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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: Start with Dr. Bryan Burgess who is a podiatric surgeon, practiced at – with an orthopedic group with Hinsdale Orthopedic Associates in Chicago. He is a graduate from the Scholl College of Podiatric Medicine and today he’s going to discuss the perioperative role of cold compression therapy in preventing wound complications. So thanks a lot Dr. Burgess.
Dr. Burgess: Good morning. Thank you to the committee for inviting me to speak. Here’s my disclosure information. The learning objectives for my talk today – I’m talking about the perioperative role of cold compression therapy, might be a new therapy to some people today. The goal of my talk is to get people to really understand the pathophysiology of how cold compression therapy works. Understand the different soft tissue conditions and complications around the foot and ankle. Understand the role of cold compression therapy in both preoperative as well as postoperative settings. And understand how this cold compression therapy can even help lower DVT risk. Cold compression therapy: what is it and what does it do? Obviously there’s cold and there’s compression. The thermal components of cold compression therapy decreases metabolic activity, it slows it down. This results in less inflammation. It does induce a vasoconstriction. It also decreases motor and sensory function which allows less pain. The compression side of cold compression therapy translocates edema away from the side of the injury, pushes edema and swelling towards the proximal non-compressed tissues where it can be resolved more effectively by the lymphatic system. Adding cold to compression, so the combination of the two, it increases the rate, magnitude, and depth of temperature reduction as well as the speed of lymphatic evacuation. Cold compression therapy can also have a positive effect on wound healing. A hyperspectral imaging study that was done it shows that intermittent pneumatic compression applied to the calf does increase cutaneous blood flow almost by 50%. So like I said we discussed the – and we can use cold compression therapy both preoperative and postoperatively. Here’s an example of an x-ray. Obviously first thing everybody sees is an ankle fracture. Everybody knows this but as practitioners and surgeons we treat the patient not the fractures, so this patient also has a soft tissue envelope which needs lot of respect in addition to the fracture. So here you can see that this fracture is actually an open fracture so this really complicates the fracture. And again most of your attention in this patient is going to be drawn towards managing the soft tissue components of this patient. Here’s another example, your eyes are drawn to the fracture, the calcaneal fracture, throw on a fact that it’s an open, contaminated calcaneal fracture with compromised soft tissue envelope and it’s a whole different animal. So these are common problems that we see as surgeons if you’re doing any trauma surgery. You see a wide variety of soft tissue conditions, you see patients that are very swollen, patients with minimal swelling, you see serious fracture blisters, hemorrhagic fracture blisters, and you really have to decide when to operate, how to operate, how you’re going to manage your incisions around fracture blisters like this. Like I said, you really need to respect the soft tissue envelope when treating surgical patients, trauma patients. We all know that performing surgery in a setting of significant edema can impede wound healing and lead to very serious complications. Soft tissue complications are associated with prolonged hospitalization, increased resources, prolonged recovery, infection, obviously lower patient satisfaction, and increased mortality rates. So when we look at the surgical timing for ankle fractures, we’re all taught in medical school that you need to treat fractures immediately within 8 hours of injury or minimum of 5 days. But in clinical practice that’s just not practical. A lot of times patients don’t present to us within 8 hours of injury. A lot of the times if there are trauma patients, they need further workup medical management, medical clearance, cardiac workup, EKG, stress test, so to get to a patient within 8 hours, a lot of time it’s just not reasonable. And then in the other side of things is that the other recommendation is to wait a minimum of 5 days. Well if a lot of these patients are admitted to the hospital, and they are cleared and ready for surgery, you’re not going to sit there for 5, 6, 7 days while the soft tissue envelope improves unless there’s a serious problem.
You might be surprised to hear that there’s really no high level of evidence to support that concept that you that need to wait 5 days for the soft tissue envelope to improve. There’s a lot of literature out there in different journals, JBJS, Foot & Ankle International that shows that delaying surgery results in poor outcomes. Here’s three different studies here that shows that it results in poor outcomes, longer operative times, and increase the rate of complications when you wait more than 4 or 5 or 7 days to operate. There’s one specific study that looked at the strict protocols, a randomized study. They randomized patients to either operating within 8 hours or waiting a minimum of 5 days. And the results of the study is that they actually found higher rates of wound necrosis and a higher rate of infection when they did delay surgery. So this kinda leaves us to a dilemma right? If you perform a surgery in the setting of significant edema, you might have wound problems. But if you wait on it until the edema has completely resolved, then that’s going to increase the technical difficulty of the procedure and as we just showed might lead to poor outcomes. So kinda leaves you with this dilemma right? Do we operate in time when we want optimal fracture reduction? Do we operate at a time when we have ideal soft tissue conditions? And like everybody in the room we want the best of both worlds. So cold compression therapy can be used preoperatively to improve the soft tissue envelope, to decrease the risk of complications, decrease edema allowing you to operate quicker so that you don’t have to wait. There was one good study in Foot & Ankle International that did look at using cold compression therapy preoperatively on ankle fractures that were eventually heading to the operating room. They had two groups, they had one that used cold compression therapy and they had another one that just did splinting and elevation. The findings of this article is that cold compression therapy did decrease edema almost two-fold above one day, two days and three days after use. So the take home message with using cold compression therapy preoperatively is that if you decrease swelling and improve the condition of the soft tissue envelope, you can operate quicker, easier, and hopefully with less complications. Obviously you can use cold compression therapy in the postoperative setting. This is probably what most people are most familiar with. This is what we tell most of our patients now that have below-the-knee splint, is that we tell them to ice behind the knee. I just really don’t think this works. You know a lot of times if you see these patients after surgery in the hospital, you’re rounding at them and you find the warm ice pack wrapped around their ankle which is obviously doing no good. You find a warm ice pack behind the knee, or you see an ice pack that’s leaking all over your surgical dressing. Postoperative edema contributes to multiple complications as well, obviously pain, wound dehiscence, delayed healing. Currently ways to control postoperative edema are compressive dressings, Ace wraps, elevation, and ice. We already commented on this but using this therapy you can decrease metabolic activity, resulting in less inflammation, less swelling, and less pain. And you can also push the swelling away from the surgical site. So an article looking at that concept of using cold compression therapy postoperatively, there’s an article in Foot & Ankle International where they looked at the effectiveness of different treatment modalities for reducing postoperative swelling following foot and ankle trauma. So they had three different groups and specifically they looked at edema postoperatively after 4 days of treatment, and patients who had intermittent pneumatic compression. Their swelling is decreased by 74% or patients that only used ice packs, their swelling went down 45% and that was significant. Cold compression therapy can also help your patients with postoperative pain. It can improve their postoperative comfort. Can also decrease through use of narcotics, and also improve overall patient satisfaction with their treatment. So here’s a case example where we can show how cold compression therapy can be used both preoperatively and postoperatively to improve the soft tissue conditions around the foot and ankle. This patient here is a 54-year old male patient. He was involved in a motor vehicle accident which is a high-energy injury, usually have – it wore soft tissue envelope.
He had a very comminuted medium [indecipherable] [10:01] fractures as you can see, very competitive athletic male, one of the top water skiers in the country. So he wanted to get back to his normal level of function as quickly as possible. Here this patient was in the operating room. I did use cold compression therapy preoperatively for a couple of days. You can see that he has a resolved fracture blister to the medial heel. You can see he’s got maybe moderate swelling to the ankles, skin lines are absent. CT scan shows a very comminuted fracture, so you know that this is going to require incision, plates and screws, hardware, nothing you can do percutaneously or minimally invasively. So again CT scan shows severe comminution. This guy’s very young and active, you need to get him back darn near perfect. So this guy eventually went to the operating room, followed by use of cold compression therapy postoperatively. Postoperatively compression setting was set at 30 millimeters of mercury. I like cold compression therapy set up at 43 degrees, and I cycle this 45 minutes on, 45 minutes off. Ankle fracture went well, you can see combination of plates and screws and K-wires for the smaller fragments that were not amendable to screw fixation. Obviously that required a fair amount of incisional dissection. And here he is just 4 days postop after using cold compression therapy. On the left, there you can see that he has significant edema and 4 days postoperatively same ankle. You can see his swelling significantly down. You can see the skin lines have returned, incision looks good, there’s no gap or dehiscence, so overall an improved soft tissue envelope postoperatively with the use of cold compression therapy. Another case example, fairly similar, 59-year-old patient was transferred from an outside hospital. This patient just had a low energy rotational injury. We presented about 8 hours from time of injury to the operating room. You can tell from that x-ray there that the bone is poking to the soft tissue. It’s an open fracture and it compromised soft tissue envelope once again. Picture on the left there is the medial laceration from the bone poking through the skin and then again you see the x-ray that kinda corresponds to that clinical picture there. So this patient here obviously underwent fairly urgent wound debridement irrigation. He had an ORIF of the fibula done followed by use of cold compression therapy postoperatively. Fairly similar protocol of 30 millimeters of mercury of compression, cold therapy of 43 degrees which has been shown to be cool enough to decrease pain, swelling and inflammation but not cold enough to cause any thermal injury. And then again I cycled this 45 minutes on, 45 minutes off. Here’s the x-ray status post-ORIF, soft tissue envelope is now well-lined. So here’s this patient 48 hours later. Was a fairly large, dirty laceration, 8 hours old. So I didn’t close it primarily but some retention sutures in there. And as you can see after 48 hours, the soft tissue envelope looks pretty darn good after sustaining an open traumatic ankle fracture. At this point in time, this patient was ready for irrigation debridement and wound closure. So you might be wondering how you can apply cold compression wrap intraoperatively. That’s very simple. It doesn’t take more than extra minute or two. You just do your standard wound closure, your standard sterile gauze dressing. I like a little bit more webril around the incisions than elsewhere. You can apply the wrap, little more webril, then the splint, then we’re going to go through this. So here’s a patient, who has sterogauze dressing on, couple of layers of webril around the foot where the incisions were. Less webril around the ankle where the cold therapy is applied. Here is a picture of the application of the foot and ankle sleeve, this goes right over the webril. Again, you can see it contours very nicely. I like to put a little bit more webril on over this just for more padding so the sleeve isn’t in direct contact with the splint. And finally one step forward by 30 splint. Ace wraps and there’s kinda your final construct. There’s not really bulk here than your normal splints. You can see here your tubing there so the patient’s all set to go home from the operating room, on discharge and hooked up to their device and start therapy.
Kinda how Dave talked about the benefit of total contact cast is that you ensure compliance. It’s kinda the same thing with these wraps. If you tell patients to go home and ice behind their knee or apply ice to the surgical site, I think you probably won’t be surprised at how few patients actually do that. Once patients are upstairs in their bed, they’re certainly not making their way down the stairs to get to the freezer to get more ice packs. Other benefits of cold compression therapy is that you control the amount of compression you can dial that in, you can set that before the patient even gets it. You can control the degree of cooling, ice packs, and other devices. You really can’t have any say to the exact temperature that you want placed on the skin. And you can also control the duration of treatment. Take home messages here is that you can decrease postoperative pain and edema with the use of cold compression therapy in a very controlled manner. You can improve wound healing and prevent soft tissue complications. Lastly, cold compression therapy, the compression component of it can be used outpatient DVT prophylaxis. I think this is very important. Act Fast recently just put together their consensus statement for DVT prophylaxis, for foot and ankle surgery, very good important article. If you haven’t read it, I would definitely recommend doing so. You kinda have to extrapolate the data and apply it to your practice. Overall, they looked at large database looking at the rate of DVT and they found that for foot and ankle surgery the overall rate was 0.3%. And I think you have to keep reading before you just walk away from that because if you’re – somebody’s doing a lot of polytrauma patients, ankle fractures, Achilles tendon ruptures, I think that DVT rate is much higher than this. I certainly have DVTs in my practice and I even had a few PEs on both surgical and non-surgical patients. So I don’t think it’s something to just say DVT rate is low, we don’t have to worry about it. And in the same paragraph in the Act Fast consensus statement, comments on two articles where shows that DVT rate was as high as 28% for ankle fractures and 36% for Achilles tendon ruptures. That’s extremely high. Same article, they say that the use of intermittent pneumatic compression when possible and liberal use of graduated compression stocking should be promoted to reduce postoperative and post-injury DVT. Now a lot people are thinking why use SCDs at time of surgery. That’s fine and dandy but almost 75%, 73.7% of DVTs occurring in the outpatient setting. So after the patients off of the operating room, after the patient has their SCDs removed is when these patients develop their DVTs. An overall study on DVTs a [indecipherable] [17:54] collaboration shows that combining pneumatic compression as well as pharmacologic prophylaxis can reduce the overall PE and DVT rate from 4 to 1%. It is a fairly safe driven modality obviously there are some contraindications. It’s not for every patient. You wanna be cautious in patients who have untreated or uncompensated CHF. If they have a preexisting DVT, this would be a contraindication for use. Have to be very careful or probably should avoid treatments in patients who are neuropathic. A lot of trauma patients I do popliteal sciatic nerve block. And these patients I like to wait 24 hours before initiating therapy just so they are not neuropathic to what’s going on underneath the splint, and obviously contraindicated in patients with peripheral arterial disease. There are many different devices out there you’ve probably heard of some of them. A lot of similarities and a lot of differences. The future direction of cold compression therapy basically is the use of standalone dedicated device that can provide modalities and the controlled regulated and quantifiable manner. And this can help mitigate the liability of excessive cooling that can cause tissue damage. You need to find a safe unit that can be worn underneath the splint. Another unit can be worn underneath the splint. You need a unit that specifically avoids moisture around the incisions. You need a unit that can provide proximal cooling around the calf and circumferential intermittent pneumatic compression. So in closing, these are devices that incorporate cold and intermittent pneumatic compression in a controlled fashion. They’re very good for getting patients healed and recover in the shortest time possible. That’s it. Thank you.