Surgical Science, 2011, 2, 437-441
doi:10.4236/ss.2011.29095 Published Online November 2011 (
Copyright © 2011 SciRes. SS
Postoperative Drains at the Donor Sites of Iliac-Crest
Bone Grafts in Patients Who Had a Single
Comminuted Long Bone Fracture
Ali Karbalaeikhani1, Alireza Saied2
1Hand and Plastic Surgery Department, Emam Reza Ho spital,
AJA University of Medical Sciences, Tehran, Iran
2Kerman Neurosceicne Research Center, Kerman University of Medical Sciences, Kerman, Iran
E-mail: {arsaiedmd, aliamousavi}
Received July 14, 2011; revi sed Octobe r 13, 2011; accepted O ct o be r 28, 2011
In this clinical trial, 90 patients admitted to orthopedics ward, Shahid Mohammadi Hospital, Bandar Abbass
with a long bone fracture, comminuted more than 30%, were randomly divided into two groups. In the first
group, after the completion of the operation, a single hemovaccum drain was inserted into the iliac crest
wound, the site of cancellous bone removal, whereas the second group didn’t receive a drain. The two groups
were followed for at least six months and the results were compared with Chi-Square and T-Tests. The two
groups, at the end of the follow up period, had no statistically significant difference with regard to pain se-
verity and need for dressing change (in the immediate postoperative period), hematoma formation and infec-
tion. So it seems that drain insertion in the wound of patients in whom cancellous bone is removed from the
iliac crest, is not necessary.
Keywords: Drain, Surgery, Bone Graft, Fracture
1. Introduction
Use of devices to evacuate pus and fluids out of the body
has been mentioned in Hippocrates records that used a
metal tube and wine to evacuate pus from the pleural
space of a patient [1]. Drains are used commonly and as
a routine procedure after clean surgical operations in
hope to prevent hematoma formation and as a result in-
fection occurrence. The rational (but scientifically un-
proven) reason for this routine has been the hypothesis
that a drain would evacuate any oozing blood, serous
fluid and forming hematoma from the operation site and
so will prevent infection. But this has been a matter of
considerable debate: many studies performed on the
topic could not prove the ability of drains to prevent he-
matoma formation [2-4] and aside from this in old [5,6]
and new [7] studies drains not only have not prevented
infection but have been noticed to be independent risk
factors in wound infection after surgery! From a theo-
retical point of view in addition to prevention of hema-
toma formation and infection drains would decrease the
patients’ pain and the need for dressing change in the
immediate postoperative days. The aim of this study was
to examine the efficacy of drains in the aforementioned
subjects (with emphasis on hematoma formation and in-
fection) in one of the common surgical operations in or-
thopedics, bone graft removal from the iliac crest.
2. Patients and Methods
In this clinical trial 102 patients referring to our Hospital
emergency room with single comminuted long bone
fracture necessitating open reduction and bone graft ad-
dition were randomly assigned into Drain (control) and
Nondrain (case) groups. The two groups were compara-
ble with regard to age, sex and the broken bone (Table
The patients entering the trial had a single long bone
fracture comminuted more than 30% in whom bone graft
was removed from their iliac crest and added to the frac-
ture site during the surgical procedure of open reduction
and internal fixation using either plate and screws or in-
tramedullary nails (performed as an open procedure).
Inclusion criteria were as follows:
Table 1. Fracture distribution of the patients enrolled in the
Nondrained Drained
female Male female Male
Tibia fracture 6 15 4 18
Femur fracture 5 18 2 21
humerus fra cture - - - 1
1) Age above 18 years old;
2) Informed consent fo r entering the trial;
3) Completion of the follow up period of at least 6
4) Absence of systemic disease, pathologic fracture,
pregnancy, or chronic medication use;
5) Absence of head, chest or abdominal trauma.
Bone graft was removed from the external iliac crest
table in all of the patients and all of the surgical proce-
dures were performed by the senior author. After prep
and drape and antibiotic injection (Cephalotine 2 grams
intravenous), as the need for bone graft was certain, it
was removed first. Using a 10 cm incision on the iliac
crest the muscles were stripped and the cancellous bone
was removed by use of osteotome or curette. After the
completion of the procedure the wound was irrigated and
sutured layer by layer. No attempt was made at hemosta-
sis except for electrocautery. The and in no patient bone
wax was used. The surgeon was not aware of the pa-
tient's group until this stage when the assistant told him
to use or not to use drains before wound closure. In the
control group a single hemovacum drain was inserted
and sutured to skin. The drain was of the SUPA factory
in all of the patients and was removed on the third post-
operative day if there was no active drainage. The pa-
tients were closely observed for the following during
their hospital course and in later follow up in O.P.D. vis-
1) Dressing wetting in the first 24 hours so that the
staff had to change the dressing. They were unaware of
the study conductio n.
2) Pain at the site of bone graft removal so that the pa-
tient asked for oral and if nonresponsive for intravenous
analgesic. This variable was difficult to measure accu-
rately as the patient may ask for analgesic because of
limb pain and this will obscure th e pelvic pain.
3) The operation site morbidity (hematoma, infection,
serous drainage, infection or any other problem), from
the second day after operation up to six months.
The follow up routine in our clinic was as follows: 2
weeks after the operations for wound inspection and su-
ture removal, 4 weeks later for control radiograms and
union assessment, 6 weeks later (3 months after the op-
eration) for taking control radiograms and probable dis-
continuation of limb protection if the union was com-
plete and ultimately 3 months later for assessment of the
general conditio n of the p atient and any probab le sugges-
tion. In addition the patient was visited out of the pro-
gram in case of any unexpected complications. In case of
infection, oral antibiotics and topical wound care were
advised. If there was no or inadequate response, the pa-
tient had to be admitted and receive intravenous antibi-
otics, and if necessary wound irrigation in the operation
room under anesthesia would be performed.
The study results were analyzed by computer P4 and
SPSS 16 soft ware. The statistical used tests were Chi
square and Student’s T-Test.
3. Results
90 patients entered the trial with the completion of pre-
determined follow up period, 73 men and 17 women. In
total 46 individuals were assigned into Drain and 44 to
Nondrain group. The characteristics of both groups are
shown in the follo wing tab les.
At the end of the follow up period these were the
1) In the Drain group dressing wetting necessitatin g its
change in the first 24 hours didn’t occur in any patient,
but in 2 of the No ndrain gr ou p .
2) In the Drain group 38 needed oral analgesic and 4
needed injection forms, in the Nondrain group 40 needed
oral and 2 needed injection analgesic.
3) No patient of either groups developed persistent
bleeding or hematoma, although four in the drain group
had serosanginous discharge of their wound which had
resolved after the first follow up and did not progress to
any problem. In the Nondrain group, 2 patients noted
severe ecchymosis of their flank up to the mid-thoracic
area and their back. Although this caused earlier than
scheduled follow up of the patients and their fear, it was
apparently harmless and resolved spontaneously without
any intervention except reassurance.
4) Three patients developed superficial wound infec-
tion, all of the drained group. They noted erythema, pain
and warmness in addition to mild discharge of the wound.
In all of them the culture was positive for S. aureus and
all of them responded to oral antibio tics and local wound
care. Deep infection was not observed in any of the pa-
tients of the two groups.
Statistical analysis revealed no significant difference
between the two groups in any of the aforementioned
variables (Table 2).
4. Discussion
In this clinical trial we examined the efficacy of drains in
Copyright © 2011 SciRes. SS
Table 2. Variables of the study as measured in the two
Variable Nondrained Drained p-value
Analgesic requirement 42 42 0.68
Oral analgesic 40 48 0.6
Parenteral analgesic 2 4 o.68
Dressing change 2 - 0.24
Hematoma - - -
Infection - 4 0.24
one of the common orthopedic surgical procedures, i.e.
bone graft removal from the iliac crest. Although theo-
retically there is no difference between the wound of
iliac crest in patients with different types of surgery on
the limbs (for example arthrodesis versus fracture or
multiple fractures or nonunion), to lower the chance of
bias we determined to limit our study to a very narrow
area, namely patients with a single comminuted long
bone fracture necessitating bone grafting after open re-
duction and internal fixation. On the other hand, despite
the advances in intramedullary nailing techniques, plat-
ing and bone grafting is still mentioned as an acceptable
alternative in comminuted long bone fractures and is
used in many university hospitals. In addition open in-
tramedullary nailing does not eliminate the need for bone
grafts. So we think the study was worthful to be con-
From the theoretical point of view a drain is used for
the following purposes:
1) Prevention of hematoma as it evacuates any fluid
from the wound.
2) Preventio n o f infection as infection occurs when the
hematoma is invaded by bacteria.
3) Decrease in the need for dressing change as the
fluid will not “overflow” from the wo und.
4) Decrease in the pain that the patient perceives by
“decompressing” the wound and lowering its pressure.
Our study could not prove the efficacy of drain in any
of the aforementioned.
Surgeons have used drains throughout the history of
surgery. No one has any doubt that drain use will be of
benefit to the patient if infection is present, but there has
been significant controversy about prophylactic use of
drains in order to prevent hematoma formation and in-
fection. In fact the advice of pioneers in surgery, about
the drain use in clean surgical wounds during the past
century has been different from “When in doubt, use
drains” [8] to “When in doubt, don’t use drains” [1]!
Although Hippocrates was probably the first surgeon to
use a drain, it was since the era of Andrias Pare and
Lister that drains were seriously considered. Pare noticed
the adverse effects of the drains and cautioned against
overuse of them, but it was until 1880 when a 40% risk
of infection in the drains was discovered. With introduc-
tion of modern suction drains several studies on the topic
have been undertaken since 1960 [9] and they have re-
sulted in contradictory information. One old study [11]
found the risk of infection 3 times less with the use of
drains and so anticipated fewer hazards. A study on fe-
mur fractures treated by open reduction and internal fixa-
tion found the risk of hematoma formation equal in the
groups with and without drains, but the risk of infection
was obviously greater in the group in which drains were
not used [11]. These are probably the only studies that
suggest routine drain usage in orthopedic surgery. In fact
the largest studies on the topic have been performed on
joint arthroplasties and have failed to ascribe any benefit
in order to decrease the rate of complications and espe-
cially infection and hematoma by drain use in these op-
erations [12-17]. In fact a large metaanalysis revealed
increased need for transfusion in patients with drain after
arthroplasty [18]!
Few studies have been performed on drain use in op-
erations related to traumatology, but in most of them
drain has not proven to be of benefit [4, 19 ,2 0] .
Up to the best of our knowledge only one study has
been performed on the topic of drain use in the surgical
operation of graft removal from iliac crest [21]. The re-
sult was similar to our findings. Drain use did not help in
prevention of complications. It is interesting that in nei-
ther of these studies even a single case of hematoma was
found, as the rate of this complication has been reported
to be 3% [22].
Aside from the unproven benefit, drain use may be
associated with complications. In some cases as almost
all of us remember, a second operation has been neces-
sary for its removal [19,22].
The serosanginous drainage that was observed after
drain removal in some of patients in the present study
has been the experience of others too [19] and we have
encountered some other cases. Although this was not
associated with serious consequences, it was troublesome
to the patients.
It must be emphasized that up to the best of our know-
ledge the latest papers on the topic [23-27]; again did not
find drain necessar y in orthopedic surger y.
Although based on the present and other studies drain
use is unnecessary after surgery, it is difficult to prevent
surgeons from a practice that has become a routine and
seems rationale: two recent studies [28,29] showed that
more than 90% of surgeons continued to use drains after
total knee arthroplasty, despite their awareness of the
studies that had not proved the efficacy of drains in these
Copyright © 2011 SciRes. SS
5. References
[1] M. Levy, “I ntr aper it onea l Drai nage ,” The American Jour-
nal of Surgery, Vol. 147, No. 3, 1984, pp. 309-314.
[2] G. W. Varley and S. A. Milner, “Wound Drains in Proxi-
mal Femoral Fracture Surgery: A Randomized Prospec-
tive Trial of 177 Patients,” The Royal College of Sur-
geons of Edinburgh, Vol. 40, No. 6, 1995, pp. 416-418.
[3] J. Widman, H. Jacobsson, S. A. Larsson and J. Isacson,
“No Effect of Drains on the Postoperative Hematoma
Volume in Hip Replacement Surgery: A Randomized
Study Using Scintigraphy,” Acta Orthopaedica Scandi-
navica, Vol. 73, No. 6, 2002, pp. 625-629.
[4] R. M. Tjeenk, M. P. Peeters, E. van den Ende, G. W.
Kastelein and P. J. Breslau, “Wound Drainage versus
Non-Drainage for Proximal Femoral Fractures. A Pro-
spective Randomised Study,” Injury, Vol. 36, No. 1, 2005,
pp. 100-104.
[5] “Factors Influencing the Incidence of Wound Infection,”
Annals of Surgery, Vol. 160, Supplement 2, 1964, pp.
[6] “Report of the Public Health Laboratory Service: Inci-
dence of Surgical Wound Infection in England and
Wales,” Lancet, 1960, pp. 659-663.
[7] B. Minnema, M. Vearncombe, A. Augustin, J. Gollish
and A. E. Simor, “Risk Factors for Surgical-Site Infection
Following Primary Total Knee Arthroplasty,” Infection
Control and Hospital Epidemiology, Vol. 25, No. 6, 2004,
pp. 477-480. doi:10.1086/502425
[8] M. A. Memon, M. I. Memon and J. H. Donohue, “Ab-
dominal Drains: A Brief Historical Review,” Irish Medi-
cal Journal, Vol. 94, No. 6, 2001, pp. 164-166.
[9] J. P. Moss, “Historical and Current Perspectives on Sur-
gical Drainage,” Surgery Gynecology & Obstetrics, Vol.
152, No. 4, 1981, pp. 517-527.
[10] T. R. Waugh, “Stitch Field FE: Suction Drainage of Or-
thopedic Wounds,” Journal of Bone and Joint Surgery,
1961, Vol. 43A, No. 7, pp. 939-946.
[11] G. W. Varley and S. A. Milner, “Wound Drains in Proxi-
mal Femoral Fracture Surgery: A Randomized Prospec-
tive Trial of 177 Patients,” The Royal College of Sur-
geons of Edinburgh, Vol. 40, No. 6, 1995, pp. 416-418.
[12] K. J. Beer, A. V. Lombardi Jr., T. H. Mallory and B. K.
Vaughn, “The Efficacy of Suction Drains after Routine
Total Joint Arthroplasty,” The Journal of Bone and Joint
Surgery, American Volume, Vol. 73, No. 4, 1991, pp.
[13] X. M. Crevoisier, P. Reber and B. Noesberger, “Is Suc-
tion Drainage Necessary after Total Joint Arthroplasty? A
Prospective Study,” Archives of Orthopaedic and Trauma
Surgery, Vol. 117, No. 3, 1998, pp. 121-124.
[14] A. G. D. Valle, G. Slullitel, R. Vestri, F. Comba, M.
Buttaro and F. Piccaluga, “No Need for Routine Closed
Suction Drainage in Elective Arthroplasty of the Hip: A
Prospective Randomized Trial in 104 Operations,” Acta
Orthopaedica Scandinavica, Vol. 75, No. 1, 2004, pp.
30-33. doi:10.1080/00016470410001708050
[15] M. A. Ritter, E. M. Keating and P. M. Faris, “Closed
Wound Drainage in Total Hip or Total Knee Replace-
ment. A Prospective, Randomized Study,” The Journal of
Bone and Joint Surgery, American Volume, Vol. 76, No.
1, 1994, pp. 35-38.
[16] P. J. Walmsley, M. B. Kelly, R. M. Hill and I. Brenkel,
“A Prospective, Randomised, Controlled Trial of the Use
of Drains in Total Hip Arthroplasty,” Journal of Bone
and Joint Surgery, British Volume, Vol. 87, No. 10, 2005,
pp. 1397-1401. doi:10.1302/0301-620X.87B10.16221
[17] C. Dora, A. von Campe, B. Mengiardi, P. Koch and P.
Vienne, “Simplified Wound Care and Earlier Wound
Recovery without Closed Suction Drainage in Elective
Total Hip Arthroplasty. A Prospective Randomized Trial
in 100 Operations,” Archives of Orthopaedic and Trauma
Surgery, Vol. 127, No. 10, 2007, pp. 919-923.
[18] M. J. Parker, C. P. Roberts and D. Hay, “Closed Suction
Drainage for Hip and Knee Arthroplasty. A Meta-Analy-
sis,” The Journal of Bone and Joint Surgery, American
Volume, Vol. 86A, No. 6, 2004, pp. 1146-52.
[19] J. P. Cobb, “Why Use Drains?” Journal of Bone and
Joint Surgery, British Volume, Vol. 72, No. 6, 1990, pp.
[20] G. J. Lang, M. Richa rdson, M. J. Bosse, K. Gre ene, R. A.
Meyer Jr., S. H. Sims and J. F. Kellam, “Efficacy of Sur-
gical Wound Drainage in Orthopaedic Trauma Patients:
A Randomized Prospective Trial,” Journal of Orthopae-
dic Trauma, Vol. 12, No. 5, 1998, pp. 348-350.
[21] R. C. Sasso, J. I. Williams, N. Dimasi and P. R. Meyer Jr.,
“Postoperative Drains at the Donor Sites of Iliac-Crest
Bone Grafts. A Prospective, Randomized Study of Mor-
bidity at the Donor Site in Patients Who Had a Traumatic
Injury of the Spine,” The Journal of Bone and Joint Sur-
gery, American Volume, Vol. 80, No. 5, 1998, pp.
[22] J. P. Browett, A. N. Gibbs, S. A. Copeland and L. J. Deliss,
“The Use of Suction Drainage in the Operation of Menis-
cectomy,” Journal of Bone and Joint Surgery, British
Volume, Vol. 60B, No. 4, 1978, pp. 516-519.
[23] M. J. Parker, V. Livingstone, R. Clifton and A. McKee,
“Closed Suction Surgical Wound Drainage after Ortho-
paedic Surgery,” Cochrane Database of Systematic Re-
views, 2007, Vol. 18, No. 3, Article ID: CD001825.
[24] L. Cao, N. Ablimit, A. Mamtimin, K. Y. Zhang, G. Q. Li,
G. Li and L. B. Peng, “Comparison of No Drain or with a
Drain after Unilateral Total Knee Arthroplasty: A Pro-
spective Randomized Controlled Trial,” Chinese Journal
of Surgery, Vol. 47, No. 18, 2009, pp. 1390-1393.
[25] R. Clifton, S. Haleem, A. McKee and M. J. Parker, “Closed
Suction Surgical Wound Drainage after Anterior Cruciate
Ligament Reconstruction: A Systematic Review of Ran-
domised Controll ed Trials,” Knee, Vol. 14, No. 5, 2007, p p.
348-351. doi:10.1016/j.knee.2007.07.003
Copyright © 2011 SciRes. SS
Copyright © 2011 SciRes. SS
[26] C. Li, A. Nijat and M. Askar, “No Clear Advantage to
Use of Wound Drains after Unilateral Total Knee Arthro-
plasty: A Prospective Randomized, Controlled Trial,”
The Journal of Arthroplasty, Vol. 26, No. 4, 2011, pp.
519-522. doi:10.1016/j.arth.2010.05.031
[27] T. W. Tai, I. M. Jou, C. W. Chang, K. A. Lai, C. J. Lin
and C. Y. Yang, “Non-Drainage Is Better than 4-Hour
Clamping Drainage in Total Knee Arthroplasty,” Ortho-
pedics, Vol. 33, No. 3, 2010, pp. 156-160.
[28] A. Chandratreya, K. Giannikas and P. Livesley, “To Drain
or Not Drain: Literature versus Practice,” The Royal Col-
lege of Surgeons of Edinburgh, Vol. 43, No. 6, 1998, pp.
[29] S. J. Canty, G. J. Shepard, W. G. Ryan and A. J. Banks,
“Do We Practice Evidence Based Medicine with Regard
to Drain Usage in Knee Arthroplasty? Results of a Ques-
tionnaire of BASK Members,” Knee, Vol. 10, No. 4,
2003, pp. 385-387. doi:10.1016/S0968-0160(03)00037-1