ASEPTIC LYMPHORRHEA AFTER HIP ARTHROPLASTY

Egiazaryan K.A., Sirotin I.V., Ratyev A.P., Korobushkin G.V., Lazishvili G.D., But-Gusaim A.B.

Pirogov Russian National Research Medical University, Moscow, Russia

 ASEPTIC LYMPHORRHEA AFTER HIP ARTHROPLASTY

One of the complications of hip joint replacement is a long term chronic wound   with continuous discharge. Commonly, in such situations, surgeons use some procedures that cause the directly contrary effects – from conservative management of wounds to aggressive surgical treatment with revision of a joint and change of its components. Such difference in approaches is associated with inappropriate algorithm of activity in presence of long term open wounds without clear signs of an infection.
There is an opinion that in some cases such situation is caused by an intrasurgical injury to lymphatic vessels and nodes with development of lymphorrhea. However after reviewing the traumatology and orthopedics literature we could not find any studies of management of such patients in hip replacement and other profile operations. Moreover, mention of lymphorrhea as a separate specific complication is given only in the limited range of the publications.
As for the percentage ratio, lymphorrhea is not so rare event after hip joint replacement. So, Tkachenko and coauthors [1] report on the development of lymphorrhea as a complication of such surgery in 0.5 % of the cases. Moreover, Mayer et al notes that among all cases of lymphorrhea more than 17 % of the cases relate to hip joint replacement [2].
Nevertheless, many studies show the relationship between the long term wound discharge and the infectious process [3].
In this article, we tried to generalize the data of the phenomenon of lymphorrhea and possible management of such patients with this complication as result of hip joint replacement.

Terminology and anatomical terms

Lymphorrhea (lymph + rhoia, from Greek – course, flow; the synonym is lymphorrhagia; lympho + rhagos, from Greek – ruptured, lacerated) is lymph outflow to the surface or into body cavities as result of an injury or disease of lymphatic vessels [4].
As a complication of surgical interventions, lymphorrhea is a quite common event in practice of neurosurgeons. After inguinal lymphatic nodes, lymphorrhea is often identified after removal of veins and radical lymphoadenectomy in oncologic lesions of this region (Ducuing and Shkolnik surgeries). The feature of these surgical interventions is a partial sudden injury or subtotal removal of lymph nodes and ducts from the region of the femoral triangle.
The femoral triangle is a topographic formation, which is limited by lig. Inguinale from the upper part (the basis of the triangle), m. sartorius – from outside, m. adductor longus – from the inner part. The bottom of the triangle (fossa iliopectinea) is formed by mm. iliopsoas et pectineus [5].
A group of the lymphatic ducts is situated in this region. They form the anteromedial lymphatic collector. Also the group of superficial and deep lymphatic nodes is located under the broad fascia directly on mm. iliopsoas et pectineus, and the adjacent lymphatic nodes spread into the gluteal muscles.
The interesting moment is a relationship between complications of a postsurgical wound during angiosurgical interventions for this region. So, according to Shevchenko, lymph hematomas present about 90 % (!) of complications of phlebectomy [6].
Certainly, turning to joint replacement, one can note that such operations are conducted in somewhat different anatomic region. This fact can explain the rarer frequency of such complications of hip joint replacement, but it does not exclude a possibility of injury to the deep inguinal lymphatic vessels and nodes on m. iliopsoas. When approaching, exposing and dissecting the acetabulum or in dissection of joint capsule, removal of central and anterior osteophytes in case of arthritis, this muscle can be visualized in the wound, i.e. it can be injured like other anatomic structures near it.
Malinin et al researched the contrast lymphography in the region of the femur and the inguen [7]. The figure 1 shows the location of the anteromedial lymphatic collector consisting of 14-16 lymphatic vessels, which subsequently enter the inguinal lymphatic nodes. It is interesting that the significant amount of these vessels is situated near by the acetabulum, i.e. they can be injured theoretically (Fig. 1).        

 Figure. Direct contrast lymphorrhea through the left lower extremity: the left inguinal and iliac regions, anterior medial lymphatic collector is presented by 14-16 lymphatic vessels which subsequently enter the inguinal lymphatic nodes (according to A.A., Malinich, S.I. Pryadko, M.S. Dzhabaeva. Diagnostics and treatment of hemochiloperitoneum in chylous malformations with chyle gravitation reflux into visceral organs).

Diagnostics

The difficulties for diagnostics and differential diagnostics of lymphorrhea are mainly associated with the present opinion in surgical orthopedics that most problems of non-healing wounds and persistent wound discharge relate to a manifestation of development of the infectious process. Zimmerli et al determine the continuous wound exudate as a suspected infection that requires the postsurgical wound revision not later than 3 weeks from appearance of the symptoms [8]. Such approach is absolutely justified if the infectious origin of a complication is suspected. But if the secretion shows some signs of aseptic lymphorrhea, some authors recommend the conservative measures [9]. Such approach is advantageous owing to decreasing general costs for treatment and decreasing risk of recurrent surgery.
The clinical picture of lymphorrhea with an injury to the anteromedial collector is properly described in the studies relating to complications after removal of veins in varicose disease of the lower extremities, removal of inguinal lymph nodes in oncologic surgery. Commonly, lymphorrhea initiates in the region of a postsurgical wound on the days 4-7 after surgery, and it is characterized by secretion of light fluid with possible pink hint because of red blood cells. The secretion can be constant or periodical, with different intervals. It is associated with formation of “false lymphocele” – cavities filled with lymph. Also lymphatic infiltrates appear – soft tissues soaked with lymph, their thickening, and skin tension [10].
At the early phases of lymphorrhea, the important diagnostic moment is confirmation of the source of exudate, differential diagnostics with lysed hematoma. According to the chemical and cellular composition, the peripheral lymph in lymphatic vessels of the extremities (in contrary to plasma, the lymph composition is not homogenous and can differ in dependence on the level of a lymphatic vessel) significantly differs from plasma. Moreover, the available literature does not show any uniform opinion in relation to the qualitative composition [11-14]. Apparently, it is associated with high variability of lymph composition in normal and abnormal conditions. However, in all studies, lymph is a clear light-yellow fluid, with lower density, and with at least two-fold lower contents of protein in relation to plasma composition. The cellular composition is presented mainly by white blood cells (500-75,000 per ml). Such features can be useful during differential diagnosis for lymph secretion in lymphorrhea, and plasma in discharge of lysed hematoma.
Considering a possibility of cavities filed with lymph, the ultrasonic examination with estimation of cavity size, features of its contents and a possibility of ultrasound-guided puncture with subsequent analysis of exudate are important. In case of lymphorrhea and “false lymphocele”, the cellular and chemical composition will correspond to the lymph structure, and bacteriological inoculation will be negative [15, 16, 17]. Also magnetic resonance imaging can be used for diagnosis confirmation. It can identify the location and volume of a cavity, and will allow estimating the exudate features (serous, hemorrhagic or purulent) [18, 19].

Prevention and treatment

In contrast to lymphorrhea in distal parts of the extremity after phlebectomy, with self-arresting within 10-15 days, lymphorrhea in an injury to the anteromedial lymphatic collector requires long term treatment (if adequate therapy was not used), is prone to formation of “true lymphocele” (a cavity of “false lymphocele” overgrows with a fibrous capsule, which prevents its collapse and overgrowing) and lymphatic fistulas [10]. These complications can cause the secondary infection of the wound [20] and, as result, development of periprosthetic infection.
During surgery with a possibility of postsurgical lymphorrhea, some various preventive measures are used. Such measures are particularly useful for patients with high plasma level of interleukin-1. Such patients are more prone to formation of seromas [21]. Presurgical introduction of methylprednisolone is positive for decreasing volume of postsurgical lymphorrhea [22]. Agrawal recommends preventing lymphorrhea with the ultrasonic lancet instead of the traditional electric caute [23]. The positive feedbacks of the researchers include the local use of thrombin, as well as fibrin and thrombin glue [24, 25]. Oertli showed that the tranexamic acid decreases the blood loss and the volume of postsurgical lymphorrhea [26].
Nutritive status is also important for development of this complication. Low plasma level of protein promotes the development of lymphorrhea [21].
If evident signs of infection are absent, the common treatment of lymphorrhea is initiated with use of conservative measures, elastic compression and compressing bandage [9]. For treating lymphorrhea after general surgical interventions it is recommended to use ultrahigh frequencies, but it is doubtful for lymphorrhea after joint replacement, because a metal implant is present. The low fat diet is initiated [27]. If elastic compression is ineffective, the popular techniques are lymphocele puncture under ultrasonic control with subsequent application of compressing bandages, introduction of local action drugs through lymphatic fistulas, for example, Levomekol, 1 % iodine with sclerogenic effect [10], and 5-fluorouracil [28].
One of the efficient techniques in treatment of lymphorrhea is radial therapy. Mayer reports on efficient use of low dosages of radiation from 0.3 to 0.5 Gy for arresting lymphorrhea [2]. In absence of effects, the use of radial therapy is not recommended for more than 3 weeks [20].
The use of VAC-therapy can be efficient for closure of lymphatic fistulas. The appropriate duration of vacuum treatment is 14 days according to Abai [29]. However some authors recommend longer vacuum therapy – from 4 weeks to 2 months [30].
Surgical intervention is conducted if conservative measures are inefficient. Among various surgical interventions for inguinal lymphorrhea we note only the techniques that are possible and appropriate in case of an installed hip joint endoprosthesis.
For sealing the lymphatic vessels it is recommended to perform the revision of the postsurgical wound and ligation of identified injured lymphatic vessels. The vital dye (Evans blue or indigo carmine) is used for visualization and is introduced 1 hour before surgery [9]. It is possible to use Vvedenskiy technique, when lymphatic vessels are ligated at the level of the femoral medial condyle, where they are situated in the plane of the great saphenous vein [31]. Methylene blue and indocyanine green are also recommended [32].
Along with staining as a visualization technique before the next variant of surgery (microsurgical creation of the lymph venous anastomosis), it is appropriate to use magnetic resonance lymphangiography, which gives precise estimation of injury location [33].
According to our opinion, the visualizing techniques for lymphatic vessels with dye staining in the distal parts of lymphatic vessels may have some disadvantages for lymphorrhea after hip joint replacement. It is related to the fact that one cannot exclude the presence of an injury to lymphatic collectors delivering the lymph to the inguinal lymph nodes from more cranially located regions.   

CONCLUSION

According to our opinion, the problem of lymphorrhea after hip joint replacement deserves the close attention. A persistent open wound is associated with development of this complication, and excessively aggressive surgical management with wound debridement can worsen lymphorrhea. If an infection is suspected, the indecisiveness during early revision of the postsurgical wound can worsen the situation and cause the loss of the endoprosthesis.
Therefore, we believe that the important step is development of clear criteria for identification of the septic process in the wound and confirmation of its aseptic course.   

Information about financing and conflict of interests:
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.
 
REFERENCES:

1.  Tkachenko AN, Tkachenko AN, Lapshinov EB et al. Features of hip joint replacement in adult patients. Fundamental Researches. 2011; (10): 162-165. Russian (Ткаченко А.Н., Ткаченко А.Н., Лапшинов Е.Б.,и др. Особенности эндопротезирования тазобедренных суставов у больных старших возрастных групп // Фундаментальные исследования. 2011. № 10. C. 162-165)
2.  Mayer R, Sminia P, McBride WH et al. Lymphatic fistulas: obliteration by low-dose radiotherapy. Strahlenther Onkol. 2005; 181(10): 660-664
3.  Vinkler T, Trampush A, Rents N, Perka K, Bozhkova SA. Classification and the treatment and diagnostic algorithm for hip joint periprosthetic infection. Traumatology and Orthopedics of Russia. 2016; 1(79): 33-45. Russian (Винклер Т., Трампуш А., Ренц Н., Перка К., Божкова С.А. Классификация и алгоритм диагностики и лечения перипротезной инфекции тазобедренного сустава // Травматология и ортопедия России. 2016. № 1(79). C. 33-45)
4.  Small medical encyclopedia. M.: Medical Encyclopedia 1991-1996. Russian (Малая медицинская энциклопедия. М.: Медицинская энциклопедия. 1991-1996 гг.)
5.  Prives MG, Lysenkov NK, Bushkovich VI. Human Anatomy. M.: Hippocrates, 1998. 704 p. Russian (Привес М.Г., Лысенков Н.К., Бушкович В.И. Анатомия человека. М.: Гиппократ, 1998. 704 с.)
6.  Errors, hazards and complications in venous surgery: the manual for physicians / edited by Shevchenko YuL. St. Petersburg: PiterCom, 1999. 320 p. Russian (Ошибки, опасности и осложнения в хирургии вен: руководство для врачей / под редакцией Ю.Л. Шевченко. СПб.: ПитерКом, 1999. 320 с.)
7.  Malinin AA, Pryadko SI, Dzhadaeva MS. Diagnosis and treatment of hemochyloperitoneum in chylous malformations with gravitation reflux of chyle into visceral organs // Herald of Lymphology. 2014; (1): 29-34. Russian (Малинин А.А., Прядко С.И., Джабаева М.С. Диагностика и лечение гемохилоперитонеума при хилезных мальфорациях с гравитационным рефлюксом хилуса в висцеральные органы // Вестник лимфологии. 2014. № 1. С. 29-34)
8.  Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004; 351(16): 1645-1654
9.  Sushkov SA. Complications of surgical treatment of varicose disease of lower extremities. News of Surgery. 2008; 1 (16): 140-151. Russian (Сушков С.А. Осложнения при оперативном лечении варикозной болезни нижних конечностей // Новости хирургии. 2008. № 1(16). С. 140-151)
10. Albamasov KG, Malinin AA. Pathogenesis and management of lymphorrhea and lymphocele after vascular surgery of lower extremities. Surgery. 2004; (3): 23-30. Russian (Албамасов К.Г., Малинин А.А. Патогенез и тактика лечения лимфореи и лимфоцеле после сосудистых операций на нижних конечностях // Хирургия. 2004. № 3. С. 23-30)
11. Zhdanov DA. General anatomy and physiology of lymphatic system. Leningrad: Medgiz. Leningrad department, 1952. 336 p. Russian (Жданов Д.А. Общая анатомия и физиология лимфатической системы. Ленинград: Медгиз. Ленингр. отделение, 1952. 336 с.)
12. Rusznyák İ, Földi M, Szabó G. Lymphatics and Lymph Circulation, 2nd ed. Oxford, 1967
13. Pérez-de la Fuente T, Sandoval E, Alonso-Burgos A, García-Pardo L, Cárcamo C, Caballero O. Knee Lymphocutaneous Fistula Secondary to Knee Arthroplasty. Case Reports in Orthopedics. Volume 2014, Article ID 806164, 4 pages. URL: http://dx.doi.org/10.1155/2014/806164
14. Zavarzin AA, Rumyantsev AA. Course of histology. M., 1946. P. 421-424. Russian (Заварзин А.А., Румянцев А.А. Курс гистологии. М., 1946. С. 421-424)
15. Korneev KV. Modern directions of prevention of lymphorrhea in patients with breast cancer after radical mastectomy (literature review). Herald of Russian Scientific Center of X-ray Radiology. 2012. Mode of approach: http://vestnik.rncrr.ru/vestnik/v12/papers/korneev_v12.htm Russian (Корнеев К.В. Современные направления профилактики лимфореи у больных раком молочной железы после радикальных мастэктомий (обзор литературы) // Вестник РНЦРР МЗ РФ. 2012 Режим доступа: http://vestnik.rncrr.ru/vestnik/v12/papers/korneev_v12.htm)
16. Cihangir Ozaslan, Kerim Bora Yilmaz et al. Effect of mechanical closure of dead space on seroma formation in modified radical mastectomy. Turk j of med Sci. 2010; 40(5): 751-755
17. Katsuma Kuroi, Kojiro Shimozuma, Tetsuya Tagichi et al. Pathophysiology of seroma in breast cancer. Breast Cancer. 2005; 12(4): 34-39
18. Mazzocchi M, Dessy LA, Corrias F. A clinical study of late seroma in breast implantation surgery. Aesthetic and Plastic Surgery. 2011; 34: 53-60
19. Oliveira VM, Junior DR, Lucas F, Lucarelli A. Late seroma after breast augmentation with silicone prostheses: a case report. The Breast Journal. 2007; 12(3): 421-423
20. Konstantinova GD, Zubarev AR, Gradusov EG. Phlebology. M.: Vidar, 2000. 160 p. Russian (Константинова Г.Д., Зубарев А.Р., Градусов Е.Г. Флебология. М.: Видар, 2000. 160 с.)
1. Klink CD, Binnebosel M, Lucas AH, et al. Serum analyses for protein, albumin, and IL-1RA serve as reliable predictors for seroma formation after incisional hernia repair. Hernia. 2011; 15: 69-73
22. Okholm M, Axelsson CK. No effect of steroids on seroma formation after mastectomy. Dan Med Bul. February. 2011; 58(2): 1-5
23. Agrawal A, Abiodun A, Kwok Leung Cheung. Concepts of seroma formation and prevention in breast cancer surgery. ANZ Journal of Surgery. 2006; (76): 1088-1095
24. Jamal Bullocks, Bob Basu, Patrick Hsu et al. Prevention of hematomas and seromas. Semin Plast. Surg. 2006; 20: 233-240
25. Johnson L, Cusick T, Helmer S, Osland J. Influence of fibrin glue on seroma formation after breast surgery. Am J Surg. 2005; 189(3): 319-323
26. Oertli D, Laffer U, Haberthuer F, Kreuter U, Harder F. Perioperative and postoperative tranexamic acid reduces the local wound complication rate after surgery for breast cancer. Br J Surg. 1994; (81): 6: 856-859
27. Marts BC, Naunheim KS et al. Conservative versus surgical management of chylothorax. AMJ surg. 1992; 164: 532-535
28. Kocdor MA, Kilic Yildiz D, Kocdor H, et al. Effects of locally applied 5-Fluorourarcil on the prevention of postmastectomy seromas in a rat model. Eur surg res. 2008; 40: 256-262
29. Abai B, Zickler RW, Pappas PJ, Lal BK, Padberg FT Lymphorrhea responds to negative pressure wound therapy. Journal of Vascular Surgery. 2007; 45(3): 610-613
30. Greer SE, Adelman M, Kasabian A., Galiano RD, Scott R, Longaker MT. The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin. British Journal of Plastic Surgery. 2000; 53(6): 484-487
31. Vedenskiy AN. Varicose disease. L.: Medicine, 1983. 208 p. Russian (Веденский А.Н. Варикозная болезнь. Л.: Медицина,1983. 208 с.)
32. Azuma R, Takikawa M, Nakamura S, Sasaki K, Yanagibayashi S, Yamamoto N, et al. Indocyanine green fluorography in Plastic Surgery and Microvascular Surgery. The Open Surgical Oncology Journal. 2010; 2: 48-56
33. Lohrmann C., Foeldi E, Langer M. Lymphocutaneous fistulas: pre-therapeutic evaluation bymagnetic resonance lymphangiography. British Journal of Radiology. 2011; 84 (1004): 714-718

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