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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Brian Burgess, DPM
Clinical Assistant Professor
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Male Speaker: The patient is going to go to a different type of approach on things, dealing with actually role of cold compression therapy in the postoperative setting. We’re always focused and concentrate on the surgical procedure itself. Sometimes not taking into account what could adversely affect the healing that we expect to take place and certainly pain and swelling are factors. So we’ve asked Dr. Brian Burgess who graduated in 2009 from the Scholl College. Completed a three year surgical residency and trauma in reconstructive surgery of the foot and ankle. So he’s created enough trauma that it would be nice that it minimizes the pain and the swelling. Specializing sports medicine, arthroscopic surgery, fracture care, complex rear foot reconstructive procedures. So please welcome Dr. Brian Burgess.
Dr. Brian Burgess: Thank you for the invitation and the introduction. See if I can get this thing working. Here we go. As a disclosure I do have a relationship with the company called Work Rehabilitation Specialist. Learning objectives for this presentation, I want the residents to understand the pathophysiology of cold compression therapy. I want them to understand the soft tissue conditions and complications around the foot and ankle. I think it’s important to understand the role of cold compression therapy in both the preoperative and postoperative settings and also understand the different palpation modalities that we can utilize as physicians to lower the risk of DVT. Again, a little overview of what’s going to be presented in this presentation. It’s basically a discussion of cold compression therapy, how it can be used in both the preoperative setting and the postoperative setting to minimize pain, swelling and other complications related to the soft tissue envelope. Cold compression therapy, what is it and what does it do? That’s what we’re going to discuss. The cold part of cold compression has great therapeutic influence around the foot and ankle. The cold part of the therapy helps decrease metabolic activity. It decreases enzymatic destruction of the soft tissue envelope and decreases soft tissue swelling and inflammation. Cold as you know induces basal constriction. It provides less swelling, less edema to both the traumatized tissue and postoperative tissue. You also decrease motor and sensory function which results in less pain. The compression side of this type of therapy again decreases swelling and edema. How it does this is that you translocate the edema away from the site of injury, proximally towards non-compressed tissue where it can be resolved more efficiently by the lymphatic system. So obviously we’re taking a swollen foot, moving the edema proximally where it can be resorbed. You combine these two modalities, both cold and compression and you get an additive effect. The rate magnitude and depth of temperature reduction as well as the speed of lymphatic evacuation increases. We’re going to discuss the role of cold compression therapy in the preoperative setting. As residents, everybody gets all excited when they see an x-ray like this. They start thinking about how they’re going to fix this fracture, what systems they’re going to utilize, what rep they’re going to call and the classification system and stuff like that. As an attending who deals with a lot of trauma, the first thing that comes to your mind is the condition and quality of the soft tissue envelope as we now that’s equally as important if not more important than the fracture itself. You can see if you take a little bit of time looking at this soft tissue envelope, you can tell that this is an open fracture that presented like this. You immediately have a stronger appreciation for the soft tissue envelope around the foot and ankle. Here’s another example. You can see a fracture on x-ray but you really don’t appreciate the quality or the damage done to the soft tissue envelope. This patient actually had an open calcaneal fracture and this fracture happened in a dirty lake as he jumped off the back of a speedboat going about 40 miles per hour on a very shallow river for whatever reason. So again you see the fracture but it’s very important to appreciate, understand and respect the soft tissue envelope.
Again, there’s really nobody in this room that wants to ever operate under these conditions. Sometimes fractures and other factors dictate that you don’t have a choice but ideally you never want to operate in the presence of fracture blisters, whether they’re serous or hemorrhagic fracture blisters. The reason why is because if you do operate under these conditions, it can lead to wound complications, wound dehiscence and numerous wound healing problems as I’m sure we’ve all seen and practiced in in residency. Soft tissue complications are devastating. They result in prolonged hospitalization, increased resource consumption, prolonged recovery, infection, obviously lower patient satisfaction and increased mortality rates. If we look specifically at the surgical timing for ankle fractures, I think we’re all ingrained as residents and physicians and students that you operate on ankle fracture immediately within eight hours of injury or a minimum of five day delay. In clinical practice a lot of times that’s really not necessary or correction, it’s really not feasible, it’s not possible. If you have a patient admitted to the hospital with an ankle fracture and you’re not there within eight hours, you’re certainly not going to sit on that patient for five, six, seven days for the soft tissue envelope to calm down unless there’s a major issue with it. This timing thing really is not supported by any level one evidence either. There’s really no prospective or randomized trial to guide when it is okay to operate for ankle fractures. This is not true for other injuries. We’re just talking specifically about ankle fractures. Pilon fractures are different and there is a more so of a set timing protocol for those. In fact with ankle fractures there’s quite a bit of literature out there that supports the opposite of this, that if you do delay surgery you can have poor outcomes. There’s one article that showed if you delay surgery greater than seven days, you can have poor outcomes. Another article, any delay greater than five days resulted in longer operative times and another article that showed that there’s an increased rate of complications if the time to operation was greater than four days. Another article, they randomized patients and stuck to this strict protocol of operating within the first eight hours after injury or waiting five days. And the results of their study was that they had a higher rate of wound edge necrosis and a higher rate of infection when they did delay surgery and this did approach statistical significance. So I’m kind of left with a soft tissue and fracture dilemma here, right? Do we perform surgery when we have significant edema and run the risk of having wound complications? Or do we delay surgery until the soft tissue envelope has improved but this may complicate the procedure or increase the technical difficulty and adversely affect the outcome? So we kind of have to balance these things out, right? Do we want to operate when we have optimal fracture reduction early on or do we want to wait until the soft tissue envelope improves? If you’re like me, you want the best of both worlds. You want it all. I think that’s where cold compression therapy comes in, is that you can use this as a preoperative tool or a preoperative modality to expedite the improvement of your soft tissue envelope and get swelling down prior to surgery. The benefits of cold compression therapy diminish with time. It is best if you applied this almost immediately after an injury or after surgery. As I said, cold compression therapy can be used to reduce preoperative edema and improve the condition of the soft tissue envelope. There’s a picture there of kind of a standard device used around the foot and ankle that can be applied preoperatively again to provide cold therapy as well as compression therapy. There’s an article that looked at this specific to ankle fractures. They looked at utilizing cold compression therapy in order to decrease preoperative edema. This article is published in Foot and Ankle International. What they did is they had 24 patients who were placed in two separate groups, group one. They did utilize cold compression therapy and the other group they really just utilized the typical splinting and elevation. Their findings were not surprising as you would probably expect that patients who utilize the cold compression therapy had almost a two-fold decrease in their edema at both 24, 48 and 72 hours. They concluded that there is a benefit in reducing edema with the use of this cold compression therapy. So take-home message for using this preoperatively is that you can decrease the swelling and improve the condition of the soft tissue envelope preoperatively with the use of this therapy.
This allows you to operate quicker, easier and hopefully or potentially with less complication to the soft tissues. Cold compression therapy, it can also be used in the postoperative setting. How many people really think this works? You do a sophisticated difficult procedure, you put on a posterior splint and you walk out and tell the family to have the patient iced behind the knee. I mean I always am baffled at the looks I get from family when I tell them to ice behind the knee. And they always question me why would they ice behind the knee when the surgery was on the ankle and it’s kind of difficult to explain. Postoperative edema contributes to many complications, pain, wound dehiscence, because of tension on the skin, delayed healing. And current postoperative treatment control regiment is really compression dressings like Ace wraps, elevate above the heart, decrease your activity level and ice behind the knee if you don’t have access over the operative site. We commented on this already that the cold part of cold compression can decrease inflammation. It can induce vasoconstriction and allow less swelling. It can also decrease motor and sensory function and decrease the pain reflex. You can also translocate the edema away from the surgical site more proximally with use of intermittent pneumatic compression. So an article that I’m referencing from Foot and Ankle International looked at the use of cold compression therapy postoperatively and they looked at three different treatment groups. Looking at postoperative swelling after foot and ankle trauma. They had three groups of this in this study. They had a group that underwent compression, intermittent pneumatic compression, IPC, after surgery. They had a group that had cryotherapy after surgery and then they had a group that simply used elevation and ice packs. What they found was after four days of treatment, both the compression group and the cryotherapy group had significant and statistically significant improvement in their edema compared to the ice packs and elevation alone. Cold compression therapy can also be used to decrease pain as we discussed. It lowers the severity of pain. It reduces patient’s tolerance on narcotics and also improves patient satisfaction with their procedure as well as with you, the threating physician. We can look at a couple of cases of mine recently where I did utilize cold compression therapy postoperatively. This is a patient, 54-year-old male. He was involved in a motor vehicle accident. I think it’s important to distinguish the mechanism of injury, right? The high-energy motor vehicle accident as opposed to twisting off of a step or a lower-energy injury. These higher-energy injuries are often associated with more soft tissue envelopes and more destructions to the soft tissues. So he presented, he had a comminuted medial mal fracture and no other injuries luckily. Here’s his skin preoperatively. Certainly not terrible and we’ve all operated under these conditions probably more often than not. You can see by the heel he had a little fracture blister that did resolve before I took him to the OR. You can maybe see both proximally and distally there’s some white stuff on there as I utilize an Unna boot preoperatively just to help with edema control and decreasing the edema. Kind of a weird fracture in this patient. So I did get a CT scan just to confirm no other interarticular pathology. And you can see if we flip back and forth that this is a fairly comminuted fracture. This is not going to be amendable to your typical two cannulated screws across the fracture site. You’d probably make this fracture worse in doing so. So when studying this, you have to understand that this is going to require a fairly good size incision in order to free up these fragments, reduce them into anatomic position and provide some type of fixation in order to keep these fragments from moving around. Again, here you can see that this is just a very comminuted fracture in a young active patient and getting a good reduction is necessary. So I did perform surgery on this guy. I did fix his fracture. I did use cold compression therapy postoperatively. I was able to give him a compression, intermittent pneumatic compression of about 45 millimeters of mercury. I was also able to utilize cold therapy of 49 degrees. Here’s his postoperative x-rays. So again you can see in order to put that hardware in, he would need a fairly extensive incision. Would need quite a bit of dissection of both the skin, subcutaneous tissues and periosteum in order to reduce and fix his fracture.
What’s surprising is that you see this guy 14 days postop and you can see he still has staples in there and you can see the significant improvement in his skin. He’s got significantly less swelling. The skin lines have returned and he looks great. Another case where I utilize cold compression therapy postoperatively, recently I had a 59-year-old patient who had a low energy rotational injury. He was transferred from an outside hospital. So there’s quite a bit of delay from the time he had this injury to the time he got to my hospital. This patient as you can see from the clinical picture as well as the x-ray, he had an open injury. So again, if you look at the x-ray you see a fracture. But you have to appreciate the condition of the soft tissue envelope and any open injury, the devastating injury with high risk of infection, wound dehiscence, delayed wound healing, deep infection and even amputation. These patients in these instances, the soft tissues are more important to me than the fracture itself. You definitely had to get the fracture reduced and stabilized in order to stabilize the soft tissues but I certainly spend more time managing the soft tissues in these patients than I do the fractures themselves. This patient underwent typical ORIF of his fibula and then I utilize cold compression therapy on him postoperatively. I did debride and irrigate the wound but I left it open because there was a long delay between time of injury and the time I got into the operating room. I put him at a slightly lower level of compression. I didn’t want too much pressure on the open wound. Same degree of cold therapy on this patient. Here’s his surgical fixation. Again, you can just appreciate that by reducing and stabilizing the facture. You can also stabilize the soft tissue envelopes. That can calm down as well. This patient at 48 hours postop, I did take him back to the operating room just to take another look at his incision. Perform a final irrigation and debridement and closure of his wound. You can see that he had very minimal swelling. He had no signs of any infection and the soft tissues looked about a calm as you could possibly expect under this circumstance. Take-home message for using cold compression therapy postoperatively is that you can decrease pain. You can decrease edema with use of this therapy in a controlled and relatively safe manner. Cold compression therapy can also be used for DVT prophylaxis. In March of this year the American College of Foot and Ankle Surgeons published their clinical consensus statement on DVT prophylaxis for foot and ankle surgery. I think this was a very, very important publication for our profession. There’s different ways you can interpret the literature. I think it’s very important that you look at all the literature and interpret it and kind of apply it to every patient and apply it to your specific practice. The same paragraph within this article, they state that large review of 90,000 patients demonstrated the rate of DVT after surgery was only 0.3%. So if you stop reading there, you can make the assumption that if the DVT rate is only 0.3%, there’s really no need for any pharmaceutical prophylaxis for DVTs in foot and ankle surgery patients. But if you take it patient by patient and case specific and if you keep reading the same paragraph, there’s other studies that show things that are completely different. At the very end of this paragraph there was an article published by Lapidus that showed in his series of Achilles tendon ruptures he had almost 36% rate of DVTs following surgery. So there’s a quite a bit of difference between 0.3% and 36%. So I think you got to be careful not to say that no patient that has foot and ankle surgery needs any form of DVT prophylaxis. In the same article by the American College of Foot and Ankle Surgeons, they do suggest or recommend the use of intermittent pneumatic compression. They state that use of this when possible and liberal use of SEDs should be promoted to reduce postoperative and post injury DVT. DVT prophylaxis is very important in the United States. The mortality rates from DVT are greater than HIV and breast cancer combined. Just kind of a general study of surgery patients who did developed DVT, almost 75% of them developed the DVT in the outpatient setting. I think that applies to the majority of our patients.
What’s even a little bit scarier in this study is that a high percentage of these, somewhere around 32%, developed DVT more than 30 days after surgery. So even if you were very aggressive in treating your patients with Lovenox or Xarelto or Aspirin or whatever you want, chances are you’re not going to be treating this patient with those medications for more than 12, 14 days after surgery. There’s still a great risk for DVT one or two or three months after surgery. If you do a Cochrane collaboration of clinical studies for high risk patients and DVT, one of the findings is that the combined use of pneumatic prophylaxis, meaning pneumatic compression and pharmacological prophylaxis can reduce the incidents of DVT and PE from about 4% down to 1%. So it’s a combination of drug of your choice, Xeralto, Lovenox, as well as pneumatic prophylaxis. There are many different devices out there in the market now. Some of them have significant differences. Their differences between them are relatively minor. The future direction of cold compression therapy. The use of this is a standalone dedicated device that provides both modalities, so cold and compression, in a controlled, regulated and quantifiable manner. I think it’s important to mitigate the liability of excessive cooling that can cause tissue damage. You can have tissue damage and frostbite from use of ice packs and things like that. And you also remove the inherent random and widely varying intensity of pressure associated with bandages and elastic wraps. When I put an Ace wrap on a patient postoperatively, I’m sure it’s either too lose or too tight. Too tight can be a problem because the patient is calling in the middle of the night telling you their narcotics aren’t work. And too lose is a problem because it’s really not doing anything for edema control. So I think the future of these units is a safe unit that can possibly be worn under a splint. Something that avoids any sort of moisture around the incision. I think you need to have some proximal cooling around the calf, maybe not so much the foot and ankle around the incisions. It’s obviously important to have circumferential intermittent pneumatic compression. So in closing, these devices that incorporate cold and compression in a controlled fashion in my opinion are the best option. They provide the patient with the maximum degree of comfort and the shortest time to functional recovery. References, questions; that is it.