Rethinking routine drain usage in total knee arthroplasty: how tranexamic acid changed clinical practice – a review of literature

Abstract

The routine uses of closed suction drainage in total knee arthroplasty has been a longstanding practice aimed at preventing hematoma formation and infection. However, the introduction of tranexamic acid has revolutionized blood loss management. This review evaluates the current utility of suction drains in primary total knee arthroplasty within the context of widespread tranexamic acid adoption. A comprehensive literature review was conducted, focusing on studies published between 2004 and 2025. Special emphasis was placed on randomized controlled trials and comparative cohort studies evaluating outcomes of drain versus no-drain protocols in patients receiving tranexamic acid. Key outcome measures included total blood loss, transfusion rates, length of hospital stay, infection rates, and functional outcomes. Historical meta-analyses conducted prior to the tranexamic acid era indicated increased transfusion requirements associated with drain use. Recent evidence from the tranexamic acid era, including a pivotal 2019 randomized controlled trial by Maniar et al and a 2023 retrospective cohort study by Albasha et al, demonstrates that drains offer no benefit regarding blood conservation or complication reduction. Albasha et al found that drain placement was associated with significantly longer hospital stays (10.7 versus 5.4 days), greater hemoglobin decline, and higher transfusion rates. No significant differences were observed in deep vein thrombosis or surgical site infection rates between groups. In the tranexamic acid era, the theoretical benefits of negative suction drains are outweighed by associated disadvantages, including increased hidden blood loss, higher transfusion costs, and prolonged hospitalization. Current evidence supports abandoning routine drainage in primary total knee arthroplasty when tranexamic acid is administered.