F. S. Santori, A. Vitullo, M. Stopponi, N. Santori
S.PIETRO FATEBENEFRATELLI HOSPITAL, ROME
J Bone Joint Surg (Br) 1994
| DEEP VEIN THROMBOSIS PROPHYLAXIS IN TOTAL HIP ARTHROPLASTY
F. S. Santori, A. Vitullo, M. Stopponi, N. Santori |
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| One of the most worrying complications of total hip arthroplasty is lower limb deep vein thrombosis (DVT). Pharmacological prophylaxis is frequently used, but is associated with a number of problems and its efficacy is limited. Mechanical prophylaxis, by intermittent plantar venous compression with the A-V Impulse System appears an interesting alternative. | This randomised controlled study involves 132 patients who underwent total hip replacement surgery. Following surgery all patients used elastic stockings with 67 being treated with the intermittent plantar pump, and 65 with calcic heparin. DVT screening was by Doppler ultrasound and thermography, followed by phlebography. The incidence of DVT was 23 (35.4%) in the heparin group with 16 major and 7 minor thromboses, compared to 9 (13.4%) in the pumped group with 3 major and 6 minor thromboses. The differences for all DVT and major DVT were both significant (p < 0.005). The heparin group had one pulmonary embolism (PE) death and 9 cases of excessive bleeding or wound haematoma complications. |
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| THE USE OF INTERMITTENT PLANTAR VENOUS IMPULSE COMPRESSION TO REDUCE POST-OPERATIVE DEEP VENOUS THROMBOSIS A Randomised Prospective Trial
J. G. Bradley, H. Jaeger, G. Kruegener
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| The purpose of this study was to investigate the effectiveness of intermittent pneumatic compression of the plantar venous plexus with the newly developed A-V Impulse System. Seventy-four patients about to undergo primary unilateral total hip arthroplasty for osteoarthrosis, all receiving a standard thrombosis prophylaxis regime of thigh-length antiembolic stockings, 5,000 IU heparin delivered subcutaneously twice daily, and 400 mg hydroxychloroquine sulphate delivered twice daily, were entered in a prospective trial. | The patients were allocated at random to also receive the A-V Impulse System on the foot of the operated side. On approximately postoperative day 12 bilateral ascending venography was performed. There were 44 patients in the non-pumped group and 30 patients in the pumped group. The incidence of deep venous thrombosis was 6.6% in the pumped group and 27.27% in the non-pumped group.The incidence of thrombosis was significantly lower in the pumped group (p< 0.025). The authors conclude that chemical prophylaxis plus the use of the A-V Impulse System reduces the incidence of thromboembolic complications further than chemical prophylaxis alone. |
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| A VENOUS FOOT PUMP REDUCES THROMBOSIS AFTER TOTAL HIP REPLACEMENT
M. J. F. Fordyce, R. S. M. Ling |
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| In a prospective, randomised controlled trial, the efficacy of the A-V Impulse System in the prevention of deep vein thrombosis was investigated in 84 patients who had undergone total hip replacement. The incidence of venographically proven, and clinically significant postoperative deep vein thrombosis was 40% in the control group and 5% in the treatment group (p<0.001). No adverse reactions were recorded. |  |
| THROMBO-EMBOLIC PROPHYLAXIS IN TOTAL KNEE REPLACEMENT Evaluation of the A -V Impulse System |
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| We performed a prospective randomised controlled trial of a new mechanical method of prophylaxis for venous thromboembolism in 60 patients undergoing knee replacement surgery. The method uses the A-V Impulse System to produce cyclical compression of the venous reservoir of the foot. The overall incidence of deep-vein thrombosis was 68.7% in patients receiving no prophylaxis and 50% in those using the device. The difference was not significant. There was, however, a reduction of the extent of thrombosis in the treated group. |  |
| There were 13 major calf-vein thrombi and six proximal-vein thrombi in the control group compared with only five major calf-vein thrombi in the treated group. This difference was significant (p = 0.014). No patient developed clinical features of a pulmonary embolism. | |
| THE PREVENTION OF DEEP VEIN THROMBOSIS AND REDUCTION OF POST-OPERATIVE SWELLING FOLLOWING SURGERY FOR FRACTURES OF THE NECK OF FEMUR A Study Using the A-V Impulse System to Stimulate the Physiological Venous Foot Pump |
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Deep vein thrombosis after surgery for fractures of the hip remains a substantial problem, with no ideal method of prophylaxis. In seeking for alternative methods we assessed the effectiveness of a simple mechanical technique in a prospective, randomised, controlled study of 82 patients. All patients underwent hemi-arthroplasty for subcapital fractures of the neck of femur.
Swelling also contributes to morbidity and as a secondary objective we evaluated the relative contributions resulting from immobility and from trauma and surgery. We also investigated the effectiveness of the mechanical device in reducing this swelling. In the control group there was an incidence of 23% proximal deep vein thrombosis compared with 0% in the treatment group (p<0.01) as assessed by Doppler ultrasound. Both immobility and trauma contributed to leg swelling and the device produced a substantial reduction in this swelling. In the treatment group there was a mean reduction of swelling in the thigh of 32.7cm (p<0.001) and 1.55cm in the calf (p<0.001) at seven to ten days post-operatively. |
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| PNEUMATIC PLANTAR COMPRESSION VERSUS LOW MOLECULAR WEIGHT HEPARIN IN THE PREVENTION OF DEEP VEIN THROMBOSIS TOTAL HIP REPLACEMENT
D Warwick, J Harrison |
| There is good evidence from clinical trials that low molecular weight heparins (LMWH) are the most effective form of thromboprophylaxis after hip replacement surgery. Despite this many orthopaedic surgeons are reluctant to use them because of perceived haemorrhagic risks. A device has been developed which intermittently compress a venous plexus in the foot. This device appears to significantly reduce the venographic rate of deep vein thrombosis (DVT).
Purpose of the Study. To compare the safety and efficacy of Enoxaparin (Rhone Poulenc Rorer, Eastbourne, UK) and the A-V Impulse Foot Pump (Novamedix, Andover, UK). Materials and Methods. 223 consecutive primary total hip replacement patients were randomised to receive either: Enoxaparin 40mg daily for 7 days - starting 12 hours pre-operatively, or the foot Pump for 7 days - starting post-operatively and worn whenever the patients was not walking. Patients were blindly assessed for DVT by venography between the 6th and 10th post-operative day. Patients were also assessed for operative blood loss, drain loss, transfusion requirement, soft tissue bruising, wound site ooze and thigh swelling. |
Results. 201 patients completed to venography, 95 patients in the Enoxaparin group
and 106 in the Foot Pump group.
There were no significant differences in known risk factors between the two groups. There was no statistical difference between groups with respect to blood loss, drain volume, haemoglobin drop or transfusion requirements. There was a small reduction in thigh swelling in favour of the foot Pump group (20mm vs. l0mm). There was a higher incidence of wound oozing in the Enoxaparin group, but no significant difference in haematoma formation. Whilst bruising was more common in the Enoxaparin group, the clinical significance of this is unclear. After three months follow-up two patients (one from each group) have been re-admitted for proven DVT. Conclusion. Both Enoxaparin and the A-V Impulse Foot Pump provide safe and extremely effective prophylaxis against deep vein thrombosis. The pneumatic plantar compression device represents an important advance, it is as effective as LMWH but produces fewer soft tissue side-effects such as bruising, oozing and thigh swelling. |
| THROMBO-EMBOLIC PROPHYLAXIS FOLLOWING HIP FRACTURE USING A FOOT PUMP
M. F. Gargan, J. Lawrence, H. Thomas, H. Trundle, J. C. T. Fairbank |
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| Ninety-two patients attending the John Radcliffe Hospital, Oxford between July 1990 and June 1992 following femoral neck fracture were entered into the trial, having given informed consent. A table of random numbers was used to allocate the patients into two groups, with the details being held in sealed envelopes in the Accident Department.
Those patients randomised to the A-V Impulse System group had the device fitted to the affected limb and were pumped continuously (except during their operation and when mobilising). |
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Ascending ipsilateral venography was performed between 7 and 10 days post-operatively. Each venogram was independently assessed by two radiologists 'blind' to the group patient. All patients with femoral neck fracture requiring internal fixation were included. Proximal DVT was reduced from 15.2% to 5.9% and all thromboembolic complications were reduced from 54.6% to 23.5%. There was a reduction in fatal pulmonary emboli (6.8% compared with 0%) and 6 month mortality (18.2% compared with 6.3%).
This small study demonstrates that the A-V Impulse System is effective in reducing the incidence of deep vein thrombosis in patients following fixation of fractured neck of femur. There is also a trend to lower the incidence of fatal pulmonary embolism and the six-month mortality, although statistical significance is not achieved. |
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