A review of thigh-length vs knee-length antiembolism stockings

The effectiveness of graduated compression stockings for prevention of venous thromboembolism in orthopedic and abdominal surgery patients requiring extended pharmacologic thromboprophylaxis

OBJECTIVE

There is an increasing evidence base to support the use of extended pharmacologic thromboprophylaxis in selected surgical patients to prevent venous thromboembolism (VTE). The benefit of graduated compression stockings (GCS) in addition to extended pharmacologic thromboprophylaxis is unclear. The aim of this study was to systematically review the evidence relating to the effectiveness of using GCS in conjunction with extended pharmacologic thromboprophylaxis to prevent VTE in surgical patients.

METHODS

A literature search of MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in April 2017. The review protocol was published on PROSPERO (CRD42017062655). Randomized controlled trials (RCTs) were eligible if one of the study arms included patients receiving extended pharmacologic thromboprophylaxis alone (>21 days) or in conjunction with GCS. Data on deep venous thrombosis (DVT), pulmonary embolism (PE), and VTE-related death were compiled. Pooled proportions of the VTE rates were determined using random-effects meta-analysis.

RESULTS

The systematic search identified 1291 studies, of which 19 studies were eligible for inclusion. No RCT directly compared extended pharmacologic thromboprophylaxis alone with GCS plus extended pharmacologic thromboprophylaxis. A total of 9824 patients from 16 RCTs were treated with extended pharmacologic thromboprophylaxis, of whom 0.81% (95% confidence interval [CI], 0.5-1.20) were diagnosed with symptomatic DVT and 0.2% (95% CI, 0.12-0.36) with PE. Three trials included 337 patients who received extended pharmacologic thromboprophylaxis in conjunction with GCS. In this group, 1.61% (95% CI, 0.03-5.43) had symptomatic DVT with no reported PE. Similar VTE rates were observed when studies in orthopedic and abdominal surgery were analyzed separately.

CONCLUSIONS

There is insufficient evidence to recommend GCS in conjunction with extended pharmacologic prophylaxis to prevent VTE in patients undergoing orthopedic and abdominal surgery. A clinical trial directly investigating this important subject is needed.

Postoperative quality of life, satisfaction, and skin condition after varicose vein surgery

Compression is performed postoperatively with the intention of minimising side effects, such as bleeding and haematoma in the area of operation, as well as postoperative oedema and pain. Compression stocking manufacturing has incorporated the addition of skin care products into the yarn material in recent years. However, the benefits of these products remain controversial. In addition, the length of the compression stocking is disputed in terms of its effectiveness. This effectiveness was investigated in the present study.

Before surgery, 160 patients with indication of surgical removal of varicose veins were randomly divided into four groups with different types of compression stockings in each case. In each group, 40 patients received a knee-length stocking (length A–D), thigh-length stocking (length A–G), knee-length stocking with Aloe vera or thigh-length stocking with AV. At time 0 (before surgery), one week and 8 weeks after surgery, skin moisture was measured as an objective parameter, quality of life was determined using the Freiburger questionnaire of quality of life in veinous disease (FLQA-vs), benefit to patients was evaluated using the patient benefit index (PBI-v) and further subjective parameters were investigated with a free-text questionnaire. After surgery, the extent of haematoma was determined using the point count method.

After surgery, at both post-operative times, the FLQA-vs decreased significantly (corresponding to a better quality of life), and the PBI-v increased. In the group with Aloe, pruritus was significantly lower, comfort and skin moisture were increased, and skin condition was significantly improved. The extent of haematoma decreased regardless of the length of the stockings.

A benefit of AV as a skin care additive was observed. This finding was objectively confirmed based on the skin moisture. The multifactorial quality of life was not affected by the skin care additive. Thigh-length compression stockings did not provide a measurable benefit.

A randomised clinical trial comparing the patient comfort and efficacy of three different graduated compression stockings in the prevention of postoperative deep vein thrombosis

AIMS AND OBJECTIVES

To compare the comfort levels of patients regarding the use of three different graduated compression stockings and to analyse the efficacies of the graduated compression stockings in relation to patient comfort and compliance in prevention of postoperative deep vein thrombosis.

BACKGROUND

Graduated compression stockings are very important with other prophylaxis methods in postoperative deep vein thrombosis prophylaxis. In meta-analyses and systematic review studies, it was reported that knee-length and thigh-length graduated compression stockings had similar efficacies. However, there is no randomised study in literature regarding the patient problems and levels of comfort with the use of graduated compression stockings of different sizes and pressures.

DESIGN

A randomised clinical trial design.

METHODS

A total of 219 patients were randomised into three groups (n = 73 in each group). Group I was given low-pressure, knee-length graduated compression stockings, group II was given low-pressure, thigh-length graduated compression stockings and group III was given moderate-pressure, knee-length graduated compression stockings. The level of patients comfort regarding the graduated compression stockings and occurrence of deep vein thrombosis were examined.

RESULTS

The vast majority of the patients (79·5%) in group III and 52·1% of the patients in group II stated experiencing problems during the use of the graduated compression stockings (p < 0·001). The graduated compression stockings were reported by the patients as being very comfortable in the group I (p < 0·001). No findings of thrombosis were observed in any of the groups.

CONCLUSION

The low-pressure, knee-length graduated compression stockings are as effective as the other graduated compression stockings of different pressures and sizes in the postoperative deep vein thrombosis prophylaxis, and the patients have fewer problems while using these graduated compression stockings with a high satisfaction.

RELEVANCE TO CLINICAL PRACTICE

The combined use of pharmacological, mechanical and physical methods and patient education is effective in the prevention of postoperative deep vein thrombosis. The use of low-pressure, knee-length graduated compression stockings in clinical practice may be recommended, as the patients have fewer problems while using these graduated compression stockings with a high satisfaction.

The additional benefit of graduated compression stockings to pharmacologic thromboprophylaxis in the prevention of venous thromboembolism in surgical inpatients

OBJECTIVE

The evidence base supporting the use of graduated compression stockings (GCS) for venous thromboembolism (VTE) prevention has been challenged, and there appears to be a lack of evidence for the additional benefit of GCS to pharmacologic thromboprophylaxis. This study aimed to summarize and quality assess the existing evidence concerning whether GCS offer a significant benefit in addition to pharmacologic thromboprophylaxis in surgical inpatients.

METHODS

A systematic review of published literature was performed. Inclusion criteria were (1) randomized controlled trials (RCTs), (2) surgical inpatients, (3) study arms examining prophylactic-dose pharmacologic thromboprophylaxis alone or in conjunction with GCS, and (4) outcome of VTE.

RESULTS

In the review, 1025 articles were screened, of which 27 RCTs were included. Six RCT study arms included patients with GCS in conjunction with pharmacologic thromboprophylaxis, whereas 22 RCT study arms included patients treated with pharmacologic thromboprophylaxis alone. One RCT had both of its study arms included in the systematic review. The total number of patients that received pharmacologic thromboprophylaxis alone was 12,481. Of these patients, 1292 (10.4%) suffered VTE. The total number of patients that received GCS in conjunction with pharmacologic thromboprophylaxis was 1283. Of these patients, 75 had VTE (5.8%). Heterogeneity analysis demonstrated that the results of included study arms were significantly heterogeneous, precluding a valid summation analysis.

CONCLUSIONS

The additional benefit of GCS to pharmacologic thromboprophylaxis in surgical inpatients is not clear on the basis of existing data. Further clinical trials directly evaluating this clinical question are recommended.

Clinical thromboembolic detterrent stockings application: Are thromboembolic detterrent stockings in practice matching manufacturers application guidelines

Background

Thromboembolic detterrent (TED) stockings have been shown to be effective in the reduction of thromboembolic events in post operative patients. These manufactured stockings create graduated compression from ankle to calf.

Aim

To assess whether the manufacturers' recommendations for application were being met in a District general hospital setting and whether this achieved the desired gradient of compression.

Methods

We carried out pressure measurements on 100 legs in post-operative patients and recorded reasons for poorly fitting stockings. Pressure measurements were taken at standard positions around calf and ankle using a pre-calibrated subbandage pressure measuring device.

Results

About 20% of stockings were worn incorrectly by patients. Median pressure applied at the ankle was 13 mmHg (range, 6.5–18.5) compared to the manufacturers' intended compression of 18 mmHg. Only 14% of the stockings showed an acceptable gradation of reduced pressure between ankle and calf. About 23% of the stockings exerted a positive pressure at calf level compared to the ankle.

Conclusion

Most TED stockings do not produce a standardised Siegel profile pressure gradient decrease from ankle to calf. This may be due in part to fluid changes after surgery in combination with the large variation in size of lower limbs. Our District general hospital utilises three of the six sizes of TED stocking, and remeasurement was not taking place every 24 h as per guidance. This as the result show not only negates the benefit of TED stockings but may also exert harm in terms of venous thromboembolism risk. This finding adds further weight to the argument of whether TED stockings may not be having the desired prophylactic effect and may even be resulting in harm in select cases.

Review article: Anti-embolism stockings

The National Institute for Health and Clinical Excellence (NICE) guidelines recommend combined mechanical and pharmacological prophylaxis to reduce the risk of venous thromboembolism (VTE) in patients undergoing orthopaedic surgery. There is increasing evidence that anti-embolic stockings (AES) have little effect on reducing such risk. Articles in the MEDLINE, EMBASE, and Cochrane Library were reviewed. Studies on the use of pharmacological prophylaxis recommended in the 2010 NICE guidelines including low-molecular-weight heparin, unfractionated heparin, rivaroxaban, and dabigatran with and without AES in patients undergoing orthopaedic surgery were included. A total of 1171 trauma and elective orthopaedic patients in 4 studies were included; 587 received pharmacological prophylaxis alone, and 584 received a combination of pharmacological prophylaxis and above- or belowknee AES. Of the respective patients, 44 (7.5%) and 31 (5.3%) developed deep vein thrombosis (p=0.1587) and 7 (1.2%) and 9 (1.5%) developed pulmonary embolism (p=0.8493). The overall VTE rates did not differ significantly (p=0.2864). No death from VTE was reported. Addition of AES did not confer significant benefit in terms of reducing the risk of VTE in orthopaedic patients.

Graduated compression stocking and intermittent pneumatic compression device length selection

PURPOSE

The purpose of this project was to incorporate current evidence into length selection for graduated compression stockings (GCS) and intermittent pneumatic compression (IPC) devices in order to evaluate and modify current practice.

RATIONALE

Staff nurses relate concerns regarding the fit and complications related to poorly fitting thigh length GCS and IPC devices. Current evidence supports using knee length over thigh length.

DESCRIPTION OF THE PROJECT

With the use of Melnyk and Fineout-Overholt's model of evidence-based practice and Norwood's consultation model, current practice was evaluated and practice changes were implemented based on results of a literature review.

OUTCOME

Knee length will be selected instead of thigh length in general and urology surgery patients. The department of obstetrics and gynecology has taken the practice change under consideration.

CONCLUSION

Knee-length GCS and IPC devices are as effective as thigh-length GCS and IPC devices, are more comfortable for patients, are easier for staff and patients to use, pose less risk of injury to patients, and are less expensive. Knee-length GCS and IPC devices may safely be used for general, gynecology, and urology surgery patients and are preferable to thigh-length GCS and IPC devices.

IMPLICATIONS

Venous thromboembolism prophylaxis is an important component of surgical care; proper length selection of GCS and IPC devices should be based on current evidence. This project outlines a method to change practice regarding length selection of GCS and IPC devices.

The use of graduated compression stockings in association with fondaparinux in surgery of the hip

Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit.

The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49).

The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism.

The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient.

The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone.

The Use of Knee-Length Versus Thigh-Length Compression Stockings and Sequential Compression Devices

BACKGROUND

Nurses on an Acute Care Evidence Based Practice Committee, creating a policy to increase patient compliance with thromboembolic deterrent stockings (TEDS) and sequential compression devices (SCDs) for deep vein thrombosis prophylaxis, found limited literature on patient preference and response to this treatment.

STUDY AIM

The study purpose was to determine whether knee-length or thigh-length TEDS and/or SCDs were more comfortable, correctly applied, and worn by patients, and to assess patient reasons for noncompliance.

METHOD

A patient survey and observational data tool was designed. Six surveyors collected data (interrater reliability = 93%) from 137 randomly selected patients with orders for TEDS and/or SCDs admitted to acute care medical or surgical nursing units.

RESULTS

Most patients wore thigh-length SCDs and TEDS. However, only 29.2% (n = 40) had SCDs on them at the time of survey, and 62.8% (n = 86) were compliant with TEDS. The most common reasons given for noncompliance with SCDs were that the devices were not reapplied after bathing or ambulating, or were removed because they were hot or itchy. Complaints of discomfort were highest among patients wearing thigh-length SCDs and TEDS. Problems with fit were 50% higher in those who wore thigh-length TEDS, and involved stockings that created restricting bands. Most patients understood the purpose of treatment, and older patients were more compliant than younger patients.

IMPLICATIONS FOR PRACTICE

Knee-length TEDS and SCDs are more comfortable for patients, encourage higher levels of compliance with treatment, do not pose a risk for venous stasis to patients by creating restricting bands, and are less expensive. Patients need ongoing education to resume wearing TEDS and SCDs after activities of daily living, and knee-length stockings and devices would be easier to reapply. The policy in our institution was changed for the use of knee-length compression stockings and SCDs.

Knee versus Thigh Length Graduated Compression Stockings for Prevention of Deep Venous Thrombosis: A Systematic Review

OBJECTIVE

Graduated compression stockings are a valuable means of thrombo-prophylaxis but it is unclear whether knee-length (KL) or thigh length (TL) stockings are more effective. The aim of this review was to systematically analyse randomised controlled trials that have evaluated stocking length and efficacy of thromboprophylaxis.

METHOD

A systematic review of the literature was undertaken. Clinical trials on hospitalised populations and passengers on long haul flights were selected according to specific criteria and analysed to generate summated data.

RESULTS

14 randomized control trials were analysed. Thirty six of 1568 (2.3%) participants randomised to KL stockings developed a deep venous thrombosis, compared with 79 of 1696 (5%) in the TL control/thigh length group. Substantial heterogeneity was observed amongst trials. KL stockings had a significant effect to reduce the incidence of DVT in long haul flight passengers, odds ration 0.08 (95%CI 0.03-0.22). In hospitalised patients KL stockings did not appear to be far worse than TL stockings, odds ratio 1.01 (95%CI 0.35-2.90). For combined passengers and patients, there was a benefit in favour of KL stockings, weighted odds ratio 0.45 (95% CI 0.30-0.68).

CONCLUSION

KL graduated stockings can be as effective as TL stockings for the prevention of DVT, whilst offering advantages in terms of patient compliance and cost.

Above-knee versus below-knee stockings in total knee arthroplasty

INTRODUCTION

Graduated compression stockings are frequently used following arthroplasty surgery for deep vein thrombosis (DVT) prophylaxis. There are often strongly held beliefs regarding whether below-knee or above-knee stockings should be used in total knee joint replacement. Many surgeons argue that below-knee stockings are more likely to induce wound complications because of increased swelling above the stocking and the elastic causing localised pressure on the wound.

PATIENTS AND METHODS

This study is a prospective comparison of above and below-knee stockings in patients undergoing total knee joint replacement. A total of 50 patients were recruited and studied - 23 patients in the above-knee stocking group and 24 in the below-knee group. Swelling around the knee was measured over the course of an in-patient stay, together with wound complication rates and patients' preference.

RESULTS

No statistical difference was found between the groups and no difference in wound complication rates was determined.

CONCLUSIONS

Below-knee stockings are safe following total knee replacement and are preferred by patients.

What information patients require on graduated compression stockings

Graduated compression stockings are used prophylactically on a variety of patients within acute hospitals. Anecdotal evidence suggests patients have a limited understanding of this treatment. The aim of this qualitative study was to explore patients' experiences of compression stockings and to ascertain perceptions of their use. Information was gathered using telephone interviews from a sample of 12 adults who had been patients within the past 2 months, and who had worn compression stockings for more than 48 hours. The results showed that patients received little or no information from healthcare staff regarding compression stockings, but that they did have knowledge from other sources, such as long-haul flight advice. This raises issues of informed consent and patient empowerment and highlights the need for both verbal and written information. The information gained informed a patient information leaflet, which was developed in partnership with a patient focus group.