Alejandro Gonzalez Della Valle, Christian B. Ong, Eduardo A. Salvati, Paul Lachiewicz.
Response/Recommendation: Elastic compression stocking may provide some protection against thromboembolic disease.
Strength of Recommendation: Moderate.
Rationale: Mechanical means can be used alone or in conjunction with other modalities, including anticoagulation agents, to prevent venous thromboembolism (VTE). Mechanical thromboprophylaxis includes rapid postoperative mobilization and ambulation, intermittent pneumatic compression (IPC), and the use of graduated compression stockings (GCS), which apply varying amounts of pressure to different parts of the leg.
There is controversy regarding the efficacy of GCS to prevent VTE following orthopaedic procedures, with studies reporting conflicting results. A prospective trial of 440 Asian patients undergoing total knee arthroplasty (TKA), randomized patients to receiving no prophylaxis, GCS, IPC, or low-molecular-weight heparin (LMWH). A significantly lower rate of deep venous thrombosis (DVT) was observed for patients receiving IPC (8%, p=0.032) or enoxaparin (6%, p=0.001). Patients using GCS had a lower rate of asymptomatic DVT (13%) in comparison to the control group (22%); however, the difference was not statistically significant1. This observation suggested that the use of GCS may provide some protection against DVT in comparison to receiving no thromboprophylaxis, however, the effect is likely to be substantially lower than that provided by anticoagulants and IPC.
Camporese et al., evaluated the combined incidence of asymptomatic proximal DVT, symptomatic VTE, and all-cause mortality in 1,761 adult patients undergoing knee arthroscopy. Patients were randomly assigned to wear GCS for 7 days (660 patients), or to receive a once-daily subcutaneous injection of LMWH for 7 days (657 patients) or 14 days (444 patients). The 3-month cumulative incidence of asymptomatic proximal DVT, symptomatic VTE, and all-cause mortality was 3.2% (21 of 660) in the GCS group, 0.9% (6 of 657 patients) in the 7-day LMWH group (p=0.005), and 0.9% (4 of 444 patients) in the 14-day LMWH group2.
As chemoprophylaxis appears to be more protective against DVT than GCS, the use of GCS in patients who are concomitantly receiving anticoagulation prophylaxis may not be necessary. Cohen et al., conducted a prospective, randomized study in 795 patients undergoing elective and emergency hip arthroplasty, and hip fracture fixation; to determine whether the addition of GCS to fondaparinux conferred any additional benefit. Fondaparinux was given post-operatively for 5 to 9 days, either alone (400 patients) or combined with GCS (395 patients). GCS were worn for an average of 42 days. The prevalence of asymptomatic DVT was similar in the two groups (5.5 and 4.8% respectively, p=0.69)3. In another systematic review, Milinis et al., recently reported no additional reduction in the rate of DVT when comparing patients who underwent orthopaedic or abdominal surgery and received anticoagulation with and without GCS4.
Similarly, as IPC has shown to provide efficacious prophylaxis, the concomitant use of GCS in patients using IPC may not provide additional protection. In a comparative study of 846 consecutive patients undergoing total hip arthroplasty (THA) or TKA, Pitto et al., reported that those who used GCS and IPC had a similar rate of DVT and pulmonary embolism (PE) to those who only used IPC5.
There is a lack of large, randomized control trials (RCT) evaluating the efficacy of GCS for the prevention of DVT in patients undergoing orthopaedic surgery; with some studies being likely underpowered1 or using GCS in conjunction with other mechanical methods or different chemoprophylactic agents. These factors diminish the ability to determine if GCS should be prescribed postoperatively. In order to overcome these limitations, some investigators have recently conducted systematic reviews. Lin et al., compared the efficacy and safety of chemoprophylaxis with and without the use of GCS in patients undergoing hip surgery. Three studies published between 1989 and 2007 were included in the systematic review. Chemoprophylaxis included dextran, fondaparinux, and LMWH. There were 478 patients using a combination of chemoprophylaxis and GCS, and 779 using only chemoprophylaxis. A significantly lower rate of distal DVT was observed in the combinational group (Odds ratio [OR] 0.46, p=0.03). The combination group exhibited similar rates of proximal DVT and PE in relation to the group using chemoprophylaxis alone (OR 0.66, p=0.13; and OR 0.91, p=0.86, respectively)6. However, it may be argued that this study included a limited number of patients, some of which received obsolete chemoprophylaxis.
More recently, Sachdeva et al., conducted a systematic review to evaluate the effectiveness of GCS for the prevention of DVT in hospitalized medical and surgical patients. Twenty RCT encompassing 1,681 individual patients and 1,172 individual legs were included. Six of the 20 randomized trials included patients undergoing orthopaedic surgery. GCS were applied on the day before surgery or on the day of surgery and were worn until discharge or until the participants were fully mobile. Duration of follow-up ranged from 7 to 14 days. When all specialties were considered, the GCS group had a significantly lower risk of distal DVT (9%) and proximal DVT (1%) in comparison to the control group (without GCS) (21% and 5%, respectively) (p<0.001 and p<0.001, respectively). The authors concluded that there is high-quality evidence that GCS are effective in reducing the risk of DVT in hospitalized patients who underwent general and orthopaedic surgery, with or without other methods of thromboprophylaxis. There was moderate-quality evidence that GCS reduced the risk of proximal DVT, and low-quality evidence that GCS may reduce the risk of PE7. These results confirmed what was proposed by the authors in a prior systematic review8.
In summary, GCS may be used alone or in combination with other forms of thromboprophylaxis. The protective effect is likely to be additive and may be lower when used concomitantly with chemoprophylaxis or IPC.
References:
1. 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
2. Camporese G, Bernardi E, Prandoni P, et al. Low-molecular-weight heparin versus compression stockings for thromboprophylaxis after knee arthroscopy: a randomized trial. Ann Intern Med. 2008;149(2):73-82. doi:10.7326/0003-4819-149-2-200807150-00003
3. Cohen AT, Skinner JA, Warwick D, Brenkel I. The use of graduated compression stockings in association with fondaparinux in surgery of the hip. A multicentre, multinational, randomised, open-label, parallel-group comparative study. J Bone Joint Surg Br. 2007;89(7):887-892. doi:10.1302/0301-620X.89B7.18556
4. Milinis K, Shalhoub J, Coupland AP, Salciccioli JD, Thapar A, Davies AH. The effectiveness of graduated compression stockings for prevention of venous thromboembolism in orthopedic and abdominal surgery patients requiring extended pharmacologic thromboprophylaxis. J Vasc Surg Venous Lymphat Disord. 2018;6(6):766-777.e2. doi:10.1016/j.jvsv.2018.05.020
5. Pitto RP, Young S. Foot pumps without graduated compression stockings for prevention of deep-vein thrombosis in total joint replacement: efficacy, safety and patient compliance. A comparative, prospective clinical trial. Int Orthop. 2008;32(3):331-336. doi:10.1007/s00264-007-0326-9
6. Lin F-F, Lin C-H, Chen B, Zheng K. Combination prophylaxis versus pharmacologic prophylaxis alone for preventing deep vein thrombosis in hip surgery. Hip Int. 2016;26(6):561-566. doi:10.5301/hipint.5000384
7. Sachdeva A, Dalton M, Lees T. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2018;11:CD001484. doi:10.1002/14651858.CD001484.pub4
8. Sachdeva A, Dalton M, Amaragiri SV, Lees T. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2014;(12):CD001484. doi:10.1002/14651858.CD001484.pub3