[Diagnosis, differential diagnosis and therapy of lymphedema]

Swellings in the legs, caused by lymphedema, are encountered quite frequently in everyday orthopedic practice. The swellings are hard, pale in color and usually painful. Swellings of this kind occasionally atrain a completely disproportionate size and are the referred to as elephantiasis. Lymphedemas fall into two categories: 1. Congenital lymphedemas. These comprise lymphedemas occuring as a result of aplasias or dysplasias of lymph vessels. 2. Acquired lymphedemas: In such cases the edema may be due to mechanical causes, or it may be the result of a disturbance of lymph drainage, e.g., due to the destruction of lymph vessels by metastases, following extirpation of lymph nodes and radiation therapy; or it may be the result of inflammatory processes, e.g., following erysipelas, in filariasis or after a wound infection. Four stages of lymphedema are also distinguished: Stage I - latent lymphedema Stage II - reversible lymphedema Stage III - irreversible lymphedema Stage IV - Elephantiasis. Apart from clinical diagnosis the most comprehensive and reliable diagnostic procedure is lymphangiography. A simple and well-tried method of diagnosing lymphedema is to inject lymphotropic dye subcutaneously. The technique is outlined. The differential diagnosis of lymphedema is described. With regard to treatment, reference is made to surgical possibilities. However, these do not always augur success and the complication rate is high. Massive lymphedemas, therefore, are usually treated conservatively, by Van der Molen's tube method, with intermittent cuff pressure (pressure-curve therapy) and manual lymph drainage. The various treatment methods are described and some of the disadvantage and risks involved are pointed out.