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COMPRESSION FOR LYMPHOEDEMA
896
Abduction-extension osteotomy appears to be useful as a salvage procedure in a small number of patients whose progress is poor in the early stages of Perthes’ disease. Most children with Perthes’ disease seem to do well in the short term, whatever method of treatment is used. The presence or absence of risk factors may be useful in deciding whether a varus-rotation osteotomy is advisable. In the long term osteotomy can be justified only by evidence that it eventually reduces the risk of osteoarthritis of the hip. A prospective trial could resolve this question, perhaps by comparing the results of osteotomy and splintage, although this may prove difficult since there is no general agreement about the best type of splint or how long splintage should be maintained. Meanwhile the somewhat unsatisfactory conclusion is that there is no best buy in the treatment of Perthes’ disease.
COMPRESSION FOR LYMPHOEDEMA LYMPHOEDEMA may be
primary, commonly due to congenital lymphatic hypoplasia and usually involving the lower limb, or secondary, which in developed countries is most often due to surgical removal of draining lymph nodes, when either upper
or
lower limbs may be affected. Whether
primary or secondary it is a tiresome, cosmetically unsightly, and mechanically embarrassing condition for which treatment is unsatisfactory. The patient may be unable to wear normal clothing because of limb bulk, and the weight of a lymphoedematous leg or arm often leads to aching and fatigue with impaired joint function. Other complications such as recurrent cellulitis are common. Some patients with severe lymphoedema may be suitable for one of the surgical reduction procedures aimed at removing the oedematous thickened subcutaneous tissue; with suitable selection, excellent results may be obtained. In mild cases, by contrast, little more than explanation and reassurarice is needed, perhaps with nocturnal raising of the foot of the bed and some form of elastic support hose. In women averse to wearing elastic stockings by day, control can commonly be achieved if they are worn only at night. The aim is to achieve a normal sized limb on waking in the morning even if some swelling recurs throughout the day. In the upper limb the milder forms of secondary lymphoedema usually require no treatment, but a more bulky limb may be helped with an elastic arm stocking. There remains a group of patients who have bulky oedematous limbs, poorly responsive to the simple measures previously outlined, and unsuitable for reduction surgery, in whom symptoms are moderately disabling. It is in this group of patients that various types of external compression therapy have been tried. These include tight bandaging with heavyduty bandages (eg, "blue line"), compression by a spirally wound rubber tube,2 graduated compression elastic stockings (’Sigvaris’, ’Struva’, ’Jobst’, &c), and various machines that massage the limb with inflatable bags. In the earlier machines the bag used was of the single chamber type (’Flowtron’, Jobst). Such machines were originally devised to provide intermittent compression of the legs during surgery, for the primary prevention of deep-vein thrombosis. The adaptation of these machines for use in lymphoedema was described 20 years ago3 and has continued with mixed 1 Chilvers
AS, Kinmonth JD Operations for lymphoedema of the lower limbs J Cardiovasc Surg 1975; 16: 115-19 2 Van der Molen HR, Toth LM The conservative treatment of lymphoedema of the extremities. Angiology 1974, 25: 470-83. 3 Sanderson RG, Fletcher WS Conservative management of primary lymphoedema. Northwest Med 1965, 64: 584-88
enthusiasm over the intervening years.’ Improvement in the oedema can often be obtained by regular use of such machines, especially in those patients in whom the oedema still pits on pressure, but the degree of reduction commonly fails to live up to the patients expectations. Even when the apparatus for home use, few continue to patients purchase 5 use it for long. The main disadvantages of the single-chamber device are the even distribution of pressure in all directions, so that only part of this is transmitted proximally, and the long duration of the pressure cycle, which makes the use of high pressure very uncomfortable. Increasing the peak pressure slightly to 60 mm Hg and shortening the cycle to 30 seconds may 4 improve the results.4 The disadvantages of the single-bag machine led Zelikovski and his colleagues6,-, to develop the ’Lympha-Press’. This instrument consists of a sleeve that is closely fitted over the limb and contains a series of individual inflatable cells, each overlapping the next, with a single cell for the foot. A pressure cycle is applied in such a way that they are inflated in turn from the foot upwards until all are distended. After 2 seconds of complete inflation all cells are automatically deflated and the cycle begins again. The cycle is short enough to allow 80-130 mm Hg without discomfort. The number of cells in the sleeve is varied from nine to twelve according to limb length, and the device can be used on the arm as well as the leg. Periods of treatment are 6-8 hours. Richmond, O’Donnell, and Zelikovski have lately reported a prospective study with the lympha-press in 25 lymphoedematous limbs-18 lower limbs, 9 with primary and 9 with secondary lymphoedema; and 7 upper limbs with secondary lymphoedema. In the lower limb, reduction of volume was 37% at the ankle, 47% at mid-calf, and 3107o at mid-thigh. For the upper limb the figures were 45% at wrist, 28% at mid-forearm, and 25% at mid-arm. In about halfofthe patients most of the reduction following one treatment was maintained over several months, best results being obtained in those patients who were diligent in nocturnal limt elevation and in the wearing of proper elastic compression hose. Repeated treatments produced the best long-term results. This report shows clearly that, in most patients, good and sometimes spectacular reductions in limb volume can be obtained without surgical treatment by the use of graduated pneumatic massage and subsequent maintenance by the diligent use of elastic compression hose; but experience in the UK points to two drawbacks.’The first is expense. Outside of specialist units, most hospitals will see only a few of these patients and the purchase will be hard to justify, and the average patient will be unable to afford a machine for home use. The second disadvantage results from difficulty of applying the multicompartment stockings; many patients will find the technique beyond them. Despite these disadvantages, moderate to severe lymphoedema is unsightly and disabling and a non-invasive technique which is capable of effecting considerable improvement ought to be more widely available for trial than it is at present. JK, O’Donnell TF, Kalisher L, et al Selection of patients with lymphoedema for compression therapy Am J Surg 1977, 133: 130-36 5. Kmmonth JB. The lymphatics. 2nd ed. London: Edward Arnold, 1982: 322. 6 Zelikovski A, Manoach M, Giler S, et al Lympha-Press A new pneumatic device for the treatment of lymphedema of the limbs Lymphology 1980, 13: 68-73 7 Zelikovski A, Melamed I, Kott M, et al The ’Lympha-Press’ A new pneumatic device for the treatment of lymphedema Clinical trial and results. Folia Angiol 1980, 28:
4 Raines
165-69. 8 Richmond DM, O’Donnell
TF, Zelikovski A Sequential pneumatic compression for
lymphedema. Arch Surg 1985,
120: 1116-19
Abduction-extension osteotomy appears to be useful as a salvage procedure in a small number of patients whose progress is poor in the early stages of Perthes’ disease. Most children with Perthes’ disease seem to do well in the short term, whatever method of treatment is used. The presence or absence of risk factors may be useful in deciding whether a varus-rotation osteotomy is advisable. In the long term osteotomy can be justified only by evidence that it eventually reduces the risk of osteoarthritis of the hip. A prospective trial could resolve this question, perhaps by comparing the results of osteotomy and splintage, although this may prove difficult since there is no general agreement about the best type of splint or how long splintage should be maintained. Meanwhile the somewhat unsatisfactory conclusion is that there is no best buy in the treatment of Perthes’ disease.
COMPRESSION FOR LYMPHOEDEMA LYMPHOEDEMA may be
primary, commonly due to congenital lymphatic hypoplasia and usually involving the lower limb, or secondary, which in developed countries is most often due to surgical removal of draining lymph nodes, when either upper
or
lower limbs may be affected. Whether
primary or secondary it is a tiresome, cosmetically unsightly, and mechanically embarrassing condition for which treatment is unsatisfactory. The patient may be unable to wear normal clothing because of limb bulk, and the weight of a lymphoedematous leg or arm often leads to aching and fatigue with impaired joint function. Other complications such as recurrent cellulitis are common. Some patients with severe lymphoedema may be suitable for one of the surgical reduction procedures aimed at removing the oedematous thickened subcutaneous tissue; with suitable selection, excellent results may be obtained. In mild cases, by contrast, little more than explanation and reassurarice is needed, perhaps with nocturnal raising of the foot of the bed and some form of elastic support hose. In women averse to wearing elastic stockings by day, control can commonly be achieved if they are worn only at night. The aim is to achieve a normal sized limb on waking in the morning even if some swelling recurs throughout the day. In the upper limb the milder forms of secondary lymphoedema usually require no treatment, but a more bulky limb may be helped with an elastic arm stocking. There remains a group of patients who have bulky oedematous limbs, poorly responsive to the simple measures previously outlined, and unsuitable for reduction surgery, in whom symptoms are moderately disabling. It is in this group of patients that various types of external compression therapy have been tried. These include tight bandaging with heavyduty bandages (eg, "blue line"), compression by a spirally wound rubber tube,2 graduated compression elastic stockings (’Sigvaris’, ’Struva’, ’Jobst’, &c), and various machines that massage the limb with inflatable bags. In the earlier machines the bag used was of the single chamber type (’Flowtron’, Jobst). Such machines were originally devised to provide intermittent compression of the legs during surgery, for the primary prevention of deep-vein thrombosis. The adaptation of these machines for use in lymphoedema was described 20 years ago3 and has continued with mixed 1 Chilvers
AS, Kinmonth JD Operations for lymphoedema of the lower limbs J Cardiovasc Surg 1975; 16: 115-19 2 Van der Molen HR, Toth LM The conservative treatment of lymphoedema of the extremities. Angiology 1974, 25: 470-83. 3 Sanderson RG, Fletcher WS Conservative management of primary lymphoedema. Northwest Med 1965, 64: 584-88
enthusiasm over the intervening years.’ Improvement in the oedema can often be obtained by regular use of such machines, especially in those patients in whom the oedema still pits on pressure, but the degree of reduction commonly fails to live up to the patients expectations. Even when the apparatus for home use, few continue to patients purchase 5 use it for long. The main disadvantages of the single-chamber device are the even distribution of pressure in all directions, so that only part of this is transmitted proximally, and the long duration of the pressure cycle, which makes the use of high pressure very uncomfortable. Increasing the peak pressure slightly to 60 mm Hg and shortening the cycle to 30 seconds may 4 improve the results.4 The disadvantages of the single-bag machine led Zelikovski and his colleagues6,-, to develop the ’Lympha-Press’. This instrument consists of a sleeve that is closely fitted over the limb and contains a series of individual inflatable cells, each overlapping the next, with a single cell for the foot. A pressure cycle is applied in such a way that they are inflated in turn from the foot upwards until all are distended. After 2 seconds of complete inflation all cells are automatically deflated and the cycle begins again. The cycle is short enough to allow 80-130 mm Hg without discomfort. The number of cells in the sleeve is varied from nine to twelve according to limb length, and the device can be used on the arm as well as the leg. Periods of treatment are 6-8 hours. Richmond, O’Donnell, and Zelikovski have lately reported a prospective study with the lympha-press in 25 lymphoedematous limbs-18 lower limbs, 9 with primary and 9 with secondary lymphoedema; and 7 upper limbs with secondary lymphoedema. In the lower limb, reduction of volume was 37% at the ankle, 47% at mid-calf, and 3107o at mid-thigh. For the upper limb the figures were 45% at wrist, 28% at mid-forearm, and 25% at mid-arm. In about halfofthe patients most of the reduction following one treatment was maintained over several months, best results being obtained in those patients who were diligent in nocturnal limt elevation and in the wearing of proper elastic compression hose. Repeated treatments produced the best long-term results. This report shows clearly that, in most patients, good and sometimes spectacular reductions in limb volume can be obtained without surgical treatment by the use of graduated pneumatic massage and subsequent maintenance by the diligent use of elastic compression hose; but experience in the UK points to two drawbacks.’The first is expense. Outside of specialist units, most hospitals will see only a few of these patients and the purchase will be hard to justify, and the average patient will be unable to afford a machine for home use. The second disadvantage results from difficulty of applying the multicompartment stockings; many patients will find the technique beyond them. Despite these disadvantages, moderate to severe lymphoedema is unsightly and disabling and a non-invasive technique which is capable of effecting considerable improvement ought to be more widely available for trial than it is at present. JK, O’Donnell TF, Kalisher L, et al Selection of patients with lymphoedema for compression therapy Am J Surg 1977, 133: 130-36 5. Kmmonth JB. The lymphatics. 2nd ed. London: Edward Arnold, 1982: 322. 6 Zelikovski A, Manoach M, Giler S, et al Lympha-Press A new pneumatic device for the treatment of lymphedema of the limbs Lymphology 1980, 13: 68-73 7 Zelikovski A, Melamed I, Kott M, et al The ’Lympha-Press’ A new pneumatic device for the treatment of lymphedema Clinical trial and results. Folia Angiol 1980, 28:
4 Raines
165-69. 8 Richmond DM, O’Donnell
TF, Zelikovski A Sequential pneumatic compression for
lymphedema. Arch Surg 1985,
120: 1116-19