Total knee replacement is a standard procedure for the end-staged knee joints. The main concerns at the perioperative period are infection prophylaxis, pain control, and blood loss management. Several interventions are designed to decrease the blood loss during and after the operation of total knee arthroplasty. In the recent meta-analysis showed that early tourniquet release of the tourniquet for hemostasis increased the total measured blood loss with primary TKR about 228.7 ml. So, Intra-operative blood loss for hemostasis can be saved by not to release the tourniquet after implants fixation, irrigation, closure of the wound and the application of compression dressing. Our study showed that most of the post-operative blood loss was collected during the first few postoperative hours: 37% in the first 2 hours and 55% in the first 4 hours and 82.1% in the first 24 hours. So, clamping the drainage for the first 4 postoperative hours would reduce blood loss after TKA (518 v.s. 843 mL). The fall in hemoglobin and Hct are also of significant difference (1.64 vs. 2.09 for Hb; 5.18 vs.7.69 for Hct). Appropriate clamping for an optimal time may be the most economical and simple, and the benefits of clamping also appear to outweigh its potential risks. NO DRAIN at all is able to reduce the post-operative blood loss. Our study showed that the decrease of postoperative hemoglobin was significantly less than that in no-drain group (1.45±0.72 vs 1.8±0.91). Shorter hospital stay was achieved in the no-drain group (8.3 ± 2.6 vs 10.7±3.2 days). All patients achieved good range of motion (flexion: 0 to >90 degree)by the five days after operation and no prosthetic infection was noted during follow-up. Thus, the routine use of closed suction drains for elective minimal-invasive total knee arthroplasty is not recommended

A seventy-five-year-old female patient presented with pain and deformity of her left leg of three days duration. Hybrid THRA has been done 11 years ago at her left hip for the treatment of osteoarthritis. Massive osteolysis and pathologic fracture were observed on plain radiograph (Fig. 1). Revision THRA using an allograft prosthesis composite (APC) was planned for solution of extensive bone loss of the proximal femur. Surgical exposure was performed through extended trochanteric osteotomy with the patient supine. Step-cut osteotomy was done at the remained proximal part of host femur to make match with the distal part of APC. Meticulous removal of granulation tissues and remaining cement was done. As Acetabular cup was stable, 60 mm sized high-walled polyethylene liner was exchanged. Calcar reconstruction prosthesis was cemented into a proximal femoral allograft measuring 15 cm and cement at the vicinity of the step-cut osteotomy was removed for later bony union at interface. After solid fixation of APC with cement, the distal half of APC was cemented with the host femur. Step-cut osteotomy was wired and autogenous bone grafts from the greater trochanter were added at the interface. Leg length and stability were rechecked using a standard necked 28 mm metal head and reduction was done stably. Greater trochanter was fixed over the trimmed proximal allograft with multiple wiring and paper-thin host femur was enveloped around the femoral allograft using absorbable sutures. Following insertion of the closed suction drainage drains, closure was done as routine fashion and healing of the wound was uneventful (Fig. 2). An abduction brace was applied post operatively for a period of four weeks. Crutch walking with partial weight bearing was started at four weeks and crutch protection was applied for a period of six months. Incorporation of allograft with the host bone was observed on two-year follow-up radiographs. At seven-year follow-up, the patient walks well with a mild limp, and Harris score is 90. We report on a seven-year follow-up case of revision THRA with APC with references (Fig. 3)