GUYS.. here I thought we were friends ;) · 1. Lower limb venous ultrasound 2. Endovenous saphenous ablation 3. Bandaging, Adjustable Compression Wraps, Intermittent Pneumatic Compression

compression therapy inpost-TRAUMA INFLAMMATION & OEDEMA

Sergio Gianesini, MD, PhD, FACS

University of Ferrara (ITALY)USUHS University (BETHESDA, USA)

NO CONFLICT OF INTERESTS

…GUYS.. here I thought we were friends ;)

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AVAILABLE LITERATURE

STANDARDIZED TRAUMA

Champion HR.Major trauma in geriatric patientsAm J Public Health. 1989

LEADING CAUSE OF MORBILITY and MORTALITY

Physiological - SCORE - Anatomical

TRAUMA & INJURY Severity SCOREJavali R. Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for MortalityPrediction in Elderly Trauma PatientsIndian J Critical Care Med 2019

10.5% documented LYMPHATIC lesions

23.6% consequence of DVT

65.9% edema related to INFLAMMATION.

G. Szczesny.

Post-traumatic lymphatic and venous drainage changes in persistent edema of lower extremities. Chirurgia Narzad´ow Ruchu iOrtopedia Polska,vol. 65, no. 3, pp. 315–325, 2000.

TRAUMATIC OEDEMA

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OEDEMA

Venous-lymphatictrauma component

increasedcapillary permeability

INFLAMMATION

OEDEMA



abnormal loss ofplasma proteins

INFLAMMATION

OEDEMA




swelling

cellulitis/infection

INFLAMMATION

OEDEMA




reduced mobility

Holm B. Loss of knee-extension strength isrelated to knee swelling after total knee

arthroplasty. Arch Phys Med Rehabil. 2010;91(11):1770–6.

swelling


INFLAMMATION

OEDEMA




reduced mobility

less lymphatic pump



swelling


INFLAMMATION

OEDEMA




increasedinterstitialpressure

reduced mobility

less lymphatic pump



swelling


INFLAMMATION

Eur J Trauma Emerg Surg. 2017 Aug;43(4):451-459.

Compression therapy after ankle fracture surgery: a systematic review.

Winge R

8 studies (451 patients)

Bandages, GCS, IPC:

- significant effect on EDEMA (7 studies)

- significant reduction in PAIN (2 studies)

- positive effect on ANKLE ROM (1 study)

- effect on WOUND HEALING (2 studies)

- length of stay reduction (1 study)

- reduction in time to surgery (2 studies).

8 studies (451 patients)

Bandages, GCS, IPC: from 10 mmHg to 130 mmHg.

- significant effect on EDEMA (7 studies)

- significant reduction in PAIN (2 studies)

- positive effect on ANKLE ROM (1 study)

- effect on WOUND HEALING (2 studies)

- length of stay reduction (1 study)

- reduction in time to surgery (2 studies).

*methodological limitations

Eur J Trauma Emerg Surg. 2017 Aug;43(4):451-459.

Compression therapy after ankle fracture surgery: a systematic review.

Winge R

knee length GCS20–30 mmHg

EDEMA70.00% vs. 33.33%; p.0.0045

Phlebology. 2019 Graduated compression stockingseffects on chronic venous disease

signs and symptoms duringpregnancy.

Saliba Júnior OA

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BMC Musculoskeletal Disorders (2019) 20:161.

Impact of compression stockings on leg

SWELLING after arthroscopyTischer T

CHANGE OF CICUMFERENCE KNEE

CHANGE OF CICUMFERENCE MID LEG

CHANGE OF CICUMFERENCE MIDDLE THIGH

23-32 mmHgvs

NO compression

p<.05

10 days

Munk S. Effect of compression

therapy on knee swelling and pain after total knee arthroplasty.

Knee Surg Sports Traumatol Arthrosc. 2013;21(2):388–92.

23-32 mmHgvs

NO compression

p<NS

Post-op day: 1, 2, 7, 14, 30




23-32 mmHgvs

NO compression

p<NS

Post-op day: 1, 2, 7, 14, 30

..but assessment at knee level and below(Tischer > edema at the thigh)




23-32 mmHgvs

NO compression

p<NS

Post-op day: 1, 2, 7, 14, 30

..but assessment at knee level and below(Tischer > edema at the thigh)

GCS:

- 69% increased knee stability

- 60% felt a reduction in knee swelling

- 38% reduction in knee pain

J Bone Joint Surg Am. 2014;96:1263-71Effective Treatment of Posttraumatic and

Postoperative Edema in Patients with

Ankle and Hindfoot Fractures

Rohner-Spengler M

median EDEMA:

MULTILAYER > COLD PACK > IMPULSE

0%

222%

17%

COLD PACKfoundation, ONLUS

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Ann R Coll Surg Engl 2012; 94: 463–467GCS in hip fractures

A Alsawadi

GCS, foot impulse devices or IPC should be offered to all patientsundergoing hip fracture surgery

based on individual patient factors

Venous ThromboembolismLondon: NICE

2010

The evidence supporting theserecommendations

is very limited

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Global guidelines trends & ocntroversies in

lower limb venous and lympahtic disease

Sergio Gianesini, MD, PhD, FACS

University of Ferrara (ITALY)UCES University (ARGENTINA)USUHS University, Bethesda (USA)

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SECTIONS

1. Lower limb venous ultrasound

2. Endovenous saphenous ablation

3. Bandaging, Adjustable Compression Wraps, Intermittent

Pneumatic Compression

4. Graduated Elastic Stockings

5. Sclerotherapy for varicose veins

6. Aesthetic phlebology

7. Acute and chronic deep venous disease

8. Venous Active Drugs - Ulcer management

9. Lower limb lymphedema

10. Venous thrombosis management

POST-PREOCEDURAL COMPRESSION

1B1A 1A

2B 2B2C 2C2C

1B

24 hours

3 weeks


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40 mmHg16 mmHg

*NICE, EUR and LATAM don’t specify

GLOBAL 2019: based on the physician indication

INTERMITTENT

PNEUMATIC COMPRESSION

for

reducing

TRAUMATIC OEDEMA

Caschman J, The efficacy of the A-V Impulse system in the

treatment of posttraumatic swelling following ankle fracture: a

prospective randomized controlled study. J Orthop Trauma. 2004

Oct;18(9):596-601.

Myerson MS. The use of a pneumatic intermittent impulse

compression device in the treatment of calcaneus fractures. Mil Med.

2000 Oct;165(10):721-5.

Thordarson DB. Facilitating edema resolution with a foot pump after

calcaneus fracture. J Orthop Trauma. 1999 Jan;13(1):43-6.

St¨ockle U. Fastest reduction of posttraumatic edema: continuous

cryotherapy or intermittent impulse compression? Foot Ankle Int. 1997

Jul;18(7):432-8.

Myerson MS. Clinical applications of a pneumatic intermittent

impulse compression device after trauma and major surgery to the foot

and ankle. Foot Ankle. 1993 May;14(4):198-203.

Gardner AM. Reduction of post-traumatic swelling and compartment

pressure by impulse compression of the foot. J Bone Joint Surg Br.

1990 Sep;72(5):810-5.

McMullin G. An assessment of the effect of the foot pump on venous

emptying in chronic venous insufficiency. In: Davy A, Stremmer R,

editors. Phlebologie. London: John Libbey; 1989. p 69-71.

Gardner AM. The venous pump of the human foot—preliminary report.

Bristol Med Chir J. 1983 Jul;98(367):109-12.

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Phlebology 2015

Pneumatic thigh compression reduces calf volume and augments the venous return

Lattimer C

Thigh compression Venous dilation After load microcirculation resistance

• Interface pressure in B and B1Gianesini S, Raffetto J, Mosti G et al. Graduated Compression Lower Limb Volume Control in Different Muscle Pump Activation Conditions and Related Limb ShapeImpact. J Vasc Surg VL 2019;7(2):295-296.

• Compliance assessment

• IPC proper use Only 19% of trauma patients are receiving proper IPC

Cornwell EE, 3rd, Chang D, Velmahos G, et al. Compliance with sequentialcompression deviceprophylaxis in at-risk trauma patients: a prospective analysis. Am Surg. 2002;68:470-473.

• IPC protocols

NEWS

BACKGROUNDHow do we define

a “long-haul” flight?

PROLONGED FLIGHT BRITISH JOURNAL OF HEMATOLOGY 2011:

NO indication to GCS to everybody (1C).

Patients at risk of DVT should wear GCS

if >3 hrs.




if >3 hrs.NICE:

recommendes in all patients at risk




if >3 hrs.

ACCP 2012:

for patients at risk, in >3 hrs, 15-30 mmHg

(GRADE 2C)

NICE:


PROLONGED FLIGHT

EUROPE 2018: in all patients at risk (2B),

but theguidelines are also recommending

GCS in healthy subjects at risk of developing edema (1B)

BRITISH JOURNAL OF HEMATOLOGY 2011:



if >3 hrs.

ACCP 2012:

for patients at risk, in >3 hrs, 15-30 mmHg

(GRADE 2C)

NICE:


Always report

INTERFACE PRESSUREIn

B & B1foundation, ONLUS

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Medsurg Nurs. 2013 Nov-Dec;22(6):370-4.

Incidence of incorrectly sized graduated compression stockings and

lower leg skin irregularities in postoperative orthopedic patients.

52 patients (total hip/knee arthoplasty)

Incorrectly fitting: 10%

Edema, erythema, ecchymosis,

blistering, breaks in the skin: 4%

flow velocity increase in the compressed thigh,but also in the caval vein

, J DERMATOL SURG ONCOL_1991

18-21 mmHg

APG (ns)

CIVIQ 20 (p)

VVSYMQ (p)

CIRCUMEFERENCE (p)

CUTE FASCIA US III MEDIO GAMBA E COSCIA

ROM CAVIGLIA (3 gadi)

QUESTIONARIO ORTOPEDICO (migliorato)

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v-WIN EDUCATIONAL QUESTIONNAIRESwww.vwinfoundation.com/education

PHLEB-Ortho project

J Clin Epidemiol. 2010 May;63(5):550-7. The Italian version of the lower extremity functional scale was reliable, valid, and responsive.

Cacchio A

ValidReliable

Responsive

For

musculo-skeletaldysfunctionassessment

PHLEB-Ortho STUDY(Knee arthroplasty/Hip replacement)

23-32 mmHg18-21 mmHg

30 daysCIRCUMEFERENCE

LEG VOLUMEUS subcutaneous thickness

APG

Ankle ROM

CIVIQ 20VVSYMQ

LOWER EXTREMITY FUNCTIONAL SCALE

PRELIMINARY DATA

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STUDY POPULATION14 patients

GROUP 18-21 mmHg(group A)

10 patients

GROUP 23 -32 mmHg(group B)4 patients

P*

Agemean±st. dev

69±13 71±14 67±13 0.55

M/F 2/12 1/6 1/8

BMImean±st. dev

27±3 27±3 27±3 0.67

CEAP C1 n°12C2 n°2

C1 n°4C2 n°2

C1 n°8C2 n°0

KNEE (n°) 6 4 2

HIP (n°) 8 6 2

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2241 2230 2616 2437

0

500

1000

1500

2000

2500

3000

3500

T0 T1 T0 T1

LEG VOLUME (mL)

± 327 ± 310

± 469± 457

p<0.0001p<0.4967

-179 mL (-6.8%)-11 mL (0.5%)

18-21 mmHg 23-32 mmHg

Two-tailed paired Student-T Test

PHLEB-Orthostudy

18-21 mmHg 23-32 mmHg

± 9

± 11

p<0.01p<0.1019

14° (32%)7° (16%)

± 10

42 48 4458

0

10

20

30

40

50

60

70

T0 T1 T0 T1

Flexion-extension width

± 8


PHLEB-Orthostudy

1,121,07

0,68

0,50

0,00

0,20

0,40

0,60

0,80

1,00

1,20

1,40

1,60

1,80

2,00

T0 T1 T0 T1

VFI

p<0.08

p<0.8146

± 0.60± 0.71

± 0.15

± 0.24

18-21 mmHg 23-32 mmHg


PHLEB-Orthostudy

0,76

0,61

0,84

0,61

0,00

0,20

0,40

0,60

0,80

1,00

1,20

1,40

T0 T1 T0 T1

Leg-Subcutaneous Thickness (cm)

18-21 mmHg 23-32 mmHgTwo-tailed paired Student-T Test

± 0.35

± 0.38

± 0.41

± 0.35

p<0.004

p<0.2418p<0.05

1,4 1,2 1,2 1,0

0,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

1,6

1,8

2,0

T0 T1 T0 T1

Thigh-SubcutanousThickness (cm)

± 0.54± 0.52

± 0.41

± 0.40

p<0.2339

p<0.05

PHLEB-Ortho study

LEFSPre-Op

LEFSPost-Op

pCIVQ-20Pre-Op

CIVQ-20Post-Op

pVVSym-Q

Pre-OpVVSym-QPost-Op

p

18-21mmHg

21.6±7.3 39.8±7.1 0.01 48.6±7.9 71.3±5.3 0.003 4.5±1.2 3.3±0.8 0.03

23-32 mmHg

25.5±7.449.1±8.3

0.003 46.8±13.3 80.1±22.9 0.005 4.3±0.7 1.75±1.9 0.008

QoL


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2240

26 49

0

10

20

30

40

50

60

70

T0 T1 T0 T1

LEFS

92%p<0.0003

83%p<0.01

± 7.3

± 7.1

± 7.5

± 8.3

18-21 mmHg 23-32 mmHg

PHLEB-Orthostudy

2240

26 49

0

10

20

30

40

50

60

70

T0 T1 T0 T1

LEFS

92%p<0.0003

83%p<0.01

± 7.3

± 7.1

± 7.5

± 8.3

18-21 mmHg 23-32 mmHg

PHLEB-Orthostudy

< (p: NS)

RISK

BENEFIT

*meeting in conjunction with VAICON 2021 – Chandigarah (INDIA)ONE registration, TWO meetingsfoundation, ONLUS

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Documents

GUYS.. here I thought we were friends ;) · 1. Lower limb venous ultrasound 2. Endovenous saphenous ablation 3. Bandaging, Adjustable Compression Wraps, Intermittent Pneumatic Compression