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Dahl VA, Tadisina KK, Xu KY. Limb Salvage and Treatment of Posttraumatic Lymphedema in a Mangled Lower Extremity. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6209. [PMID: 39359702 PMCID: PMC11444531 DOI: 10.1097/gox.0000000000006209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 08/14/2024] [Indexed: 10/04/2024]
Abstract
Post traumatic lymphedema (PTL) is a known complication of extremity trauma that is detrimental to limb form and function, healing, and quality of life. In cases of complex lower extremity trauma with vascular and extensive soft tissue injury, the risk of PTL is increased. However, many trauma patients are lost to follow-up, making the risk and potential management of these patients' lymphedema difficult to characterize. The purpose of this report is to describe the successful surgical management of PTL secondary to significant lower extremity trauma requiring complex limb salvage reconstruction. A 43-year-old woman involved in a motorcycle accident presented with a Gustilo IIIB right tibial fracture and single-vessel leg. She underwent successful limb salvage with serial debridement, bony fixation, creation of an arteriovenous loop with a contralateral saphenous vein graft, and a chimeric latissimus dorsi-serratus anterior muscle flap. At the 5-month follow-up, she presented with significant right lower extremity lymphedema. She underwent lymphovenous bypass surgery guided by preoperative indocyanine green lymphography, which resulted in a 62% improvement in functional outcome measures, eliminated her prior need for compression garments and inability to wear regular shoes, and sustained improvement at two years follow-up. This case illustrates a near circumferential traumatic defect reconstructed with a muscle flap and successful delayed lymphatic reconstruction with lymphovenous bypass in the same patient.
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Affiliation(s)
- Victoria A Dahl
- From the Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | | | - Kyle Y Xu
- From the Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Fla
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Dahl VA, Tadisina KK, Hale E, Fullerton N, Mella-Catinchi J, Xu KY. Techniques and Outcomes in Microsurgical Treatment of Posttraumatic Lymphedema: A Systematic Review. J Reconstr Microsurg 2024; 40:635-641. [PMID: 38290562 DOI: 10.1055/a-2257-5345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND The microsurgical treatment of lymphedema has been well-studied and has been shown to be effective, especially in cancer-related lymphedema. Posttraumatic lymphedema (PTL) is a debilitating condition that remains understudied and underreported, and surgical techniques for PTL treatment are not well-represented in the literature. The purpose of this study was to systematically review all published reports of physiologic surgical interventions for PTL. METHODS A search was conducted on PubMed, MEDLINE, Embase, and Web of Science, from January 1, 2000 to December 6, 2022, using keywords "PTL," "lymphedema," and "surgery" to identify reports of PTL treated with microsurgical lymphatic reconstruction techniques. PTL cases treated with ablation, debulking, or decongestive therapy were excluded. RESULTS A total of 18 records that met the inclusion criteria were identified, representing 112 patients who underwent microsurgical operations for PTL. This included 60 cases of lymph flow restoration (LFR) via lymph axiality and interpositional flap transfer, 29 vascularized lymph node transfers, 11 lymphatic vessel free flaps, 10 lymphovenous anastomoses (LVAs), and 2 autologous lymphovenous transfers. Outcomes were primarily reported as clinical improvement or LFR by lymphatic imaging. All studies showed qualitative improvement of symptoms and reports with quantitative data showed statistically significant improvements. CONCLUSION PTL is currently underrepresented in lymphedema treatment literature, however, our results show that microsurgical techniques are successful in treating lymphedema in PTL patients. Increasing awareness of PTL and establishing standardized diagnostic criteria and treatment options will help clinicians better understand how to diagnose and treat this condition. Prospective and comparative studies are needed to determine true prevalence of PTL and optimal treatment strategies.
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Affiliation(s)
- Victoria A Dahl
- Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Kashyap K Tadisina
- Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Eva Hale
- Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Natalia Fullerton
- Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan Mella-Catinchi
- Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Kyle Y Xu
- Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Ciudad P, Huayllani MT, Forte AJ, Boczar D, Avila FR, Escandón JM, Manrique OJ, Chen HC. Vascularized Lymph Node Transfer for the Treatment of Posttraumatic Lower Extremity Lymphedema: A Preliminary Report. Indian J Plast Surg 2022; 55:97-101. [PMID: 35444749 PMCID: PMC9015821 DOI: 10.1055/s-0041-1740520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background
Posttraumatic lymphedema develops more frequently than expected and reports on its management are scarce in the literature. We aimed to report the clinical outcomes of a case series of posttraumatic lymphedema patients treated with different vascularized lymph node transfers (VLNTs).
Patients and Methods
Five patients with secondary posttraumatic lower limb lymphedema treated with VLNT were included in this report. The groin-VLNT (
n
= 1), supraclavicular-VLNT (
n
= 2), and gastroepiploic-VLNT (
n
= 2) were implemented. The average flap area was 69.8 cm
2
. Patients underwent postoperative complex decompressive therapy for an average of 10.0 months.
Results
The average mean circumference reduction rate was 24.4% (range, 10.2–37.6%). Postsurgical reduction in the number of infection episodes per year was observed in all patients. The mean follow-up was 34.2 months.
Conclusions
VLNT is a promising surgical treatment for posttraumatic lymphedema patients. In our report, VLNT has demonstrated to reduce the volume and number of infections per year in posttraumatic lymphedema.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Maria T. Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Francisco R. Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Wagner JM, Grolewski V, Reinkemeier F, Drysch M, Schmidt SV, Dadras M, Huber J, Wallner C, Sogorski A, von Glinski M, Schildhauer TA, Lehnhardt M, Behr B. Posttraumatic Lymphedema after Open Fractures of the Lower Extremity-A Retrospective Cohort Analysis. J Pers Med 2021; 11:jpm11111077. [PMID: 34834429 PMCID: PMC8620266 DOI: 10.3390/jpm11111077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
Secondary lymphedema is a very common clinical issue with millions of patients suffering from pain, recurrent skin infections, and the constant need for a decongestive therapy. Well-established as a consequence of oncologic procedures, secondary lymphedema is also a well-known phenomenon after trauma. However, precise epidemiological data of lymphedema progress upon severe extremity injuries are still missing. In the present work, we analyzed a patient cohort of 94 individuals who suffered open fractures of the lower extremity and soft tissue injury, of 2nd and 3rd grade according to Tscherne classification, between 2013 and 2019. Typical symptoms of lymphedema have been obtained via interviews and patient medical records in a retrospective cohort analysis. Of all patients, 55% showed symptoms of secondary lymphedema and 14% reported recurrent skin infections, indicating severe lymphedema. Furthermore, comparing patients with and without lymphedema, additional parameters, such as obesity, total number of surgeries, infections, and compartment syndrome, related to lymphedema progress could be identified. According to these data, posttraumatic secondary lymphedema has a highly underestimated clinical prevalence. Further prospective studies are needed to validate this first observation and to identify high-risk groups in order to improve patient’s health care.
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Affiliation(s)
- Johannes Maximilian Wagner
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Victoria Grolewski
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Felix Reinkemeier
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Marius Drysch
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Sonja Verena Schmidt
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Mehran Dadras
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Julika Huber
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Christoph Wallner
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Alexander Sogorski
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Maxi von Glinski
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Thomas A. Schildhauer
- Department of Traumatology and Orthopedic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany;
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
| | - Björn Behr
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, 44789 Bochum, Germany; (J.M.W.); (V.G.); (F.R.); (M.D.); (S.V.S.); (M.D.); (J.H.); (C.W.); (A.S.); (M.v.G.); (M.L.)
- Correspondence: ; Tel.: +49-2343443; Fax: +49-2346379
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Ring A, Dellmann NC, Kirchhoff P. [Traumatic lesion of peripheral lymphatics: Fluorescence-guided detection and reconstruction by lymphatico-venous anastomosis]. Unfallchirurg 2021; 124:678-679. [PMID: 33709199 DOI: 10.1007/s00113-021-00981-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Andrej Ring
- Klinik für Plastische und Rekonstruktive Chirurgie, Handchirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland.
| | - Niklas-Chris Dellmann
- Klinik für Plastische und Rekonstruktive Chirurgie, Handchirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
| | - Pascal Kirchhoff
- Klinik für Plastische und Rekonstruktive Chirurgie, Handchirurgie, St. Rochus Hospital, Glückaufstraße 10, 44575, Castrop-Rauxel, Deutschland
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