Tara G. Moncman, Alexander C. Top, Brian S. Winters, Charles Deltour, Jan F. Noyez.
Response/Recommendation: The use of a foot pump is as effective as a lower extremity intermittent compression device when used in combination with chemical prophylaxis.
Strength of Recommendation: Moderate.
Rationale: Deep venous thrombosis (DVT) is a prevalent early complication after lower extremity surgery and extended periods of immobilization1-3. Accurate prevention of these events is therefore of substantial importance following orthopaedic surgery to the lower limb. The foot pump is a recognized method of venous thromboembolism (VTE) prophylaxis after orthopaedic surgery4. The foot-sole pump works similarly to the lower extremity intermittent compression device (ICD), in that it simulates active weight-bearing in the bed-ridden patient through sudden and intermittent increases in venous flow. Overall, the foot pump has been shown to maintain venous circulation as well as normal ambulation4-6.
Various randomized control trials (RCT) have evaluated the effectiveness of the foot pump against DVT and pulmonary embolism (PE) after orthopaedic procedures. Although a significant effect is often reported4,7-10, there were limitations in many of these studies, including small sample sizes4,7-9 and a lack of power analysis4,7-11. In addition, DVT and PE were diagnosed by postoperative duplex ultrasonography, ascending venography, or perfusion scintigraphy regardless of symptoms, which likely overestimates the number of events4,7-8,10-12.
A number of studies have shown that the foot pump is not effective as monotherapy against VTE8,11-15. For example, a single large retrospective review of 1,659 primary total hip arthroplasty (THA) surgeries found the foot-sole pump alone to be less effective at preventing DVT15. Patients using only the foot pump had a significantly greater incidence of DVT (9.5%) compared to those who received combined mechanical and chemical prophylaxis (fondiparinux 0.7%, enoxaparin 0.0%).
However, combined prophylaxis consisting of both a foot pump and chemoprophylaxis is consistently reported to significantly lower the risk of DVT in comparison to the administration of chemoprophylaxis alone after orthopaedic procedures8,11,13,15-18. An RCT by Sakai et al., evaluated the effectiveness of the foot pump in 120 patients given edoxaban after total knee arthroplasty (TKA)13. The incidence of DVT was significantly reduced with combined prophylaxis of the foot pump with edoxaban (31.0%) compared to the control group with edoxaban alone (17.7%).
A small number of studies directly compared the foot pump to the lower extremity ICD. Although a single study did find the ICD to be preferred to the foot pump in combined mechanical and chemical VTE prophylaxis5, most studies report no significant differences between the two pump15,17-21. A comparative study of 121 patients evaluated the efficacy of the lower extremity ICD and foot pump by comparing pre-and postoperative D-dimer values following THA20. At seven days postoperative, the mean D-dimer value was significantly reduced for both pumps (< 10 μg/ml), whereas in patients using no pump it was significantly more elevated (16.5 μg/ml)20. Although promising results, there’s limited data on the correlation between actual clinical cases of DVT and the D-dimer value, undermining the strength of these findings22. A non-randomized controlled trial by Spain et al., compared the incidence DVT in 184 high-risk patients with lower extremity fractures using the foot pump or another lower extremity ICD21. Incidence of DVT (7% ICD; 3% foot pump) and PE (2 foot pump; 1 ICD) were similar between groups.
Interestingly, the foot-sole pump may have greater compliance and patient satisfaction than other lower extremity ICD11-12. The popular reasons for inpatient non-compliance include heat/sweating, discomfort, and sleep disturbance5,11-12,23-25. Since compliance to a lower extremity ICD is generally low and appliances are often placed incorrectly, a smaller, simpler device like the foot pump may be a user-friendlier and better-tolerated choice24,26-27.
To conclude, only few studies compared the foot-sole pump with other ICD and none of these mechanical means of VTE prophylaxis proved to be superior to one another.
However, patient compliance and user-friendliness are probably better with a foot-sole pump. A systematic review and meta-analysis of six RCT found that a lower extremity ICD combined with chemical prophylaxis decreases the risk of DVT after TKA and THA compared to chemical prophylaxis alone28. Likewise, the current guidelines from the American College of Chest Physicians recommend combining chemical antithrombotic agents with ICD during a patient’s hospital stay28. Based on the current evidence, similar conclusions can be drawn in regard to the use of a foot pump. Therefore, the foot pump is as effective as other types of lower extremity ICD, when used in combination with chemical prophylaxis.
- Imberti D, Bianchi C, Zambon A, Parodi A, Merlino L, Gallerani M, et al. Venous thromboembolism after major orthopaedic surgery: a population-based cohort study. Intern Emerg Med. 2012 Jun;7(3):243-9.
- Leizorovicz A, Turpie AG, Cohen AT, Wong L, Yoo MC, Dans A. SMART Study Group. Epidemiology of venous thromboembolism in Asian patients undergoing major orthopedic surgery without thromboprophylaxis. The SMART study. J Thromb Haemost. 2005 Jan;3(1):28-34.
- Choi BY, Huo MH. Venous thromboembolism following total knee replacement. J Surg Orthop Adv. 2007;16:31-35.
- Fordyce M, Ling RS. A venous foot pump reduces thrombosis after total hip replacement. J Bone Joint Surg Br. 1992 Jan;74(1):45-9.
- Westrich GH. Thromboembolic Disease Prophylaxis in Orthopaedic Surgery: Use of Mechanical Compression Devices. Techniques in Orthopaedics. 2004;19(4):283-292.
- Gardner AMN, Fox RH. The venous foot pump: influence on tissue perfusion and prevention of venous thrombosis. Am Rheum Dis. 1992;51:1173-1178.
- Wilson NV, Das SK, Kakkar VV, Maurice HD, Smibert JG, Thomas EM, et al. Thromboembolic prophylaxis in total knee replacement: evaluation of the A-V Impulse system. J Bone Joint Surg Br. 1992 Jan;74(1):50-2.
- Bradley JG, Krugener GH, Jager HJ. The effectiveness of intermittent plantar venous compression in prevention of deep venous thrombosis after total hip arthroplasty. J Arthroplasty. 1993 Feb;8:57-61.
- Asano H, Matsubara M, Suzuki K, Morita S, Shinomiya K. Prevention of pulmonary embolism by a foot sole pump. The Journal of Bone and Joint Surgery. 2001 Nov;83(8):1130–1132.
- Santori FS, Vitullo A, Stopponi M, Santori N, Ghera S. Prophylaxis against deep-vein thrombosis in total hip replacement. Comparison of heparin and foot impulse pump. J Bone Joint Surg Br. 1994 Jul;76(4):579-83.
- Warwick D, Harrison J, Glew D, Mitchelmore A, Peters TJ, Donovan J. Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. A prospective, randomized trial. J Bone Joint Surg Am. 1998 Aug;80(8):1158-66.
- Pitto RP, Hamer H, Heiss-Dunlop W, Kuehle J. Mechanical prophylaxis of deep-vein thrombosis after total hip replacement. The Journal of Bone and Joint Surgery Br. 2004 Jul;86(5):639–642.
- Sakai T, Izumi M, Kumagai K, Kidera K, Yamaguchi T, Asahara T, et al. Effects of a Foot Pump on the Incidence of Deep Vein Thrombosis After Total Knee Arthroplasty in Patients Given Edoxaban: A Randomized Controlled Study. Medicine. 2016 Jan;95(1):e2247.
- Blanchard J, Meuwly JY, Leyvraz PF, Miron MJ, Bounameaux H, Hoffmeyer P, et al. Prevention of deep-vein thrombosis after total knee replacement. Randomised comparison between a low-molecular-weight heparin (nandroparin) and mechanical prophylaxis with a foot-pump system. J Bone Joint Surg Br. 1999 Jul;81:654-659.
- Ishibe M, Kariya S. Deep venous thrombosis after mini-posterior total hip arthroplasty in Japanese patients. Hip International. 2011 Nov-Dec;21(6): 684–687.
- Haas SB, Insall JN, Scuderi GR, Windsor RE, Ghelman B. Pneumatic sequential-compression boots compared to aspirin prophylaxis of deep venous thrombosis after total knee arthroplasty. J Bone Joint Surg. 1990 Jan;72:27-31.
- Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty. Pneumatic plantar compression and aspirin compared with aspirin alone. J Bone Joint Surg Am. 1996 Jun;78(6):826-34.
- Westrich GH, Bottner F, Windsor RE, Laskin RS, Haas SB Sculco TP. Aspirin plus Vena-Flow vs. lovenox plus VenaFlow for deep venous thrombosis. J Arthroplasty. 2006 Sep;21(6):139-43.
- Ilgenfritz FM, Meier JR. Venous velocity increase with a pneumatic foot compression garment. Angiology. 1994 Nov;45(11):949-52.
- Motoyuki F, Naito M, Asayama I, Kambe T, Koga K. Effect of calf-thigh intermittent pneumatic compression device after total hip arthroplasty: comparative analysis with plantar compression on the effectiveness of reducing thrombogenesis and leg swelling. J Orthop Sci. 2003; 8(6):807–811.
- Spain DA, Bergamini, Hoffman JF, Carrillo EH, Richardson JD. Comparison of sequential compression devices and foot pumps for prophylaxis of deep venous thrombosis in high-risk trauma patients. Am Surg. 1998 Jun;64(6):522-526.
- Cofrancesco E, Cortellaro M, Corradi A, Ravasi F, Bertocchi F. Coagulation activationmarkers in the prediction of venous thrombosis after electivehip surgery. Thromb Haemost. 1997 Feb;77:267–9.
- Robertson KA, Bertot AJ, Wolfe MW, Barrack RL. Patient compliance and satisfaction with mechanical devices for preventing deep venous thrombosis after joint replacement. J South Orthop Assoc. 2000;9(3):182-6.
- Chan JC, Roche S, Lenehan B, O’Sullivan M, Kaar K. Compliance and satisfaction with foot compression devices: an orthopaedic perspective. Arch Orthop Trauma Surg. 2007 Sept;127(7):567.
- Sanjeev A, Asamu T. Patient acceptance of a foot pump device used for thromboprophylaxis. Acta Orthop Belg. 2007 Jun;73(3):386-389.
- JO Anglen, Goss K, Edwards J, Huckfeldt RE. Foot pump prophylaxis for deep venous thrombosis: the rate of effective usage in trauma patients. Am J Orthop. 1998 Aug;27(8):580-2.
- Dietz MJ, Ray JJ, Witten BG, Frye BM, Klein AE, Lindsey BA. Portable compression devices in total joint arthroplasty: poor outpatient compliance. Arthroplast Today. 2020 Mar;6(1):118-122.
- Sobieraj DM, Coleman CI, Tongbram V, Chen W, Colby J, et al. Comparative Effectiveness of Combined Pharmacologic and Mechanical Thromboprophylaxis versus Either Method Alone in Major Orthopedic Surgery: A Systematic Review and Meta-analysis. Pharmacotherapy. 2013 Mar;33(3):275–283.