The Clinical Usefulness of Ultrasonographic Measurement Technique in Patients with Lower Extremity Lymphedema

A Method to Improve the Accuracy for the Comparison of Consecutively Determined Upper Limb Cross-Sectional Area Profiles of Test Subjects: Impact on (Segmental) Limb Volume and Local Limb Circumference

Background: Chronic edema management depends on measuring small volume changes over time. Therefore, a highly sensitive, accurate, and reliable technique is needed to objectively judge sequential measurements. Methods and Results: The prototype of the Peracutus Aqua Meth (PAM), a new volumetric measuring device, was used in an experimental study. Thirty-nine healthy test subjects were measured three times. The measuring principle of the PAM is based on obtaining a profile of cross-sectional areas along the length of an object or limb. Besides total arm volumes, the volume of any chosen segment can be determined. The utmost tip of the middle finger appeared to be an unreliable reference point. Instead, the concept of "hand median" was introduced to align and compare profiles of cross-sectional areas of sequential measurements. Using the hand median strongly improved the measuring accuracy, rendering standard deviation values of 0.4%-1.3% for (segmental) volume determination. Conclusions: Measurements with the PAM show that accurate local/segmental volume determination of a limb is possible. Standard deviations of less than 1.3% are easily obtained for cross-sectional area and volume determination.

Ultrasonographic features of the skin and subcutis: correlations with the severity of breast cancer-related lymphedema

PURPOSE

Assessing the severity of breast cancer-related lymphedema (BCRL) requires various clinical tools, yet no standardized methodology is available. Ultrasonography shows promise for diagnosing lymphedema and evaluating its severity. This study explored the clinical utility of ultrasonography in patients with BCRL.

METHODS

In this retrospective cross-sectional study, patients with unilateral BCRL were examined. The analyzed data included demographics, lymphedema location, International Society of Lymphology (ISL) stage, surgical history, treatment regimens, and arm circumference. Skin, subcutis, and muscle thicknesses were assessed ultrasonographically at predetermined sites, and the percentage of excess thickness was calculated. Multivariate logistic regression analysis was employed to identify associations between ultrasonographic measurements and advanced lymphedema (ISL 2 or 3). The Lymphedema Quality of Life arm questionnaire was used to evaluate patient-reported outcomes regarding lymphedema and their correlations with ultrasonographic findings.

RESULTS

Among 118 patients, 71 were classified as ISL 0-1 and 47 as ISL 2-3. Patients with advanced lymphedema were older, had higher nodal stages, underwent more axillary lymph node dissections, and had higher rates of dominant-arm lymphedema. Multivariate logistic regression revealed significant associations of greater skin thickness (adjusted odds ratio [OR], 4.634; 95% confidence interval [CI], 1.233 to 17.419), subcutis thickness (adjusted OR, 7.741; 95% CI, 1.649 to 36.347), and subcutis echogenicity (adjusted OR, 4.860; 95% CI, 1.517 to 15.566) with advanced lymphedema. Furthermore, greater skin thickness (P=0.016) and subcutis echogenicity (P=0.023) were correlated with appearance-related discomfort.

CONCLUSION

Ultrasonographic measurements were significantly associated with advanced lymphedema in BCRL. Ultrasonography represents a valuable diagnostic and severity assessment tool for lymphedema.

Optimal Cut-Off Value for Detecting Breast Cancer-Related Lymphedema Using Ultrasonography

Background: We previously devised an ultrasonographic evaluation to calculate subcutaneous tissue cross-sectional area (△CSA). The reliability and accuracy of this method were demonstrated in healthy individuals and in patients with lymphedema. The purpose of this study was to estimate the optimal cut-off value of the ratio of the △CSA of the involved side (lesion side) to the contralateral side for detecting breast cancer-related lymphedema (BCRL) using ultrasonography. Methods and Results: Ultrasonographic measurements were performed 290 times in 150 patients. BCRLD was defined as a confirmed difference of >2 cm in arm circumference. BCRL confirmed by a clinician (BCRLC) was defined as the patient group that included not only BCRLD but also patients with subcutaneous thickening and abnormal findings on lymphoscintigraphy, even if the difference in arm circumference was <2 cm. The △CSAs of both upper arms and forearms were calculated by measuring the thickness of the subcutaneous tissue at four locations using ultrasonography (superior, medial, inferior, lateral) at 10 cm above the elbow and 10 cm below the elbow. With a 1.35 △CSA ratio as the cut-off value for detecting BCRLD, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were 0.88, 0.87, and 0.95, respectively. With a 1.20 △CSA ratio as the cut-off value for detecting BCRLC, the sensitivity, specificity, and AUC were 0.92, 0.89, and 0.97, respectively. Conclusions: Our findings suggest that a 1.20 △CSA ratio as determined using ultrasonography, corresponding to a tape measurement of 1.05 cm, can be considered as a diagnostic criterion for lymphedema.

Postoperative lymphedema after primary total hip arthroplasty: prospective analysis of bikini incision-type direct anterior approach versus established standard approaches

BACKGROUND

Minimally invasive approaches to the hip joint for total hip arthroplasty such as the DAA ("Direct Anterior Approach with bikini incision") are increasingly utilized. According to the literature, this approach is more muscle-sparing, results in less postoperative pain, and achieves higher patient satisfaction. The existence of postoperative lymphedema after hip arthroplasty is hardly considered. The aim of this paper is to contribute to the evaluation of the different access methods related to postoperative lymphedema and their functional outcomes.

METHODS

This is a prospective non-randomized study at an orthopedic specialist clinic in Northern Europe. The surgeons that performed the arthroplasties are high-volume surgeons in private practice affiliated to the clinic. The study included 188 patients with primary hip arthroplasty in a 1:1 ratio (DAA: standard accesses (posterior, transgluteal, and anterolateral access)). Epidemiologic data, Harris Hip Score, Oxford Hip Score, European Quality of Life 5, and Visual Analog Scale were collected preoperatively on admission day, 3rd and 5th postoperative day, and follow-up after 1 year. Furthermore, the range of motion, gait, and ability to climb stairs, as well as the presence of hypesthesia were assessed. To evaluate the edema situation, both legs were measured on the 3rd and 5th postoperative day. The prescription of manual lymphatic drainage and remaining swelling conditions 1 year postoperatively were recorded.

RESULTS

For each group, 94 patients with a mean age of 61.7 years (DAA 60.7 and standard access 62.6) were included. All but one patient in the DAA group showed postoperative lymphedema (n: 93/94; 98.9%). In the standard surgery group, only n: 37/94 (39.4%) showed swelling symptoms requiring treatment. After 1 year, lymphedema persisted in 20 patients in the DAA group and 0 patients in the standard-OR group. Hypesthesia at the ventral thigh persisted in 16/94 (= 17%) patients of the DAA group versus 0/94 patients of the standard group after 12 months. Of these 16 cases, 10 had concomitant edema (62.5%). The DAA showed better results than the standard accesses in terms of Oxford Hip Score (p < 0.05) and ability to climb stairs (p < 0.05). In contrast, the Visual Analog Scale and patient quality of life results showed no significant difference (p > 0.05).

CONCLUSION

The present study demonstrated the increased incidence of postoperative lymphedema in patients operated on via DAA access using a Bikini-type skin incision. In the follow-up, significantly more hypesthesia of the ventral thigh occurred in the DAA group. Otherwise, the DAA proved to be superior to the standard approaches from a functional point of view at short-term follow-up. Future research is needed to compare the horizontally oblique to the longitudinal oblique skin incision technique in direct anterior hip surgery regarding the above-mentioned adverse effects found in this study.

The relationship between the degree of subcutaneous fluid accumulation and the lymphatic diameter

BACKGROUND

The relationship between the fluid accumulation in the subcutaneous tissue and the lymphatic degeneration in the lymphedematous limbs has not been elucidated, and we have evaluated it in the current study.

METHODS

Twenty-five patients (50 limbs) were included in this retrospective study. We performed lymphatic ultrasound by separating the limbs into four lymphosomes: the saphenous (medial) thigh, saphenous (medial) calf, lateral thigh, and lateral calf. In each lymphosome, the lymphatic diameter, the degree of lymphatic degeneration, and the fluid accumulation in the subcutaneous tissue were evaluated. The lymphatic vessels were detected based on the index of D-CUPS (Doppler, Crossing, Uncollapsibe, Parallel, and Superficial fascia). Lymphatic degeneration was diagnosed based on the NECST (Normal, Ectasis, Contraction, and Sclerosis Type) classification.

RESULTS

All patients were women with a mean age of 62.7 years. Lymphatic vessels were detected using lymphatic ultrasonography in 50 saphenous (medial) thigh lymphosomes, 43 saphenous (medial) calf lymphosomes, 34 lateral thigh lymphosomes, and 22 lateral calf lymphosomes. The fluid accumulation tended to be more acute in the more severe stages of lymphedema. As for the NECST classification, the normal type was observed only in the areas without fluid accumulation. Among the other areas, the percentage of contraction type was the largest in the area with slight edema and decreased in the areas with severe edema.

CONCLUSION

The lymphatic vessels were dilated to a greater extent in legs with more severe fluid accumulation. Therefore, there is no hesitation needed to perform lymphaticovenous anastomosis because of severe lymphedema.