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 immobilization^1-3. 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 ambulation^4-6.

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 reported^4,7-10, there were limitations in many of these studies, including small sample sizes^4,7-9 and a lack of power analysis^4,7-11. 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 events^4,7-8,10-12.

A number of studies have shown that the foot pump is not effective as monotherapy against VTE^8,11-15. 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 procedures^{8,11,13,15-18}. 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 pump^15,17-21. 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 ICD^11-12. The popular reasons for inpatient non-compliance include heat/sweating, discomfort, and sleep disturbance^{5,11-12,23-25}. 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 choice^24,26-27.

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.

References:

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