. [26] also confirmed that drainage placement does not bring significant benefits to wound recovery in patients undergoing primary TKA. The research findings reveal that Group ND exhibited significantly elevated levels of HGB and HCT at 1 day, 3 days, and 7 days postoperatively compared to Group D, along with a notably lower total blood loss. The knee joint cavity, when left undrained, tends to be relatively closed, thereby mitigating the risk of infection. As postoperative bleeding accumulates, pressure will form in the joint cavity, generating a blocking effect that can reduce bleeding from small blood vessels.This is consistent with the “tamponade effect ” proposed by Taietal et al. [27] In group D, the presence of drainage allow communication between the joint cavity and the external environment. This results in sustained lower pressure within the joint cavity. [28] At the same time, the drainage is often in a negative pressure suction state, which is not only unfavorable for hemostasis but may also lead to continuous bleeding within the joint cavity, resulting in a significantly increased blood loss in group D compared to group ND. Furthermore, in non-closed joint cavities, there is a risk of bacterial reflux due to improper nursing procedures and other factors, which can lead to infection and other risks. [29] There is no significant difference in postoperative pain symptoms and functional scores between the two groups of patients, indicating that not placing a drain after total knee arthroplasty does not have a significant impact on early postoperative functional recovery and exercise for patients. The above results suggest that for patients undergoing primary unilateral TKA, it is safe and feasible not to place a drain postoperatively and is more in line with the concept of accelerated recovery blood management. Our research findings suggest that omitting postoperative drainage in primary unilateral TKA patients does not significantly affect the improvement of knee joint pain and symptom recovery, which aligns with initial partial research results. Furthermore, a meta-analysis of six randomized controlled trials (RCTs) indicates that the use of drainage following total knee arthroplasty has no significant impact on the recovery of postoperative joint function in patients. [22] The quadriceps femoris muscle plays a crucial role in knee joint function. In a study by Jennings et al. [30] , 29 patients who underwent bilateral total knee arthroplasty were evaluated for the recovery of quadriceps femoris muscle function as the primary outcome. Secondary outcome measures included quadriceps femoris muscle activation, joint effusion, lower limb swelling, and pain. The findings indicated that the absence of drainage following total knee arthroplasty does not have a significant impact on quadriceps strength, muscle activity, joint effusion, lower limb swelling, knee range of motion, or pain. After total knee arthroplasty, placing drainage may also increase the psychological burden on patients, which is not conducive to early functional exercises for patients. [22] The related studies show that active functional exercise after TKA is beneficial for the early recovery of knee joint function and can reduce the occurrence of related complications. [31] The extent of knee joint swelling at different post-operative time intervals did not exhibit a significant disparity between the two cohorts, implying that proficient blood management and efficient compression dressing may preempt excessive knee joint swelling and congestion following TKA even in the absence of drainage placement. Therefore, based on the above study and the results of this study, there is no significant difference between not placing drainage and placing drainage after primary unilateral TKA in terms of postoperative knee joint function recovery. 5. Conclusion For patients undergoing primary unilateral TKA,the drainage may not be necessary postoperatively. Omitting the drainage does not affect surgical efficacy, nor does it increase the degree of knee swelling or the patient’s pain sensation. Inserting a drainage tube increases the total blood loss for patients, raises the probability of blood transfusion, and the risk of infection. Declarations Author contributions Xing Yu contributed to the research and design of this article. Shuyin Tan contributed to the first draft of the article. Dingyan Zhao contributed to organizing, editing, and summarizing the text. Yukun Ma and Yang Xiong contributed to carrying out the literature search, and quality evaluation. Xinliang Yue, Yishu Zhou, Jieyun Wei, and Letian Meng contributed to data collection and analysis. All authors agree to be accountable for all aspects of the work. All authors read and approved the final manuscript. Declaration of competing interest The authors disclose no relevant financial relationships, conflicts of interest, or other potential sources of bias related to the content of this work. Funding declaration No funding support was received for the analysis of the data preparation of this article. References Du X, Liu ZY, Tao XX, Mei YL, Zhou DQ, Cheng K, et al. Research Progress on the Pathogenesis of Knee Osteoarthritis. 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A systematic review and meta-analysis. Med (Baltim). 2018;97(30):e11290. Sharma GM, Palekar G, Tanna DD. Use of closed suction drain after primary total knee arthroplasty - an overrated practice. SICOT J. 2016;2:39. Mainard D. Drainage in primary and revision hip and knee arthroplasty. Orthop Traumatol Surg Res. 2024;110(1S):103764. 10.1016/j.otsr.2023.103764 . Yin D, Delisle J, Banica A, Senay A, Ranger P, Laflamme GY, et al. Tourniquet and closed-suction drains in total knee arthroplasty. No beneficial effects on bleeding management and knee function at a higher cost. Orthop Traumatol Surg Res. 2017;103(4):583–9. Tai TW, Yang CY, Jou IM, Lai KA, Chen CH. Temporary drainage clamping after total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty. 2010;25(8):1240–5. Esler CN, Blakeway C, Fiddian NJ. The use of a closed-suction drain in total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br. 2003;85(2):215–7. Almeida RP, Mokete L, Sikhauli N, Sekeitto AR, Pietrzak J. The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review. EFORT Open Rev. 2021;6(10):872–80. Jennings JM, Loyd BJ, Miner TM, Yang CC, Stevens-Lapsley J, Dennis DA. A prospective randomized trial examining the use of a closed suction drain shows no influence on strength or function in primary total knee arthroplasty. Bone Joint J. 2019, 101–B(7_Supple_C):84–90. Shan L, Shan B, Suzuki A, Nouh F, Saxena A. Intermediate and long-term quality of life after total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Am. 2015;97(2):156–68. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4535094","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318821752,"identity":"6d06adc2-51f6-42ff-94f5-68eace335a60","order_by":0,"name":"Shuyin Tan","email":"","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Shuyin","middleName":"","lastName":"Tan","suffix":""},{"id":318821753,"identity":"66f7cb56-bf21-45f7-ab38-59948990bbdc","order_by":1,"name":"Dingyan Zhao","email":"","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Dingyan","middleName":"","lastName":"Zhao","suffix":""},{"id":318821754,"identity":"dec26cea-79f5-4e5a-adfa-9f0b790f390e","order_by":2,"name":"Xing Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYJCCA2DEwHyAIYFELWwJxGuB6GLgMSBOrcGNHMPDBb/uJPZPO/P5w8Mddgz87d34LTO4kZZweGbfs8QZt3O3SSSeSWaQOHN2AwEtyQcO8/YcTtwgnbuNIbGNmcFAIpeQlsQGqJacxx8S2+qJ0QK0hecHWAuDRGLbYcJaJM88SzjM2/DMeMbtNDOgluM8BP3CdzzH+DPPnzuy/bOTH3/82VYtx9/ei1+LwgEgwdiGEODBqxwE5BtA5B+C6kbBKBgFo2AkAwCsYlPx2lzwwwAAAABJRU5ErkJggg==","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":true,"prefix":"","firstName":"Xing","middleName":"","lastName":"Yu","suffix":""},{"id":318821755,"identity":"46ad98dd-95e7-4241-b72c-2f561e752562","order_by":3,"name":"Yukun Ma","email":"","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yukun","middleName":"","lastName":"Ma","suffix":""},{"id":318821756,"identity":"85fd8aa7-ae09-4ddc-b194-01cfb5cc7590","order_by":4,"name":"Yang Xiong","email":"","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Xiong","suffix":""},{"id":318821757,"identity":"ca2010d0-91b8-43e4-ac64-ead6e54d4e25","order_by":5,"name":"Xinliang Yue","email":"","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Xinliang","middleName":"","lastName":"Yue","suffix":""},{"id":318821758,"identity":"0f455529-3ff4-47e6-a5d7-ff31a0aba9bf","order_by":6,"name":"Yishu Zhou","email":"","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yishu","middleName":"","lastName":"Zhou","suffix":""},{"id":318821759,"identity":"487b3ef1-5e04-4b91-9198-89d085ae440e","order_by":7,"name":"Jieyun Wei","email":"","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jieyun","middleName":"","lastName":"Wei","suffix":""},{"id":318821760,"identity":"ece2a272-556a-4063-95a0-bfccbb49e310","order_by":8,"name":"Letian Meng","email":"","orcid":"","institution":"Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Letian","middleName":"","lastName":"Meng","suffix":""}],"badges":[],"createdAt":"2024-06-05 15:21:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4535094/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4535094/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60455641,"identity":"37145af7-720e-4f64-8d14-f2e3d798b501","added_by":"auto","created_at":"2024-07-17 02:18:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":799191,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4535094/v1/5e706e0d-8f19-46ac-b94d-35c7e0e7032a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of Placing or not Placing Drainage after Primary Unilateral Total Knee Arthroplasty on Blood Loss and Knee Function: A Retrospective Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eKnee osteoarthritis (KOA) is a common degenerative knee joint condition, mostly seen in middle-aged and elderly individuals, with a higher incidence in females than males.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e The clinical manifestations include knee joint pain and restricted knee joint function. In the early stages of KOA, the pain is usually intermittent and of mild to moderate intensity, which can be relieved with rest, and joint movement restriction is not significant. Satisfactory clinical outcomes can be achieved through non-surgical treatment. In advanced stages of KOA, knee joint pain is severe, movement is significantly restricted, joint surface damage is complete, and deformities such as knee varus, knee valgus, and knee flexion contracture may occur. \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e TKA is an effective method for treating severe KOA, which can significantly reduce knee joint pain, restore knee joint function, and improve the patient’s quality of life. However, TKA involves a large incision, bone resection during the procedure, the opening of the femoral medullary canal, and extensive detachment of loose soft tissues, leading to significant perioperative blood loss. Since TKA patients are mostly elderly, with relatively weaker hematopoietic function, the demand for allogeneic blood transfusion significantly increases after TKA.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e Therefore, perioperative blood management in TKA has always been a hot topic in TKA-related research.\u003c/p\u003e \u003cp\u003ePlacement of drainage after TKA has been the standard practice for many years.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e In the past, most scholars believed that routine drainage placement in the joint cavity after TKA could be important clinically in reducing incision tension, and local tissue pain, preventing the formation of hematomas near the incision, and reducing the risk of infection. But placing drainage also brings some problems, such as the lack of tamponade effect leading to a significant increase in blood loss. Studies have shown that postoperative drainage bleeding in TKA is an important component of total blood loss, with drainage bleeding accounting for up to 50% of total blood loss.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e In recent years, with the advancement of TKA technology and the increasing emphasis on rapid postoperative recovery, some scholars have started to attempt postoperative non-drainage, and have found that this can effectively reduce postoperative blood loss. There is currently a debate on whether drainage should be placed after TKA. Therefore, this study conducted a retrospective comparative study on patients undergoing primary unilateral total knee arthroplasty, evaluating the impact of postoperative drainage placement and non-placement on blood index and knee joint functional recovery.\u003c/p\u003e "},{"header":"2. Methods","content":"\u003ch2\u003e2.1. Study subjects and inclusion/exclusion criteria\u003c/h2\u003e\u003cp\u003eRetrospective analysis of clinical data of patients who underwent primary unilateral total knee arthroplasty in our department due to KOA from January 2015 to October 2022, divided into a drainage group (D group) and a non-drainage group (ND group) according to whether drainage was placed after TKA. Diagnosis criteria for KOA: ①Repeated knee joint pain in the past month. ②X-ray (standing or weight-bearing) shows joint space narrowing, subchondral bone sclerosis, and/or cystic changes, as well as osteophyte formation at the joint margins. ③Age ≥ 50 years. ④Morning stiffness ≤ 30 minutes. ⑤Crepitus present during joint movement. Meeting the diagnostic criteria of ①+ any 2 of ②③④⑤ can lead to a diagnosis of knee osteoarthritis.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e Inclusion criteria: ①Diagnosed as late-stage severe KOA, ineffective after conservative treatment for more than 3 months; ②First-time unilateral TKA; ③Ages between 60–80 years old. Exclusion criteria: ①Patients with coagulation disorders or those taking anticoagulants and antiplatelet drugs; ②Patients with bleeding disorders; ③Patients undergoing revision surgery; ④Patients undergoing TKA due to knee joint tumors, tuberculosis, traumatic infection, and other reasons. This study has been approved by the Medical Ethics Committee of Dongzhimen Hospital, Beijing University of Chinese Medicine. (Approval Number:2024DZMEC-109-02)\u003c/p\u003e\u003ch2\u003e2.2. Surgical method\u003c/h2\u003e\u003cp\u003eIn our study, all patients diagnosed with KOA underwent surgical intervention conducted by the principal orthopedic surgeon along with their surgical team, utilizing fixed-platform bone cement joint prostheses supplied by Aikang Company in China. The surgical procedure was carried out under combined spinal and epidural anesthesia, with the patients positioned supine. A tourniquet was applied from the commencement of bone resection until the completion of prosthesis implantation. A midline incision was performed anterior to the knee joint, followed by meticulous dissection of the inner aspect of the patella to expose the joint capsule and facilitate comprehensive visualization of the joint. Additionally, debridement of proliferative bone spurs and diseased joint surfaces was performed for each patient. The femoral component was positioned with intramedullary guidance, whereas the tibial component was positioned extramedullary. Subsequently, both femoral and tibial prostheses were implanted, followed by the execution of trial reduction and the adjustment of the flexion extension and medial-lateral gap balance. The patellar track was evaluated after trial reduction, and once satisfactory, the knee joint prosthesis was installed routinely. The patella was only de-nervein after removing proliferative bone spurs, and no patellar joint surface replacement was performed. The incision was closed layer by layer after washing. All patients had zero milliliters of intraoperative bleeding. Both groups were injected with tranexamic acid into the joint cavity. The entire surgical process involves careful and thorough hemostasis, with autologous bone strips used to fill the medullary cavity opening. Group D placed drainage before closing the incision, which was clamped for 6 hours before opening and left in place for 24 hours before removal, while Group ND closed the incision normally without placing drainage. Both groups loosen the tourniquet before closing the incision to perform electrocoagulation hemostasis on the active bleeding point, cover the wound with a thick sterile dressing after closing the incision, apply pressure bandaging from the distal end of the lower leg to the proximal end of the thigh with elastic bandages, elevate the affected limb postoperatively, and continue cold compress at the surgical site. Both lower limbs were equipped with pneumatic compression devices and a Continuous Passive Motion (CPM) machine to facilitate the restoration of knee joint function. Tranexamic acid was administered intravenously to control bleeding, while Rivaroxaban was orally consumed for the prevention of deep vein thrombosis in the lower limbs.\u003c/p\u003e\u003ch2\u003e2.3. Clinical efficacy index\u003c/h2\u003e\u003cp\u003eUsing VAS for pain assessment, HSS evaluates improvement in patient symptoms. Assess postoperative functional improvement in patients based on knee swelling and knee range of motion. During measurement, use a tape measure to measure the circumference of the thigh (10 cm above the upper edge of the patella) and the circumference of the calf (10 cm below the lower edge of the patella). Use a goniometer to measure the range of motion of both knee joints (align the upper end with the greater trochanter of the femur, align the axis with the middle of the patella, and align the lower end with the outer ankle).\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e To reduce the errors caused by individual differences, when measuring the degree of knee swelling, subtract the measurement values at each postoperative time point from the preoperative measurement value of the knee joint, using the difference to represent the degree of knee swelling on that side. Compare the changes in VAS, HSS, knee swelling, and knee range of motion of patients at various follow-up time points before and after surgery.\u003c/p\u003e\u003cp\u003eAll measurements were independently carried out by two trained orthopedic surgeons, with each value measured three times and the average taken as the measurement value. In cases where there are significant discrepancies in the results, a third senior orthopedic surgeon is to assist in completing the measurements.\u003c/p\u003e\u003ch2\u003e2.4. Haematological index\u003c/h2\u003e\u003cp\u003eUse hemoglobin (HGB), hematocrit (HCT), as well as the total estimated blood loss based on surgical theory to evaluate the patient’s blood loss. Collect HGB and HCT values from patients before surgery, 1 day after surgery, 3 days after surgery, and 7 days after surgery. According to Gross equation\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, calculate the total blood loss of two groups of patients: total blood loss = preoperative blood volume × [preoperative hematocrit - postoperative hematocrit (taking the lowest postoperative value)] / preoperative hematocrit. According to the Nadler equation\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, calculate the preoperative blood volume of two groups of patients: blood volume = k1×height(m)³ + k2×body weight(kg) + k3. (For male patients, k1 = 0.3669, k2 = 0.03219, k3 = 0.6041; for female patients, k1 = 0.3561, k2 = 0.03308, k3 = 0.1833). Compare the differences in indicators between the two groups of patients at various follow-up time points before and after surgery.\u003c/p\u003e\u003ch2\u003e2.5.Statistical analysis\u003c/h2\u003e\u003cp\u003eThe statistical analysis was conducted using SPSS version 26.0 software. Measurement values were presented as mean ± standard deviation (M ± SD). Paired sample t-tests were used for within-group comparisons when the data followed a normal distribution, while independent sample t-tests were utilized for between-group comparisons. The Wilcoxon test was employed for non-normally distributed parameters. A significance level of p \u0026lt; 0.05 was applied to determine statistical significance.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThis study included a total of 115 patients who met the criteria, with females accounting for 80.9% (93/115) and males accounting for 19.1% (22/115). The D group had 53 cases (46.1%), and the ND group had 62 cases (53.9%). There was no statistically significant difference in baseline data between the two groups (P \u0026gt; 0.05). \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003eTable 1)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Summary of the demographic data.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eD Group (n=53)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eND Group (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCases (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex (M/F)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e10/43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e12/50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.947\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e68.57\u0026plusmn;5.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e67.15\u0026plusmn;5.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e27.80\u0026plusmn;3.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e27.55\u0026plusmn;3.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Side\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Left/Right,n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e22/31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e26/36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.963\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension(n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.801\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes(n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoke(n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDrink(n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.985\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTourniquet Time(minutes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e86.2\u0026plusmn;5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e87.6\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery Time(minutes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e97.00\u0026plusmn;4.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e97.45\u0026plusmn;4.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.722\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.986754966887418%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up (mouths)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.14569536423841%\" valign=\"top\"\u003e\n \u003cp\u003e15.57\u0026plusmn;1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.304635761589402%\" valign=\"top\"\u003e\n \u003cp\u003e15.16\u0026plusmn;2.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e No significant difference was found between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1.Clinical efficacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with before surgery, both groups of patients showed improvement in knee range of motion\u0026nbsp;,VAS,and HSS after surgery. The differences were statistically significant (P\u0026lt;0.05). There was no significant statistical difference in knee range of motion ,VAS,and HSS at each follow-up time point before and after surgery between the two groups (P\u0026gt;0.05). \u003cstrong\u003e(Table 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2. K\u003c/strong\u003e\u003cstrong\u003enee range of motion\u003c/strong\u003e\u003cstrong\u003e、\u003c/strong\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003cstrong\u003e、\u003c/strong\u003e\u003cstrong\u003eHSS\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eD Group (n=53)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eND Group (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnee range of motion(\u0026deg;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e66.51\u0026plusmn;6.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e65.82\u0026plusmn;6.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.572\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Days after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e84.08\u0026plusmn;2.99*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e84.84\u0026plusmn;3.05*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.185\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 Weeks after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e102.02\u0026plusmn;5.87*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e102.58\u0026plusmn;4.97*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.494\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Months after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e113.34\u0026plusmn;5.66*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e114.08\u0026plusmn;5.29*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.469\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Year after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e115.08\u0026plusmn;5.75*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e116.42\u0026plusmn;5.27*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.205\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e6.66\u0026plusmn;1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e6.31\u0026plusmn;1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Days after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e4.19\u0026plusmn;0.76*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e4.00\u0026plusmn;0.79*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 Weeks after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e2.36\u0026plusmn;0.52*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e2.33\u0026plusmn;0.76*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.491\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Months after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e1.36\u0026plusmn;0.48*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e1.42\u0026plusmn;0.53*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Year after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e0.4\u0026plusmn;0.49*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e0.42\u0026plusmn;0.50*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.802\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e62.77\u0026plusmn;2.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e63.18\u0026plusmn;2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.358\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Days after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e71.28\u0026plusmn;2.13*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e71.47\u0026plusmn;2.34*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.612\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 Weeks after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e80.45\u0026plusmn;3.07*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e81.00\u0026plusmn;3.1*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Months after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e87.83\u0026plusmn;1.65*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e87.92\u0026plusmn;1.66*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.738\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Year after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.714524207011685%\" valign=\"top\"\u003e\n \u003cp\u003e88.19\u0026plusmn;1.79*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.04841402337229%\" valign=\"top\"\u003e\n \u003cp\u003e88.27\u0026plusmn;1.72*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.52253756260434%\"\u003e\n \u003cp\u003e0.851\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e *\u0026nbsp;\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 compared with the preoperative period.\u003c/p\u003e\n\u003cp\u003eIn terms of the degree of knee swelling, no significant statistical difference was observed between the two groups at each postoperative time point (P\u0026lt;0.05). The knee swelling increased gradually three days after the operation, peaked at one week postoperatively, and then decreased gradually. \u003cstrong\u003e(Table 3)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eknee swelling\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eD Group (n=53)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eND Group (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Days after Surgery(cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ethigh circumference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e1.30\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e1.24\u0026plusmn;0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\"\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ecalf circumference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e1.30\u0026plusmn;0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e1.16\u0026plusmn;0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\"\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Week after Surgery(cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ethigh circumference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e2.88\u0026plusmn;0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e2.82\u0026plusmn;0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\"\u003e\n \u003cp\u003e0.727\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ecalf circumference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e2.62\u0026plusmn;0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e2.68\u0026plusmn;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\"\u003e\n \u003cp\u003e0.651\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 Weeks after Surgery(cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ethigh circumference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e1.59\u0026plusmn;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e1.69\u0026plusmn;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\"\u003e\n \u003cp\u003e0.518\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ecalf circumference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e1.74\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e1.65\u0026plusmn;0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Months after Surgery(cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ethigh circumference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e0.44\u0026plusmn;0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e0.49\u0026plusmn;0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\"\u003e\n \u003cp\u003e0.376\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.438127090301002%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ecalf circumference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.585284280936456%\" valign=\"top\"\u003e\n \u003cp\u003e0.50\u0026plusmn;0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25752508361204%\" valign=\"top\"\u003e\n \u003cp\u003e0.53\u0026plusmn;0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.719063545150501%\"\u003e\n \u003cp\u003e0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.Blood index\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth groups of patients showed no significant statistical difference in preoperative HGB and HCT (P\u0026gt;0.05). One day after surgery, the HGB and HCT in both groups of patients decreased compared to preoperative levels (P\u0026lt;0.05), but the decrease was more significant in Group D compared to Group ND (P\u0026lt;0.05). Three days after surgery, the HGB and HCT in both groups of patients continued to decrease, with Group D having lower values than Group ND (P\u0026lt;0.05). Seven days after surgery, the HGB and HCT in both groups of patients showed some recovery compared to three days postoperatively, but the levels in Group D remained lower than in Group ND (P\u0026lt;0.05). The total amount of blood loss in Group D was significantly higher than in Group ND, with a statistically significant difference (P\u0026lt;0.05). \u003cstrong\u003e(Table 4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. HGB\u003c/strong\u003e\u003cstrong\u003e、\u003c/strong\u003e\u003cstrong\u003eHCT\u003c/strong\u003e\u003cstrong\u003e、\u003c/strong\u003e\u003cstrong\u003eTotal blood loss\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eD Group (n=53)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eND Group (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHGB\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003eg/L\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e134.11\u0026plusmn;12.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e135.66\u0026plusmn;12.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Day after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e112.91\u0026plusmn;10.19*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e119.23\u0026plusmn;11.56*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Days after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e100.06\u0026plusmn;9.16*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e108.98\u0026plusmn;11.70*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 Days after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e103.83\u0026plusmn;9.58*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e112.66\u0026plusmn;12.17*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCT\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e39.76\u0026plusmn;3.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e40.44\u0026plusmn;3.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.301\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Day after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e33.24\u0026plusmn;2.89*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e35.32\u0026plusmn;3.61*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Days after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e29.45\u0026plusmn;2.54*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e32.28\u0026plusmn;3.61*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 Days after Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e30.57\u0026plusmn;2.68*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e33.37\u0026plusmn;3.75*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDrainage Blood Loss(mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e489.25\u0026plusmn;106.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.623931623931625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Blood Loss(mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.205128205128204%\" valign=\"top\"\u003e\n \u003cp\u003e910.70\u0026plusmn;242.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\" valign=\"top\"\u003e\n \u003cp\u003e809.44\u0026plusmn;228.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e *\u0026nbsp;\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 compared with the preoperative period.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eTKA is currently the standard procedure for clinical treatment of advanced severe KOA.\u003csup\u003e[10]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eFor patients with advanced severe KOA, TKA can effectively alleviate knee joint pain symptoms, and enable them to achieve better knee function and higher quality of life.\u003csup\u003e[11]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eAlthough current research on KOA shows that non-surgical treatments such as physical therapy, injection therapy, and other surgical treatments can benefit patients in improving symptoms and delaying disease progression, TKA remains the ultimate effective treatment for severe KOA.\u003csup\u003e[12]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eAlthough TKA technology is very mature, the issues of preoperative anemia and high rates of allogeneic blood transfusion in TKA patients are still difficult problems in need of urgent clinical resolution.The research shows that the average blood transfusion rate for TKA patients can reach 12.7% .\u003csup\u003e[13]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eTherefore, perioperative blood management is of great clinical significance for patients undergoing total knee arthroplasty. With the continuous development of the Enhanced Recovery After Surgery (ERAS) related concepts in modern orthopedics, some scholars have applied the ERAS concept to the perioperative blood management of TKA. Several findings indicate that efficient blood management can significantly decrease perioperative blood loss and decrease the need for transfusions.\u0026nbsp;\u003csup\u003e[14]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eBlood management throughout the perioperative phase encompasses three key elements: preoperative, intraoperative, and postoperative strategies. The management of postoperative drainage stands as a crucial aspect of blood management following TKA.\u003c/p\u003e\n\u003cp\u003eThere is currently no consensus on whether drainage should be placed after TKA and how long the drainage should be placed.Since the concept of placing drainage was first proposed by Waugh et al\u003csup\u003e[15]\u003c/sup\u003ein the 1960s, the postoperative placement of drainage after TKA has undergone long-term practice in clinical settings. This method can effectively reduce the formation of local hematomas at the wound site, thereby lowering the incidence of secondary infections.\u003csup\u003e[16]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eHowever, with the widespread use of drainage, some scholars believe that it may increase apparent blood loss, and the presence of drainage can provide a gateway for bacterial invasion, increasing the risk of infection.\u003csup\u003e[17]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThere is insufficient evidence to suggest that placing drainage helps reduce postoperative infection rates, and prolonged drainage placement is instead highly prone to retrograde infection.\u003csup\u003e[18]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eContinuous negative pressure drainage can help to drain the blood in the joint cavity, reduce incision tension and local tissue pain, assist in eliminating inflammatory exudate, and prevent intra-articular adhesions. However, it may lead to an increased risk of bleeding and related complications, significantly raise the rate of allogeneic blood transfusion, and hinder early rehabilitation training for patients.\u003c/p\u003e\n\u003cp\u003eSince the 1990s, scholars have debated the placement of drainage following TKA. Watanabe et al.\u003csup\u003e[19]\u003c/sup\u003e argue that there is no significant difference in patients\u0026rsquo; blood management and prognosis whether drainage is used or not. However, Albasha et al.\u003csup\u003e[20]\u003c/sup\u003e and Xu H et al.\u003csup\u003e[21]\u003c/sup\u003e\u003csup\u003e\u0026nbsp; \u0026nbsp;\u003c/sup\u003efound that patients who undergo TKA with drainage experience longer hospital stays, increased blood loss, and higher transfusion rates. Quinn et al.\u003csup\u003e[22]\u003c/sup\u003e conducted a meta-analysis of 594 TKA cases from six studies. The results revealed that in 83% of the studies, the placement of drains did not confer a significant advantage in immediate postoperative knee flexion function or periarticular edema. Additionally, 66% of the studies confirmed that drain placement did not significantly affect changes in hemoglobin levels.\u0026nbsp;Another meta-analysis of 19 RCTs showed that for 945 patients undergoing TKA with drain placement and 920 patients without drain placement, the placement of a drain effectively reduced the incidence of hematoma but increased the transfusion rate\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csup\u003e[23]\u003c/sup\u003e. So much so that in 2016 Sharma et al.\u003csup\u003e[24]\u003c/sup\u003e concluded: for patients undergoing primary TKA, drainage offers no benefits and can be safely omitted. Based on the above research findings, Mainard et al.\u003csup\u003e[25]\u003c/sup\u003e believe that the placement of drainage is no longer a necessary procedure for primary TKA. In addition, the study by Yin D et al.\u003csup\u003e[26]\u003c/sup\u003e also confirmed that drainage placement does not bring significant benefits to wound recovery in patients undergoing primary TKA.\u003c/p\u003e\n\u003cp\u003eThe research findings reveal that Group ND exhibited significantly elevated levels of HGB and HCT at 1 day, 3 days, and 7 days postoperatively compared to Group D, along with a notably lower total blood loss. The knee joint cavity, when left undrained, tends to be relatively closed, thereby mitigating the risk of infection. As postoperative bleeding accumulates, pressure will form in the joint cavity, generating a blocking effect that can reduce bleeding from small blood vessels.This is consistent with the \u0026ldquo;tamponade effect \u0026rdquo; proposed by Taietal et al.\u003csup\u003e[27]\u003c/sup\u003eIn group D, the presence of drainage allow communication between the joint cavity and the external environment. This results in sustained lower pressure within the joint cavity.\u0026nbsp;\u003csup\u003e[28]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eAt the same time, the drainage is often in a negative pressure suction state, which is not only unfavorable for hemostasis but may also lead to continuous bleeding within the joint cavity, resulting in a significantly increased blood loss in group D compared to group ND. Furthermore, in non-closed joint cavities, there is a risk of bacterial reflux due to improper nursing procedures and other factors, which can lead to infection and other risks.\u003csup\u003e[29]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThere is no significant difference in postoperative pain symptoms and functional scores between the two groups of patients, indicating that not placing a drain after total knee arthroplasty does not have a significant impact on early postoperative functional recovery and exercise for patients. The above results suggest that for patients undergoing primary unilateral TKA, it is safe and feasible not to place a drain postoperatively and is more in line with the concept of accelerated recovery blood management.\u003c/p\u003e\n\u003cp\u003eOur research findings suggest that omitting postoperative drainage in primary unilateral TKA patients does not significantly affect the improvement of knee joint pain and symptom recovery, which aligns with initial partial research results. Furthermore, a meta-analysis of six randomized controlled trials (RCTs) indicates that the use of drainage following total knee arthroplasty has no significant impact on the recovery of postoperative joint function in patients.\u003csup\u003e[22]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThe quadriceps femoris muscle plays a crucial role in knee joint function. In a study by Jennings et al.\u003csup\u003e[30]\u003c/sup\u003e, 29 patients who underwent bilateral total knee arthroplasty were evaluated for the recovery of quadriceps femoris muscle function as the primary outcome. Secondary outcome measures included quadriceps femoris muscle activation, joint effusion, lower limb swelling, and pain. The findings indicated that the absence of drainage following total knee arthroplasty does not have a significant impact on quadriceps strength, muscle activity, joint effusion, lower limb swelling, knee range of motion, or pain. After total knee arthroplasty, placing drainage may also increase the psychological burden on patients, which is not conducive to early functional exercises for patients.\u003csup\u003e[22]\u003c/sup\u003eThe related studies show that active functional exercise after TKA is beneficial for the early recovery of knee joint function and can reduce the occurrence of related complications.\u003csup\u003e[31]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThe extent of knee joint swelling at different post-operative time intervals did not exhibit a significant disparity between the two cohorts, implying that proficient blood management and efficient compression dressing may preempt excessive knee joint swelling and congestion following TKA even in the absence of drainage placement. Therefore, based on the above study and the results of this study, there is no significant difference between not placing drainage and placing drainage after primary unilateral TKA in terms of postoperative knee joint function recovery.\u003c/p\u003e"},{"header":"5. Conclusion","content":" \u003cp\u003eFor patients undergoing primary unilateral TKA,the drainage may not be necessary postoperatively. Omitting the drainage does not affect surgical efficacy, nor does it increase the degree of knee swelling or the patient\u0026rsquo;s pain sensation. Inserting a drainage tube increases the total blood loss for patients, raises the probability of blood transfusion, and the risk of infection.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXing Yu contributed to the research and design of this article. Shuyin Tan contributed to the first draft of the article. Dingyan Zhao contributed to organizing, editing, and summarizing the text. Yukun Ma and Yang Xiong contributed to carrying out the literature search, and quality evaluation. Xinliang Yue, Yishu Zhou, Jieyun Wei, and Letian Meng contributed to data collection and analysis. All authors agree to be accountable for all aspects of the work. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors disclose no relevant financial relationships, conflicts of interest, or other potential sources of bias related to the content of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding support was received for the analysis of the data preparation of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDu X, Liu ZY, Tao XX, Mei YL, Zhou DQ, Cheng K, et al. Research Progress on the Pathogenesis of Knee Osteoarthritis. Orthop Surg. 2023;15(9):2213\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorgiev T, Angelov AK. Modifiable risk factors in knee osteoarthritis: treatment implications. 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Bone Joint J. 2019, 101\u0026ndash;B(7_Supple_C):84\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShan L, Shan B, Suzuki A, Nouh F, Saxena A. Intermediate and long-term quality of life after total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Am. 2015;97(2):156\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Knee osteoarthritis, Total knee arthroplasty, Blood management, Drainage, Postoperative blood loss","lastPublishedDoi":"10.21203/rs.3.rs-4535094/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4535094/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eOBJECTIVE\u003c/h2\u003e \u003cp\u003eTo observe the impact of placing or not placing drainage on the changes in blood index and knee function recovery in patients undergoing initial unilateral total knee arthroplasty (TKA).\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eA review was conducted on 115 cases of primary unilateral total knee arthroplasty (TKA) patients at our hospital. The patients were categorized into two groups: a drainage group (D group) and a non-drainage group (ND group) depending on the usage of a postoperative drainage tube. In Group D, there were 53 cases (10 males, 43 females) with an average age of 68.57\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34 years. The distribution of cases was 22 on the left knee and 31 on the right knee, with an average follow-up period of 15.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92 months. In Group ND, there were 62 cases (12 males, 50 females) with an average age of 67.15\u0026thinsp;\u0026plusmn;\u0026thinsp;5.78 years. The distribution of cases was 26 on the left knee and 36 on the right knee, with an average follow-up period of 15.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04 months. Relevant data was collected for both groups of patients during hospitalization and follow-up periods, which included: pain assessment using the Visual Analogue Scale (VAS), evaluation of patient symptoms improvement using the Hospital for Special Surgery Knee Score (HSS), assessment of postoperative functional improvement based on knee swelling and knee range of motion, and evaluation of blood loss using hemoglobin (HGB), hematocrit (HCT), and total theoretical blood loss during surgery.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eBoth patient groups exhibited enhancements in postoperative VAS, HSS, and knee joint activity levels compared to pre-surgery values, all with statistically significant disparities (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There were no notable statistical variations in knee joint activity, VAS, and HSS at different follow-up intervals between the two patient groups before and after the surgical procedure (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Following surgery, knee swelling progressed incrementally over 3 days, culminating at its peak one week postoperatively, and subsequently subsided gradually. No significant statistical differences in knee swelling were observed between the two groups at any time point post-surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, there were no statistically significant variances in preoperative levels of HGB (134.11\u0026thinsp;\u0026plusmn;\u0026thinsp;12.16 vs. 135.66\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26) and HCT (39.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32 vs. 40.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60) between the patient groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). One day following the surgery, both groups exhibited decreased HGB levels compared to the preoperative readings (D group: 112.91\u0026thinsp;\u0026plusmn;\u0026thinsp;10.19 vs. 134.11\u0026thinsp;\u0026plusmn;\u0026thinsp;12.16; ND group: 119.23\u0026thinsp;\u0026plusmn;\u0026thinsp;11.56 vs. 135.66\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and HCT levels demonstrated similar decreases compared to preoperative levels (D group: 33.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89 vs. 39.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32; ND group: 35.32\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61 vs. 40.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The decrease in HGB and HCT levels in the D group was significantly greater compared to the ND group, with a statistically significant difference observed (HGB: 112.91\u0026thinsp;\u0026plusmn;\u0026thinsp;10.19 vs 119.23\u0026thinsp;\u0026plusmn;\u0026thinsp;11.56; HCT: 33.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 vs 35.32\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). On the third day post-surgery, both HGB (D group: 100.06\u0026thinsp;\u0026plusmn;\u0026thinsp;9.16 vs 112.91\u0026thinsp;\u0026plusmn;\u0026thinsp;10.19; ND group: 108.98\u0026thinsp;\u0026plusmn;\u0026thinsp;11.70 vs 119.23\u0026thinsp;\u0026plusmn;\u0026thinsp;11.56) and HCT (D group: 29.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54 vs 33.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89; ND group: 32.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61 vs 35.32\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61) continued to decrease compared to the first-day post-surgery, with group D exhibiting lower levels of HGB and HCT than group ND (HGB: 100.06\u0026thinsp;\u0026plusmn;\u0026thinsp;9.16 vs 108.98\u0026thinsp;\u0026plusmn;\u0026thinsp;11.70; 29.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54 vs 32.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Following seven days post-surgery, both groups demonstrated recovery in HGB (D group: 103.83\u0026thinsp;\u0026plusmn;\u0026thinsp;9.58 vs 100.06\u0026thinsp;\u0026plusmn;\u0026thinsp;9.16; ND group: 112.66\u0026thinsp;\u0026plusmn;\u0026thinsp;12.17 vs 108.98\u0026thinsp;\u0026plusmn;\u0026thinsp;11.70) and HCT (D group: 30.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68 vs 29.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54; ND group: 33.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.75 vs 32.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61) compared to three days post-surgery. However, levels in group D remained lower than in group ND, with statistical significance. Throughout the perioperative period, the total blood loss in group ND was significantly less than that in group D (910.70\u0026thinsp;\u0026plusmn;\u0026thinsp;242.73 vs 809.44\u0026thinsp;\u0026plusmn;\u0026thinsp;228.55, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eDrainage may not be necessary after initial unilateral total knee arthroplasty (TKA). Omitting drainage can reduce the total amount of blood loss in patients and does not affect the postoperative recovery of knee joint function.\u003c/p\u003e","manuscriptTitle":"The Effect of Placing or not Placing Drainage after Primary Unilateral Total Knee Arthroplasty on Blood Loss and Knee Function: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-17 02:10:53","doi":"10.21203/rs.3.rs-4535094/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2024-06-25T12:06:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-25T08:27:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2024-06-05T15:20:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8d7a0583-3c04-4dca-8f87-70df1354a845","owner":[],"postedDate":"July 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-07-17T02:10:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-17 02:10:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4535094","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4535094","identity":"rs-4535094","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}