The Effect o f Intermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Mooclie
THE EFFECT OF INTERMITTENT PNEUMATIC COMPRESSION ON THE HAND AFTER FASCIECTOMY E. Z. HAZARIKA, M. T. N. KNIGHT, London and A. FRAZER-MOODIE, Bristol SUMMARY Thirty-nine patients undergoing surgery for Dupuytren's contracture were included in a fully randomised, matched, prospective trial to evaluate the effect of intermittent compression on the post-operative hand. The study revealed a definite improvement in the treated, over the control patients. There was a distinct decrease in oedema with almost immediate return to normal hand function in the group treated by compression. Other benefits accrued from the earlier subsidence of pain in treated hands requiring reduced or no analgesia and from the earlier expression of fluid discharge from the w o u n d thus preventing h a e m a t o m a formation and the consequent ills.
INTRODUCTION It is universally agreed that post-operative oedema of the hand is undesirable. Following surgery, the smooth functioning of the tendons in their sheaths is at stake and is of the utmost importance to the success of the operation. Many methods of managing the hand both during operation and postoperatively have been proposed to prevent oedema and to eliminate the possibility of haematoma formation. These have particularly relied on various modes of splinting and bandaging, on the open palm technique (McCash 1964), and on elevation of the hand (Ward 1976; Ward 1977; Beltran 1976; Noble 1976). The use of a tourniquet during the operation is said to produce increased postoperative oedema as shown in the study undertaken by Ward (1976). Many surgeons have abandoned the use of a tourniquet and now use the elevated hand table which they have found gives an adequately bloodless field while reducing post-operative oedema. However, to many surgeons the tourniquet is still a necessary evil, affording the required operating conditions while followed unavoidably by the increased oedema. All the patients in this study were operated upon using a tourniquet. The trial attempts to show the effects of pneumatic intermittent compression on the hand following fasciectomy. MATERIALS AND METHODS From amongst the thirty-nine patients included in the trial, eleven closely matched pairs were obtained. There were twenty-two hands from twenty-one patients with previously untreated Dupuytren's contracture. The trial was prospective, fully randomised and the patients matched for the nature and degree of involvement, the extent and ease, or otherwise, of operative dissection, type of incision, tourniquet time and other salient features including the age, sex and build of the patient. The patients ranged between forty-six and seventy-six years of age and there were four female and seventeen male patients.
E. Z. Hazarika,Departmentof Surgery,RoyalPostgraduateMedicalSchool,LondonW120HS. The Hand-- Volume 11
No. 3
1979
309
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
Fig. 1. The apparatus in use with the hand within the Compress garment showing the fingers in extension and flexion.
The operation carried out in every case was limited fasciectomy and all but two patients had transverse incisions. The wounds were closed post-operatively using black silk sutures. The hands were allocated to control~ and treated groups by random selection. One patient's left hand served as control to her treated right hand both having undergone fasciectomy. The hands from both groups underwent similar surgery under similar operating conditions. There was no difference in the mean length of tourniquet time between the two groups. Post-operatively, the control hands were managed in the Classical " b o x i n g - g l o v e " dressing and roller towel elevation. The treated hands were loosely dressed with a small strip of gauze over the wound and introduced into the compression garment (Fig. 1) immediately on completion of the operation. The garment comprises a forearm length glove with a bulbous expansion around the hand. There is an inner lining and outer layer, both transparent polyvinyl chloride and, into the space between the two is fed air under pressure from an electrically driven p u m p (Fig. 2). A ringed " p l u g " has been fitted in a safer3 exit valve should the need arise for rapid deflation. The hand is remarkably free to move within the glove at the height of compression (Figs. la and b) and is easily observable through the transparent material. This factor is especially useful to the physiotherapist during periods of exercise. In both groups, finger movement was encouraged as soon as practicable on return to the ward from the operating theatre. Formal physiotherapy sessions also took place equally in the two groups. The electric p u m p (Fig. 2) which constitutes the driving force of the pneumatic intermittent compression is small (6 inches square and 2V2 inches high), neat and compact making it easily portable. Separate outlet ports make it possible to use the same machine for two garments in the same or in two patients. The cycle is of four minutes duration equally divided between inflation and deflation with a fifteen second change-over period. Inflation is held at a constant pressure once the required m a x i m u m is reached. Pressure to be exerted on the hand within the glove is 310
The H a n d - - Volume 11
No. 3
1979
The Effect o f lnterm#tent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
Fig. 2. Flowtron Apparatus.
regulated at the pump by a knob which spans a range between 30 to 80 mmHg. The patient is given a demonstration in the use of the garment pre-operatively. Postoperatively, compression is started at low pressure gradually increasing to the maximum pressure compatible with comfort as the patient gains confidence. A switch on the front o f the machine can turn it on or o f f without manipulating the plug in the wall socket. A red warning light on the facing indicates a leak in the closed circuit of compressed air. The treated patients wore the compression garment almost continuously for between two and six days post-operatively (with one exception) at variable pressure settings between 30 and 80 mmHg. The apparatus was disconnected when necessary, for example during meals and ablutions and sometimes during sleep. Measurement of hand volumes was carried out pre-operatively on admission after the technique of Eccles (1956) wherein the hand, with fingers extended, is immersed in fluid contained in a transparent tank at room temperature. The middle finger is flanked by two vertical extensions from the base. This ensures a constant position of the hand at every measurement. The displaced fluid collects, via a syphon, in a measuring cylinder from which the reading is obtained. All twenty-two hands were measured similarly on the seventh post-operative day. Apart from hand volume measurements, observations on wound discharge and dressing saturation were recorded on each of the first seven post-operative days. Pain and the dispensing of analgesics were similarly recorded. The presence or absence of haematoma in the wound was noted. The Hand-- Volume 11
No. 3
1979
311
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
TABLE 1 COMPARISON OF MEAN PRE- A N D POST-OPERATIVE H A N D VOLUMES IN TREATED AND CONTROL GROUPS OF PATIENTS
Group
No. in Group
Mean Pre-op. Hand vol. (mls)
Mean Post-op. Hand vol. (mls)
Mean diff. (mls)
Treated
11
447.36
453.18
5.82
SEM " t " df
p
3.68 4.15 20
THE EFFECT OF INTERMITTENT PNEUMATIC COMPRESSION ON THE HAND AFTER FASCIECTOMY E. Z. HAZARIKA, M. T. N. KNIGHT, London and A. FRAZER-MOODIE, Bristol SUMMARY Thirty-nine patients undergoing surgery for Dupuytren's contracture were included in a fully randomised, matched, prospective trial to evaluate the effect of intermittent compression on the post-operative hand. The study revealed a definite improvement in the treated, over the control patients. There was a distinct decrease in oedema with almost immediate return to normal hand function in the group treated by compression. Other benefits accrued from the earlier subsidence of pain in treated hands requiring reduced or no analgesia and from the earlier expression of fluid discharge from the w o u n d thus preventing h a e m a t o m a formation and the consequent ills.
INTRODUCTION It is universally agreed that post-operative oedema of the hand is undesirable. Following surgery, the smooth functioning of the tendons in their sheaths is at stake and is of the utmost importance to the success of the operation. Many methods of managing the hand both during operation and postoperatively have been proposed to prevent oedema and to eliminate the possibility of haematoma formation. These have particularly relied on various modes of splinting and bandaging, on the open palm technique (McCash 1964), and on elevation of the hand (Ward 1976; Ward 1977; Beltran 1976; Noble 1976). The use of a tourniquet during the operation is said to produce increased postoperative oedema as shown in the study undertaken by Ward (1976). Many surgeons have abandoned the use of a tourniquet and now use the elevated hand table which they have found gives an adequately bloodless field while reducing post-operative oedema. However, to many surgeons the tourniquet is still a necessary evil, affording the required operating conditions while followed unavoidably by the increased oedema. All the patients in this study were operated upon using a tourniquet. The trial attempts to show the effects of pneumatic intermittent compression on the hand following fasciectomy. MATERIALS AND METHODS From amongst the thirty-nine patients included in the trial, eleven closely matched pairs were obtained. There were twenty-two hands from twenty-one patients with previously untreated Dupuytren's contracture. The trial was prospective, fully randomised and the patients matched for the nature and degree of involvement, the extent and ease, or otherwise, of operative dissection, type of incision, tourniquet time and other salient features including the age, sex and build of the patient. The patients ranged between forty-six and seventy-six years of age and there were four female and seventeen male patients.
E. Z. Hazarika,Departmentof Surgery,RoyalPostgraduateMedicalSchool,LondonW120HS. The Hand-- Volume 11
No. 3
1979
309
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
Fig. 1. The apparatus in use with the hand within the Compress garment showing the fingers in extension and flexion.
The operation carried out in every case was limited fasciectomy and all but two patients had transverse incisions. The wounds were closed post-operatively using black silk sutures. The hands were allocated to control~ and treated groups by random selection. One patient's left hand served as control to her treated right hand both having undergone fasciectomy. The hands from both groups underwent similar surgery under similar operating conditions. There was no difference in the mean length of tourniquet time between the two groups. Post-operatively, the control hands were managed in the Classical " b o x i n g - g l o v e " dressing and roller towel elevation. The treated hands were loosely dressed with a small strip of gauze over the wound and introduced into the compression garment (Fig. 1) immediately on completion of the operation. The garment comprises a forearm length glove with a bulbous expansion around the hand. There is an inner lining and outer layer, both transparent polyvinyl chloride and, into the space between the two is fed air under pressure from an electrically driven p u m p (Fig. 2). A ringed " p l u g " has been fitted in a safer3 exit valve should the need arise for rapid deflation. The hand is remarkably free to move within the glove at the height of compression (Figs. la and b) and is easily observable through the transparent material. This factor is especially useful to the physiotherapist during periods of exercise. In both groups, finger movement was encouraged as soon as practicable on return to the ward from the operating theatre. Formal physiotherapy sessions also took place equally in the two groups. The electric p u m p (Fig. 2) which constitutes the driving force of the pneumatic intermittent compression is small (6 inches square and 2V2 inches high), neat and compact making it easily portable. Separate outlet ports make it possible to use the same machine for two garments in the same or in two patients. The cycle is of four minutes duration equally divided between inflation and deflation with a fifteen second change-over period. Inflation is held at a constant pressure once the required m a x i m u m is reached. Pressure to be exerted on the hand within the glove is 310
The H a n d - - Volume 11
No. 3
1979
The Effect o f lnterm#tent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
Fig. 2. Flowtron Apparatus.
regulated at the pump by a knob which spans a range between 30 to 80 mmHg. The patient is given a demonstration in the use of the garment pre-operatively. Postoperatively, compression is started at low pressure gradually increasing to the maximum pressure compatible with comfort as the patient gains confidence. A switch on the front o f the machine can turn it on or o f f without manipulating the plug in the wall socket. A red warning light on the facing indicates a leak in the closed circuit of compressed air. The treated patients wore the compression garment almost continuously for between two and six days post-operatively (with one exception) at variable pressure settings between 30 and 80 mmHg. The apparatus was disconnected when necessary, for example during meals and ablutions and sometimes during sleep. Measurement of hand volumes was carried out pre-operatively on admission after the technique of Eccles (1956) wherein the hand, with fingers extended, is immersed in fluid contained in a transparent tank at room temperature. The middle finger is flanked by two vertical extensions from the base. This ensures a constant position of the hand at every measurement. The displaced fluid collects, via a syphon, in a measuring cylinder from which the reading is obtained. All twenty-two hands were measured similarly on the seventh post-operative day. Apart from hand volume measurements, observations on wound discharge and dressing saturation were recorded on each of the first seven post-operative days. Pain and the dispensing of analgesics were similarly recorded. The presence or absence of haematoma in the wound was noted. The Hand-- Volume 11
No. 3
1979
311
The Effect o f lntermittent Pneumatic Compression on the Hand after Fasciectomy E. Z. Hazarika, M. T. N. Knight and A. Frazer-Moodie
TABLE 1 COMPARISON OF MEAN PRE- A N D POST-OPERATIVE H A N D VOLUMES IN TREATED AND CONTROL GROUPS OF PATIENTS
Group
No. in Group
Mean Pre-op. Hand vol. (mls)
Mean Post-op. Hand vol. (mls)
Mean diff. (mls)
Treated
11
447.36
453.18
5.82
SEM " t " df
p
3.68 4.15 20
