Combined (mechanical and pharmacological) modalities for the prevention of venous thromboembolism in joint replacement surgery
ABSTRACT We performed a systematic review and meta-analysis to compare the efficacy of intermittent mechanical compression combined with pharmacological thromboprophylaxis, against either mechanical compression or pharmacological prophylaxis in preventing deep-vein thrombosis (DVT) and pulmonary embolism in patients undergoing hip or knee replacement. A total of six randomised controlled trials, evaluating a total of 1399 patients, were identified. In knee arthroplasty, the rate of DVT was reduced from 18.7% with anticoagulation alone to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03; number needed to treat: seven). There was moderate, albeit non-significant, heterogeneity (I(2) = 42%). In hip replacement, there was a non-significant reduction in DVT from 8.7% with mechanical compression alone to 7.2% with additional pharmacological prophylaxis (RR 0.84) and a significant reduction in DVT from 9.7% with anticoagulation alone to 0.9% with additional mechanical compression (RR 0.17, p < 0.001; number needed to treat: 12), with no heterogeneity (I(2) = 0%). The included studies had insufficient power to demonstrate an effect on pulmonary embolism. We conclude that the addition of intermittent mechanical leg compression augments the efficacy of anticoagulation in preventing DVT in patients undergoing both knee and hip replacement. Further research on the role of combined modalities in thromboprophylaxis in joint replacement and in other high-risk situations, such as fracture of the hip, is warranted.
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ABSTRACT: Objectives Orthopaedic trauma surgery is still associated with major complications related to reduced circulation, including thromboembolic events, oedema, deficient healing and infections. Adjuvant therapy by intermittent pneumatic compression (IPC) has recently demonstrated encouraging results and versatility. In this review, we discuss the indications, effects, mechanisms of action and the future potential of IPC. Data sources, study selection, data extraction, data synthesis We conducted a MEDLINE search on intermittent pneumatic compression, identifying 707 articles from 1970 to 2012. The emphasis was placed on recent patient-oriented level 1 literature using the strength-of-recommendation taxonomy (SORT) strength of recommendation grades. Conclusions IPC prevents deep venous thrombosis (DVT) post-surgery at an equal rate as unfractioned heparin and may be the only prophylaxis available for trauma patients at high risk of bleeding (SORT-A). Combining IPC with pharmacoprophylaxis (PT) significantly reduced the incidence of symptomatic DVT compared with PT alone (SORT-A). In patients with swelling after, e.g. foot, ankle and lower limb fractures, IPC reduces pre- and postoperative oedema leading to shortened hospital stay, improved joint mobility, pain relief and decreased incidence of skin complications (SORT-A). Recent studies on fracture and soft tissue repair concluded that IPC appears to be an effective modality for enhancing fracture and soft-tissue healing and decreasing infection rate, this should, however, be verified by large clinical studies (SORT-B). The mechanisms of action of IPC include: (1) increased venous, arterial and interstitial circulation improving the supply of oxygen, anti-thrombotic substances and growth factors, (2) alterations in cellular gene expression and (3) improved structural tissue properties. Strength-of-recommendation taxonomy A: Consistent, good-quality patient-oriented evidence B: Inconsistent or limited quality patient-oriented evidence C: Consensus, disease-oriented evidence, usual practice, expert opinion or case series03/2012; 4(1). DOI:10.1007/s12570-012-0151-5
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ABSTRACT: Venous thromboembolism (VTE) is an important complication of major orthopedic surgery (total hip arthroplasty-THA, total knee arthroplasty-TKA, hip fracture surgery-FHS) and is associated with significant morbidity and mortality. Despite this, not all patients receive an appropriate prophylaxis, often due to a disproportionate fear of bleeding complications. A challenge in the management of VTE prophylaxis is to balance the benefits of the treatment with the risk of bleeding. In this article, we review the latest guidelines recommendations regarding prevention of postoperative VTE in patients undergoing orthopedic surgery.06/2013; 8(2):189-194.
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ABSTRACT: We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (ϕ = 0.71; p = 0.019), leading to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application. Cite this article: Bone Joint J 2013;95-B:1227-31.09/2013; 95-B(9):1227-1231. DOI:10.1302/0301-620X.95B9.31162