CARE OF A PATIENT WITH SEVERE LYMPHEDEMA PRE-and POST -OP TOTAL
KNEE REPLACEMENT

The patient first visited our clinic for lymphedema therapy in July 1998. Having had
lymphedema for almost 10 years, secondary to hysterectomy for cancer followed by
radiation of the lower abdomen, she was well acquainted with bandaging and self-MLD.
Her daytime garment was a unilateral CCIII - AG and her nighttime garment was a
custom Legacy - AG over which she either applied a pump sleeve and pumped before
retiring or she would wrap short stretch bandages. Our concerns were: the very dry
condition of the skin and the presence of a large erythematous area on the anterior lower
leg; the increased girth of the lower leg and calf; the knee was very heavy with
lymphedema and becoming increasingly immobile; and there was a ridge of fibrosis
extending posterior from the ankle into the popliteal space. Though the patient stated the
area of erythema had always "been that way and sometimes worse", we were concerned
about the possibility of a chronic inflammatory process of the lower leg. And when the
patient repeatedly commented about increasing pain and immobility of the affected left
knee, we became concerned about the efficiency of fluid movement through, and away
from the knee joint. It appeared that the knee was the "problem area” for the lower leg
and calf. The patient then stated her fears of possible knee surgery. Our focus was to
reduce and maintain the left affected leg by: concentrating on intensive skin care to
reduce inflammatory processes, increasing combined decongestive therapy (CDT)
sessions; checking the viability of compression supplies and her present gradient
compression stockings along with the directional flow garment, initiating an exercise
regimen, planning different compression solutions to enhance reduction, and protecting
the unaffected right leg from the possibility of lymphedema occurrence. As knee pain and
immobility increased, she continued to have severe back problems, and any amount of
exercise became a real challenge.

By January 2002, the patient's posture was worsening - she was stooping over more
radically and any slight rotation of the knee brought on excruciating pain. She began
preparation for knee surgery by scheduling pre-operative CDT sessions and getting
mentally and emotionally prepared. Therapy sessions included: gradient sequential
pumping by applying a full leg pneumatic appliance over a directional flow garment for
30 minutes while manual lymph drainage was performed on the torso; intensive manual
lymph drainage was continued on the left affected lower leg and calf post pumping; fullleg
circumferential measurements; intensive specialized skin care especially in the
erythematous areas of the anterior lower leg; and application of an accessory compression
garment (an AD (toes to knee) garment over an AG (toes to groin) garment) to give a
greater degree of compression on the distal calf.

Post-surgical protocol for therapy was planned focusing on channeling lymph medial to
lateral left torso and upper leg, including affected knee, into ipselateral collaterals. The
directional flow garment was constructed to follow protocol exactly and designed in two
pieces: a high body part around the torso and a separate open full leg unit with Velcro
closure tabs positioned laterally.
Velcro tabs, positioned vertically, anterior and posterior on both garments made it
possible to attach them together during application. Directional flow garments are
designed with gradient pressure from many directional flow angles. Each unit is also
constructed with passive compression to allow movement of lymph fluid along normal
lymph pathways. These three ingredients: gradient pressure, directional flow, and passive
compression must work together to be effective. In addition, it is very important for the
lymphedema therapist to have experience in post-operative care so that protocol for
therapy is correct in order to effectively protect the patient. Post-op care for the patient
meant protecting the knee. After thorough hand washing, MLD was performed according
to protocol, the skin cleansed well and lotions applied and the surgical incision well
protected. The affected left leg was then placed into the open directional flow garment
and using the lateral Velcro tabs, the leg unit was lightly tightened from ankle to groin to
the patient's tolerance. The body part was then fastened around her waist and attached to
the leg portion thus completing directional flow, gradient pressure and passive
compression. Following hospitalization, this "open directional flow garment” was
perfect for the patient's home care until the knee healed sufficiently and she was able to
apply her regular directional flow garment.

In conclusion: comprehensive care post-operative knee replacement using CDT and a
directional flow garment indicates:
reduction of fluid retention at operative site
inflammatory processes reduced
earlier mobility of the knee with gradual greater range of motion
reduction in pain
accelerated wound healing
decreased possibility of keloid process
reduced recovery time
safeguards patient against lymphedema crisis
patient's satisfaction of overall care

Submitted by Phyllis Tubbs-Gingerich, RN, BSN, LE, CLT-Lymphedema Therapist
(LANA)

Ginger-K Center
16130 Juan Hernandez Or, Ste 108 Morgan Hill, CA 95037
Tel: 408-782-1028
Fax: 408-782-1061
e-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it. web site: www.gingerkcenter.com
November 10 ,2002