臺灣博碩士論文加值系統

Introduction: Patients with pre-existing lymphedema who undergo total knee arthroplasty for osteoarthritis are at a high risk of periprosthetic joint infection. This complication usually requires removal of the implant. This study aims to investigate whether surgical treatment of lymphedema reduced the rate of implant/prosthesis removal in such patients.
Materials and methods: We retrospectively reviewed our prospective database of patient information collected between January 2009 to December 2018. A total of 348 cases of lower extremity lymphedema were reviewed and those who underwent total knee arthroplasty (TKA) for osteoarthritis (OA) of the knee were included. Patient demographics, clinical data, lymphedema surgical history, and TKA surgical history including any episodes of removal were collected and analyzed.
Results: There were 9 lymphedema patients with knee OA who subsequently underwent TKA. The mean patient age was 70.4 ± 7.1 years. A total of 18 TKAs were performed in 9 patients. The knee prosthesis removal rate was 66.7% (12/18). The prosthesis removal rate was 40% (2/5) in patients who underwent lymphedema microsurgery versus 76.9% (10/13) for those who did not (p = 0.03).
Conclusions: Pre-existing lymphedema is associated with a high rate of knee prosthesis removal. Lymphedema microsurgery reduced the removal rate of knee prostheses. We recommend that surgical lymphedema treatment is considered for patients who require TKA as treatment for osteoarthritis of the knee.

Recommendation Letter from the Thesis Advisor………………………..
Thesis/Dissertation Oral Defense Committee Certification………………
Acknowledgments………………………………………………………... iii
Abstract…………………………………………………………………… iv
Table of contents………………………………………………………….. vi
List of tables………………………………………………………………. vii
List of figures……………………………………………………………... viii
Chapter 1 – Introduction ..………………………………………………… 1
Chapter 2 – Materials and Methods……………………………………….. 2
Chapter 3 – Results………………………………………………………... 7
Chapter 4 – Case Presentation ……………………………………………. 10
Chapter 5 – Discussion……………………………………………………. 12
Chapter 6 – Conclusion…………………………………………………… 16
References………………………………………………………………… 17
Tables and Figures………………………………………………………... 21

List of Tables
Table 1 Demographic data of lymphedema patients with knee OA
who underwent TKA 21
Table 2 Surgical treatment course in all patients 22
Table 3 Outcomes of lymphedema patients with TKA only versus
TKA with lymphedema microsurgery 23
Table 4 Microorganisms found preceding knee prosthesis removal 24




List of Figures
Figure 1 Flow Diagram of Study Patients 25
Figure 2 Anterior- posterior and lateral plain film views of the
patient’s left knee in standing position prior to the first knee
replacement showing joint space narrowing of both the
medial and lateral sides with a miniscule bone spur (marginal
osteophyte) at the medial proximal tibia. 26
Figure 3 Lymphoscintigraphy of the patient showing partial
lymphatic obstruction of right leg with presence of a right
intermediate node at 1.5 hours after Tc- 99m injection and a
right inguinal lymph nodes chain at 2.5 hours after Tc- 99m
injection ( Taiwan Lymphoscintigraphy Stage P2) . Left
inguinal node was not demonstrated and total lymphatic
obstruction was diagnosed ( Taiwan Lymphoscintigraphy
Stage T5). 27
Figure 4 Case presentation of a patient with bilateral lower limb
lymphedema and total knee arthroplasty for osteoarthritis of
the knee. Left: preoperative; right: 24 months following
vascularized submental lymph node transfer. 28
Figure 5 Anterior- Posterior and lateral plain film views of the
patient’s left knee after the fourth total knee arthroplasty
depicting a clear view of the successful hinge knee prosthesis
in situ. 29
Figure 6 Proposed algorithm for the lymphedema patients who have
knee osteoarthritis and require total knee arthroplasty 30

1. Rockson, S.G. and K.K. Rivera, Estimating the population burden of lymphedema. Ann N Y Acad Sci, 2008. 1131: p. 147-54.
2. Allen, R.J., Jr. and M.H. Cheng, Lymphedema surgery: Patient selection and an overview of surgical techniques. J Surg Oncol, 2016. 113(8): p. 923-31.
3. Warren, A.G., et al., Lymphedema: a comprehensive review. Ann Plast Surg, 2007. 59(4): p. 464-72.
4. Gustafsson, J., et al., Correlation between Quantity of Transferred Lymph Nodes and Outcome in Vascularized Submental Lymph Node Flap Transfer for Lower Limb Lymphedema. Plast Reconstr Surg, 2018. 142(4): p. 1056-1063.
5. Ackerman, I.N., et al., Substantial rise in the lifetime risk of primary total knee replacement surgery for osteoarthritis from 2003 to 2013: an international, population-level analysis. Osteoarthritis Cartilage, 2017. 25(4): p. 455-461.
6. Dupuy, A., et al., Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ, 1999. 318(7198): p. 1591-4.
7. Moffatt, C.J., et al., Lymphoedema: an underestimated health problem. QJM, 2003. 96(10): p. 731-8.
8. Chlebicki, M.P. and C.C. Oh, Recurrent cellulitis: risk factors, etiology, pathogenesis and treatment. Curr Infect Dis Rep, 2014. 16(9): p. 422.
9. Mallon, E.C. and T.J. Ryan, Lymphedema and wound healing. Clin Dermatol, 1994. 12(1): p. 89-93.
10. Scaglioni, M.F., et al., Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery, 2017. 37(8): p. 947-953.
11. Cheng, M.H., C.Y.Y. Loh, and C.Y. Lin, Outcomes of Vascularized Lymph Node Transfer and Lymphovenous Anastomosis for Treatment of Primary Lymphedema. Plast Reconstr Surg Glob Open, 2018. 6(12): p. e2056.
12. Sharkey, A.R., et al., Do surgical interventions for limb lymphoedema reduce cellulitis attack frequency? Microsurgery, 2017. 37(4): p. 348-353.
13. Shrader, M.W. and B.F. Morrey, Insall Award paper. Primary TKA in patients with lymphedema. Clin Orthop Relat Res, 2003(416): p. 22-6.
14. Poultsides, L.A., et al., Infection risk assessment in patients undergoing primary total knee arthroplasty. Int Orthop, 2018. 42(1): p. 87-94.
15. Pulido, L., et al., Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res, 2008. 466(7): p. 1710-5.
16. Ming-Huei Cheng, M.D.M.B.A.F., D.W. Chang, and K.M. Patel, Principles and Practice of Lymphedema Surgery. 2015: Elsevier Health Sciences.
17. Cheng, M.H., et al., Validity of the Novel Taiwan Lymphoscintigraphy Staging and Correlation of Cheng Lymphedema Grading for Unilateral Extremity Lymphedema. Ann Surg, 2018. 268(3): p. 513-525.
18. Ito, R., et al., Successful treatment of early-stage lower extremity lymphedema with side-to-end lymphovenous anastomosis with indocyanine green lymphography assisted. Microsurgery, 2016. 36(4): p. 310-5.
19. Cheng, M.H., et al., A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol, 2012. 126(1): p. 93-8.
20. Poccia, I., C.Y. Lin, and M.H. Cheng, Platysma-sparing vascularized submental lymph node flap transfer for extremity lymphedema. J Surg Oncol, 2017. 115(1): p. 48-53.
21. Cole, B.J. and C.D. Harner, Degenerative arthritis of the knee in active patients: evaluation and management. J Am Acad Orthop Surg, 1999. 7(6): p. 389-402.
22. Hespe, G.E., et al., Pathophysiology of lymphedema-Is there a chance for medication treatment? J Surg Oncol, 2017. 115(1): p. 96-98.
23. Kataru, R.P., et al., Regulation of Immune Function by the Lymphatic System in Lymphedema. Front Immunol, 2019. 10: p. 470.
24. Avraham, T., et al., Radiation therapy causes loss of dermal lymphatic vessels and interferes with lymphatic function by TGF-beta1-mediated tissue fibrosis. Am J Physiol Cell Physiol, 2010. 299(3): p. C589-605.
25. Zampell, J.C., et al., CD4(+) cells regulate fibrosis and lymphangiogenesis in response to lymphatic fluid stasis. PLoS One, 2012. 7(11): p. e49940.
26. Koh, C.K., et al., Periprosthetic Joint Infection Is the Main Cause of Failure for Modern Knee Arthroplasty: An Analysis of 11,134 Knees. Clin Orthop Relat Res, 2017. 475(9): p. 2194-2201.
27. Postler, A., et al., Analysis of Total Knee Arthroplasty revision causes. BMC Musculoskelet Disord, 2018. 19(1): p. 55.
28. Kubista, B., et al., Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty. Int Orthop, 2012. 36(1): p. 65-71.