Managing Lymphedema in Fracture Care

Current Concepts and Treatment Principles

Christopher Thomas, DO; Jessica T. Le, DO; Emily Benson, MD

Disclosures

J Am Acad Orthop Surg. 2020;28(18):737-741. 

In This Article

Management of Lymphedema

Although orthopaedic surgeons may frequently encounter lymphedema in practice, currently no curative treatments or benchmark treatment exists. Most treatment methods are designed to promote the movement of fluid out of affected limbs back into the lymphatic system. Treatment of lymphedema after trauma is focused on reducing swelling, restoring function to the affected area of the body, and preventing further potential complications, such as delayed or poor fracture healing and wound complications.[3] Prevention and early recognition of lymphedema in this setting is crucial to avoid such complications from occurring.

Conservative Management

First-line therapy for lymphedema is usually compression. Often accomplished in a controlled fashion by using compression therapy garments or elastic compression bandages. Compression has been found to reduce edema volume by up to 31% to 46%.[8] In very mild cases of lymphedema, simply elevating the limb may be sufficient.[11]

Complete decongestive therapy (CDT) or complex physical therapy (CPT), also known as decongestive lymphatic therapy (DLT), has shown positive results in reducing lymphedema as well. CDT is therapist directed and often done in outpatient clinics. CPT incorporates multiple modalities such as manual lymph drainage, compression bandaging, exercise, and skin care. This therapy is divided into two phases—intensive and maintenance. In CPT, the maximum reduction of swelling is achieved in the first (intensive) phase. This phase is then followed by the second (maintenance) phase, which aims to maintain the improved status of volume reduction of the affected area of the body.[8,10,13,15,16] The intensive phase uses manual lymph drainage, pneumatic compression devices, compression bandages, and exercise to focus on volume reduction.[8] This phase generally occurs over a 4- to 6-week period.[10,13] To achieve the maximum benefit of this treatment, patients should have CDT at least 5 days per week.[10,17] The maintenance phase is more patient directed. In this, phase patients continue using compression and are taught self-lymph drainage techniques in which they can perform daily.

No current pharmacologic agents are recommended for use in the treatment of lymphedema. Diuretics have been tried in the past; however, they have proven little benefit and have in some cases been found to increase tissue fibrosis.[8] Benzopyrones, designed to breakdown protein accumulation in tissues by increasing proteolysis, have also been commonly used, although no significant evidence supports efficacy in the prevention or treatment of lymphedema.[8,10,13] Nutritional supplements such as sodium selenite and vitamin E in combination with pentoxifylline have also been studied without notable evidence to warrant their use in the treatment of lymphedema without further investigational studies.

Surgical Management

If lymphedema is not improving after conservative treatment, treating physicians should consider consulting with a specialist in plastic and reconstructive surgery to explore alternatives for reducing fluid accumulation in the tissues. Surgical approaches aim to either reconstruct and restore function of the lymphatic system or debulk and reduce tissues and fluids. Reconstructive procedures work to create lymphatic anastomoses and repair vessels. Debulking procedures remove fibrosis, hypertrophic tissue, and redundant skin to reduce the size and weight of the affected limb.[10,13] Microsurgical techniques include lymphovenous anastomosis and lymph node transfer. Lymphovenous anastomosis uses the microsurgical technique to anastomosis lymphatic vessels identified with dye to small subcutaneous veins 1 to 3 mm diameter to enhance fluid movement. In one retrospective study, this technique was effective in 50% of patients.[17] Lymph node transfer involves the transfer of a vascularized lymphatic containing soft-tissue flap to the affected limb. In a recent meta-analysis, the results regarding outcomes and complications have been inconsistent.[17] Suction lipectomy has become a more favorable treatment option in patients with lymphedema poorly controlled with compression dressing and therapy.[13] The benefits of suction lipectomy include the following: small incisions, ability to circumferentially remove tissue, cosmesis, encouraging long-term functional results, and most importantly no additional risk to lymphatic structures.[17] The use of circumferential compression dressings postoperatively is crucial for the success of suction lipectomy (Figure 1).

Figure 1.

Figure demonstrating the management of lymphedema.

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