Hattie Smith age 86 Situation: Has swelling in her right l

Patient

Q: Hattie Smith age 86
Situation:
Has swelling in her right lower leg and foot.
She recently (6/5/16) had a growth removed from her right posterior thigh. It was about the size of an egg and was diagnosed as benign. The nerves were attached and were detached from the growth during surgery. The feeling in her leg and foot has partially returned to some areas. She is taking the following medicines: Fluconazole, Metforman, Symbicort, Lantus and Amlodipine Besylate. A recent test show that she has no blood clots. Her physician has her wearing a compression sock that comes up to her knee. She has some soreness in the leg and the pad of her foot. The sock causes the knee to swell and cause knee pain when she tries to walk. The right knee is a knee replacement. She has been very active prior to the surgery (i.e. exercises at the gym 2-3 days/wk.)
Diagnosis:
The surgeon feels that the swelling is not coming from the surgery. Her physician feels as though it may be coming from the surgery. He says that the nerves have not fully recovered from the surgery and are not working in conjunction with the blood vessels. This is why fluid is being retained in the lower leg and foot.
What are your thoughts?

Doctor

A:   Hi,

Thanks for your query.

Read the history and understood the concerns.

Noted the findings of surgery for a benign lesion in the right posterior thigh - medication list, swelling as described, soreness in the leg and the pad of her foot, The sock causes the knee to swell and cause knee pain when she tries to walk.

My thoughts:
The posterior part of the thigh has no major blood vessels or nerves, hence the surgery in this part causing edema of the leg and foot is difficult to explain.

Please tell me the following observations:
- Whether the toes are swollen or not.
If the toes are also swollen, then the problem is related to the blocked veins.
If the toes are not swollen, then the edema is a lymph edema.

I would advise the following in such a case:
Ultrasonography and color doppler to see whether there are incompetent perforators causing some varicose veins causing the edema.
Review of the right knee as there is swelling and pain in the knee- this can also cause edema in the leg and the foot.
Whatever the reason of swelling in the leg and foot: the elevation of the leg and foot above the heart level in laying down position helps to reduce the edema effectively, better than the socks.

Please check for the observations asked for and give feedback.

Comments / Follow Ups

Patient: The toes are swollen. The surgeon said that some of the feeling may not return to the foot and leg. We would have to wait and see. He state that he had to remove 2 nerves from the growth (the one that goes to the bottom of the foot and one that ends at the beginning of the big toe).
Doctor: Thank for your feedback.
If the toes are involved, this is not the lymphedema.
The commonest causes can be attributed to the Venous origin hence the need of an ultrasound with color doppler.
Since the surgeon has said that he had to cut the 2 nerves from the growth - the one that goes to the bottom of foot and the one that ends at the beginning of the big toe, the sensation may not return back. This can cause the secondary edema also. There would have tying of the main blood vessel as it have been going through the tumor for which you were operated.
You may take a second opinion of a Neurologist, request for nerve conduction tests and give the final diagnosis as well as proper treatment.

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