Hypothesis The causes and management of lower limb lymphedema in the Western population are different from those in the developing world. Objective To look at the differential diagnosis, methods of investigation, and available treatments for lower limb lymphedema in the West. Data Source A PubMed search was conducted for the years 1980-2002 with the keyword "lymphedema." English language and human subject abstracts only were analyzed, and only those articles dealing with lower limb lymphedema were further reviewed. Other articles were extracted from cross-referencing. Results Four hundred twenty-five review articles pertaining to lymphedema were initially examined. This review summarizes the findings of relevant articles along with our own practice regarding the management of lymphedema. Conclusions The common differential diagnosis in Western patients with lower limb swelling is secondary lymphedema, venous disease, lipedema, and adverse reaction to ipsilateral limb surgery. Lymphedema can be confirmed by a lymphoscintigram, computed tomography, magnetic resonance imaging, or ultrasound. The lymphatic anatomy is demonstrated with lymphoscintigraphy, which is particularly indicated if surgical intervention is being considered. The treatment of choice for lymphedema is multidisciplinary. In the first instance, combined physical therapy should be commenced (complete decongestive therapy), with surgery reserved for a small number of cases.

https://jamanetwork.com/journals/jamasurgery/articlepdf/394351/ssa2105.pdf

Differential diagnosis, investigation, and current treatment of lower limb lymphedema

Free, vascularized thin corticoperiosteal grafts and small periosteal bone grafts harvested from the supracondylar region of the femur are described. These grafts are nourished from the articular branch of the descending genicular artery and vein. Thin corticoperiosteal grafts consist of periosteum with a thin layer of outer cortical bone and include the cambium layer, which has a better osteogenic capacity. This graft is elastic and readily conforms to the recipient bed configuration. Thin corticoperiosteal grafts were used to treat 11 patients with fracture non-union of an upper extremity that had no massive bone defects. Early, rapid union occurred in all patients except three: one in which the anastomosed vessel became obstructed and two in which the internal fixation of the fracture was unsecured. The small bone grafts consist of periosteum, full thickness cortex, and the underlying cancellous bone. This graft can be successfully harvested without disturbing the vascularity, unlike the currently used vascularized bone grafts. This graft was used to treat three patients with avascular necrosis of the body of the talus and could prevent the necrotic talus body from progressive collapse in patients in early stages of the disease. One patient with an infectious bone defect of the first metatarsal bone was successfully treated by vascularized bone graft with an accompanying skin flap.

Vascularized periosteal bone graft from the supracondylar region of the femur

Nine vascularized autogenous whole joint transfers were employed in the reconstruction of traumatized joints of six male patients ages 6 to 38 years. The proximal interphalangeal joint was involved in four patients, the thumb metacarpophalangeal (MP) joint in two, and the small finger MP joint in one. In five patients, the donor joint came from the foot, and in one patient an MP joint was transferred from a digit that had sustained a more distal amputation. The mean follow-up was 24 months (range 13 to 38). Bony union as well as full radiographic preservation of the articular space has occurred in each case. Four joints were transferred with an open epiphysis and three demonstrated longitudinal growth and an intact epiphyseal plate. The mean range of active motion was 22°/55°. We believe the early results demonstrate the feasibility of this method of joint reconstruction in the young patient.

Vascularized autogenous whole joint transfer in the hand--a clinical study.

At the present time there is confusion as to what pharmacological adjuncts are helpful toward increasing patency rates of microvascular repairs. To select a drug rationally, an understanding of the clotting mechanism in small vessels is essential so that agents may be selected that alone or in combination will react with the elements of the blood and will allow for continued perfusion without risk of hemorrhage or toxicity. Drugs which are Federal Drug Administration approved and currently available are drugs having nonspecific effects involving more than one aspect of the clotting mechanism; they often result in undesirable as well as desirable effects. Further development will result in the use of more selective and sophisticated agents. Presently it would appear desirable to employ agents to (1) increase blood flow and decrease blood viscosity, such as dextran 70; (2) decrease platelet functions, such as aspirin-type drugs; (3) mitigate against the actions of thrombin on platelets and fibrinogen using low-dose heparin; (4) reduce anxiety and vasospasm using chlorpromazine or Thorazine.

Pharmacological alterations in the clotting mechanism: Use in microvascular surgery

Free microvascular epiphyseal transplantation: an experimental study in dogs.

Microvascular reconstructive surgery

Microlymphaticovenous Anastomosis in the Treatment of Lower Limb Obstructive Lymphedema: Analysis of 91 Cases

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Microvascular reconstructive surgery

Microlymphaticovenous Anastomosis in the Treatment of Lower Limb Obstructive Lymphedema: Analysis of 91 Cases