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Vol. 28 No. 2 - Total Knee Replacement and Lower Extremity Cancer-Related Lymphedema: A Case Study

By Marie Newkirk, PT, DPT, CSCS, NYU Langone Medical Center
Rusk Rehabilitation, Department of Women’s and Men’s Health, New York, NY

Vol. 28 No. 2 - Lymphlink Reprint, Archived April 2015
Click here to download a pdf.

Lymphedema is the swelling of an extremity (or other body part) due to the accumulation of protein-rich fluid as a result of damage to the lymphatic system. This damage can be of genetic etiology or a result of trauma to the lymphatic system by means of surgery or radiation.1 Lymphedema can be primary or secondary. Primary lymphedema is usually congenital while secondary lymphedema is a result of an acquired cause, including trauma, recurrent infection, and malignancy.1 Lymphedema can occur in both sexes at any age and may be unilateral or bilateral. Lymphedema usually manifests initially as painless swelling, and patients usually report additional symptoms of heaviness and tightness. The current recommended treatment for lymphedema is complete decongestive therapy (CDT), and the purpose of this case study is to evaluate the effects of CDT on lower extremity lymphedema.1-3

Case Description

BD is a 62 year-old female who was referred to outpatient physical therapy (PT) with a diagnosis of left lower extremity secondary lymphedema due to excision of malignant melanoma from the upper inner thigh. BD was diagnosed with melanoma in 1990 and underwent surgical treatment in 1990. In addition to the removal of the melanoma, several inguinal lymph nodes were removed, all negative for metastasis. She did not receive any chemotherapy or radiation. Other medical history includes anemia, rheumatoid arthritis, and epilepsy. She developed lymphedema affecting the lower thigh just above the knee and the lower leg down to her ankle. Swelling began after her surgery in 1990 and has worsened in the past year. BD underwent a left total knee replacement in early 2014, after which lymphedema symptoms returned. The trauma from the surgery could have been a factor
in exacerbating her lymphedema. To manage her symptoms, BD wears compression stockings but has not sought out any formal physical therapy prior to this year.

BD is a professor at a local college and lives with her husband in a walk-up apartment. Since the recent exacerbation of her lymphedema, she has difficulty walking long distances and standing for long periods of time when she teaches. In addition, she has difficulty negotiating the steps into her apartment. 

Assessment

On the initial evaluation, BD had several objective measurements taken. The first were girth measurements, taken in 10 cm increments beginning at the top of the knee and going superiorly as well as inferiorly. There were 13 measurements altogether, including the ankle and first and second toes. The next measurement was lower extremity range of motion (ROM) and strength at the hip, knee, and ankle. Data were collected on both lower extremities for comparison. BD had limited knee flexion to 110 degrees. All other measurements were within normal limits. BD had 5/5 (normal) strength throughout both of her lower limbs. Sensation was intact to light touch throughout both limbs.

Next, BD’s tissue texture and integrity were assessed. She had mild-moderate edema. The edema was firm but non-pitting. There was an incision from the inguinal dissection that was completely healed and began at the upper thigh and scalloped down to mid-thigh, measuring 19 cm. BD denied pain on the initial evaluation but reports her pain level can be 4/10 after walking or standing for long periods of time. 

BD’s goals for therapy included reducing the swelling in the left lower extremity, learning the techniques of manual lymph drainage (MLD) and bandaging, and increasing her walking and standing tolerance. 

Intervention

BD’s physical therapy intervention spanned a six-week period. She attended physical therapy sessions 2 times per week for the first 3 weeks, then 1 time per week for the last 3 weeks. BD’s treatment consisted of CDT including MLD, compression therapy, lower extremity exercises, and skin care/hygiene education. She was motivated to begin therapy and was very compliant throughout the course of treatment. 

Skin Care Precautions and Lymphedema Precautions: Methods to reduce the risk of infection and improve lymphedema symptoms were reviewed, including skin hygiene and the importance of protecting the skin from cuts and burns. Avoiding cutting cuticles and limiting use of alcohol and other irritating substances were also discussed. 

Manual Lymphatic Drainage: MLD was performed on the patient’s left lower extremity. The purpose of MLD is to help move the accumulated fluid to other lymph nodes of the body and back into circulation. MLD was performed with the patient lying on her back. Drainage began at the neck to facilitate the lymph nodes above the clavicles and then to the armpit and groin. Once those lymph nodes were facilitated, the drainage of the left lower extremity began from the top of the thigh, down to the foot, and then back up again. 

BD was educated about simple self-MLD in a similar pattern. She was provided with a written handout and demonstrated the proper technique. BD was instructed to perform MLD daily prior to putting on her compression garment. 

Compression: BD was also educated about the importance of applying compression 23 hours per day. The therapist discussed with her the difference between multilayer bandaging and alternative compression garments. BD chose an alternative garment over the bandaging for convenience purposes. Throughout the course of treatment the patient was compliant and wore the garment 23 hours each day. 

Exercises: In order to further assist in the movement of lymphatic fluid, BD was instructed in lower extremity exercises. The home exercise program included hip adduction and abduction, mini-squats, hip flexion, and calf (heel) raises. These exercises help increase the strength and ROM in lower extremities. 

The therapist discussed with BD the importance of the self-management program, including compression, MLD, exercises, and skin hygiene. BD reported understanding and demonstrated good technique. Each of the components were to be done daily. 

Outcomes

At the end of the six-week treatment, BD was re-evaluated. There was a significant decrease in lymphedema in the left lower extremity, noted by the decrease in girth measurements. The tissue texture improved from moderate firmness to mild firmness. Left knee flexion improved from 110 degrees to 140 degrees, and her pain improved from 4/10 at worst, to 0/10. 

BD reports that she is able to walk longer distances and is able to stand for longer periods of time while teaching her class. She states there is an overall improvement since the beginning of physical therapy. 

Discussion

This case was chosen because the patient developed lymphedema due to a melanoma excision and lymph node dissection. In addition, she had a total knee replacement, which could have exacerbated her symptoms. The local trauma and inflammation associated with the knee surgery are factors that may have increased the lymphedema. This case shows that prior lymphedema may worsen after joint replacement surgery, although it is not common after knee surgery.

Short stretch compression bandages could be used instead of the alternative garment. The bandages may provide a specific graded compression and may have resulted in greater decrease in limb girth. Due to patient preferences, however, the alternative garment was used. BD underwent CDT for six weeks and saw decreases in girth measurement, increased ADLs (activities of daily living), and was educated about self-management. These findings further confirm the importance and efficacy of CDT for treatment of lymphedema. 

References:

  1. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema. Consensus document of the International Society of Lymphology. Lymphology. 2003;36:84-91.
  2. Yamamoto T, Todo Y, Kaneuchi M, Handa Y, Watanabe K, Yamamoto R. Study of edema reduction patterns during the treatment phase of complex decongestive physiotherapy for extremity lymphedema. Lymphology. 2008;41:80-6.
  3. Todo Y, Yamamoto R, Minobe S, et al. Risk factors for postoperative lower-extremity lymphedema in endometrial cancer survivors who had treatment including lymphadenectomy. Gynecol Oncol. 2010;119(1):60-4.