Neuromuscular electrostimulation viathe common peroneal nerve promotes lower limb blood flow in a below-kneecast: A potential for thromboprophylaxis

Neuromuscular Electrostimulation Increases Microcirculatory Flux in Mixed Etiology Leg Ulcers

OBJECTIVE

To determine if intermittent neuromuscular electrostimulation (NMES) of the common peroneal nerve increases microvascular flow and pulsatility in and around the wound bed of patients with combined venous and arterial etiology.

METHODS

Seven consenting participants presenting with mixed etiology leg ulcers participated in this study. Microvascular flow and pulsatility was measured in the wound bed and in the skin surrounding the wound using laser speckle contrast imaging. Measurements were made at baseline and when the venous pumps of the leg were activated by 1 Hz intermittent neuromuscular stimulation of the common peroneal nerve. The nerve was stimulated transdermally at the head of the fibula.

RESULTS

When activated by NMES, wound bed flux increased by 38% (95% CI, 11%-73%; P = .023), and periwound flux increased by 19% (95% CI, 9%-32%; P = .009). Pulsatility increased in the wound bed by 214% (95% CI, 51%-985%; P = .017) and in the periwound by 122% (95% CI, 38%-299%; P = .014).

CONCLUSIONS

The results indicate that NMES is effective in augmenting microvascular flow in leg ulcers with combined venous and arterial etiology.

Assessing the Quality of Use of Venous Thromboembolism (VTE) Prophylactic Devices for Stroke Patients at Leeds General Infirmary: An Audit and Re-audit

BACKGROUND

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients suffering from stroke. Intermittent pneumatic compression devices (IPCs) and geko™ devices are used to reduce the risk of VTE in patients who have suffered an acute stroke. Correct use of the devices is essential for achieving the reduced risk of VTE.  Objectives: To assess the quality of use of VTE prophylactic devices by observing if they are both applied and working correctly. To identify and address factors that contribute to suboptimal use of VTE prophylactic devices.  Methods: Patients in beds 1-20 in the Acute Stroke Unit at Leeds General Infirmary were assessed on three separate days in June 2024. Data collected included: 'VTE prophylaxis prescribed', 'VTE prophylaxis in place and working correctly?', 'If not, how so?', 'Notes'. Following an intervention, an identical audit was performed three months later. A total of 41 and 42 patients were included in the audit and re-audit, respectively.

RESULTS

The audit included 35 patients who were prescribed IPCs (Kendall SCD™ 700 Smart Compression System) and demonstrated a very poor quality of use, with only 22.9% (n=35) observed to be in place and working correctly. The audit included six patients who were prescribed geko™ devices (Firstkind Ltd.) and found that 50% (n=6) were observed to be in place and working correctly. After a presentation of the results at local clinical governance and implementation of interventions, the re-audit demonstrated a substantial increase in the quality of use of both devices. The re-audit included 36 patients who were prescribed IPCs and six who were prescribed geko™ devices. The percentage of IPC and geko™ devices in place and working correctly increased to 75.0% (n=36, p<0.01) and 88.3% (n=6, p>0.01), respectively.  Conclusions: The intervention focused on increasing staff awareness of the importance of proper use of VTE prophylaxis and awareness of how to use the devices. It is reasonable to conclude that the improvement seen is a result of a change in these factors. To maintain and further improve quality, awareness of the importance of the devices and how to use them must also be maintained and improved. This should be done by additional systematic measures, such as regular training, and should be regularly reassessed.

Continuous muscle pump activation by neuromuscular electrical stimulation of the common peroneal nerve in the treatment of patients with venous leg ulcers: A position paper

The standard treatment for patients with confirmed Venous Leg Ulcers (VLUs) is compression therapy to improve the function of the calf muscle pump. There is a significant cohort of patients who are unable to tolerate optimal compression therapy or indeed any level of compression therapy. In addition, there is a cohort of patients who can tolerate compression whose ulcers show little or no evidence of healing. There is a need for ways to further improve calf muscle pump function and to improve venous ulcer healing in these patients. Published data were reviewed on the use of Muscle Pump Activation (MPA) using common peroneal nerve neuromuscular electrical stimulation (NMES) to improve calf muscle pump function. There is physiological evidence that MPA can improve calf muscle pump function and venous return in both control subjects and in patients with venous disease. The use of MPA has also been shown to improve venous flow volume and venous flow velocity on ultrasound scanning in patients with venous disease. MPA has been shown to improve microcirculation in the skin using Laser Doppler and laser Doppler Speckle Contrast Imaging, in both normal subjects as well as in patients with venous disease and VLU. A recent randomized controlled trial of MPA plus compression therapy compared with compression therapy alone, found significantly faster rates of healing with the use of MPA in addition to compression therapy. There are indications for the use of MPA as an adjunctive treatment to enhance calf muscle pump function in patients with VLU: who cannot tolerate compression therapy who can only tolerate suboptimal, low-level compression whose ulcer healing remains slow or stalled with optimal compression.

The muscle pump activator device: From evidence to lived experiences

A chronic wound is one that fails to progress through a normal timely sequence of repair, or in which the repair process fails to restore anatomic and functional integrity after 3 months. The most common chronic wounds include venous, ischaemic and mixed leg ulcers, diabetic foot ulcers and pressure injuries. Chronic wounds place immense physical and psychosocial burden on patients and exact heavy costs for healthcare systems, with many patients continuing to live with chronic wounds even after all management options have been exhausted. The muscle pump activator (MPA) device can be used to bridge this therapeutic gap. By stimulating the common peroneal nerve to activate venous muscle pump of the leg and foot, the MPA device increases blood flow to the lower leg and foot to improve conditions for healing. Currently, evidence in the literature exist to show that the MPA device improves wound outcomes over standard compression therapy, decreases edema and increases wound healing rates. In this review, we also present a series of chronic wound patients treated with the MPA device in multicentre clinics to demonstrate the ability of the MPA device to improve wound outcomes, reduce pain and edema and improve patient quality of life.

Position- and posture-dependent vascular imaging-a scoping review

OBJECTIVES

Position- and posture-dependent deformation of the vascular system is a relatively unexplored field. The goal of this scoping review was to create an overview of existing vascular imaging modalities in different body positions and postures and address the subsequent changes in vascular anatomy.

METHODS

Scopus, Medline, and Cochrane were searched for literature published between January 1, 2000, and June 30, 2022, incorporating the following categories: image modality, anatomy, orientation, and outcomes.

RESULTS

Out of 2446 screened articles, we included 108. The majority of papers used ultrasound (US, n = 74) in different body positions and postures with diameter and cross-sectional area (CSA) as outcome measures. Magnetic resonance imaging (n = 22) and computed tomography (n = 8) were less frequently used but allowed for investigation of other geometrical measures such as vessel curvature and length. The venous system proved more sensitive to postural changes than the arterial system, which was seen as increasing diameters of veins below the level of the heart when going from supine to prone to standing positions, and vice versa.

CONCLUSIONS

The influence of body positions and postures on vasculature was predominantly explored with US for vessel diameter and CSA. Posture-induced deformation and additional geometrical features that may be of interest for the (endovascular) treatment of vascular pathologies have been limitedly reported, such as length and curvature of an atherosclerotic popliteal artery during bending of the knee after stent placement. The most important clinical implications of positional changes are found in diagnosis, surgical planning, and follow-up after stent placement.

CLINICAL RELEVANCE STATEMENT

This scoping review presents the current state and opportunities of position- and posture-dependent imaging of vascular structures using various imaging modalities that are relevant in the fields of clinical diagnosis, surgical planning, and follow-up after stent placement.

KEY POINTS

• The influence of body positions and postures on the vasculature was predominantly investigated with US for vessel diameter and cross-sectional area. • Research into geometrical deformation, such as vessel length and curvature adaptation, that may be of interest for the (endovascular) treatment of vascular pathologies is limited in different positions and postures. • The most important clinical implications of postural changes are found in diagnosis, surgical planning, and follow-up after stent placement.

The impact of a new intervention for venous leg ulcers: A within-patient controlled trial

A major obstacle to the development of new treatments for venous leg ulcers is the difficulty in generating evidence for their effectiveness. Randomised controlled trials using complete healing as the endpoint are seldom powered to be successful, owing to the heterogeneity of cohorts. A novel approach to the evaluation of treatments is presented, using a self-controlled trial model and two metrics of short-term healing rate as alternate endpoints: rate of wound margin advance, and percentage area reduction over 4 weeks. Two different treatment regimens are compared: multi-layer compression alone, versus multi-layer compression combined with activation of the venous leg pump by neuromuscular stimulation. With 60 patients, adding neuromuscular stimulation to multilayer compression resulted in a significant two-fold increase in the rate of wound healing over a 4-week period, both in terms of wound margin advance and in terms of percentage area reduction. The use of these short-term intermediate endpoint metrics together with a self-controlled study design offers potential for distinguishing between the relative efficacies of interventions more rapidly, with greater sensitivity, and with fewer subjects than a conventional RCT cohort model.

Clinical Study of Neuromuscular Electrical Stimulation in the Prevention of Deep Venous Thrombosis of Lower Extremities after Anterior Cruciate Ligament Reconstruction

This paper is written to observe the clinical effects of "neuromuscular electrical stimulation in the prevention of deep venous thrombosis of lower extremities after anterior cruciate ligament reconstruction" in our department. Data from March 2018 to March 2021 was selected including 187 males and 91 females. They were randomly divided into experimental groups and control groups. The experimental group adopted DVT general prevention + basic physical prevention + NMES and the control group adopted DVT general prevention + basic physical prevention. The VAS score, the content of blood D-dimer, the circumference of the affected knee, and results of DVT color ultrasound screening were studied in each group on the first day before operation and the fourth day after the operation. Results obtained showed that there were no significant differences in the baseline characteristics of the two groups of patients, such as gender composition, age, and so on (P > 0.05). The VAS scores, blood D-dimer content, and knee circumference of each group on the day before and on the fourth day after surgery were observed. Diameter and DVT color Doppler ultrasound screening results were superior to the control group in the test group and the difference was statistically significant (P < 0.05). It was concluded that NMES can effectively reduce the pain, knee swelling, and incidence of DVT in patients after ACL reconstruction. It is a simple and effective intervention therapy to prevent the occurrence of DVT.

Comparison of the Hemodynamic Performance of Two Neuromuscular Electrical Stimulation Devices Applied to the Lower Limb

Currently, 1% of the population of the Western world suffers from venous leg ulcers as a result of chronic venous insufficiency. Current treatment involves the use of moist wound healing, compression bandages, and intermittent pneumatic compression. Neuromuscular electrical stimulation is a novel potential new therapeutic method for the promotion of increased lower limb hemodynamics. The aim of this study was to measure the hemodynamic changes in the lower limb with the use of two neuromuscular electrical stimulation devices. Twelve healthy volunteers received two neuromuscular stimulation device interventions. The Geko^TM and National University of Ireland (NUI) Galway neuromuscular electrical stimulation devices were randomized between dominant and non-dominant legs. Hemodynamic measurements of peak venous velocity (cm/s), the time average mean velocity (TAMEAN) (cm/s), and ejected volume (mL) of blood were recorded. Peak venous velocity was significantly increased by the Geko^TM and the NUI Galway device compared to baseline blood flow (p < 0.0001), while only the voluntary contraction produced significant increases in TAMEAN and ejected volume (both p < 0.05). Neuromuscular muscular electrical stimulation can produce adequate increases in lower limb hemodynamics sufficient to prevent venous stasis. Greater use of neuromuscular stimulation devices could be considered in the treatment of conditions related to chronic venous insufficiency but requires further research.

Effects of graduated compression stockings, local vibration and their combination on popliteal venous blood velocity

Objectives

The purpose of this pilot study was to examine and compare the effects of graduated compression stockings, local vibration, and combined graduated compression stockings and local vibration on popliteal venous blood velocity.

Method

Twenty-four healthy subjects received four 15 min interventions (control, graduated compression stockings alone, local vibration alone, and combined graduated compression stockings and local vibration), while resting inactive in the prone position. Popliteal vein blood velocity was investigated before (PRE) and at the end (POST) of each intervention using Doppler ultrasound.

Results

At POST, peak velocity was reported to be 26.3 ± 53.5% ( p <  0.05) greater for local vibration than control (CONT). Peak velocity was 46.2 ± 54.6% ( p <  0.001) and 21.1 ± 37.6% ( p <  0.01) higher for graduated compression stockings than CONT and local vibration, respectively. Graduated compression stockings + local vibration presented 64.1 ± 58.0% ( p <  0.001), 38.4 ± 52.4% ( p <  0.001) and 15.0 ± 31.6% ( p <  0.05) greater values than CONT, local vibration and graduated compression stockings, respectively.

Conclusions

This study demonstrated an increase in popliteal venous blood velocity after graduated compression stockings and local vibration application. Their combination provided the greatest effects.

Electrical stimulation devices for the prevention of venous thromboembolism: Preliminary studies of physiological efficacy and user satisfaction

Introduction

Electrical stimulation could provide an alternative method for preventing venous thromboembolism in stroke patients. The purpose of this preliminary study was to explore the effects of electrical stimulation and intermittent pneumatic compression on enhancing lower limb venous return in healthy and chronic stroke patients and also to evaluate patient and nurse satisfaction.

Methods

We investigated the effectiveness of two electrical stimulation devices: Geko (Firstkind Ltd, High Wycombe, UK) and Orthopaedic Microstim 2V2 (Odstock Medical Ltd, Salisbury, UK); and one intermittent pneumatic compression device: Huntleigh Flowstron Universal (Huntleigh Healthcare Ltd, Cardiff, UK). We recruited 12 healthy and 5 chronic stroke participants. The devices were fitted sequentially, and Doppler ultrasound measurements were taken. Eight patients and nurses were also recruited for a separate usability evaluation.

Results

The electrical stimulation devices emulated the blood flow characteristics of intermittent pneumatic compression in both healthy and stroke participants provided that the intensity of electrical stimulation was sufficient. Patients and nurses also felt that the electrical stimulation devices were acceptable.

Conclusions

Electrical stimulation may offer benefit as an alternative method for venous thromboembolism prevention in stroke patients. The apparent benefit is sufficient to warrant further investigation in a full powered randomised controlled trial.

Neuromuscular electrical stimulation reduces sludge in the popliteal vein

BACKGROUND

The common peroneal nerve stimulator (CPNS) is a UK-approved device for reducing venous thromboembolism (VTE) risk. It resembles a wrist watch and is placed over the common peroneal nerve, discharging electricity at a rate of 1 impulse/s. It has been presumed that as blood flow slows, erythrocytes aggregate into ultrasound-detectable echogenic particles, described as venous sludge. The aim of the study was to determine whether the CPNS reduces venous sludge by using an ultrasound-derived gray-scale (0-255) venous sludge index (VSI).

METHODS

Twenty-five healthy volunteers had their right popliteal vein video recorded using B-mode ultrasound at 22 frames/s in longitudinal and transverse views, standing and lying. This was performed first with the CPNS off and then with the CPNS on. The CPNS impulse intensity used was set from 1 to 7 for each individual, and the level was sufficient to cause an outward jerking movement of the foot. A single frame of the possible 154 frames, lasting 7 seconds, was selected using a random number generator for the image analysis. The "brightness" of the erythrocyte aggregates (pixels) within a circular sampling area was quantified using the VSI. The brighter the sample, the greater the sludge.

RESULTS

Values are expressed as median (interquartile range). On standing with the device off, there was a significantly higher VSI (P < .0005) compared with lying (longitudinal view, 27.7 [18.8-41.4] vs 11.7 [5.5-17.5]; transverse view, 20.7 [13.6-32.2] vs 11.4 [6.3-15.9]). Activation of the CPNS significantly reduced all the VSI values (P < .0005) shown (longitudinal view, 2 [1.1-3.2] and 1.5 [0.5-3.1]; transverse view, 1.1 [0.6-2.7] and 0.8 [0.5-2.1]).

CONCLUSIONS

The CPNS device significantly reduces venous sludge within the popliteal vein irrespective of whether the subject is standing or lying down or of the longitudinal or transverse position of the ultrasound transducer. The principal mode of action of the device in the claim that it may reduce venous thromboembolism risk may be through a reduction of venous sludge. However, the relationship between erythrocyte aggregation, venous stasis, and venous thromboembolism risk requires more investigation.

Neuromuscular electrical stimulation for the prevention of venous thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a serious but preventable cause of morbidity and mortality. Neuromuscular electrical stimulation systems (NMES) for the prevention of VTE may be beneficial for patients in whom pharmacological or standard mechanical prophylaxis methods are contraindicated or are regarded as unsafe or impractical. Although findings of experimental studies suggest that NMES reduce venous stasis, the clinical utility and effectiveness of NMES in VTE prevention remain controversial.

OBJECTIVES

To assess the effectiveness of neuromuscular electrical stimulation in the prevention of venous thromboembolism.

SEARCH METHODS

The Cochrane Vascular Group Information Specialist (CIS) searched the Specialised Register (22 March 2017) and the Cochrane Central Register of Controlled Studies (CENTRAL (2017, Issue 2)). The CIS also searched trial registries for details of ongoing and unpublished studies. The review authors searched the bibliographic lists of relevant articles and reviews to look further for potentially eligible trials.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) and quasi-randomised trials that compared any form of neuromuscular electrical stimulation as an intervention for VTE prophylaxis (alone or combined with pharmacological or other mechanical methods) versus no prophylaxis and other mechanical or pharmacological methods of VTE prophylaxis.

DATA COLLECTION AND ANALYSIS

At least two independent review authors were involved in study selection, data extraction, methodological quality assessment of included studies, and data analysis. We resolved disagreements by discussion between the two review authors. If no agreement could be reached, a third review author acted as an adjudicator. The main outcomes of the review were total deep vein thrombosis (DVT), symptomatic and asymptomatic DVT, pulmonary embolism (PE), total VTE and bleeding (major and minor). The quality of evidence was assessed using the GRADE approach and is indicated in italics.

MAIN RESULTS

We included in the review five randomised controlled trials and three quasi-randomised trials, enrolling a total of 904 participants. Among these, four studies included patients undergoing major surgical procedures; one study included patients undergoing surgery for hip fracture under spinal anaesthesia; one study included trauma patients with a contraindication for prophylactic heparin; one study included neurosurgical patients who were operated on under general anaesthesia; and one study included patients with non-functional spinal cord injuries. Overall, eight studies investigated 22 treatment arms. Four studies compared the NMES arm with a no prophylaxis arm, and five studies compared the NMES arm with alternative methods of prophylaxis arms. Alternative methods of prophylaxis included low-dose heparin (5000 IU subcutaneously) - two studies, Dextran 40 - one study, graduated compression stockings (GCS) and intermittent pneumatic compression devices (IPCD) - one study. One study compared combined NMES and low-dose heparin versus no prophylaxis or low-dose heparin alone.We found no clear difference in risks of total DVT (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.60 to 1.70, P = 0.98; 6 studies, 415 participants; low-quality evidence), asymptomatic DVT (OR 1.61, 95% CI 0.40 to 6.43, P = 0.50; 1 study, 89 participants; low-quality evidence), symptomatic DVT (OR 0.40, 95% CI 0.02 to 10.07, P = 0.58; 1 study, 89 participants; low-quality evidence), PE (OR 1.31, 95% CI 0.38 to 4.48, P = 0.67; 2 studies, 126 participants;low-quality evidence), and total VTE (OR 0.92, 95% CI 0.34 to 2.52, P = 0.88; 1 study, 72 participants; low-quality evidence) between prophylaxis with NMES and alternative methods of prophylaxis. None of the studies in this comparison reported bleeding.Compared with no prophylaxis, NMES showed lower risks of total DVT (OR 0.40, 95% CI 0.23 to 0.70, P = 0.02; 4 studies, 576 participants; moderate-quality evidence) and total VTE (OR 0.23, 95% CI 0.09 to 0.59, P = 0.002; 1 study, 77 participants; low-quality evidence). Data show no clear differences in risk of asymptomatic DVT (OR 0.32, 95% CI 0.06 to 1.62, P = 0.17; 1 study, 200 participants; low-quality evidence), symptomatic DVT (OR 0.06, 95% CI 0.00 to 1.36, P = 0.08; 1 study, 160 participants;low-quality evidence), or PE (OR 0.36, 95% CI 0.12 to 1.07, P = 0.07; 1 study, 77 participants; low-quality evidence) between prophylaxis with NMES and no prophylaxis. None of the studies in this comparison reported bleeding.In comparison with low-dose heparin, NMES was associated with higher risk of total DVT (OR 2.78, 95% CI 1.19 to 6.48, P = 0.02; 2 studies, 194 participants; low-quality evidence), but data were inadequate for other comparisons (NMES vs Dextran 40, NMES vs GCS, or NMES vs IPCD) and for other clinical outcomes such as symptomatic or asymptomatic DVT, PE, total VTE, and bleeding in individual comparisons.Overall, we judged the quality of available evidence to be low owing to high or unclear risk of bias and imprecise effect estimates due to small numbers of studies and events.

AUTHORS' CONCLUSIONS

Low-quality evidence shows no clear difference in the risk of DVT between NMES and alternative methods of prophylaxis but suggest that NMES may be associated with lower risk of DVT compared with no prophylaxis (moderate-quality evidence) and higher risk of DVT compared with low-dose heparin (low-quality evidence). The best available evidence about the effectiveness of NMES in the prevention of VTE is not adequately robust to allow definitive conclusions. Adequately powered high-quality randomised controlled trials are required to provide adequately robust evidence.

Venous Thromboprophylaxis With Neuromuscular Stimulation: Is It Calf Muscle Pumping or Just Twitches and Jerks?

The common peroneal nerve stimulator (CPNS) is a UK-approved device for reducing venous thromboembolism risk. It resembles a wrist watch and is placed over the common peroneal nerve to fire at 1 electrical impulse/sec. The aim was to quantify the claim that it drives the venous muscle pump and imitates walking. Twelve healthy volunteers performed 10 tip-toe maneuvers and 10 ankle dorsiflexions to imitate walking movements. The reductions in calf volume were recorded using air plethysmography (APG). The common peroneal nerve was stimulated for over 10 seconds at each of the 7 increasing electrical impulse settings, and the volume reductions were measured for comparison. The results are expressed as median (interquartile range) absolute (mL), and percentage reduction in calf volume. Tip-toe and dorsiflexion pumping maneuvers were not significantly different: 59 (33.6-96.1), 81.9% vs 51.4 (34-68.5), 59.7%, respectively ( P = .53). However, they both outperformed the CPNS: 10.8 (7.3-18), 13.2% at P = .002 and P = .002, respectively. Qualitatively, the CPNS registered on the tracings as a small spike (muscle twitch) at low settings, with larger amplitudes (ankle jerk) at higher settings. The CPNS activity spikes were discrete, lasting a median (range) of 0.24 (0.16- .3) seconds. The claim that the CPNS empties veins by pumping is supported statistically. However, the amount is small versus the tip-toe and dorsiflexion maneuvers. Furthermore, the CPNS has a short activity profile on the APG trace. Innovations that produce sustained contraction and involve the posterior calf compartments may improve pumping.

Clinical and Functional Results of 119 Patients With Knee Dislocations

OBJECTIVES

To describe clinical results and functional outcomes of knee dislocations treated with a consistent strategy within our institution.

DESIGN

Retrospective case series.

SETTING

Level 1 trauma center.

PATIENTS

One hundred nineteen patients were treated at one institution between 2000 and 2014 for knee dislocation.

MAIN OUTCOME MEASUREMENTS

Knee range of motion, functional instability, and complications were recorded. Musculoskeletal Function Assessment (MFA) and Lysholm scores were obtained after minimum of 1 year.

RESULTS

Sixty-three early complications were noted in 36 patients (32%), with an overall amputation rate of 9.2% (8 early and 3 late amputations). Of the patients who retained their limb, 4.5% reported instability. Open knee dislocations were associated with amputation (26% vs. 1.3%, P < 0.001). Popliteal arterial injuries were associated with more amputation (31% vs. 3.2%, P = 0 < 0.001), infection (37% vs. 8%, P = 0.002), and deep venous thrombosis (32% vs. 8.8%, P = 0.014). Patients with wound infection were more likely to develop heterotopic ossification (36% vs. 9.4%, P = 0.017) and less knee motion (77.5 vs. 117 degrees P = 0.049). Knee motion improved over time for all patients with a mean arc of 86 degrees at 3 months, 109 degrees at 6 months, and 115 degrees at 12 months. An Injury Severity Score of ≥20 was associated with less knee motion (97 vs. 121 degrees P = 0.029). Mean Lysholm score was 86.7, and mean MFA score was 35.7 after mean follow-up of 90 months and 82 months, respectively.

CONCLUSIONS

Few patients (4.5%) experienced functional instability. However, early complications occurred frequently (32%) as expected, particularly in patients with open injuries and/or arterial injury. Limitations in knee motion were associated with high Injury Severity Score, infection, and heterotopic ossification. Mean knee scores were good, consistent with reasonable knee function, although MFA scores suggest a lower level of generalized function.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Augmentation of arterial blood velocity with electrostimulation in patients with critical limb ischemia unsuitable for revascularization

Aim

This pilot study aimed to reveal whether combination of electrostimulation with iloprost treatment achieves better results compared to iloprost alone in patients with critical limb ischemia.

Material and methods

Patients were randomized into Group 1 ( n = 11, mean age: 65.3 ± 4.2 years, received iloprost infusion protocol alone) or Group 2 ( n = 11, mean age: 62.9 ± 6.7, received iloprost infusion plus standardized protocol of peroneal nerve electrostimulation). Electrostimulation was delivered with 1 Hz frequency, 27 mA current, and 200 ms pulse width. Peak blood flow velocities in the anterior and posterior tibialis arteries were measured with duplex ultrasound.

Results

There was a slight insignificant increase in blood velocity in anterior tibialis artery in Group 1 (from 17.6 ± 13.0 to 18.6 ± 13.1, p = 0.57), whereas the increase in Group 2 was marked (from 23.8 ± 18.3 to 32.2 ± 19.7, p = 0.01). Blood velocity in posterior tibialis artery also increased in both groups, but it was not of statistical significance. No significant difference was found between two groups in regard to final pulse oximetry oxygen saturation levels.

Conclusion

Electrostimulation of the peroneal nerve caused a substantial increase in anterior tibialis artery blood velocity when used as an adjunct to medical therapy in patients with critical limb ischemia.

The comparative hemodynamic efficacy of lower limb muscles using transcutaneous electrical stimulation

BACKGROUND

Circulation in the limbs can be augmented using transcutaneous electrical stimulation devices. The optimum muscle stimulation sites for enhancement of vascular hemodynamic parameters have not been identified.

METHODS

Seven suitable anatomic sites were identified within the right leg. Twelve healthy participants were recruited (mean age, 23.1 ± 3 years; body mass index, 23.1 ± 3 kg/m(2)). Muscles were stimulated by transcutaneous bipolar electrodes at a current twice their motor threshold, at 1 Hz, for 5 minutes. Hemodynamic ultrasound measurements were taken from the right femoral vein. Laser Doppler measurements from the feet of the stimulated and nonstimulated sides were obtained. Baseline measurements were compared with readings after 5 minutes of stimulation, with device active. Discomfort experienced for stimulation of each muscle was rated out of 100.

RESULTS

Hemodynamic changes displayed large intersubject variation, with no muscle statistically superior to the others. All muscles increased peak velocity; contraction of medial gastrocnemius increased time-averaged maximum velocity and volume flow. All muscles increased foot fluximetry (P < .05). Discomfort correlated weakly with current applied. Tibialis anterior and vastus lateralis were most tenable.

CONCLUSIONS

Transcutaneous stimulation increases hemodynamic parameters significantly, locally and systemically. No optimum stimulation site has been identified, and it is limited by comfort and variability in the subject's response. Gastrocnemius, tibialis anterior, and vastus lateralis all provoke large changes in hemodynamic parameters, but clinical efficacy in disease prevention and management has not been explored.

Two Cases of Transcutaneous Electrical Nerve Stimulation of the Common Peroneal Nerve Successfully Treating Refractory, Multifactorial Leg Edema

The treatment of leg edema often involves promoting venous blood flow but can be difficult in patients with comorbidities that prevent traditional management strategies such as limb elevation or mechanical compression devices. The geko device is a self-contained neuromuscular stimulation device that adheres to skin over the common peroneal nerve and delivers a low-voltage stimulus that activates the lower-leg musculature resulting in enhanced superficial femoral vein blood flow and velocity. Here we report 2 cases of multifactorial and refractory leg edema successfully treated with the geko device over a period of 4 to 16 weeks. The device also improved pain and chronic wound healing. Although the geko device is costly, it was well tolerated and may provide another treatment strategy for resistant leg swelling.

A multicentre retrospective review of muscle necrosis of the leg following spinal surgery with motor evoked potential monitoring: a cause for concern?

PURPOSE

There are very few reported cases of compartment syndrome of the leg following spinal surgery via a posterior approach. An association between compartment syndrome and muscle over-activity via nerve stimulation during evoked potential monitoring was first suggested in 2003. No further reports have suggested this link. We present a multicentre retrospective review of a series of five patients who developed compartment syndrome of the leg following spinal surgery via a posterior approach, whilst un-paralysed and with combined sensory (SSEP)/motor evoked potential (MEP) monitoring with an aim of highlighting this possible causative factor.

METHODS

All data were collected contemporaneously and retrospective analysis was performed. We then arranged for a multidisciplinary review of the cases including surgeons, anaesthetists, radiologists, neurophysiologists and theatre and ward nursing staff. Finally, the literature was reviewed.

RESULTS

All patients were operated on by three different surgeons, on different operating tables/mattresses in the prone position. The common factors were un-paralysed patients having motor/sensory monitoring, mechanical calf pumps and total intravenous anaesthesia. Three patients underwent surgical decompression of their compartments and two were treated expectantly. Three patients had confirmed intra-compartmental changes on MRI consistent with compartment syndrome and one had intra-compartmental pressure monitoring which confirmed the diagnosis.

CONCLUSIONS

Previous cases in the literature have related to mal-positioning on the Jackson table or use of the knee-chest position for surgery. This was not the case for our patients; therefore, we suspect an association between overactive muscle stimulation and muscle necrosis. Further experimental studies investigating this link are required.

Potential role of electrostimulation in augmentation of venous blood flow after total knee replacement: A pilot study

Aim

To investigate the potential role of a novel electrostimulation device in augmenting the femoral vein venous blood flow following total knee replacement surgery.

Material and methods

A total of 30 consecutive patients undergoing total knee replacement were allocated to receive either peroneal nerve electrostimulation plus low molecular weight heparin and below-knee compression stockings (Group 1, electrostimulation group, n = 15, mean age: 63.40 ± 5.91 years, male: female ratio 9:6) or low molecular weight heparin and below-knee compression stockings alone (Group 2, control group, n = 15, mean age: 63.86 ± 7.47 years, male: female ratio 8:7). Electrostimulation was performed for 1 h in every 4 h after the operation. Peak blood velocity in the femoral vein was evaluated with Duplex ultrasonongraphy in supine position. Presence of leg edema and calf diameter was also taken into consideration as outcome measures, which were recorded both before surgery and at the time of discharge from hospital.

Results

Postoperative peak blood flow velocity in the femoral vein was significantly higher in electrostimulation group compared to control group (17.46 ± 2.86 cm/s vs. 13.84 ± 3.58 cm/s, p < 0.02). Electrostimulation group achieved a significant increase in peak blood flow velocity in the femoral vein after the operation (mean increase 67.48 ± 17.38%, p < 0.001).

Conclusion

Electrostimulation of the common peroneal nerve enhanced venous flow in the lower limb and may potentially be of use as a supplementary technique in deep venous prophylaxis following lower limb orthopedic operations.

The geko™ electro-stimulation device for venous thromboembolism prophylaxis: a NICE medical technology guidance

The geko™ device is a single-use, battery-powered, neuromuscular electrostimulation device that aims to reduce the risk of venous thromboembolism (VTE). The National Institute for Health and Care Excellence (NICE) selected the geko™ device for evaluation, and invited the manufacturer, Firstkind Ltd, to submit clinical and economic evidence. King's Technology Evaluation Centre, an External Assessment Centre (EAC) commissioned by the NICE, independently assessed the evidence submitted. The sponsor submitted evidence related to the geko™ device and, in addition, included studies of other related devices as further clinical evidence to support a link between increased blood flow and VTE prophylaxis. The EAC assessed this evidence, conducted its own systematic review and concluded that there is currently limited direct evidence that geko™ prevents VTE. The sponsor's cost model is based on the assumption that patients with an underlying VTE risk and subsequently treated with geko™ will experience a reduction in their baseline risk. The EAC assessed this cost model but questioned the validity of some model assumptions. Using the EACs revised cost model, the cost savings for geko™ prophylaxis against a 'no prophylaxis' strategy were estimated as £197 per patient. Following a second public consultation, taking into account a change in the original draft recommendations, the NICE medical technologies guidance MTG19 was issued in June 2014. This recommended the adoption of the geko™ for use in people with a high risk of VTE and when other mechanical/pharmacological methods of prophylaxis are impractical or contraindicated in selected patients within the National Health Service in England.

Neuromuscular electrical stimulation for thromboprophylaxis: A systematic review

OBJECTIVE

To evaluate the effect of neuromuscular electrical stimulation on lower limb venous blood flow and its role in thromboprophylaxis.

METHOD

Systematic review of randomised and non-randomised studies evaluating neuromuscular electrical stimulation, and reporting one or more of the following outcomes: incidence of venous thromboembolism, venous blood flow and discomfort profile.

RESULTS

Twenty-one articles were identified. Review of these articles showed that neuromuscular electrical stimulation increases venous blood flow and is generally associated with an acceptable tolerability, potentially leading to good patient compliance. Ten comparative studies reported DVT incidence, ranging from 2% to 50% with neuromuscular electrical stimulation and 6% to 47.1% in controls. There were significant differences, among included studies, in terms of patient population, neuromuscular electrical stimulation delivery, diagnosis of venous thromboembolism and blood flow measurements.

CONCLUSION

Neuromuscular electrical stimulation increases venous blood flow and is well tolerated, but current evidence does not support a role for neuromuscular electrical stimulation in thromboprophylaxis. Randomised controlled trials are required to investigate the clinical utility of neuromuscular electrical stimulation in this setting.

Efficacy and safety of flurbiprofen axetil in the prevention of pain on propofol injection: a systematic review and meta-analysis

Background

Pain on injection is an acknowledged adverse effect (AE) of propofol administration for the induction of general anesthesia. Flurbiprofen axetil has been reported to reduce the pain of injection. However, results of published papers on the efficacy of flurbiprofen axetil in managing pain on injection of propofol are inconsistent.

Material/Methods

We conducted a comprehensive meta-analysis of studies to appraise the efficacy and safety of flurbiprofen axetil for controlling pain induced by propofol injection. The pooled risk ratio (RR) with corresponding 95% confidence intervals (CI) was calculated employing fixed- or random-effects models, depending upon the heterogeneity of the included trials.

Results

Compared with the placebo group, flurbiprofen axetil allows more patients to have no pain (RR 3.51, 95% CI 2.22–5.55, p=0.000), and decreases the cumulative number of patients with mild, moderate, and severe pain on injecting propofol (RR 0.70, 95% CI 0.58–0.86, p=0.000; RR 0.59, 95% CI 0.46–0.75, p=0.000; RR 0.25, 95% CI 0.16–0.38, p=0.000, respectively). In the stratified analysis by the doses, flurbiprofen axetil at a dose of over 50 mg was found to be effective in reducing propofol-induced pain on injection; however, there were no significant differences in relieving pain between treatment and placebo groups with flurbiprofen axetil at a dose of 25 mg. In terms of drug safety, there were no adverse effects (AEs) reported between flurbiprofen axetil-based regimens and placebo regimens.

Conclusions

Flurbiprofen axetil, an injectable prodrug of flurbiprofen, can significantly prevent or relieve the pain induced by propofol injection. More studies are required to assess its adverse effects.