Treatment of leg edema and wounds in a patient with severe musculoskeletal injuries

Lymphatic treatments after orthopedic surgery or injury: A systematic review

BACKGROUND

Orthopedic injuries in conjunction with extensive damage to tissues, bones and blood vessels, usually require a long recovery. Associated consequences are pain, movement limitations, decreased function and occasionally, prolonged edema, which can delay or interfere with the healing process. Lymphatic and compression therapy have become increasingly common, intending to reduce edema and pain, thus, promoting the recovery process.

AIMS

To examine the efficacy of methods commonly used to reduce edema after orthopedic injury or surgery, i.e. decongestive therapy, manual lymphatic drainage, and compression bandaging.

METHODS

English literature search was undertaken in January 2019, in the following databases: Cochrane Library, MEDLINE, PEDro.

INCLUSION CRITERIA

randomized controlled or quasi-controlled trials in adults who have edema or pain after recent limb trauma or surgery. Two independent assessors rated study quality and risk of bias using the PRISMA recommendations and PEDro score.

RESULTS

We evaluated 71 papers. After excluding duplicated and irrelevant papers, 15 met the eligibility criteria (6 on lymphatic treatment and 9 on compression). Quality of papers ranged from 3 to 7 on PEDro score; of them, 13 were 1b Level of Evidence and two were 1c.

CONCLUSION

After elective surgeries, when the significant edema appears or persists beyond recovery time, complex decongestive therapy and manual edema mobilization should be recommended in addition to conventional physical therapy. In acute injuries such as ankle or distal radius fractures, lymphatic treatments and compression bandaging should be considered as part of the therapeutic protocol. Nine studies evaluated different compression modalities found that only multilayer and long stretch compression significantly reduce edema.

Pyoderma Gangrenosum-Like Lesion in an Older Adult

Pyoderma gangrenosum (PG) is a rare but serious neutrophilic dermatosis characterized by ulcerative lesions with violaceous borders. The disease mainly occurs in young or middle-aged adults. The authors present the case of a 79-year-old female nursing home patient who had an idiopathic PG-like ulcer on her lower extremity. Initial treatment with 3 courses of antibiotics and topical wound care for assumed cellulitis failed to improve the lesion, but the ulcer healed rapidly after a 1-week course of prednisone therapy (15 mg/d). This case provides insights into the challenges that arise in the diagnosis and management of PG in an older patient with extensive comorbidities. It also highlights the importance of considering PG as a diagnosis for older patients with a distinctive inflammatory ulcer that does not respond to antibiotics and topical wound care, since timely treatment with low-dose steroids can lead to quick healing by aborting the underlying autoinflammatory process.

Adjuvant Lymphatic Osteopathic Manipulative Treatment in Patients With Lower-Extremity Ulcers: Effects on Wound Healing and Edema

Context

In 2012, the US wound registry estimated that the cost of managing chronic wounds in the United States exceeded $50 billion. A large percentage of these wounds are venous stasis ulcers of the lower extremity. Evidence suggests that adjuvant osteopathic manipulative treatment (OMT) may provide a benefit by reducing edema and subsequent healing times in venous stasis ulcers of the lower extremity.

Objective

To determine whether a lymphatic OMT protocol improves wound healing rates among patients with lower-extremity edema.

Methods

This pilot study was a nonrandomized before-after community trial of lymphatic OMT in patients with lower-extremity wounds and edema. Wound surface area measurements for the preliminary phase were obtained retrospectively. During the intervention period, patients received 10 minutes of OMT twice per week. The OMT protocol, which aimed to improve lymphatic flow, included myofascial thoracic outlet release, doming of the diaphragm, pelvic diaphragm release, popliteal release, and pedal pump (2-3 minutes of continuous pump) performed in sequence. Rates of wound healing were compared between the preliminary (standard therapy), intervention (standard therapy plus OMT), and follow-up (standard therapy) phases. Rates of change in edema (measured using leg volume) were evaluated during the intervention phase. A custom-designed questionnaire was used to assess patients’ satisfaction with their treatment and confidence that its effects on their health were good.

Results

Eight patients were included in the study. The wound surface area increased during the preliminary phase by a mean of 10 cm2/wk and decreased during the intervention phase by a mean of 4.9 cm2/wk. Patients’ mean leg volume decreased during the intervention phase. Six patients were “very satisfied” with their treatment.

Conclusion

The adjunctive OMT protocol may have reduced edema and reversed the trend of wound growth in patients with venous stasis ulcers. Edema reduction is a mainstay of current wound therapy, and any modality that decreases edema may subsequently decrease healing times.

Recommendations of the Brazilian Society of Rheumatology for the diagnosis and treatment of chikungunya fever. Part 2 - Treatment

Chikungunya fever has become an important public health problem in countries where epidemics occur because half of the cases progress to chronic, persistent and debilitating arthritis. Literature data on specific therapies at the various phases of arthropathy caused by chikungunya virus (CHIKV) infection are limited, lacking quality randomized trials assessing the efficacies of different therapies. There are a few studies on the treatment of musculoskeletal manifestations of chikungunya fever, but these studies have important methodological limitations. The data currently available preclude conclusions favorable or contrary to specific therapies, or an adequate comparison between the different drugs used. The objective of this study was to develop recommendations for the treatment of chikungunya fever in Brazil. A literature review was performed via evidence-based selection of articles in the databases Medline, SciELO, PubMed and Embase and conference proceedings abstracts, in addition to expert opinions to support decision-making in defining recommendations. The Delphi method was used to define the degrees of agreement in 2 face-to-face meetings and several online voting rounds. This study is part 2 of the Recommendations of the Brazilian Society of Rheumatology (Sociedade Brasileira de Reumatologia - SBR) for the Diagnosis and Treatment of chikungunya fever and specifically addresses treatment.

Treatment in an Outpatient Setting for a Patient With an Infected, Surgical Wound With Hypergranulation Tissue

The purpose of this article is to describe a multifaceted approach to wound care in an outpatient setting for a patient with an infected, nonhealing surgical wound with hypergranulation tissue following fasciotomy for acute compartment syndrome. A 44-year-old male underwent an anterior and lateral lower extremity compartment fasciotomy and developed a persistent right anterolateral lower leg wound. Thirty-six days after fasciotomy he came to the authors' clinic after 2 failed skin grafts with an infected wound covered in hypergranulation tissue. Treatment included sharp debridement, saline irrigation, patient education, and dressing changes during 9 treatment sessions. The patient's total wound surface area decreased from 5.2 cm × 17.3 cm to 4 cm × 15 cm with increased epithelialization from approximately 40% to 85% after 29 days of treatment. This article demonstrates the positive effect of a multifaceted approach for facilitation of wound healing in a lower extremity wound following fasciotomy.

Systematic review of efficacy for manual lymphatic drainage techniques in sports medicine and rehabilitation: an evidence-based practice approach

Manual therapists question integrating manual lymphatic drainage techniques (MLDTs) into conventional treatments for athletic injuries due to the scarcity of literature concerning musculoskeletal applications and established orthopaedic clinical practice guidelines. The purpose of this systematic review is to provide manual therapy clinicians with pertinent information regarding progression of MLDTs as well as to critique the evidence for efficacy of this method in sports medicine. We surveyed English-language publications from 1998 to 2008 by searching PubMed, PEDro, CINAHL, the Cochrane Library, and SPORTDiscus databases using the terms lymphatic system, lymph drainage, lymphatic therapy, manual lymph drainage, and lymphatic pump techniques. We selected articles investigating the effects of MLDTs on orthopaedic and athletic injury outcomes. Nine articles met inclusion criteria, of which 3 were randomized controlled trials (RCTs). We evaluated the 3 RCTs using a validity score (PEDro scale). Due to differences in experimental design, data could not be collapsed for meta-analysis. Animal model experiments reinforce theoretical principles for application of MLDTs. When combined with concomitant musculoskeletal therapy, pilot and case studies demonstrate MLDT effectiveness. The best evidence suggests that efficacy of MLDT in sports medicine and rehabilitation is specific to resolution of enzyme serum levels associated with acute skeletal muscle cell damage as well as reduction of edema following acute ankle joint sprain and radial wrist fracture. Currently, there is limited high-ranking evidence available. Well-designed RCTs assessing outcome variables following implementation of MLDTs in treating athletic injuries may provide conclusive evidence for establishing applicable clinical practice guidelines in sports medicine and rehabilitation.