Foot-sparing postoperative compression bandage: a possible alternative to the traditional bandage

Introduction

Among validated varicose vein treatments, simplified techniques (laser, radiofrequency [RF], ambulatory phlebectomy, Cure Conservatrice et Hemodynamique de l'Insufficience Veineuse en Ambulatoire [CHIVA]) have been developed as an alternative to the traditional great saphenous vein (GSV) stripping. The techniques use local anaesthesia and require no more than one day of hospitalization or even an office setting. The patient can walk straight after the procedure as the anaesthesia spares muscles or motor nerves.

Central to this kind of management is postsurgery compression of the limb, especially when treatment of varicosities is in part or exclusively based on stab avulsion phlebectomy: ¹ the compression by selective pads over the operated parts prevents bleeding, allowing immediate postprocedure rising and walking. It also improves venous blood flow and provides analgesia making systemic analgesic medication unnecessary in the vast majority of patients.

Compression of the treated limb may be performed by stockings ² or bandages for an average of seven days.^3,4 There is no evidence that one type of compression is better than another; the type of compression applied depends on personal preference and economic consideration. ²

Of special interest is the effectiveness of the foot-sparing bandage. Indeed, such a bandage would not require special shoes and would be better tolerated. Examples of foot-sparing bandage are already provided in sport medicine. ⁵ Furthermore, it has recently been shown that a stocking providing a greater pressure on the calf than on the ankle increased the local ejection fraction in varicose vein patients more than a traditional progressive stocking did. ⁶ Finally, according to Gardner and Fox, ⁷ ‘if function can be maintained, encircling bandages limited to the proximal limb are permissible – as long as they are not excessively tight – since the muscle-venous pump is able to overcome resistances in excess of 150 mmHg’.

On these bases, we present our one-year experience with the foot-sparing bandage in our Institution (Universitè Campus Bio-Medico di Roma, Area di Geriatria, Rome, Italy).

Material and methods

Compression bandaging

The bandage consists of (1) skin protection by a few layers of thin polyurethane underwrap (Pronto-mousse PMAsrl – Lainate, Milano), (2) cotton pads selectively placed over operated tracts to enhance local compression and absorb any bleeding. They have different shapes, consistencies and thicknesses according to the selective compression needed in that specific site. Joints and prominent bones are protected by cotton wool or rubber pads and (3) final adhesive bandaging, performed by 50% overlapping layers of 10 cm large short-stretch elastic adhesive bandage (Fortelast, Lohmann & Rauscher Inc., Rubano, Padova, Italy). It must not be applied at maximum stretch; if additional compression is needed, more layers are applied. The adhesive bandage must extend, both distally and proximally about 10 cm beyond the operated area to avoid bruising, oedema and haematoma formation. As the glue of these bandages has an adhesion power too high for the skin when submitted to traction, ¹ it should not touch the skin but lie over the underwrap. To avoid the slipping down of the bandage, we place two turns of acrylic glue bandages directly onto the skin of the most proximal part of the concerned area as an anchor grip, this type of glue being practically harmless to the skin although less adhesive (Flexoplast Acrilico, Nova Medical 2000, Roma, Italy). ¹

Pressures generated by the short-stretch bandaging, measured in 14 consecutive patients through a Kikuhime device (Meditrade, Soro, Denmark) in supine, standing position and during an exercise programme (walking on spot 20 steps) resulted, respectively, (mean) in 25, 30 and 35 mmHg. After six hours the pressures registered a mean reduction of 20% each. (Unpublished thesis, Corso laurea Infermieristica 2008 – F Petini – ‘Confronta tra la pressione d'interfaccia [Stiffness Index] del bendaggio elastico-anaelastco a doppio strata con sistema di ancoraggio e diversi metodi di compressione flebologica).

We used two different bandagings as follows:

(1)

Classical bandaging, where a compressive bandage covers the foot except the toes, was performed if the foot and/or the distal leg had to be involved in the procedure, or when the limb's clinical state and history asked for a sustained action against stasis (chronic oedema, long-lasting disease, healed ulcers, skin lesions, etc.) corresponding to C3–C6 (of CEAP [clinical, aetiological, anatomical and pathological elements]) cases;

(2)

Foot-sparing bandaging, covering the upper half of the leg and leaving out the ankle and foot. This bandage, previously tested and proved effective and well tolerated in purely ‘cosmetic’ cases, was used for cases where the foot and distal leg were not involved in varicose pathology. The ideal candidate was then the C2 (of CEAP) patient with a normal deep venous system, without tendency to oedema, and actively walking (most of the authors’ patients). Being weakly elastic, the compression acts strongly during muscle activity and is relatively low at rest. The compression area must involve the gastrocnemious area, giving to the gastrocnemious/sural calf pump a sustained support.

A picture of the foot-sparing bandage is provided in Figure 1.

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Figure 1

After a phlebectomy under local anaesthesia the limb is bandaged, leaving the foot out of compression in cases where venous insufficiency signs are not present, stab avulsion did not involve the foot and the patient is able to actively walk

Results

We used the foot-sparing bandage in 90 of the 183 phlebectomies in 129 patients.

In no case did we have to change the bandaging option during the postoperative week, before the programmed end of treatment. Four of the first 20 patients experienced limited swelling upon rising from bed on the first day. Thus, in the remaining patients we covered the foot and distal limb with a custom short tubular-shaped ‘sock’ providing 10 mmHg compression, to be worn during the first 24 hours, with the purpose of eliminating any anxiety for both patient and doctor. This measure could prevent any swelling in the 70 lower legs.

Satisfaction was very high or high in all cases. However, the lack of a comparable control group, i.e. matched to study group, but randomized to the classical bandage (procedure A), prevented us from performing a comparative analysis.

Discussion

We demonstrated that a foot-sparing bandage is effective and well tolerated in actively walking C2 CEAP patients undergoing ambulatory phlebectomy This finding conflicts with the traditional view of compression as intended to provide a degressive gradient ⁶ proximally oriented, so that flow will proceed from distal to proximal. Theoretically, applying a proximal compression without a distal compression is expected to create an inverse gradient slowing the venous return. ⁶ However, during walking intravenous pressure peaks occur, transiently reverting the pressure gradients at every step, due to muscle contraction which activates muscle/venous pumps. ⁶ Thus, an external segmental compression limited to the calf may simply assist this physiological gastrocnemious pump mechanism likely without conditioning the independent, yet co-ordinated, actions of more distal pumps (foot and distal calf pumps). Being inelastic, during the relaxation phase (40% of the action) ⁷ the external compression is low enough (24 mmHg after 6 hours) to allow for the reconstitution of a degressive gradient. Indeed, an inelastic bandage, similar to the one we use in our postoperative phase, has been demonstrated to be the most effective for improving the pump function, with nearly no effect on the resting phase. ⁸

Analogous to our foot-sparing bandage, inversely graduated stockings, providing a higher pressure over the calf than over the ankle region – that is ‘progressive elastic compression stockings’ – have recently been proposed with beneficial effects in sport applications ⁷ as well as in venous disease patients. ⁸ These ‘progressive’ compression stockings have been demonstrated to increase the venous ejection fraction from the leg more than traditional ‘degressive'-type stockings. ⁹

The postoperative foot-sparing bandaging has many strengths if compared with conventional ‘foot in’ bandaging: it allows the wearing of normal shoes, conceals the surgical procedure and allows washing of the foot, besides being more comfortable. Compared with postoperative thigh-high elastic stockings, ² an alternative compression method, bandages seem better adaptable to every limb shape, may be reinforced on demand in the sites needing a stronger haemostatic effect, may be corrected during the walking test in the event of bleeding, are comfortably worn at night and are very cheap (about 10 euros). Furthermore, stockings produce a similar basic pressure (Kl = 20 mmHg or K2 = 30 mmHg at the ankle) but a lower walking compression ⁹ and, as a matter of fact, a weaker haemostatic effect in more severe cases even when cotton rolls are employed. Superimposition of two thigh-high stockings during walking ¹⁰ may overcome the problem, but with more discomfort ¹¹ and higher costs (70–100 euros), which deserves consideration particularly in countries like Italy, where stocking reimbursement is not admitted.

A negative aspect of bandaging is the necessity for a skilled operator to run a ‘perfect’ bandage, i.e. a bandage which does not cause discomfort or disruption of tightness; however, this skill is usually achieved in few days.

This study has the limitation of lacking a control group proving the superiority of the proposed method. However, this method might be superior due to our objective findings and the patients’ satisfaction.

In conclusion, the foot-sparing or suspended bandage qualifies as an effective, comfortable and cheap compressive technique for patients undergoing varicose vein surgery, being in the C2 class, having a normal deep venous system and actively walking.