PLAN 1) Introduction Compression Stockings, HOT or NOT? 2) Current guidelines in VTE prophylaxis after THA 3) What about GCS? Literature review The use of Graduated Compression Stockings after THA : Tradition or Evidence-Based Medicine ? 4) Conclusion Dr Sophie MERCIER (PG – UCL) Dr Xavier MOREL (PG – ULB) CHEMICAL VTE MECHANICAL VTE PROPHYLAXIS PROPHYLAXIS • Low Molecular Weight Heparin (LMWH) • Unfractionated Heparin (UFH) • Intermittent Pneumatic Compression • Fondaparinux Device (IPCD) • Vitamin K Antagonists (VKA) • Mobilization • Direct-Acting Oral Anticoagulants (DOAC) • Venous Foot Pump (VFP) - Factor Xa inhibitor - Thrombin inhibitor • Graduated Compression Stockings (GCS) • Aspirin FOCUS ON GCS FOCUS ON GCS : CONS • Optimal pressure gradient : • Contraindicated when peripheral arterial insufficiency, severe cardiac insufficiency - 18 mmHg at the ankle and ulceration of the lower limb - 14 mmHg at the calf • Risk of impairment in tissue oxygenation - 8 mmHg at the knee ▷ 98% of stockings failed to produce this gradient • Risk of skin complication • Existence of a “reversed gradient” : higher incidence • Lack of compliance (uncomfortable, of DVT! difficult to use) • Must be sized and fitted properly • Costly • No statistical difference between below-knee or above-knee stockings Shalhoub J, et al. Graduated Compression Stockings as an Adjunct to Low Dose Low Molecular Weight Best AJ, Williams S, Crozier A, Bhatt R, Gregg PJ, et al . Graded compression stockings in elective orthopaedic surgery. An assessment of the in vivo performance of commercially available Heparin in Venous Thromboembolism Prevention in Surgery: A Multicentre Randomised Controlled stockings in patients having hip and knee arthroplasty. J Bone Joint Surg Br 2000; 82: 116-118. Trial, European Journal of Vascular and Endovascular Surgery (2017) 1
CURRENT GUIDELINES : VTE PROPHYLAXIS ACCP GUIDELINES AFTER THA • Use of one of the following for a minimum of 10 to 14 days rather than • American College of Chest Physicians ( ACCP ) 2012 no anti- thrombotic prophylaxis: low-molecular-weight heparin • National Institute for Health and Care Excellence ( NICE ) 2018 (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin (LDUH), adjusted-dose VKA, aspirin (all Grade • Scottish Intercollegiate Guidelines Network ( SIGN ) 2010 – 2015 1B) , or an intermittent pneumatic compression device (IPCD) (Grade 1C) • In patients undergoing major orthopedic surgery, we suggest using dual • American Academy of Orthopaedic Surgeons ( AAOS ) 2011 prophylaxis with an antithrombotic agent and an IPCD during the hospital stay (Grade 2C) • In patients undergoing major orthopedic surgery and increased risk of bleeding, we suggest using an IPCD or no prophylaxis rather than pharmacologic treatment Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombolic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-325S. NICE GUIDELINES SIGN GUIDELINES • LMWH (for 10 days) followed by aspirin (75 or 150 mg) for a further • Patients undergoing THA or TKA surgery should receive 28 days. pharmacological prophylaxis (with LMWH, fondaparinux, rivaroxaban or dabigatran) combined with mechanical prophylaxis • LMWH (for 28 days) combined with anti-embolism stockings (until unless contraindicated (GRADE A) discharge). • Patients with increased risk of bleeding should be given • Rivaroxaban mechanical prophylaxis alone (GRADE C) NICE . Venous thromboembolism: reducing the risk: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. London: National Institute for Health and Clinical Excellence; 2010. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of venous thromboembolism. SIGN publication no. 122. Edinburgh: SIGN; 2010. AAOS GUIDELINES CHALLENGING THE GUIDELINES… • Patients with no other VTE or bleeding risk than the surgery : Chemical • ACCP does not mention the use of GCS and/or compressive devices (Moderate) • NICE recommends the use of GCS + LMWH, though none of the • Patients with previous VTE history : Chemical and compressive devices reviewed studies included the comparison between LMWH alone vs (Consensus) LMWH + GCS • Patients with a known bleeding disorder (e.g., hemophilia) and/or • SIGN recommends the use of IPCD or VFP active liver disease : Compressive devices alone (Consensus) • AAOS does not specify the type of mechanical device recommended Lack of evidence/support regarding the use of GCS Unit ACPG ed . AAOS clinical guideline on preventing venous thrombo- embolic disease in patients undergoing elective hip and knee arthroplasty. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011. Whittaker L, Baglin T, Vuylsteke A . Challenging the evidence for graduated compression stockings. BMJ 2013;346:f3653 2
WHAT ABOUT GCS? LITERATURE REVIEW 1) GCS for prevention of DVT after hip and knee replacement (1996) • Features : 2) The use of GCS in association with fondaparinux in surgery of the hip (2007) - Prospective, randomised controlled-trial (RCT) 3) Value of GCS in Prevention of VTE after THA and TKA (2013) - n = 177 (THA = 64) 4) Traditions and myths in hip and knee arthroplasty (2014) - 2 groups : GCS vs no prophylaxis • Conclusions : 5) Combination prophylaxis versus pharmacologic prophylaxis alone for - GCS are ineffective as a DVT prophylaxis in THA patients preventing DVT in hip surgery (2016) - Use of GCS is based on weak scientific and clinical evidence 6) Thromboembolism prophylaxis in orthopaedics : an update (2018) - Higher proportion of patients developed DVT when wearing the 7) DVT in orthopaedic surgery (2018) stockings (p = 0.03 with below-knee stockings) 8) Prevention of VTE in adult orthopaedic surgical patients (2018) Hui AC, Heras-Palou C, Dunn I, et al. Graded compression stockings for prevention of deep-vein thrombosis after hip and knee replacement. J Bone Joint Surg [Br] 1996;78-B:550-4 • Features : • Features : - Retrospective study, over 18 months - Multicentre, multinational, randomised, open–label comparative study - 2 groups : Enoxaparin + GCS (n = 480 THA) vs Enoxaparin (n = 368 THA) - Single-blind - 2 groups : fondaparinux (n = 400) vs fondaparinux + GCS (n = 395) • DVT prevalence : • DVT prevalence : - 0.47% (group I) vs 0.81% (groupe II) - 5.5% in group I vs 4.8% in group II • Conclusions : • Conclusions : - No obvious benefit of GCS in the prevention of VTE after THA in the - The addition of GCS does not appear to improve the effectiveness of VTE prophylaxis with fondaparinux presence of Enoxaparin prophylaxis • Negative sides : THA + HFS patients Majeed H, Szypryt EP (2013) Value of Graduated Compression Stockings in Prevention of Venous Thromboembolism after Total Hip and Knee Arthroplasty. Cohen AT. The use of graduated compression stockings in association with fondaparinux in surgery of the hip. A multicentre, multinational, randomised, open-label, parallel-group J Gen Pract 1: 116. doi: 10.4172/2329-9126.1000116 comparative study. J Bone Joint Surg Br 2007; 89: 887-92. Traditions and myths in hip and knee arthroplasty : a narrative review • Features : • Features : - Narrative review - Meta-analysis of VTE prophylaxis in hip surgery • Conclusion : - 3 high-quality studies (though one of them as Dextran as VTE prophylaxis) - There is no evidence to recommend the use of GCS after THA or TKA • Results : - Excluding the Fredin’s 1989 study (Dextran), combinated pharmacologic + GCS did not reduce the risk of distal DVT. - It is not necessary to combined the use of GCS if we use the current recommended prophylaxis Husted H, Gromov K, et al. Traditions and myths in hip and knee arthroplasty. A narrative review. Acta Orthopaedica 2014; 85 (6): 548-555 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 3
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