Clin Orthop Relat Res (2019) 477:134-144
DOI 10.1097/CORR.0000000000000459
2018 Knee Society Proceedings
Does an Elastic Compression Bandage Provide Any Benefit After
Primary TKA?
Christopher N. Matthews BS, Antonia F. Chen MD, MBA, Tanine Daryoush BA,
Richard H. Rothman MD, PhD, Mitchell G. Maltenfort PhD, William J. Hozack MD
Received: 15 January 2018 / Accepted: 30 July 2018 / Published online: 31 August 2018
Copyright © 2018 by the Association of Bone and Joint Surgeons
Abstract
Background Compression bandages often are used after
TKA to reduce swelling. However, the degree to which
they are helpful has not been well characterized.
Questions/purposes The purpose of this study was to de-
termine whether use of a compression bandage after TKA was
One of the authors (AFC) reports other from SLACK Incorporated
(Thorofare, NJ, USA), nonfinancial support from Joint Purification
Systems (Solana Beach, CA, USA), other from 3M (Maplewood, MN,
USA), personal fees from ACI Medical (Bala Cynwyd, PA, USA),
other from Myoscience (Fremont, CA, USA), other from the
American Academy of Orthopaedic Surgeons (Rosemont, IL, USA),
personal fees from DJ Orthopaedics (Vista, CA, USA), nonfinancial
support and other from the European Knee Association (Evergem,
Belgium), other from the Musculoskeletal Infection Society
(Rochester, MN, USA), other from Smith & Nephew (London, UK),
and personal fees from Stryker (Kalamazoo, MI, USA), outside the
submitted work. One of the authors (RHR) reports personal fees
from Stryker, outside the submitted work. One of the authors
(WJH) reports other from the Journal of Arthroplasty and personal
fees and other from Stryker, outside the submitted work.
Clinical Orthopaedics and Related Research® neither advocates nor
endorses the use of any treatment, drug, or device. Readers are
encouraged to always seek additional information, including FDA
approval status, of any drug or device before clinical use.
Each author certifies that his or her institution approved the hu-
man protocol for this investigation and that all investigations were
conducted in conformity with ethical principles of research.
The Rothman Institute of Orthopedics at Thomas Jefferson
University, Philadelphia, PA, USA
A. F. Chen (✉), The Rothman Institute, 925 Chestnut Street,
Philadelphia, PA 19107, USA, email: antoniachen1@gmail.com
All ICMJE Conflict of Interest Forms for authors and Clinical
Orthopaedics and Related Research® editors and board members
are on file with the publication and can be viewed on request.
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
associated with (1) less leg swelling (our primary endpoint); or
(2) secondary study endpoints, including improved ROM of
flexion and extension, lower visual analog scale (VAS) pain
scores for worst pain and pain during physical therapy just
before surgery, postoperative day (POD) 1, POD 2, and POD
28, or fewer wound complications within 90 days of surgery.
Methods A prospective, single-center, two-arm, parallel-
group randomized controlled trial was conducted on 51
patients undergoing simultaneous, bilateral, primary TKA
between February 2015 and August 2016. Patients were
excluded if they had a body mass index > 40 kg/m2, a
history of a venous thromboembolic event, an allergy to the
dressing or compression bandage, or lymphedema in one or
both legs. Participants averaged a mean age of 62 years
(range, 40-83 years). In all patients, we released the tour-
niquet after full wound closure, and we applied an Aquacel
dressing to both limbs. Patients were randomized by opa-
que envelope, and the compression bandage was applied to
the randomized limb. For each leg, study personnel not
involved in patient care measured the patients’ limb cir-
cumference (thigh, knee, and tibia), ROM, and VAS pain
scores 24 hours after surgery, 48 hours after surgery, and on
POD 28. The minimal clinically important difference for
circumference was 2 cm with a SD of 2 cm in the cir-
cumference. For VAS, it was 2 points with a SD of 2. For
ROM, it was 10° with a SD of 15. We conservatively
picked an effect size of 0.5 SD and assumed a correlation
between limbs of 0.3. This set the power level at 0.80 with
an a error of 0.05; thus, a power analysis for paired t-tests
indicated that 45 patients would be an appropriate sample
size. There were 29 patients randomized to the right leg
group and 22 patients randomized to the left leg group.
There were no differences between the limb with and
without the compression bandage preoperatively.
 Volume 477, Number 1
Results Postoperatively, there were no differences be-
tween the groups in terms of leg swelling at the thigh (POD
1: mean 6 SD = 51 6 6 with compression bandage versus
mean 6 SD = 51 6 6 without compression bandage, mean
D = - 0.14, 95% confidence interval [CI], -0.65 to 0.37], p =
0.586; POD 2: mean 6 SD = 53 6 6 with compression
bandage versus mean 6 SD = 53 6 7 without compression
bandage, mean D = -0.22, 95% CI, -0.95 to 0.51, p = 0.548;
POD 28: mean 6 SD = 47 6 6 with compression bandage
versus mean 6 SD = 47 6 6 without compression bandage,
mean D = -0.01, 95% CI, -0.39 to 0.38, p = 0.975), knee
(POD 1: mean 6 SD = 45 6 4 with compression bandage
versus mean 6 SD = 45 6 5 without compression bandage,
mean D = -0.44, 95% CI, -1.16 to 0.28, p = 0.223; POD
2: mean 6 SD = 46 6 4 with compression bandage versus
mean 6 SD = 46 6 4 without compression bandage, mean
D = -0.30, 95% CI, -0.69 to 0.10, p = 0.137; POD 28: mean
6 SD = 42 6 5 with compression bandage versus mean 6
SD = 42 6 5 without compression bandage, mean D = 0.21,
95% CI, -0.34 to 0.76, p = 0.446), and shin (POD 1: mean
6 SD = 40 6 4 with compression bandage versus mean 6
SD = 40 6 4 without compression bandage, mean
D = -0.22, 95% CI, -1.23 to 0.79, p = 0.659; POD 2: mean
6 SD = 41 6 4 with compression bandage versus mean 6
SD = 41 6 4 without compression bandage, mean
D = -0.31, 95% CI, -0.72 to 0.09, p = 0.126; POD 28: mean
6 SD = 37 6 4 with compression bandage versus mean 6
SD = 37 6 4 without compression bandage, mean
D = -0.34, 95% CI, -0.92 to 0.24, p = 0.246). There were no
differences between the groups in terms of flexion ROM
(POD 1: mean 6 SD = 56 6 25 with compression bandage
versus mean 6 SD = 58 6 22 without compression ban-
dage, mean D = -2.63, p = 0.234; POD 2: mean 6 SD = 64
6 20 with compression bandage versus mean 6 SD = 63 6
23 without compression bandage, mean D = 1.22, p =
0.534; POD 28: mean 6 SD = 101 6 20 with compression
bandage versus mean 6 SD = 102 6 20 without com-
pression bandage, mean D = -1.64, p = 0.103) and exten-
sion (POD 1: mean 6 SD = 12 6 7 with compression
bandage versus mean 6 SD = 12 6 7 without compression
bandage, mean D = 0.51, p = 0.328; POD 2: mean 6 SD = 9
6 5 with compression bandage versus mean 6 SD = 10 6
6 without compression bandage, mean D = -1.28, p =
0.061; POD 28: mean 6 SD = 6 6 14 with compression
bandage versus mean 6 SD = 4 6 4 without compression
bandage, mean D = 2.19, p = 0.252). With the numbers
available, we observed greater maximal postoperative pain
for the limb with the compression bandage than the control
limb on POD 1 and POD 2, but not on POD 28 (POD 1:
mean 6 SD = 8 6 3 with compression bandage versus
mean 6 SD = 7 6 3 without compression bandage, mean
D = 0.66, p = 0.030; POD 2: mean 6 SD = 7 6 2 with
compression bandage versus mean 6 SD = 7 6 3 without
compression bandage, mean D = 0.80, p = 0.008; POD 28:
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Compression Bandage After Primary TKA 135
mean 6 SD = 4 6 3 with compression bandage versus
mean 6 SD = 3 6 3 without compression bandage, mean
D = 0.14, p = 0.526). Likewise, there was greater pain
during physical therapy for the limb with the compression
bandage than the limb without on POD 2, but not on POD 1
and POD 28 (POD 1: mean 6 SD = 7 6 3 with com-
pression bandage versus mean 6 SD = 6 6 3 without
compression bandage, mean D = 0.29, p = 0.460; POD 2:
mean 6 SD = 8 6 2 with compression bandage versus
mean 6 SD = 7 6 3 without compression bandage, mean
D = 0.67, p = 0.018; POD 28: mean 6 SD = 5 6 2 with
compression bandage versus mean 6 SD = 5 6 3 without
compression bandage, mean D = 0.14, p = 0.600). With the
numbers available, we observed no difference in 90-day
wound healing complications between the limb with and
the limb without the compression dressing; however, the
sample size was too small to analyze this in a meaningful
statistical way. Overall, there were 6% total wound com-
plications in the compression bandage group and 12%
total wound complications in the group without the
compression bandage (odds ratio [OR], 0.47; p = 0.487).
Drainage was not observed in the group with the com-
pression bandage, whereas the group without the com-
pression bandage had 6% drainage (OR, 0.00; p = 0.243).
There were no deep infections or reoperations within
90 days postoperatively.
Conclusions Applying a compression bandage after TKA
did not result in any clinical improvement in limb cir-
cumference, ROM, or pain. Based on this study, we believe
that applying a compression bandage after TKA neither
benefits nor harms the patient. Thus, we no longer use
compression dressings for routine primary TKA.
Level of Evidence Level I, therapeutic study.
Introduction
The use of compression bandages is common after TKA.
These bandages apply external pressure on the knee,
thereby reducing intraarticular and extraarticular accumu-
lation of blood and limb swelling [7, 9]. Less leg swelling
may enhance recovery by reducing pain and increasing
ROM [3]. However, a prospective randomized study has
shown no difference in blood loss, blood transfusion
requirements, pain, or swelling when comparing the use
of a modified Robert Jones compression dressing with a
standard dressing [10]. Another randomized controlled
trial has shown that compression bandages reduced pain
when high-volume local infiltration analgesia was used [1].
Although the potential advantages of compression ban-
dages are reduced swelling as well as subsequent enhanced
recovery and a reduced complication rate, the evidence has
been inconclusive. The potential disadvantages of these
bandages are additional cost and discomfort in knee
 136 Matthews et al. Clinical Orthopaedics and Related Research®

flexion > 45° as a result of the nonelastic properties of the
dressing [8].
Currently, at our institution, it is up to the discretion of
the surgeon whether to utilize a compression bandage
after TKA. The compression bandage under investigation
in this study is commonly referred to as an ace bandage
and can be described as a large, 6-inch elastic bandage
used to create localized pressure. This is the standard
compression bandage used at our institution. The litera-
ture does not adequately address the use of a compression
bandage of this type compared with that of no bandage
when releasing the tourniquet after wound closure as a
result of variation in bandage type and methodology of
application.
We therefore sought to determine whether use of a
compression bandage after TKA was associated with (1)
less leg swelling (our primary endpoint); or (2) secondary
study endpoints, including improved ROM of flexion and
extension, lower visual analog scale (VAS) pain scores for
worst pain and pain during physical therapy just before
surgery, postoperative day (POD) 1, POD 2, and POD 28,
or fewer wound complications within 90 days of surgery.
The null hypothesis is that there will be no difference be-
tween the groups.
Patients and Methods
We conducted a prospective, single-center, two-arm,
parallel-group randomized controlled trial (RCT), in
which we enrolled 57 patients undergoing simultaneous
bilateral primary TKA between February 2015 and August
2016. The specific flow of patients from enrollment to
analysis has been outlined (Fig. 1). The study proposal was
approved by our institutional review board and registered
at clinicaltrials.gov (ID number: NCT03521869). Each
patient served as his or her own control with one limb
receiving an elastic compression bandage (Sterile Matrix
Elastic Bandage; Medline Industries, Inc, Mundelein, IL,
USA) over an Aquacel Surgical dressing (AQUACEL® Ag
Surgical; ConvaTec Inc, Greensboro, NC, USA) and the
other limb only receiving an Aquacel Surgical dressing.
Ages of eligible participants ranged between 40 and 83
years with a mean age of 62 years. Patients were excluded if
they had a body mass index > 40 kg/m2, a previous venous
thromboembolic event, or lymphedema in one or both legs.
In addition, patients undergoing unicondylar
arthroplasty, a surgical approach other than a medial par-
apatellar approach, and TKA resulting from posttraumatic
arthritis were not included. Patients allergic to the Aquacel

Fig. 1 This figure displays a flow diagram of patients through the various stages of the study.
Superscript numbers correlate to superscripts in Table 1. R = right; L = left.

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 477, Number 1
dressing or compression bandages were not included.
Three adult reconstruction surgeons performed the sur-
geries (AFC, RHR, WJH) at a single academic institution.
The left knee was always operated on first, and the same
team did one knee followed by the subsequent knee. The
closure technique and sequence were the same for all cases,
ending with dressing with Aquacel for 1 week followed by
application of a compression dressing unilaterally as the
study variable.
We completed randomization on the day of surgery to
select which limb would get the compression bandage and
which one would not. Allocation order was created using an
Excel random number generator (Excel 2013; Microsoft,
Redmond, WA, USA) following simple randomization
procedures. Sequentially numbered sealed envelopes were
opened consecutively irrespective of the surgeon just before
compression bandage application. Separate individuals
performed the random allocation sequence (CR), patient
recruitment and enrollment (TD), opening of randomization
envelopes, and assessment of outcomes (CNM). The fol-
lowing individuals were blinded: research recruiter (TD),
outcome assessor (CNM), and statistician (MGM). How-
ever, it was impossible to blind the patient, operating room
staff, and surgeons as a result of the obvious appearance and
physical sensation of the compression bandage.
Aquacel dressing was applied to both limbs after closure
with the compression bandage then applied to the ran-
domized limb just around the knee according to a standard
protocol. Both bandaging techniques are approved and
used routinely at our institution. The compression bandage
was removed the morning of POD 1.
Components of perioperative care such as prophylactic
antibiotics, surgical technique, knee implant fixation,
thromboembolism prophylaxis, pain management pro-
tocol, postoperative rehabilitation, and followup intervals
were similar for all patients. Preoperatively, patients re-
ceived oral acetaminophen (975 mg), celecoxib (400 mg),
and pregabalin (75 mg) within 2 hours of surgery. Surgeon
discretion was maintained regarding implant model and
manufacturer used; however, all patients received a
cemented, posterior-stabilized prosthesis with patellar
resurfacing. Surgical drains were not used. Of critical im-
portance to this study, the tourniquet was not released be-
fore full wound closure. Postoperatively, standing doses of
oral acetaminophen (650 mg) every 6 hours, pregabalin
(75 mg) every 12 hours, and intravenous ketorolac (30 mg)
were administered. Oral narcotics for residual break-
through pain included oxycodone (10 mg) and tramadol
(50 mg). Thromboembolism prophylaxis of aspirin (81 mg
or 325 mg) or warfarin (target international normalized
ratio, 1.5-2.0) was administered. Thirty-eight patients
(75%) received tranexamic acid (20 mg/kg); however, 13
patients (25%) were not cleared to receive it by anesthesia.
All patients were mobilized on the day of surgery.
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Compression Bandage After Primary TKA 137
Just before surgery, as well as 24 6 4 hours after sur-
gery, 48 6 4 hours after surgery, and on POD 28 6 7 days,
an individual not involved with care (CNM) measured all
patients for the following: circumference of each leg, ROM
on each leg, and VAS pain scores for each leg. With a tape
measure, we measured thigh circumference (10 cm above
the proximal pole of the patella); knee circumference (at the
center of the patella); and shin circumference (10 cm below
the distal pole of the patella). We used a goniometer to
measure the ROM of both knees (the superior arm aligned
with the greater trochanter of the femur, the axis aligned
with the middle of the patella, and the inferior arm
aligned with the lateral malleolus) (see Appendix,
Supplemental Digital Content 1). VAS pain scores
included the worst pain in the past 24 hours and pain
during physical therapy using a VAS scale of 0 (no pain) to
100 mm (worst pain possible). Patients were instructed to
indicate their pain levels by marking an X on the scale,
which we then measured with a ruler (for the VAS pain
questionnaire, see Appendix, Supplemental Digital
Content 2). Wound healing was assessed by
retrospectively reviewing patient medical charts, phone
records, and visits within 90 days after surgery. Wound
complications recorded were erythema, drainage, and the
type of drainage classified as serous or bloody.
Review of the literature [1, 3, 8, 10] indicated that the
minimal clinically important difference (MCID) for cir-
cumference was 2 cm with a SD of 2 cm in the circum-
ference. For VAS, it was 2 points with a SD of 2. For ROM,
it was 10° with a SD of 15. We conservatively picked an
effect size of 0.5 SD and assumed a correlation between
limbs of 0.3. This set the power level at 0.80 with an a error
of 0.05; thus, a power analysis for paired t-tests indicated
that 45 patients would be an appropriate sample size.
For the statistical analysis, we used R software 3.5 (R
Foundation for Statistical Computing, Vienna, Austria) on
51 patients. We utilized a paired t-test to compare the
measurements for the limb that received the compression
bandage and the limb that did not at each time interval
separately for circumference, ROM, VAS worst pain, and
VAS pain during physical therapy. We used a linear mixed
model to compare the measurements for the limb that re-
ceived the compression bandage and the limb that did not
for each participant across time. Each outcome (circum-
ference, ROM, VAS worst pain, and VAS pain during
physical therapy) had time in days, randomization of the
compression bandage, and preoperative measurement as
predictors. We performed a Fisher’s exact test to determine
the difference between wound complications among the
groups. Probability values < 0.05 were considered statis-
tically significant.
Although 57 patients undergoing bilateral TKA con-
sented to participate, 51 patients received the intervention
and were included in the statistical analyses. This included
 138 Matthews et al. Clinical Orthopaedics and Related Research®

Table 1. Considerations for consented patient exclusion

Patient factor n = 57 Considerations
Declined to participate further before 1 Voluntary dropout
induction of anesthesia2
Adductor canal block3 1 Deviation from perioperative protocol
Aquacel allergy1 1 Positive exclusion criteria
Decreased pulse postoperatively4 1 R popliteal to R tibial artery bypass
surgery POD 0
GI hemorrhage postoperatively5 1 Hypotension and ICU admission
Subchondral fracture POD 15 1 Surgical intervention required
Total (%) 6 (11)
Superscript numbers correlate to superscripts in Figure 1; GI = gastrointestinal; R = right; ICU = intensive care unit; POD =
postoperative day.

29 patients randomized to receive the compression ban- addition, there were no differences preoperatively between
dage on the right leg and 22 patients randomized to receive the limb with and without the compression bandage in
the compression bandage on the left leg. Patients were terms of circumference, ROM, or pain (Table 3).
excluded for a variety of reasons ranging from voluntary
drop, allergy to the dressing, to surgery during their post-
operative stay (Table 1). Results
There was no difference between the limb with and
without the compression bandage regarding demographics, Limb Circumference
comorbidities, and operative time, because each patient
served as his or her own matched pair (Table 2). In We found no difference at any time point in circumference
measurements between the limbs treated with a compres-
sion bandage and those not so treated. Specifically, there
Table 2. Patient demographics
were no differences between the groups in terms of leg
Demographics Description swelling at the thigh (POD 1: mean 6 SD = 51 6 6 with
Study participants (number) 51 compression bandage versus mean 6 SD = 51 6 6 without
Randomization right leg 29 compression bandage, mean D = -0.14, 95% confidence
Randomization left leg 22 interval [CI], -0.65 to 0.37, p = 0.586; POD 2: mean 6
Sex SD = 53 6 6 with compression bandage versus mean 6
Male 23 SD = 53 6 7 without compression bandage, mean
D = -0.22, 95% CI, -0.95 to 0.51, p = 0.548; POD 28: mean
Female 28
6 SD = 47 6 6 with compression bandage versus mean 6
Ethnicity
SD = 47 6 6 without compression bandage, mean
White 29
D = -0.01, 95% CI, -0.39 to 0.38, p = 0.975; adjusted mean
Black 18 D = -0.31, 95% CI, -0.81 to 0.18, p = 0.219), at the knee
Hispanic 2 (POD 1: mean 6 SD = 45 6 4 with compression bandage
Asian 1 versus mean 6 SD = 45 6 5 without compression bandage,
Other 1 mean D = -0.44, 95% CI, -1.16 to 0.28, p = 0.223; POD
Age 62 6 9 (40–83) 2: mean 6 SD = 46 6 4 with compression bandage versus
Mean 6 SD (years; range) mean 6 SD = 46 6 4 without compression bandage, mean
BMI 30 6 5.0 (20–40) D = -0.30, 95% CI, -0.69 to 0.10, p = 0.137; POD 28: mean
Mean 6 SD (kg/m2; range) 6 SD = 42 6 5 with compression bandage versus mean 6
AACCI 3 6 1 (1-7) SD = 42 6 5 without compression bandage, mean D = 0.21,
95% CI, -0.34 to 0.76, p = 0.446; adjusted mean D = -0.14,
Mean 6 SD (range)
95% CI, -0.55 to 0.27, p = 0.509), and at the shin (POD 1:
Surgery duration 144 6 35 (62–226)
mean 6 SD = 40 6 4 with compression bandage versus
(mean [minutes] 6 SD; range)
mean 6 SD = 40 6 4 without compression bandage, mean
BMI = body mass index; AACCI = age-adjusted Charlson D = -0.22, 95% CI, -1.23 to 0.79, p = 0.659; POD 2: mean
Comorbidity Index. 6 SD = 41 6 4 with compression bandage versus mean 6

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 477, Number 1
Table 3. Preintervention measurements
Preintervention Mean
measurements nonrandomized (SD)
Tourniquet time (minutes) 78 (22)
Circumference (cm)
Thigh 47 (6)
Knee 41 (4)
Shin 38 (4)
ROM (°)
Flexion arc 103 (20)
Flexion contracture 6 (6)
VAS pain scale
Maximal pain 6 (3)
During physical therapy 6 (3)
Mean of total preoperative outcomes and tourniquet time with SD; a p value < 0.05 is considered statistically significant; p value and
CI based on Student’s paired t-test; CI = confidence interval; VAS = visual analog scale.
SD = 41 6 4 without compression bandage, mean
D = -0.31, 95% CI, -0.72 to 0.09, p = 0.126; POD 28: mean
6 SD = 37 6 4 with compression bandage versus mean 6
SD = 37 6 4 without compression bandage, mean
D = -0.34, 95% CI, -0.92 to 0.24, p = 0.246). However,
there was a difference found in the mixed model showing
less swelling in the limb with the compression bandage
compared with that without the compression bandage
across all time points (adjusted mean D = -0.49, 95% CI,
-0.96 to -0.02, p = 0.045). Although the p value was sig-
nificant, the mean difference did not reach the MCID
(Table 4). We observed similar trends for circumference
measurements of the thigh, knee, and shin in the limb with
the compression bandage and the limb without the com-
pression bandage when comparing preoperative measure-
ments with POD 1, POD 2, and POD 28, respectively. The
thigh, knee, and shin circumference increased from pre-
operative values to POD 1; however, we observed the most
noticeable increase in all circumference measurements
from preoperative values on POD 2. At POD 28 the thigh,
knee, and shin circumference measurements were the
smallest in the postoperative period and were similar to the
preoperative values (Figs. 2, 3, and 4, respectively).
Secondary Outcomes
There were no differences between the limb that received
the compression bandage and the limb that did not in terms
of flexion ROM (POD 1: mean 6 SD = 56 6 25 with
compression bandage versus mean 6 SD = 58 6 22
without compression bandage, mean D = -2.63, 95% CI,
-7.01 to 1.76, p = 0.234; POD 2: mean 6 SD = 64 6 20
with compression bandage versus mean 6 SD = 63 6 23
without compression bandage, mean D = 1.22, 95% CI,
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Compression Bandage After Primary TKA 139
Mean 95% CI (randomized–
randomized (SD) p value nonrandomized)
80 (22) 0.370 -2.38 to 6.34
47 (6) 0.322 -0.22 to 0.66
41 (4) 0.552 -0.38 to 0.21
38 (4) 0.256 -0.17 to 0.64
104 (20) 0.770 -3.09 to 4.14
6 (6) 0.681 -0.68 to 1.03
6 (3) 0.207 -0.25 to 1.11
6 (3) 0.880 -0.94 to 0.83
-2.69 to 5.13, p = 0.534; POD 28: mean 6 SD = 101 6 20
with compression bandage versus mean 6 SD = 102 6 20
without compression bandage, mean D = -1.64, 95% CI,
-3.63 to 0.35, p = 0.103; adjusted mean D = -1.17, 95% CI,
-5.18 to 2.83, p = 0.568) and extension ROM (POD 1:
mean 6 SD = 12 6 7 with compression bandage versus
mean 6 SD = 12 6 7 without compression bandage, mean
D = 0.51, 95% CI, -0.55 to 1.57, p = 0.328; POD 2: mean 6
SD = 9 6 5 with compression bandage versus mean 6
SD = 10 6 6 without compression bandage, mean
D = -1.28, 95% CI, -2.63 to 0.06, p = 0.061; POD 28: mean
6 SD = 6 6 14 with compression bandage versus mean 6
SD = 4 6 4 without compression bandage, mean D = 2.19,
95% CI, -1.60 to 5.97, p = 0.252; adjusted mean D = 0.40,
95% CI, -1.20 to 1.99, p = 0.629). With the numbers
available, we observed greater maximal postoperative pain
for the limb with the compression bandage than the control
limb on POD 1 and POD 2, but not on POD 28 or across
time (POD 1: mean 6 SD = 8 6 3 with compression
bandage versus mean 6 SD = 7 6 3 without compression
bandage, mean D = 0.66, 95% CI, 0.07-1.26, p = 0.030;
POD 2: mean 6 SD = 7 6 2 with compression bandage
versus mean 6 SD = 7 6 3 without compression bandage,
mean D = 0.80, 95% CI, 0.22-1.39, p = 0.008; POD
28: mean 6 SD = 4 6 3 with compression bandage versus
mean 6 SD = 3 6 3 without compression bandage, mean
D = 0.14, 95% CI, -0.30 to 0.58, p = 0.526; adjusted mean
D = 0.50, 95% CI, -0.02 to 1.02, p = 0.061) (Fig. 5).
Similarly, there was greater pain during physical therapy
for the limb with the compression bandage than the limb
without on POD 2, but not on POD 1, POD 28, or across
time (POD 1: mean 6 SD = 7 6 3 with compression
bandage versus mean 6 SD = 6 6 3 without compression
bandage, mean D = 0.29, 95% CI, -0.50 to 1.08, p = 0.460;
POD 2: mean 6 SD = 8 6 2 with compression bandage
 140 Matthews et al. Clinical Orthopaedics and Related Research®

Table 4. Postoperative measurements*

Total postoperative period Mean Mean 95% CI (bandaged–
measurements bandaged (SD) unbandaged (SD) Mean D (SE) p value unbandaged)
Circumference (cm)
Thigh
POD 1 51 (6) 51 (6) -0.14 (0.52) 0.586 -0.65 to 0.37
POD 2 53 (6) 53 (7) -0.22 (0.74) 0.548 -0.95 to 0.51
POD 28 47 (6) 47 (6) -0.01 (0.40) 0.975 -0.39 to 0.38
Adjusted* -0.31 (0.51) 0.219 -0.81 to 0.18
Knee
POD 1 45 (4) 45 (5) -0.44 (0.73) 0.223 -1.16 to 0.28
POD 2 46 (4) 46 (4) -0.30 (0.41) 0.137 -0.69 to 0.10
POD 28 42 (5) 42 (5) 0.21 (0.56) 0.446 -0.34 to 0.76
Adjusted* -0.14 (0.42) 0.509 -0.55 to 0.27
Shin
POD 1 40 (4) 40 (4) -0.22 (1.03) 0.659 -1.23 to 0.79
POD 2 41 (4) 41 (4) -0.31 (0.41) 0.126 -0.72 to 0.09
POD 28 37 (4) 37 (4) -0.34 (0.59) 0.246 -0.92 to 0.24
Adjusted* -0.49 (0.48) 0.045 -0.96 to -0.02
ROM (°)
Flexion arc
POD 1 56 (25) 58 (22) -2.63 (4.47) 0.234 -7.01 to 1.76
POD 2 64 (20) 63 (23) 1.22 (3.99) 0.534 -2.69 to 5.13
POD 28 101 (20) 102 (20) -1.64 (2.03) 0.103 -3.63 to 0.35
Adjusted* -1.17 (4.09) 0.568 -5.18 to 2.83
Flexion contracture
POD 1 12 (7) 12 (7) 0.51 (1.08) 0.328 -0.55 to 1.57
POD 2 9 (5) 10 (6) -1.28 (1.37) 0.061 -2.63 to 0.06
POD 28 6 (14) 4 (4) 2.19 (3.87) 0.252 -1.60 to 5.97
Adjusted* 0.40 (1.63) 0.629 -1.20 to 1.99
VAS pain scale
Maximal pain
POD 1 8 (3) 7 (3) 0.66 (0.61) 0.030 0.07–1.26
POD 2 7 (2) 7 (3) 0.80 (0.60) 0.008 0.22–1.39
POD 28 4 (3) 3 (3) 0.14 (0.45) 0.526 -0.30 to 0.58
Adjusted* 0.50 (0.53) 0.061 -0.02 to 1.02
During physical therapy
POD 1 7 (3) 6 (3) 0.29 (0.81) 0.460 -0.50 to 1.08
POD 2 8 (2) 7 (3) 0.67 (0.56) 0.018 0.12–1.22
POD 28 5 (2) 5 (3) 0.14 (0.55) 0.600 -0.40 to 0.68
Adjusted* 0.35 (0.52) 0.183 -0.16 to 0.86

Paired t-test results, based on comparing each outcome between the randomized and nonrandomized legs at each time interval
(POD 1, POD 2, and POD 28) are displayed.
*mixed model results based on predicting each outcome from day, randomization, and preoperative measurement; aggregate of total
postoperative period (POD 1, 2, and 28) outcomes; a p value of 0.05 is considered statistically significant; D = difference of randomized mean
postoperative value to nonrandomized mean postoperative value; SE = standard error; CI = confidence interval; POD = postoperative day.

versus mean 6 SD = 7 6 3 without compression bandage, mean 6 SD = 5 6 3 without compression bandage, mean
mean D = 0.67, 95% CI, 0.12-1.22, p = 0.018; POD D = 0.14, 95% CI, -0.40 to 0.68, p = 0.600; adjusted mean
28: mean 6 SD = 5 6 2 with compression bandage versus D = 0.35, 95% CI, -0.16 to 0.86, p = 0.183). With the

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 Volume 477, Number 1 Compression Bandage After Primary TKA 141

Fig. 2 This figure displays thigh circumference measurements for the limb with the
compression bandage and the limb without the compression bandage for POD 1, POD 2,
and POD 28 versus preoperative thigh circumference measurements. There is no difference
in thigh circumference measurements for the leg that received the compression bandage
compared with the leg that did not receive the compression bandage during the post-
operative period (p = 0.219).

numbers available, we observed no difference in 90-day
wound healing complications between the limb with and
the limb without the compression dressing; however, the
sample size was too small to analyze this in a meaningful
statistical way. Overall, there were 6% (three of 51) total
wound complications in the limb with the compression
bandage and 12% (six of 51) total wound complications in
the limb without the compression bandage (odds ratio
[OR], 0.47; 95% CI, 0.07-2.37; p = 0.487). Drainage was
not observed in the group with the compression bandage,
whereas the group without the compression bandage had
6% (three of 51) drainage (OR, 0; 95% CI, 0-2.39; p =
0.243) (Table 5). There were no deep infections or reop-
erations within 90 days postoperatively.
Discussion
The appropriate management of swelling has an essential
role in the outcome of any surgical procedure and post-
operative recuperation; compression bandages are one
method that has been used to reduce swelling. According to
Silver et al. [12], a limb will swell by approximately 10% of
its original volume after release of a tourniquet as a result of
return of exsanguinated blood. According to a meta-
analysis by Rama et al. [11], the evidence supports early
tourniquet release before closure because it allows the
surgeon to secure homeostasis and to more easily recognize
major vascular injuries. Therefore, if the tourniquet was
released before wound closure, eschewing the compression
bandage was less controversial because the surgeon would
have been able to identify and coagulate bleeding vessels
before closure. As a result, the effects of a compression
bandage have not been considered instrumental. In 2015,
Heller et al. [5] illustrated that releasing the tourniquet after
wound closure but before applying a compression bandage
reduced blistering without increasing postoperative blood
loss when using calculated blood loss to account for blood
extravasation into soft tissues, bleeding into the joint, and
hemolysis. Therefore, we feel it is reasonable to question
the value of a compression dressing even if the tourniquet is
not released until full wound closure has been obtained.
This study sought to determine whether use of a com-
pression bandage after TKA was associated with less leg
swelling, improved ROM, lower VAS pain scores, or fewer
wound complications.
There are several limitations to this study. First, we were
not able to blind the patients, operating room staff, and
surgeons. However, any study evaluating the use of a
compression bandage after TKA will be subject to the same
limitations as a result of its appearance and physical pres-
ence. Second, blood loss was not recorded for each knee.

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 142 Matthews et al. Clinical Orthopaedics and Related Research®

Fig. 3 This figure displays knee circumference measurements for the limb with the com-
pression bandage and the limb without the compression bandage for POD 1, POD 2, and
POD 28 versus preoperative knee circumference measurements. There is no difference in
knee circumference measurements for the leg that received the compression bandage
compared with the leg that did not receive the compression bandage during the post-
operative period (p = 0.509).

Fig. 4 This figure displays shin circumference measurements for the limb with the
compression bandage and the limb without the compression bandage for POD 1, POD 2,
and POD 28 versus preoperative shin circumference measurements. There is no differ-
ence in shin circumference measurements for the leg that received the compression
bandage compared with the leg that did not receive the compression bandage during
the postoperative period (p = 0.045).

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 Volume 477, Number 1 Compression Bandage After Primary TKA 143

Fig. 5 This figure displays maximal pain scores for the limb with the compression bandage
and the limb without the compression bandage for POD 1, POD 2, and POD 28 versus
preoperative maximal pain. There is no difference in maximal pain scores for the leg that
received the compression bandage compared with the leg that did not receive the com-
pression bandage across the postoperative period (p = 0.061).

No drains were used; therefore, we are only able to measure
total blood loss. Third, the sample size was underpowered
to adequately analyze wound complications and identify
less frequent TKA-related complications. Fourth, we want
to acknowledge that there was an unfortunate vascular in-
jury, which represented 0.8% (one of 114) of the 114 TKAs
performed on the 57 patients undergoing bilateral TKA
who were consented in this study. This type of injury is a
potential complication of any TKA and is unlikely related
to the procedures used in this study. This type of injury is
usually caused by manipulation of the vessels during sur-
gery and manifests as loss of pulse distal to the injury. This
loss of pulse is generally discovered in the recovery room.
Finally, the pressure of the compression bandage was
not recorded. Consequently, we are unsure if the same
effects from pressure were standardized across all study
participants. However, it should be noted that in standard
practice, compression bandages are applied without pressure
recordings. Therefore, the same variation or lack thereof in
pressure would be found in our study as in regular practice.
We found no clinical difference in postoperative lower
extremity swelling whether or not a compression bandage
was used. Recently, Brock et al. [2] compared the use of an
inelastic compression bandage from toe to groin and a wool
and crepe bandage of the knee applied for 24 hours after
TKA. They found no difference in knee swelling between
the two groups, which neither supports nor refutes the use
of an elastic compression bandage. However, it should be
noted that the elastic compression bandages utilized in this
study and the current study are different. Kayamori et al. [6]
conducted a RCT comparing use of a polyethylene foam
pad wrapped with an elastic bandage for 7 days after TKA

Table 5. 90-day wound healing complications

With compression Without compression
Wound healing complications dressing (n = 51) dressing (n = 51) p value Odds ratio 95% CI
All wound complications 3 (6%) 6 (12%) 0.487 0.47 0.07–2.37
Erythema 3 (6%) 3 (6%) 1.000 1.00 0.13–7.85
Any drainage 0 (0%) 3 (6%) 0.243 0.00 0.00–2.39
Serous drainage 0 (0%) 1 (2%) 1.000 0.00 0.00–39.00
Bloody drainage 0 (0%) 2 (4%) 0.495 0.00 0.00–5.31
CI = confidence interval.

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 144 Matthews et al.
and an elastic bandage with no foam pad until 10 days after
TKA with no difference in swelling. The time period of ap-
plication was much longer in the study by Kayamori et al. [6].
The current study further investigated use of an elastic com-
pression bandage versus no bandage, which not only agrees
with previous studies, but further extends the evidence that
there is no benefit of an elastic compression bandage in terms
of swelling. Because the clinical studies available on ban-
dages after TKA assess differing types of bandages, positive
and negative controls, size of application, and length of use, it
would be of benefit to further investigate this topic with
multiple groups for each of these factors in one study design.
We found no difference in postoperative knee flexion
ROM and extension ROM whether or not a compression
bandage was used. Brock et al. [2] and Kayamori et al. [6]
also found there to be no difference in ROM between their
respective groups assessed. However, Cheung et al. [4]
found improved flexion ROM when comparing an inelastic
compression bandage from toes to groin and a crepe ban-
dage around the knee when applied 24 hours post-
operatively in an enhanced recovery setting. In addition,
we found differences in postoperative maximal pain and
pain during physical therapy between the bandaged limb
and the unbandaged limb. According to Brock et al. [2], they
found no difference in pain, which was recorded before and
after physical therapy until discharge and at 6 weeks. These
findings still align with the current study because the MCID
was not reached. Lastly, we found no difference in post-
operative wound complications between the limb with the
compression bandage and the limb without the compression
bandage. Brock et al. [2] and Kayamori et al. [6] found no
wound complications either. However, as stated in the pre-
vious paragraph, these other studies mentioned did not in-
vestigate an elastic compression bandage versus no bandage
as the current study does. In addition, methodology used and
type of bandage utilized differ in the literature, which is
why a comprehensive prospective study should be used.
Applying a compression bandage after TKA did not re-
sult in any clinical improvement of the measured outcomes
when analyzed with each patient undergoing simultaneous
bilateral primary TKA serving as their own matched pair,
even when the tourniquet was not released before wound
closure. Therefore, we believe applying compression ban-
dages after TKA is not necessary, and we no longer use
compression dressings for routine primary TKA.
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
Acknowledgments We thank the operating room staff (for consul-
tancy and assistance with the logistics), Tiffany Morrison (for con-
sultancy regarding institutional review board approval), Snir Heller
MD (for consultancy regarding study design), and Camilo Restrepo
MD (for consultancy regarding study design, logistics, and statistical
analysis).
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