Suhail Amin, Mohsin Javid, Plamen Kinov, William Jiranek.
Response/Recommendation: Pneumatic compression devices have been demonstrated to be effective prophylaxis against venous thromboembolism (VTE) following hip/knee arthroplasty when used concurrently with chemoprophylaxis. In the absence of evidence to the contrary, we support the use of pneumatic compression devices for VTE prophylaxis following ambulatory hip and knee arthroplasty as per standard the American Academy of Orthopeadic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) guidelines.
Strength of Recommendation: Limited.
Rationale: Considering the serious consequences of VTE, arthroplasty surgeons are sensitive to the need for VTE thromboprophylaxis1. Clinical practice guidelines generally recommend either pharmacologic and/or mechanical VTE prophylaxis. Pharmacologic options include anticoagulation agents such as low-molecular-weight heparin (LMWH), warfarin, new oral anticoagulants, and aspirin (ASA). The issue with the administration of anticoagulation is the associated bleeding risk with some of the agents. The focus in VTE prevention after total knee arthroplasty (TKA) and total hip arthroplasty (THA) is shifting away from the use of high-risk medications towards ASA and mechanical prophylaxis in an effort to minimize symptomatic bleeding and wound-related complications. Despite advantages, controversy remains regarding the efficacy of pneumatic compression devices in preventing VTE2. The patient population with the greatest consensus for the use of mechanical prophylaxis with intermittent pneumatic compression devices (IPCD) are those patients at high risk for bleeding3–5, due to well documented decreased risk of major bleeding and surgical site bleeding associated with IPCD6–8.
Evidence in Total Knee Arthroplasty (TKA): Numerous studies have supported the use of pneumatic compression devices (including ambulatory devices) after undergoing hip and knee arthroplasty6,9–15. According to the AAOS16 and the ACCP, pneumatic compression devices are effective against VTE after TKA as a part of multimodal VTE prophylaxis protocol4,10. Arsoy et al., reported no difference in the VTE rates in a cohort of patients receiving mobile compression devices and ASA compared with patients receiving LMWH, except that bleeding events and related complications were significantly lower in the compression device group (p = 0.015)17.
Evidence in Total Hip Arthroplasty (THA): According to the AAOS and ACCP, there is less evidence for the effectiveness of mechanical prophylaxis after THA. Nonetheless, Colwell et al.,6 in a multicenter randomized controlled trial (RCT) compared IPCD against enoxaparin and found IPCD to be just as effective as enoxaparin in preventing proximal and distal deep venous thrombosis and pulmonary embolism events, with a significantly lower bleeding risk (1.3 % IPCD vs 4.3 % LMWH). In over 400 patients, they found a significant decrease in major bleeding events in the mobile compression group (0%) compared with the LMWH group (6%) after THA (p = 0.0004). The symptomatic VTE rates using mechanical compression alone have been reported at 0.92%, in a series of patients with obesity undergoing THA18. In addition, in one RCT prolonged outpatient use of pneumatic compression devices further decreased the incidence of VTE compared to isolated inpatient use only19.
In addition, IPCD have been shown to be effective in Asian population undergoing TKA and THA12,15. The prophylactic efficacy of IPCD against VTE, when used in combination with chemoprophylaxis, has been demonstrated in many other studies20–22.
In a systemic review Pavon et al., identified 14 eligible RCT (2,633 subjects) and 3 eligible observational studies (1,724 subjects). IPCD were comparable to anticoagulation agents for major clinical outcomes (VTE: risk ratio, 1.39; 95% confidence interval, 0.73-2.64). Limited data suggest that concurrent use of anticoagulation with IPCD may lower VTE risk compared with anticoagulation alone and that IPCD alone compared with anticoagulation may lower major bleeding risk2.
The use of IPCD alone or with ASA after lower extremity arthroplasty has shown similar VTE rates to more potent chemoprophylaxis in standard-risk patients. The use of a risk stratifying protocol with ASA/LMWH and portable pneumatic compression pumps as part of a multimodal VTE prophylaxis protocol resulted in a very low rate of symptomatic VTE events in patients undergoing outpatient primary TKA11. Higher DVT risk was observed in “high-risk patients” such as those with a prior history of VTE, active cancer, or others. As IPCD continue to evolve, it is important to consider the most appropriate prophylaxis while maximizing compliance. The proposed duration for the use of IPCD is >18-20 hours a day, and with different periods of postoperative use – in hospital, for 10 days, and up to 20 days. Several studies show concerns with compliance, with many patients stopping the use of these devices upon discharge from hospital11,23.
1. Budhiparama NC, Abdel MP, Ifran NN, Parratte S. Venous Thromboembolism (VTE) Prophylaxis for Hip and Knee Arthroplasty: Changing Trends. Curr Rev Musculoskelet Med. 2014;7(2):108-116. doi:10.1007/s12178-014-9207-1
2. Pavon JM, Adam SS, Razouki ZA, et al. Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-Risk Surgical Patients: A Systematic Review. J Arthroplasty. 2016;31(2):524-532. doi:10.1016/j.arth.2015.09.043
3. 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
4. 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
5. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S-e277S. doi:10.1378/chest.11-2297
6. 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
7. Pitto RP, Hamer H, Heiss-Dunlop W, Kuehle J. Mechanical prophylaxis of deep-vein thrombosis after total hip replacement a randomised clinical trial. J Bone Joint Surg Br. 2004;86(5):639-642. doi:10.1302/0301-620x.86b5.14763
8. Warwick D, Harrison J, Whitehouse S, Mitchelmore A, Thornton M. A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement. J Bone Joint Surg Br. 2002;84(3):344-350. doi:10.1302/0301-620x.84b3.12372
9. Brookenthal KR, Freedman KB, Lotke PA, Fitzgerald RH, Lonner JH. A meta-analysis of thromboembolic prophylaxis in total knee arthroplasty. J Arthroplasty. 2001;16(3):293-300. doi:10.1054/arth.2001.21499
10. Freedman KB, Brookenthal KR, Fitzgerald RH, Williams S, Lonner JH. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am. 2000;82-A(7):929-938. doi:10.2106/00004623-200007000-00004
11. Crawford DA, Andrews RL, Morris MJ, Hurst JM, Lombardi AV, Berend KR. Ambulatory Portable Pneumatic Compression Device as Part of a Multimodal Aspirin-Based Approach in Prevention of Venous Thromboembolism in Outpatient Total Knee Arthroplasty. Arthroplasty Today. 2020;6(3):378-380. doi:10.1016/j.artd.2020.05.007
12. Liew NC, Alemany GV, Angchaisuksiri P, et al. Asian venous thromboembolism guidelines: updated recommendations for the prevention of venous thromboembolism. Int Angiol J Int Union Angiol. 2017;36(1):1-20. doi:10.23736/S0392-9590.16.03765-2
13. 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
14. Macaulay W, Westrich G, Sharrock N, et al. Effect of pneumatic compression on fibrinolysis after total hip arthroplasty. Clin Orthop. 2002;(399):168-176. doi:10.1097/00003086-200206000-00020
15. Chin PL, Amin MS, Yang KY, Yeo SJ, Lo NN. Thromboembolic prophylaxis for total knee arthroplasty in Asian patients: a randomised controlled trial. J Orthop Surg Hong Kong. 2009;17(1):1-5. doi:10.1177/230949900901700101
16. 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
17. 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
18. Haynes J, Nam D, Barrack RL. Obesity in total hip arthroplasty: does it make a difference? Bone Jt J. 2017;99-B(1 Supple A):31-36. doi:10.1302/0301-620X.99B1.BJJ-2016-0346.R1
19. Snyder MA, Sympson AN, Scheuerman CM, Gregg JL, Hussain LR. Efficacy in Deep Vein Thrombosis Prevention With Extended Mechanical Compression Device Therapy and Prophylactic Aspirin Following Total Knee Arthroplasty: A Randomized Control Trial. J Arthroplasty. 2017;32(5):1478-1482. doi:10.1016/j.arth.2016.12.027
20. Kwong LM, Luu A. DVT prophylaxis strategies following total joint arthroplasty. Semin Arthroplasty. 2016;27(1):15-20. doi:10.1053/j.sart.2016.06.027
21. Kwak HS, Cho JH, Kim JT, Yoo JJ, Kim HJ. Intermittent Pneumatic Compression for the Prevention of Venous Thromboembolism after Total Hip Arthroplasty. Clin Orthop Surg. 2017;9(1):37-42. doi:10.4055/cios.2017.9.1.37
22. Westrich GH, Menezes A, Sharrock N, Sculco TP. Thromboembolic disease prophylaxis in total knee arthroplasty using intraoperative heparin and postoperative pneumatic foot compression. J Arthroplasty. 1999;14(6):651-656. doi:10.1016/s0883-5403(99)90217-6
23. 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