One of the frustrating problem that a Patients can face after major surgery involving soft tissues in the thigh or following fracture fixation is dependent oedema of the leg that seems to persist for weeks. Once you rule out infection and DVT, What can be the cause?

1.Clinical Scenario
• Patient with **thigh muscle‑transfer surgery
• Presents with **soft, pitting oedema** of one leg
• Normal venous and arterial Dopplers
• No DVT

2. Most Likely Cause
• Lymphatic Impairment
• Muscle‑transfer procedures disrupt superficial lymphatic channels
• Leads to **reduced lymph drainage** and **fluid accumulation**
• Early lymphoedema = **soft, pitting** (later becomes firm, non‑pitting)

3. Additional Contributing Factors
• Post‑surgical inflammatory oedema
• Reduced muscle‑pump function** (weakness, altered gait)
• Post‑operative scarring – compressing lymphatics
• Deep seroma/hematoma** obstructing lymphatic flow
• Systemic factors** (less likely if unilateral)

4. Diagnostic Considerations
• Ultrasound** → rule out seroma/collection
• Lymphoscintigraphy** → confirm lymphatic dysfunction
• Basic labs** → albumin, renal function, thyroid (exclude systemic causes)

5. Management Overview
• Compression Therapy**
• Graduated compression stockings (Class II)
• Multilayer bandaging if needed
• Elevation
• Regular elevation above heart level
• Physiotherapy:
• Strengthening of thigh/calf muscles
• Gait correction
• Restores muscle‑pump efficiency
• Manual Lymphatic Drainage (MLD)
• Gentle, therapist‑performed lymph mobilization
• Intermittent Pneumatic Compression (IPC)
• Rhythmic external compression
Effective management enhances lymphatic and venous return
• Particularly effective for **early lymphoedema** and **post‑surgical swelling**
• Use with caution if infection, open wounds, or severe cardiac disease

Key Take‑Home Message:
Normal Dopplers + unilateral pitting oedema after thigh surgery → **think lymphatic** Management is **multimodal**
IPC is a **useful adjunct**, not a standalone treatment
Early intervention prevents chronic lymphoedema