Prolonged Superficial Local Cryotherapy Attenuates Microcirculatory Impairment,Regional Inflammation,and Muscle Necrosis After Closed Soft Tissue Injury in Rats

Abstract

Background: Closed soft tissue injury induces progressive microvascular dysfunction and regional inflammation. The authors tested the hypothesis that adverse trauma-induced effects can be reduced by local cooling. While superficial cooling reduces swelling, pain, and cellular oxygen demand, the effects of cryotherapy on posttraumatic microcirculation are incompletely understood.

Study Design: Controlled laboratory study.

Methods: After a standardized closed soft tissue injury to the left tibial compartment, male rats were randomly subjected to percutaneous perfusion for 6 hours with 0.9% NaCL (controls; room temperature) or cold NaCL (cryotherapy; 8°C) (n = 7 per group). Uninjured rats served as shams (n = 7). Microcirculatory changes and leukocyte adherence were determined by intravital microscopy. Intramuscular pressure was measured, and invasion of granulocytes and macrophages was assessed by immunohistochemistry. Edema and tissue damage was quantified by gravimetry and decreased desmin staining.

Results: Closed soft tissue injury significantly decreased functional capillary density (240 ± 12 cm-1); increased microvascular permeability (0.75 ± 0.03), endothelial leukocyte adherence (995 ± 77/cm2), granulocyte (182.0 ± 25.5/mm2) and macrophage infiltration, edema formation, and myonecrosis (ratio: 2.95 ± 0.45) within the left extensor digitorum longus muscle. Cryotherapy for 6 hours significantly restored diminished functional capillary density (393 ± 35), markedly decreased elevated intramuscular pressure, reduced the number of adhering (462 ± 188/cm2) and invading granulocytes (119 ± 28), and attenuated tissue damage (ratio: 1.7 ± 0.17).

Conclusion: The hypothesis that prolonged cooling reduces posttraumatic microvascular dysfunction, inflammation, and structural impairment was confirmed.

Clinical Relevance: These results may have therapeutic implications as cryotherapy after closed soft tissue injury is a valuable therapeutic approach to improve nutritive perfusion and attenuate leukocyte-mediated tissue destruction. The risk for evolving compartment syndrome may be reduced, thereby preventing further irreversible aggravation.

Keywords

closed soft tissue injury cryotherapy skeletal muscle rats microcirculation leukocyte-endothelial cell interaction intravital fluorescence microscopy

Get full access to this article

View all access options for this article.

References

Aibiki MM

Yokono S.

Moderate hypothermia improves imbalances of thromboxane A2 and prostaglandin I2 production after traumatic brain injury in humans. Crit Care Med.2000;28(12): 3902-3906.

Amon M

Menger MD

Vollmar B.

Heme oxygenase and nitric oxide synthetase mediate cooling-associated protection against TNF-alpha-induced microcirculatory dysfunction and apoptotic cell death. FASEB J.2003;17(2): 175-185.

Atherton A

Born GVR.

Quantitative investigation of the adhesiveness of circulating polymorphonuclear leukocytes to blood vessel walls. J Physiol.1972;222: 447-474.

Buckwalter JA.

Pharmacological treatment of soft-tissue injuries. J Bone Joint Surg Am.1995;77(12): 1902-1914.

Carden DL

Smith KJ

Korthuis RJ.

Neutrophil-mediated microvascular dysfunction in postischemic canine skeletal muscle: Role of granulocyte adherence. Circ Res.1990;66: 1436-1444.

Carlos TM

Harlan JM.

Leukocyte-endothelial adhesion molecules. Blood. 1994;84(7): 2068-2101.

Chiang CH

Wu K

Yu CP

Yan HC

Perng WC

Wu CP.

Hypothermia and prostaglandin (E)1 produce synergistic attenuation of ischemia-reperfusion lung injury. Am J Respir Crit Care Med.1999;160(4): 1319-1323.

Cohn BT

Jackson DW.

The effects of cold therapy in the postoperative management of pain in patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med.1989;17: 344-349.

Curl WW

Smith BP

Marr A

Rosencrance E

Holden M

Smith TL.

The effect of contusion and cryotherapy on skeletal muscle microcirculation. J Sports Med Phys Fitness. 1997;37: 279-286.

10.

Deal DN

Tipton J

Rosencrance E

Curl WW

Smith TL.

Ice reduces edema. J Bone Joint Surg Am.2002;84-(9): 1573-1578.

11.

Duckers HJ

Boehm M

True AL

et al.

Heme oxygenase-1 protects against vascular constriction and proliferation. Nat Med.2001;7(6): 656-657.

12.

Fuhrman FA

Fuhrman GJ

Farr DA

Fail JH.

Relationship between tissue respiration and total metabolic rate in hypo-and normothermic rats. Am J Physiol.1961;201: 231-234.

13.

Fuhrman GJ

Fuhrman FA.

Oxygen consumption of animals and tissues as a function of temperature. J Gen Physiol.1959;42(4): 715-722.

14.

Granger DN

Kubes P.

The microcirculation and inflammation: modulation of leukocyte-endothelial cell adhesion. J Leukoc Biol.1994;55(5): 662-675.

15.

Gustilo RB

Merkow RL

Templeman D.

The management of open fractures. J Bone Joint Surg Am.1990;72(2): 299-304.

16.

Haddix TL

Pohlman TH

Noel RF

Sato TT

Boyle EM

Verrier ED.

Hypothermia inhibits human E-selectin transcription. J Surg Res.1995;64: 176-183.

17.

Harris K

Walker PM

Mickle DA

et al.

Metabolic response of skeletal muscle to ischemia. Am J Physiol.1986;250(2 Pt 2): H213-H220.

18.

Hill AG

Hill GL.

Metabolic response to severe injury. Br J Surg.1998;85: 884-890.

19.

Hurme T

Kalimo H.

Activation of myogenic precursor cells after muscle injury. Med Sci Sports Exerc.1992;24: 197-205.

20.

Hurme T

Kalimo H

Lehto M

Jarvinen M.

Healing of skeletal muscle injury. An ultrastructural and immunohistochemical study. Med Sci Sports Exerc.1991;23: 801-810.

21.

Hurme T

Rantanen J

Kalimo H.

Effects of early cryotherapy in experimental skeletal muscle injury. Scand J Med Sci Sports.1993;3: 46-51.

22.

Järvinen TA

Kääriäinen M

Kalimo H

Järvinen M.

Muscle injuries. Biology and treatment. Am J Sports Med.2005;33(5): 745-764.

23.

Klyscz T

Junger M

Jung F

et al.

[Cap image—a new kind of computer-assisted video image analysis system for dynamic capillary microscopy]. Biomed Tech Berl.1997;42(6): 168-175.

24.

Komulainen J

Kalliokoski R

Koskinen SO

Drost MR

Kuipers H

Hesselink MK.

Controlled lengthening or shortening contraction-induced damage is followed by fiber hypertrophy in rat skeletal muscle. Int J Sports Med.2000;21(2): 107-112.

25.

Laing DR

Dalley DR

Kirk JA.

Ice therapy in soft tissue injury. N Z Med J.1973;78: 155-158.

26.

Levin LS

Condit DP.

Combined injuries—soft tissue management. Clin Orthop Relat Res.1996;327: 172-181.

27.

Ley K

Bullard DC

Arbones ML

Bosse R

Vestweber D

Tedder TF

Beaudet AL.

Sequential contribution of L-and P-selectin to leukocyte rolling in vivo. J Exp Med.1995;181: 669-675.

28.

Menger MD

Pelikan S

Steiner D

Messmer K.

Microvascular ischemiareperfusion injury in striated muscle: significance of “reflow paradox.”

Am J Physiol.1992;263(6 Pt 2): H1901-H1906.

29.

Menth-Chiari WA

Curl WW

Rosencrance E

Smith TL.

Contusion of skeletal muscle increases leukocyte-endothelial cell interactions: an intravital microscopic study in rats. J Trauma.1998;45: 709-714.

30.

Mittlmeier T

Vollmar B

Raschke M

Menger MD

Schewior L

Schaser KD.

Small volume hypertonic hydroxyethyl starch reduces acute microvascular dysfunction following closed soft tissue trauma. J Bone Joint Surg Br.2003;81: 126-132.

31.

Nash GB

Abbitt KB

Tate K

Jetha KA

Egginton S.

Changes in the mechanical and adhesive behaviour of human neutrophils on cooling in vitro. Pflügers Arch -Eur J Physiol.2001;442: 762-770.

32.

Nolte D

Zeintl H

Steinbauer M

Pickelmann S

Messmer K.

Functional capillary density: an indicator of tissue perfusion?

Int J Microcirc Clin Exp.1995;15(5): 244-249.

33.

Osborn L.

Leukocyte adhesion to endothelium in inflammation. Cell.1990;62(1): 3-6.

34.

Rantanen J

Hurme T

Lukka R

Heino J

Kalimo H.

Satellite cell proliferation and the expression of myogenin and desmin in regenerating skeletal muscle: evidence for two different populations of satellite cells. Lab Invest.1995;72: 341-347.

35.

Reed MWR

Miller FN.

Importance of light dose in fluorescent microscopy. Microvasc Res.1988;36: 104-107.

36.

Rodgers CM

Ketch LL.

Management of associated soft-tissue injury. Surg Clin North Am.1988;68(4): 823-835.

37.

Rubin BB

Romaschin A

Walker PM

Gute DC

Korthuis RJ.

Mechanisms of postischemic injury in skeletal muscle: intervention strategies. J Appl Physiol.1996;80(2): 369-387.

38.

Rubinstein I

Abassi Z

Coleman R

Winaver J

Better OS.

Involvement of nitric oxide system in experimental muscle crush injury. J Clin Invest.1998;101: 1325-1333.

39.

Saetzler RK

Jallo J

Lehr HA

et al.

Intravital fluorescence microscopy: impact of light-induced phototoxicity on adhesion of fluorescently labeled leukocytes. J Histochem Cytochem.1997;45(4): 505-513.

40.

Schaser KD

Vollmar B

Menger MD

et al.

In vivo analysis of micro-circulation following closed soft tissue injury. J Orthop Res.2000; 18(4): 683-684.

41.

Schaser K

Zhang L

Haas NP

Mittlmeier T

Duda G

Bail HJ.

Temporal profile of microvascular disturbances in rat tibial periosteum following closed soft tissue trauma. Langenbecks Arch Surg.2003;388(5): 323-340.

42.

Smith TL

Curl WW

Smith BP

et al.

New skeletal muscle model for the longitudinal study of alterations in microcirculation following contusion and cryotherapy. Microsurgery. 1993;14(8): 487-493.

43.

Springer TA.

Traffic signals for lymphocyte recirculation and leukocyte emigration: the multistep paradigm. Cell. 1994;76(2): 301-314.

44.

Thorlacius H

Vollmar B

Westermann S

Torkvist L

Menger MD.

Effects of local cooling on microvascular hemodynamics and leukocyte adhesion in the striated muscle of hamsters. J Trauma. 1998; 45(4): 715-719.

45.

Thorsson O

Lilja B

Ahlgren L.

The effect of local cold application on intramuscular blood flow at rest and after running. Med Sci Sports Exerc.1985;17: 710-713.

46.

Tscherne H

Oestern HJ.

[A new classification of soft-tissue damage in open and closed fractures (authors’ transl)]. Unfallheilkunde. 1982;85(3): 111-115.

47.

Villringer A

Dirnagel U

Them A

Shurer L

Krombach F

Einhäupl KM.

Imaging of leukocytes within the rat brain cortex in vivo. Microvasc Res.1991;42: 305-315.

48.

Weiss SJ.

Tissue destruction by neutrophils. N Engl J Med.1989; 320(6): 365-376.

49.

Westermann S

Vollmar B

Thorlacius H

Menger MD.

Surface cooling inhibits tumor necrosis factor-alpha-induced microvascular perfusion failure, leukocyte adhesion, and apoptosis in the striated muscle. Surgery. 1999;126(5): 881-889.

50.

Zador E

Mendler L

Takacs V

de Bleecker J

Wuytack F.

Regenerating soleus and extensor digitorum longus muscles of the rat show elevated levels of TNF-alpha and its receptors, TNFR-60 and TNFR-80. Muscle Nerve. 2001;24(8): 1058-1067.

51.

Zeintl H

Sack FU

Intaglietta M

Messmer K.

Computer assisted leukocyte adhesion measurement in intravital microscopy. Int J Microcirc Clin Exp.1989;8(3): 293-302.

52.

Zhang L

Bail H

Mittlmeier T

Haas NP

Schaser KD.

Immediate micro-circulatory derangements in skeletal muscle and periosteum following closed tibial fracture. J Trauma. 2003;54(5): 979-985.