Zhongming Chen, Daniel J. Berry, Mojieb Manzary, Michael A. Mont.
Response/Recommendation: Mechanical compressive devices can be used routinely in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) as venous thromboembolism (VTE) prophylaxis.
Strength of Recommendation: High.
Rationale: Prevention of VTE following total joint arthroplasty (TJA) remains a priority for orthopaedic surgeons, and many modalities are currently available. The main advantage of compressive mechanical devices is that their use, unlike chemical prophylaxis, is not associated with increased bleeding after surgical procedures.
The VTE prevention Guidelines from the American Academy of Orthopaedic Surgeons (AAOS)1 advocate for the use of mechanical compressive devices for the prevention of VTE in patients undergoing elective TJA and who, independent of the surgery, are not at an increased risk for VTE. In the consensus recommendation, the authors highlighted the benefit of mechanical compressive devices specifically for patients who are at a higher risk of bleeding, such as patients who have hemophilia, liver disease, and other bleeding disorders. The AAOS guidelines also endorse the use of mechanical compressive devices for patients with prior history of VTE who are undergoing THA or TKA1. Importantly, the AAOS recommendations are in agreement with the American College of Chest Physicians’ (ACCP) recommendations in that mechanical compression devices can be used alone, without chemical prophylaxis, for the prevention of VTE particularly in low-risk patients2. The ACCP guidelines also propose that mechanical compressive devices may be used alone in TJA patients who are at an increased risk of bleeding2.
Since the publication of AAOS and ACCP guidelines on prevention of VTE, there have been additional publications on this topic. A total of 21 studies were identified from the literature review, of these, nine reports were summaries/review articles and 12 were original studies. The study by Dietz et al., highlighted the low patient compliance (35%) with these devices3. A few other studies described the efficacy and safety of aspirin, low-molecular-weight heparin (LMWH), or direct oral anticoagulants (DOAC) in combination with mechanical prophylaxis4–7. There are many different types of compressive devices in the market, with some of them being portable devices. The study by Dietz et al., described the efficacy of a portable pneumatic compression pump, while Arsoy et al., described the efficacy of a mobile compression device3,8. A meta-analysis by Pour et al., examined the issue of distal application of compression devices, namely foot pumps, and found current literature supported the efficacy of these distal devices9. Another study by Zhao et al., a quasi-randomized controlled design, compared the efficacy of plantar compression devices and calf compression devices in 121 patients, concluding that calf-thigh pneumatic compression was more effective than plantar compression for reducing thigh swelling during the early postoperative period9,10. The remaining studies supported the use of mechanical devices in patients undergoing THA or TKA11–22.
The synergistic relationship between compression devices and chemical prophylaxis has been examined in a few studies. Kakkos et al., investigated the efficacy of combined mechanical compression and pharmacologic prophylaxis for the prevention of VTE in patients undergoing THA and TKA, performing a systematic review and meta-analyses that included a total of 22 trials (15 randomized controlled trials) and 9,137 patients7. The types of interventions studied were intermittent pneumatic leg compression devices, which included calf sleeves as well as foot pumps, and pharmacologic prophylactic agents such as unfractionated heparin and LMWH. The authors provided specific data for the additive value of mechanical compression in combination with pharmacologic prophylaxis and reported a decrease in the incidence of symptomatic pulmonary embolism (PE) from 2.92% to 1.20% when comparing pharmacological prophylaxis alone to combined mechanical compression and pharmacological prophylaxis (95% confidence interval, 0.23 to 0.64). While Harrison-Brown et al., An et al., and Torrejon et al., also argued in support of the synergistic role of chemical prophylaxis in combination with mechanical compression, their reports did not demonstrate any additive value of mechanical compression in combination with pharmacologic prophylaxis4–6.
Another issue regarding the use of mechanical compressive devices relates to the duration of use. As previously stated, guidelines from the AAOS did not give recommendations on the duration of use of mechanical compression devices1, and only recommended that patients discuss the usage duration with their treating physician. The AACP on the other hand recommended that mechanical compressive devices should be used throughout the hospital stay and for a minimum of 10 to 14 days2. Since the publication of these two guideline reports, there have been 12 original studies evaluating various compression devices used from one day to three months postoperatively. Due to the large range, there appears to be no compelling evidence to suggest an optimal duration of mechanical compression amidst the current era of short-stay hospitalizations3,8.
Another search was performed regarding VTE prophylaxis for ambulatory surgeries of the hip and knee. While several studies were found, the majority only studied pharmacological prophylaxis, and none provided compelling data on the duration of mechanical compression23–28. Further studies are needed to address this knowledge gap.
In summary, mechanical devices can be used as VTE prophylaxis in patients undergoing THA and TKA. Recent studies support prior established guidelines that recommend the use of mechanical compression devices. Further research should aim to clarify the most appropriate devices, duration of use, as well as synergistic relationship with pharmacological agents.
1. Mont MA, Jacobs JJ, Boggio LN, et al. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):768-776. doi:10.5435/00124635-201112000-00007
2. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404
3. Dietz MJ, Ray JJ, Witten BG, Frye BM, Klein AE, Lindsey BA. Portable compression devices in total joint arthroplasty: poor outpatient compliance. Arthroplasty Today. 2020;6(1):118-122. doi:10.1016/j.artd.2019.12.004
4. Harrison-Brown M, Scholes C, Douglas SL, Farah SB, Kerr D, Kohan L. Multimodal thromboprophylaxis in low-risk patients undergoing lower limb arthroplasty: A retrospective observational cohort analysis of 1400 patients with ultrasound screening. J Orthop Surg Hong Kong. 2020;28(2):2309499020926790. doi:10.1177/2309499020926790
5. An VVG, Levy YD, Walker PM, Bruce WJM. Thrombosis rates using aspirin and a compression device as multimodal prophylaxis for lower limb arthroplasty in a screened population. J Clin Orthop Trauma. 2020;11(Suppl 2):S187-S191. doi:10.1016/j.jcot.2018.10.007
6. Torrejon Torres R, Saunders R, Ho KM. A comparative cost-effectiveness analysis of mechanical and pharmacological VTE prophylaxis after lower limb arthroplasty in Australia. J Orthop Surg. 2019;14(1):93. doi:10.1186/s13018-019-1124-y
7. Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby GP, Reddy DJ. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev. 2008;(4):CD005258. doi:10.1002/14651858.CD005258.pub2
8. Arsoy D, Giori NJ, Woolson ST. Mobile Compression Reduces Bleeding-related Readmissions and Wound Complications After THA and TKA. Clin Orthop. 2018;476(2):381-387. doi:10.1007/s11999.0000000000000041
9. Pour AE, Keshavarzi NR, Purtill JJ, Sharkey PF, Parvizi J. Is venous foot pump effective in prevention of thromboembolic disease after joint arthroplasty: a meta-analysis. J Arthroplasty. 2013;28(3):410-417. doi:10.1016/j.arth.2012.08.003
10. Zhao JM, He ML, Xiao ZM, Li TS, Wu H, Jiang H. Different types of intermittent pneumatic compression devices for preventing venous thromboembolism in patients after total hip replacement. Cochrane Database Syst Rev. 2014;(12):CD009543. doi:10.1002/14651858.CD009543.pub3
11. Kapadia BH, Pivec R, Issa K, Mont MA, American College of Chest Physicians, American Academy of Orthopedic Surgeons. Prevention and management of venous thromboembolic disease following lower extremity total joint arthroplasty. Surg Technol Int. 2012;22:251-259.
12. Jauregui JJ, Kapadia BH, Banerjee S, Cherian JJ, Mont MA, Chakravarty R. Prevention and management of venous thromboembolic disease following lower extremity total joint arthroplasty. Surg Technol Int. 2014;24:283-287.
13. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013;95(19):1801-1811. doi:10.2106/JBJS.L.01328
14. Kakkos SK, Warwick D, Nicolaides AN, Stansby GP, Tsolakis IA. Combined (mechanical and pharmacological) modalities for the prevention of venous thromboembolism in joint replacement surgery. J Bone Joint Surg Br. 2012;94(6):729-734. doi:10.1302/0301-620X.94B6.28128
15. Pierce TP, Cherian JJ, Jauregui JJ, Elmallah RK, Lieberman JR, Mont MA. A Current Review of Mechanical Compression and Its Role in Venous Thromboembolic Prophylaxis in Total Knee and Total Hip Arthroplasty. J Arthroplasty. 2015;30(12):2279-2284. doi:10.1016/j.arth.2015.05.045
16. Pierce TP, Elmallah RK, Jauregui JJ, Cherian JJ, Mont MA. What’s New in Venous Thromboembolic Prophylaxis Following Total Knee and Total Hip Arthroplasty? An Update. Surg Technol Int. 2015;26:234-237.
17. Chughtai M, Newman JM, Solow M, et al. Mechanical Prophylaxis after Lower Extremity Total Joint Arthroplasty: A Review. Surg Technol Int. 2017;31:253-262.
18. Segon YS, Summey RD, Slawski B, Kaatz S. Surgical venous thromboembolism prophylaxis: clinical practice update. Hosp Pract 1995. 2020;48(5):248-257. doi:10.1080/21548331.2020.1788893
19. Giuliano KK, Pozzar R, Hatch C. Thromboprophylaxis After Hospitalization for Joint Replacement Surgery. J Healthc Qual Off Publ Natl Assoc Healthc Qual. 2019;41(6):384-391. doi:10.1097/JHQ.0000000000000204
20. Nam D, Nunley RM, Johnson SR, Keeney JA, Clohisy JC, Barrack RL. The Effectiveness of a Risk Stratification Protocol for Thromboembolism Prophylaxis After Hip and Knee Arthroplasty. J Arthroplasty. 2016;31(6):1299-1306. doi:10.1016/j.arth.2015.12.007
21. Bito S, Miyata S, Migita K, et al. Mechanical prophylaxis is a heparin-independent risk for anti-platelet factor 4/heparin antibody formation after orthopedic surgery. Blood. 2016;127(8):1036-1043. doi:10.1182/blood-2015-06-651620
22. Westrich GH, Dlott JS, Cushner FD, Johanson NA, Ruel AV. Prophylaxis for thromboembolic disease and evaluation for thrombophilia. Instr Course Lect. 2014;63:409-419.
23. Barco S, Bingisser R, Colucci G, et al. Enoxaparin for primary thromboprophylaxis in ambulatory patients with coronavirus disease-2019 (the OVID study): a structured summary of a study protocol for a randomized controlled trial. Trials. 2020;21(1):770. doi:10.1186/s13063-020-04678-4
24. Lombardi AV, Barrington JW, Berend KR, et al. Outpatient Arthroplasty is Here Now. Instr Course Lect. 2016;65:531-546.
25. Colwell CW, Froimson MI, Anseth SD, et al. A mobile compression device for thrombosis prevention in hip and knee arthroplasty. J Bone Joint Surg Am. 2014;96(3):177-183. doi:10.2106/JBJS.L.01031
26. Nutescu EA, Bautista A, Gao W, et al. Warfarin anticoagulation after total hip or total knee replacement: clinical and resource-utilization outcomes in a university-based antithrombosis clinic. Am J Health-Syst Pharm AJHP Off J Am Soc Health-Syst Pharm. 2013;70(5):423-430. doi:10.2146/ajhp120341
27. Müller S, Wilke T, Pfannkuche M, et al. [Patient pathways in thrombosis prophylaxis after hip and knee replacement surgery : results of a survey]. Orthopade. 2011;40(7):585-590. doi:10.1007/s00132-011-1741-6
28. Bonutti PM, Sodhi N, Patel YH, et al. Novel venous thromboembolic disease (VTED) prophylaxis for total knee arthroplasty-aspirin and fish oil. Ann Transl Med. 2017;5(Suppl 3):S30. doi:10.21037/atm.2017.11.22