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Three Part Question

In [adults with closed ankle fractures requiring admission and ORIF] does [application of a pneumatic foot pump] facilitate [oedema resolution and therefore improve time to surgery]

Clinical Scenario

A 25 year old man presents to the emergency department after inversion injury to his ankle. He has sustained an unstable closed ankle fracture, which requires open reduction and internal fixation. An orthopaedic consultant has told you previously that the patient should have a pneumatic foot pump incorporated into the cast, as this will speed the patient''s time to surgery by facilitating the resolution of traumatic oedema. You wonder what the evidence there is to support this.

Search Strategy

EMBASE – 1974 to date. MEDLINE 1950 to date. CINAHL 1982 to date.
Edema OR oedema / ankle AND (injury OR fracture OR trauma) / foot ADJ pump OR pneumatic ADJ compression: LIMIT to adults, English language AND human subjects

Search Outcome

EMBASE 50, MEDLINE 41, CINAHL 116. Total 207. From these 5 papers were relevant and of sufficient quality to be included.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Myerson, Henderson 1993 Baltimore USA	2 groups: - Group A - 38 acute ankle oedema post elective/trauma surgery Group B – 34 chronic ankle oedema post elective/trauma surgery	PRCT	Group A - Volumetric measurements by water displacement technique	significant (p = .001) decrease in swelling	Small numbers Different aetiology in same patient groups (elective vs traumatic) Large variety in type and severity of injury. Only examined reduction of swelling POST surgery. Measurement method difficult to use on patients with unstable fractures.
			Group B - Volumetric measurements by water displacement technique	Reduction (p = .03) decrease in swelling
Thordarson et al 1997 California USA	30 patients with acute Weber B or C ankle fracture Randomised to standard therapy (splint, ice and elevation) only or standard therapy plus intermittent pedal pressure compression.	PRCT	Days to theatre	Majority of patients taken to theatre by the third day, therefore insufficient patients to evaluate beyond day 3.	Exclusion of ankle fracture plus talar shift/dislocation (to minimize discomfort during measurements) Only relatively stable fractures could be assessed by water displacement. Patients operated on when slot became available (confounding factor for time to surgery) Small numbers (only 11left in treatment group after 4 refusals) and no power calculation to justify small sample.
			Volumetric measurements by water displacement technique and midfoot and ankle diameters every 24hrs until surgery	Significant reduction in swelling at 24 hours (p=0.027) and 48 hours (p=0.049)
Airaksinen et al 1989 Finland	22 patients with closed fractures of the lower leg randomised to intermittent pneumatic compression therapy or standard cast	PRCT	Oedema – relative volume of fluid compared to contralateral limb on CT scan	Significant reduction in oedema (p=0.001)	Small numbers No power calculation for study sample. No mention if patients underwent surgery
			Pain via visual analogue	Significant improvement in pain (p= 0.005)
			Ankle mobility via goniometer	Significant improvement in range of movement (p=0.001)
Stockle U et al. 1997 Germany	60 patients with foot and ankle trauma (fractures, dislocations and ligament ruptures) Randomised to cool pack cryotherapy, continuous cryotherapy or intermittent impulse compression.	PRCT	Average circumference measurements preoperatively from ankle, midfoot and forefoot	significant reduction (by average of 53%) in preoperative swelling compared to cool packs (10%) or cryotherapy (32%).	Circumference has been shown in other studies to be unreliable with large intraobserver variability Large variety of type and severity of injury Statement of significant results but no record of P-values No power calculations to justify sample size. No mention of effect on time to theatre, only hospital stay.
			Average circumference measurements postoperatively from ankle, midfoot and forefoot	Significant benefit (44%) compared to cryotherapy (34%) or cool packs (20%) for postoperative swelling at 24 hrs.
			Hospital stay (days)	No significant difference
Cashman et al 2004 UK	64 patients with closed ankle fractures requiring ORIF randomised to control or Impulse Intermittent Compression therapy. 10 patients were withdrawn.	PRCT	Daily measurements of foot ankle and calf diameter	Reduction in mean preoperative swelling (p = 0.03)	Different non-blinded surgeons assessing appropriateness for surgery Circumference has been shown in other studies to be unreliable with large intraobserver variability Hospital days should have been expressed from when patient was 'surgically fit' for discharge. This removes many confounding factors.
			Pain scores/analgesia	Inadequate data recorded, inconclusive.
			Soft tissue complications	Significant reduction in treatment group (P = 0.007)
			Hospital bed days	No significant difference

Comment(s)

A severely swollen ankle is a relative contraindication to ORIF due to the high incidence of wound break- down. It is standard practice to wait until the swelling has improved before surgery. Application of a compression impulse system at the time of injury would be beneficial for reduction of oedema and reduction in soft tissue complications. It may not, however, reduce hospital bed days, a measure that is likely to be confounded by many other factors. Theoretically, quicker and more effective resolution of oedema should mean earlier appropriate surgery, although the available evidence does not currently support this. There are other beneficial effects demonstrated, but not specifically examined in all of these papers - pump systems are known to be effective and are commonly used as prophylaxis for deep vein thrombosis, and have been shown in some studies to improve pain.

Editor Comment

RB

Clinical Bottom Line

These papers have demonstrated evidence that an intermittent pneumatic compression device is beneficial for patients requiring admission and ORIF of their ankle fracture if facilities are available. There is good evidence to show it speeds resolution of oedema by utilising the foot's venous pump. It seems to have been well tolerated and no significant complications have been reported in the studies. However there is no significant difference in time to surgery, outlined in our original three-part question. More research and cost-benefit analysis would need to be carried out to show a difference in hospital stay and time to theatre.

References

1. Myerson MS and Henderson MR 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
2. Thordarson et al. Intermittent pneumatic pedal compression and edema resolution after acute ankle fracture: a prospective, randomized study. Foot Ankle Int. 1997 Jun;18(6):347-50
3. Airaksinen et al Changes in posttraumatic ankle joint mobility, pain, and oedema following intermittent pneumatic compression therapy. Arch Phys Med Rehabil. 1989 Apr;70(4):341-4
4. Stockle U et al. Fastest reduction of posttraumatic edema: continuous cryotherapy or intermittent impulse compression? Foot-Ankle-Int Jul 1997, vol. 18, no. 7, p. 432-8, ISSN: 1071-1007
5. Cashman et al 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