Limb Salvage and Treatment of Posttraumatic Lymphedema in a Mangled Lower Extremity

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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Reconstructive
CASE REPORT
Summary: Post traumatic lymphedema (PTL) is a known complication of extrem-
ity 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 difcult to characterize. The purpose of this report is to describe
the successful surgical management of PTL secondary to signicant lower extrem-
ity 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 debride-
ment, bony xation, creation of an arteriovenous loop with a contralateral saphe-
nous vein graft, and a chimeric latissimus dorsi-serratus anterior muscle ap.
At the 5-month follow-up, she presented with signicant right lower extremity
lymphedema. She underwent lymphovenous bypass surgery guided by preopera-
tive indocyanine green lymphography, which resulted in a 62% improvement in
functional outcome measures, eliminated her prior need for compression gar-
ments and inability to wear regular shoes, and sustained improvement at two years
follow-up. This case illustrates a near circumferential traumatic defect recon-
structed with a muscle ap and successful delayed lymphatic reconstruction with
lymphovenous bypass in the same patient. (Plast Reconstr Surg Glob Open 2024;
12:e6209; doi: 10.1097/GOX.0000000000006209; Published online 1 October 2024.)
Victoria A. Dahl, MD
Kashyap Komarraju Tadisina, MD
Kyle Y. Xu, MD
Post traumatic lymphedema (PTL) is a known com-
plication of traumatic extremity injury that can
result in poor wound healing and functional impair-
ment, and 20%–55% of patients who undergo surgical
treatment for traumatic injury have persistent postopera-
tive edema.1–3 Microsurgical techniques for PTL include
vascularized lymph node transfer (VLNT), lymphovenous
bypass (LVB), or prophylactic LIFT (lymph interposi-
tional ap transfer) and SCIP-LV (supercial circumex
iliac artery perforator lymphatic vessels) aps.4–7 Cases of
successfully treated PTL after limb salvage are limited,
but one study showed LVB after ap coverage of limited
soft tissue injury resulted in 55.93% reduction in excess
volume.8 However, restoration of lymphatic channels via
delayed LVB is rarely reported in complex limb salvage
patients.
Microsurgical advancements have improved 5-year
amputation free rates to 83% even in single-vessel extremi-
ties; thus, effective treatment for PTL after complex limb
salvage should be explored.9,10 We present a case of lym-
phatic reconstruction in a 43-year-old woman with right
lower extremity lymphedema after complex reconstruc-
tion of a single-vessel limb. This case adds to the sparse
literature on lymphatic outcomes of near circumferential
defects reconstructed with muscle aps and shows that
PTL can be treated with delayed LVB in limb salvage
patients.
CASE REPORT
A 43-year-old otherwise healthy woman presented to the
emergency department after a motorcycle accident with a
mangled right lower extremity. Evaluation demonstrated a
Gustilo class IIIB tibial fracture, loss of the anterior tibial and
From the Division of Plastic Surgery, University of Miami Miller
School of Medicine, Miami, Fla.
Received for publication September 10, 2023; accepted August 14,
2024.
Copyright © 2024 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
DOI: 10.1097/GOX.0000000000006209
Limb Salvage and Treatment of Posttraumatic
Lymphedema in a Mangled Lower Extremity
Disclosure statements are at the end of this article,
following the correspondence information.
Related Digital Media are available in the full-text
version of the article on www.PRSGlobalOpen.com.
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12
1October2024
1
October
2024

PRS Global Open • 2024
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peroneal artery angiosomes, compromised venous drain-
age, and single-vessel patency of the posterior tibial artery on
angiogram. Debridement revealed more than 5 cm exposed
tibia/tibial rod and a circumferential soft tissue decit
(Fig. 1). An arteriovenous (AV) loop was created outside the
zone of injury using a contralateral saphenous vein graft to
the ipsilateral supercial femoral artery and vein. After AV
loop creation, immediate free ap coverage using a chimeric
latissimus dorsi-serratus anterior muscle ap was performed,
as the wound was too large for standard skin aps. The post-
operative course was unremarkable, and care followed insti-
tutional standards. The patient was discharged 2 months
after the initial injury.
The patient presented 5 months after ap reconstruc-
tion with ISL stage II extremity lymphedema that impaired
activities of daily living and prevented her from tting into
standard sized shoes. After a 4-month failed trial of compre-
hensive decongestive therapy (CDT) and 20-30 mm Hg knee
high-compression stockings, ICG lymphography was per-
formed and demonstrated no linear patterns in the proximal
leg and dermal backow in the zone of trauma, conrming a
diagnosis of PTL. (See gure, Supplemental Digital Content
1, which displays ICG lymphography showing normal lym-
phatic channels with linearity and dermal backow in area
of trauma. http://links.lww.com/PRSGO/D536.) LVB was
planned over VLNT, as patent lymphatic channels were pres-
ent, and candidate lymphatic channels for bypass were iden-
tied. (See gure, Supplemental Digital Content 2, which
displays the preoperative markings for lymphovenous bypass
with planned bypass sites. http://links.lww.com/PRSGO/
D537.) End-to-end lymphatic bypass was performed, and
intraoperative ICG conrmed patency.
The patient reported symptom improvement 2 weeks
postoperatively and resumed CDT at 1 month postopera-
tively. At 6 months, the patient met rehabilitation goals of
ambulating without intermittent limb elevation, had a 62%
functional improvement via LLIS (Lymphedema Life Impact
Scale) score (11.76%–4.41% impairment), and a LEFS
(Lower Extremity Functional Scale) improvement from 15
(<80% impairment) to 26 (<60% impairment). There was
also a 27% improvement of difference in limb circumference
with maximum reduction of 32.42% at 30 cm proximal to
the ankle, and a nal limb volume less than 50 mL from the
contralateral limb (4.05% to 2.73% excess volume). At 2-year
follow-up, the patient reported complete functional restora-
tion, including standing for long periods and walking without
compression garments, did not require further CDT, and was
able to wear standard sized shoes (Figs. 2–4).
DISCUSSION
This report demonstrates the development of PTL after
complex limb salvage of a near circumferential defect with
free muscle ap and subsequent resolution after delayed
LVB in the same patient. A chimeric muscle ap was cho-
sen due to the defect size, and other prophylactic lym-
phatic reconstructive aps such as the SCIP-LV or the LIFT
may not be feasible in the case of total extremity anatomy
Fig. 1. Right lower leg with Gustilo class IIIB tibial fracture following debridement with exposed bone
and hardware.
Fig. 2. Clinical improvement 2 weeks postoperatively.

Dahl et al • Posttraumatic Lymphedema in Lower Extremity
3
reconstruction due to increased operating time, inability to
detect functional lymphatic channels, abnormally shaped
defects, and lack of patent recipient site vessels. In this case,
a reconstructive choice that maximized ap malleability and
coverage was prioritized.
There is no conclusive evidence on the optimal tim-
ing of lymphatic reconstruction in limb salvage patients.
Immediate reconstruction can reduce the number of
operations and prevent symptom development, whereas
delayed reconstruction can reduce donor site morbidity.
In some cases, it is not feasible to perform lymphatic pro-
cedures at the time of reconstruction due to the lack of
functional veins and soft tissue coverage, and the short-
term priority is limb salvage. When considering LVB
versus VLNT, functional lymphatic channels are ideally
treated with LVB whereas VLNT is reserved for cases
without linear functional channels. Risks associated with
VLNT include donor site lymphedema and contour defor-
mity, whereas LVB has standard surgical risks. One benet
of delayed reconstruction is the ability to determine the
patency of lymph channels after the acute injury phase has
subsided, allowing LVB to be performed over a VLNT.
Reconstructive options which include supercial lym-
phatic channels are fasciocutaneous and myocutanous
aps. Some muscular aps are well situated for concur-
rent VLNT, such as a subscapular based free ap with tho-
racic axillary nodes. Free muscle aps without VLNT may
have a higher incidence of lymphedema development, but
this has never been conclusively demonstrated. Lymphatic
anatomy should be considered in any limb salvage recon-
struction plan, whether in preserving or reconstructing
lymphatics acutely or as part of the long-term treatment
plan. This case demonstrates the use of a versatile high
volume free muscle ap and that any subsequent develop-
ment of PTL can be treated with a lymphatic reconstruc-
tive option with low morbidity.
Limitations of this report include lack of postoperative
ICG, lack of generalizability to typical injury patterns, and
limited calculations due to muscle wasting. Future directions
include comparative studies on quantitative outcomes of
delayed versus immediate lymphatic reconstruction and on
the incidence of PTL after different ap types.
Kyle Y. Xu, MD
Division of Plastic and Reconstructive Surgery
University of Miami Miller School of Medicine
1120 NW 14th Street, 4th Floor
Miami, FL 33136
Email: kxu.md@med.miami.edu
Fig. 3. Clinical improvement 6 months postoperatively.
Fig. 4. Clinical improvement and nal 2-year follow-up, with no
recurrence.

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DISCLOSURE
The authors have no nancial interest to declare in relation to
the content of this article.
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