Colin Baker, Clifford Colwell.
Response/Recommendation: Intermittent compression devices (ICD) provide protection against venous thromboembolism (VTE) development following orthopaedic surgery. Utilizing these devices has been shown to be an effective prophylactic measure.
Strength of Recommendation: Moderate.
Rationale: ICD protects against the development of VTE following orthopaedic surgery primarily by decreasing venous stasis, a contributing factor to thrombus formation. Current guidelines support the use of mechanical prophylaxis for patients undergoing orthopaedic procedures1,2. Variability among devices and a lack of strong evidence to support individual modalities makes it difficult to agree upon specific recommendations. Below-knee portable ICD that synchronize cuff contraction to venous phasic flow signal may be superior to other mechanical modalities3,4. Avoidance of complications associated with anticoagulation is a major advantage of ICD use. However, similar to chemoprophylactic regimens, compliance remains a concern. Some modalities allow for providers to monitor device use during hospitalization and after discharge, which may foster improved patient adherence5.
A retrospective database review of revision arthroplasty patients compared the use of aspirin (ASA) and ICD to warfarin and ICD. The ASA group had symptomatic pulmonary embolism (PE) and deep venous thrombosis (DVT) rates of 0.2% and 0.4%, respectively, compared to 0.9% for both in the warfarin group. Additionally, the warfarin group showed a significantly higher rate of major bleeding compared to the ASA group6. In a retrospective review of a prospectively designed VTE prophylaxis protocol, 856 consecutive primary and revision total knee arthroplasty (TKA) patients received ASA with circumferential knee-high compression devices. Each patient was evaluated for DVT via duplex ultrasonography prior to discharge and assessed for symptomatic VTE during a 90-day follow-up. Sixty-six thrombi were seen, nine patients had symptomatic DVT, and three patients developed symptomatic non-fatal PE7. The authors found that the incidence of both asymptomatic and symptomatic DVT in their study was comparable to that of using anticoagulative agents. Results from these studies support the concomitant use of mechanical compression and ASA for VTE prophylaxis, with a decreased risk of bleeding compared to anticoagulant chemoprophylaxis regimens.
The majority of studies evaluating mechanical compression device use in orthopaedic patients focus on lower extremity arthroplasty. However, some studies have assessed their use in non-arthroplasty procedures8–10. A prospective study reported VTE rates of 1% and 7% in patients using ICD alone following cervical discectomy with fusion and cervical decompression, respectively. These rates are similar to rates seen using common anticoagulants as prophylaxis10. A similar study of patients who underwent lumbar laminectomy with instrument fusion led the author to conclude that ICD use was sufficient for VTE prophylaxis while also lowering risks, such as hematoma, that are seen with chemoprophylaxis9. In a prospective trial, 1,803 German patients undergoing various orthopaedic procedures were randomized to receive a chemoprophylactic regimen including low-molecular-weight heparin (LMWH) alone or the chemoprophylactic regimen with ICD. The procedures consisted of arthroplasty (24%), knee soft tissue repair (19%), open fracture fixation (21%), tumor resection (6%), and other (28%). The ICD augmented group had a DVT rate of 0.44% compared to 1.66% with chemoprophylaxis alone, which was a statistically significant difference. Furthermore, the ICD group demonstrated a significantly lower DVT rate in total hip arthroplasty (THA) and TKA than the chemoprophylaxis group8. All three studies commented on the decreased bleeding risk associated with ICD use. Although there is a need for more studies evaluating their use in non-arthroplasty procedures, the previously mentioned studies suggest that compression devices may lower DVT and PE rates following various orthopaedic procedures.
Some orthopaedic surgeons feel that the adoption of contemporary surgical techniques and peri-operative management make it possible to use ICD as monoprophylaxis. A randomized trial comparing the use of a portable ICD to LMWH with respect to major bleeding and efficacy following THA evaluated 392 patients. The device allowed patient mobilization and continued utilization following discharge. The PE and symptomatic DVT rates were 5% in both the mobile ICD group and the LMWH group. However, a significant difference was detected between the portable compression device group (0%) and the LMWH group (6%) with regard to bleeding events11. Limitations of the study are that it was powered to detect a difference in bleeding rates and not the incidence of symptomatic VTE. Additionally, 61% of the ICD group also used ASA as part of their prophylactic regimen. Colwell et al.5, conducted a large multicenter study evaluating the use of a mobile ICD, with or without ASA, in preventing VTE. In this non-inferiority designed study, 3,060 patients who underwent either primary TKA or THA used an ICD perioperatively for a minimum of 10 days. Symptomatic VTE occurred in 28 patients, with a rate of 0.5% and 1.3% in patients who had THA and TKA, respectively. The results demonstrated non-inferior efficacy in the prevention of VTE compared with the most commonly used pharmacological protocols, with the exception of rivaroxaban use in TKA. ICD use missed the pre-determined 1% non-inferiority margin by 0.06% in rivaroxaban in TKA. The authors recommend that surgeons consider the use of this mobile compression device, with or without ASA, as an alternative to pharmacological prophylaxis in patients treated with lower-extremity arthroplasty. Findings from these studies support the augmentation of ASA with mechanical compression, particularly in patients undergoing lower extremity arthroplasty. Additionally, patients using ICD experienced significantly less major bleeding, with similar rates of VTE events, compared to patients receiving chemoprophylaxis with LMWH.
A prospective trial of 440 Asian patients undergoing TKA randomized patients to receiving no prophylaxis (control group), ICD, graded compression stockings (GCS), or LMWH. The rate of DVT was significantly lower in the ICD group in comparison to the control group. The LMWH group also showed a statistically lower DVT rate. However, patients using GCS did not demonstrate statistically significant lower DVT rates12. This study suggests the use of ICD is superior to no thromboprophylaxis at protecting against DVT while showing similar efficacy to LMWH in TKA patients.
In summary, ICD effectively reduce VTE following orthopaedic surgery to the corresponding levels of appropriate chemoprophylaxis. Additionally, ICD are shown to have increased safety with regard to bleeding complications compared to commonly used anticoagulant agents.
1. Mont MA, Jacobs JJ, Boggio LN, et al. Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty: American Academy of Orthopaedic Surgeon. 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. 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. The Journal of Arthroplasty. 2015;30(12):2279-2284. doi:10.1016/j.arth.2015.05.045
4. Froimson MI, Murray TG, Fazekas AF. Venous Thromboembolic Disease Reduction With a Portable Pneumatic Compression Device. The Journal of Arthroplasty. 2009;24(2):310-316. doi:10.1016/j.arth.2007.10.030
5. Colwell CW, Froimson MI, Anseth SD, et al. A Mobile Compression Device for Thrombosis Prevention in Hip and Knee Arthroplasty. Journal of Bone and Joint Surgery. 2014;96(3):177-183. doi:10.2106/JBJS.L.01031
6. Deirmengian GK, Heller S, Smith EB, Maltenfort M, Chen AF, Parvizi J. Aspirin Can Be Used as Prophylaxis for Prevention of Venous Thromboembolism After Revision Hip and Knee Arthroplasty. The Journal of Arthroplasty. 2016;31(10):2237-2240. doi:10.1016/j.arth.2016.03.031
7. Lachiewicz PF, Soileau ES. Mechanical Calf Compression and Aspirin Prophylaxis for Total Knee Arthroplasty. Clinical Orthopaedics.:4.
8. Eisele R, Kinzl L, Koelsch T. Rapid-Inflation Intermittent Pneumatic Compression for Prevention of Deep Venous Thrombosis: The Journal of Bone & Joint Surgery. 2007;89(5):1050-1056. doi:10.2106/JBJS.E.00434
9. Epstein NE. Efficacy of Pneumatic Compression Stocking Prophylaxis in the Prevention of Deep Venous Thrombosis and Pulmonary Embolism Following 139 Lumbar Laminectomies With Instrumented Fusions. Journal of Spinal Disorders & Techniques. 2006;19(1):28-31. doi:10.1097/01.bsd.0000173454.71657.02
10. Epstein NE. Intermittent Pneumatic Compression Stocking Prophylaxis Against Deep Venous Thrombosis in Anterior Cervical Spinal Surgery: A Prospective Efficacy Study in 200 Patients and Literature Review. Spine. 2005;30(22):2538-2543. doi:10.1097/01.brs.0000186318.80139.40
11. Colwell CW, Froimson MI, Mont MA, et al. Thrombosis Prevention After Total Hip Arthroplasty: A Prospective, Randomized Trial Comparing a Mobile Compression Device with Low-Molecular-Weight Heparin. The Journal of Bone and Joint Surgery-American Volume. 2010;92(3):527-535. doi:10.2106/JBJS.I.00047
12. Chin P, Amin M, Yang K, Yeo S, Lo N. 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