This post continues the discussion of a case study in edema management led by Marisa Perdomo PT, DPT, CLT-Foldi, CES. The first post went up last week and can be read here.

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Thank you everyone for your thoughtful comments as to how you would proceed. I will start this blog post by providing you with my own take on the questions:

  1. What interventions or strategies do you presently employ to treat post-operative edema following a total hip procedure in the home health setting?”

ANSWER: The following interventions are commonly used in a home-health setting:

  • Hip and leg exercises which include isometrics and AAROM / AROM
    • Examples: Bridging, SLRs in all four planes, heel slides, ankle pumps and circles, with progression from supine exercises to exercises in standing.
    • Functional exercises: Chair sit to stand and modified partial squats; heel raises.
  • Gait training with assistive device and weight bearing as per protocol; encourage heel-toe gait as soon as possible.
  • Possibly kinesiotaping of right hip.
  • Pulsed ultrasound (not over hip prosthesis but over soft tissue bruising).
  • General massage techniques.
  1. After examining the pictures of Mark’s right hip edema, do you consider the amount of edema as expected? Provide your clinical rationale.

Based on the picture, the swelling of the right thigh and the bruising is within the range of my expectation. There are many factors that influence the amount of post-operative edema in each client; however, this is what I consider “expected” based on the client’s age, past exercise history and general physical conditioning.

 

MARK’S PROGRESSION

Mark is now 7 weeks post-op. He was discharged from home health physical therapy one week ago, and he has been referred to an outpatient orthopedic clinic for an evaluation and treatment per “total hip protocol.”

Mark is fully independent with all self-care activities; he ambulates with a cane for short distances, and uses a walker for distances > 250 feet. He is performing a home exercise program of straight leg raises, hip abduction, bridging, and ankle pumps: 2 sets of 15 repetitions daily. He also ambulates outside with his walker 15 minutes at a time, 2 X daily. Although able, he reports continued difficulty with sitting to stand transfers, overall fatigue, and that his right leg still feels weak.

Upon initial evaluation, the therapist at the outpatient clinic observes edema present in the right hip and entire thigh, to just above the knee on the right leg. Mark reveals that the swelling extends up to include the right pelvis, suprapubic region and scrotum. He reports he experienced a similar problem after the left total hip replacement and that the edema was very painful. He reports that the previous episode of edema involving the left hip took ~ 3 months to completely resolve; he’s hoping that it doesn’t take that long this time. Mark casually asks if this swelling has anything to do with him having prostate surgery secondary to cancer when he was 50 years old. (1 year prior to the L THR.)

Markings

Here are some additional questions to consider at this point:

  1. How does the presentation of edema affect your differential diagnosis process? What additional diagnoses could potentially explain this pattern of edema?
  2. What questions do you want answered to help you explain this pattern of edema?
  3. Does your treatment plan change as far as continuing with the total hip protocol? Does your treatment plan change with respect to specific interventions for edema management?

Enjoying this case study? Once you’ve had a chance to reflect and comment below, continue to the last part of Dr. Perdomo’s case study.

This article has 11 comments

  1. Anonymous

    I would like to find out if any of the lymph nodes were removed during the prostate surgery?

  2. Johnny Galver

    I would like to know if he is running a fever or is there warm or heat associated with any part of the lower leg. Is there pitting in lower leg and ankle?

  3. Jen

    Was chemo or radiation used in the treatment of the cancer?

  4. JoAnn Stafford

    I would like to know if patient received radiation.
    If so, what side was radiated and/or had lymph nodes removed.
    What stage was the prostate Ca? Were lymph nodes positive? How many?
    Evaluate for local recurrence of cancer.
    I would not use ultrasound.
    Evaluate for thrombosis Ca recurrence,if negative initiate MLD,skin care,compression and exercise.

  5. Dr. Jasobanta Sethi

    In my opinion, post surgical edema can be treated with pressure therapy unit, compression stockings in addition to the therapeutics mentioned above

  6. Kayode Adelugba

    I suspect lymphedema in this case; Up to 70% of patients after prostate cancer do have lyphedema. Secondly,the surgery may have resulted in disruption of or damage to lymphatic.Information about the surgery procedure may help in diagnosing this case.

  7. Patrick Hansen

    I think at this point, with his surgical and edema history, you have to ask the MD to rule out blood clot in the hip/pelvic area.

  8. Radina

    Almost in every case Kinesiotaping with the right technique not the hip application is a verry appropriate and effective tool against the edema

  9. Radina

    If it can be treated with Physiotherapy, in case of any medical post surgical complications of course it is the MD and surgeon to find out the reason and the treatment. If everything is ok, and it is just post surgical edema…..Kinesiotaping

  10. Marisa Perdomo

    Hello everyone, great questions so far and I will answer them as a group.

    Question: Any of the lymph nodes were removed during the prostate surgery? Any history of radiation therapy? Cancer recurrence?

    No lymph node dissection performed, however the surgeon did state that ~ 3 nodes were removed and negative. No radiation therapy needed as the cancer was contained to the prostate. This issue of recurrence is always a consideration, but based on the neg LN status and cancer confined to prostate and stable PSA levels < 3 would not expect prostate cancer recurrence to be a cause of this edema. In fact, the patient is considered cured of the prostate cancer.
    Lymphedema is lower on the differential diagnosis list but must be considered due to surgery. May not want to consider compression bandaging yet, try other interventions first and depending upon response may not need bandages. Must consider "overload principle" for edema vs lymphedema

    Question: Fever? Warm to Palpation? any leg/foot edema? Pitting? Yes absolutely infection should also be on the differential diagnosis list.

    Via palpation, no warmth palpated or redness observed; temperature normal. No edema beyond the upper to mid thigh. Some pitting present overall the edema was soft, but viscous to palpation with pitting.

    Comment: Consider blood clot? yes i agree this should be on the differential diagnosis list and requires a discussion with home health Nurse or MD. INR levels were in the appropriate range for prevention of blood clot and he did receive compression therapy while in the hospital. The patient was aware of blood clot risk from previous THR on opposite side and therefore was very compliant with exercise program several times a day and ambulation as much as possible. In this case: no US test was performed as the behavior of the edema fluxuated (lessened) with exercise. Patient reported less swelling on days he was more active.

    Kinesiotaping: yes definitely an option

  11. Nathakorn

    Questions; Has he cleared from the complications that you suspected?… Is he taking the anticoagulant medications?…

    I would like to share my opinion that KT tape (lymphatic drainage technique), Electrotherapy (IFC) with intermittent compression and Hydrotherapy (modified Halliwick Methods) are recommended for 7 weeks post-operation if he isn’t underlying on the infection or blood clot in the peripheral vessels or any contraindications for hydrotherapy. Normally, I deliver them as multi-modal therapy in the early stage of rehabilitation programme (since the stitch wound heal and dry, roughly 1-2 weeks). Moreover, I would prefer to use US scan as a review the edema fluctuated in a weekly basis.

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