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PubMed1984

Second leg ischemia. Lower extremity bypass versus amputation in patients with contralateral lower extremity amputation.

Unilateral amputees with second leg ischemia may miss consideration for anything but amputation. Justification for a reconstructive approach for these ischemic second limbs was sought from a retrospective study of 108 patients who underwent lower extremity distal bypass. Risk factors and results were compared for the 12 unilateral amputees and the 96 nonamputees. Age and relative incidence of rest pain, claudication, and tissue loss were not significantly different for the two groups. Diabetes mellitus was present in 41.6 per cent of amputees and 31.3 per cent of nonamputees. Preoperative, average ankle-brachial blood pressure ratios were equal for both groups (0.3). Angiography showed comparable distribution of patients between the two groups with regard to distal run-off vessels. Operative mortality was 8 per cent for amputees and 3 per cent for nonamputees. Cumulative survival at 25 months was 67.5 per cent for amputees and 82.4 per cent for nonamputees. Cumulative patency at 6 months was 71.5 per cent for amputees compared with 63 per cent for nonamputees and at 25 months was 58.5 per cent for amputees and 37.6 per cent for nonamputees (no significant difference). Unilateral amputees appear to have similar risks and results for lower extremity distal bypass as do nonamputees. An independent, aggressive approach for evaluation and surgical revascularization should not be overlooked for the ischemic, remaining lower extremity in the dysvascular unilateral amputee.

Amputation, Surgical↗
PubMed1996

Lower extremity injuries in college athletes: relation between ligamentous laxity and lower extremity muscle tightness.

OBJECTIVE: Two components of flexibility, muscle tightness, and ligamentous laxity in college athletes were studied to determine whether these factors were associated with the incidence of lower extremity injuries. DESIGN: Prospective cohort study. SETTING: College athletic department. PARTICIPANTS: 201 college athletes. OUTCOME MEASURES: College men and women athletes were tested for ligamentous laxity with the Beighton scale and for muscle tightness with a new scale based on the tightness of the iliopsoas, iliotibial band, hamstring, rectus femoris, and gastrocsoleus muscles. Lower extremity injuries incurred during practice and play were recorded during the following year. RESULTS: Of the 201 athletes tested, 71 sustained 115 injuries. For each additional point on the 9-point ligamentous laxity scale (9 = hyperlax), the risk of injury decreased 16%. For each additional point on the 10-point muscle-tightness scale (10 = all muscles tight), the risk of injury increased 23%. The two scores were moderately inversely correlated (Spearman's rho = -0.3; p < .001). Women had greater mean (+/- SD) laxity scores than men (3.3 +/- 2.2 vs. 1.8 +/- 2.0; p < .001) and lower mean overall muscle tightness scores (1.5 +/- 1.6 vs. 3.5 +/- 2.1; p < .001). Among Women athletes, the rate of lower extremity injury was unrelated to ligamentous laxity or to flexibility. Among men, lower extremity injuries were associated with lower ligamentous laxity scores (p = .008) and greater muscle tightness (p = .04). CONCLUSIONS: This study introduces a new scale for lower extremity muscle tightness. Tight ligaments and muscles are related to injury in men, but not women, college athletes. A preseason flexibility program may decrease injuries in college men athletes.

Adult↗
PubMed1995

Comparing the incidence of lower extremity amputations across the world: the Global Lower Extremity Amputation Study.

A substantial proportion of lower extremity amputations (LEAs), particularly in people with diabetes, are thought to be preventable by the provision of appropriate health care. Information on the incidence of LEAs which is accurate, up-to-date, and comparable cross-sectionally and longitudinally is essential to guide and monitor interventions aimed at their prevention. Current information on the incidence of LEAs is limited and differences between studies in case definition, presentation of rates, level of ascertainment, and population age structure often make meaningful comparisons impossible. To remedy this situation the global LEA study has been established. The study is designed to compare the incidence of LEAs over time within and between communities across the world. The methodology includes adherence to a standard definition of LEA, standardized methods of data collection with built-in quality control, and correction for under-ascertainment of cases (using capture-recapture methodology). Centres wishing to take part in the study must be able to identify a study population of at least 250,000, have reasonably up-to-date population numbers by age and sex, and be prepared to stay in the study for at least 2 years. A study registration form (Appendix 1) is provided.

Age Factors↗
PubMed2002

Markers of inflammation and hypercoagulability in diabetic and nondiabetic patients with lower extremity ischemia.

Lower extremity ischemia is one aspect of atherosclerosis, a disease associated with both inflammation and hypercoagulability. Many recent studies have focused on a diversity of mechanisms by which inflammation can promote blood clotting. However, it has not been proven that inflammation can actually trigger clinically relevant thrombus formation in vivo. The purpose of the study was to determine the plasma levels of markers of inflammation and their possible association with markers for coagulability with special emphasis on the difference between patients with and without diabetes. Forty-six patients, 20 diabetics and 26 without diabetes scheduled for lower extremity revascularisation were examined by preoperative blood sampling. A strong positive correlation between C-reactive protein (CRP) and fibrinogen was found, particularly in diabetics. A high fibrinogen level was not associated with other markers of hypercoagulability, Thrombin-Antithrombin (TAT), Prothrombin Fragment 1+2 (F 1+2) and D-dimer although the latter three correlated with each other. There was also a correlation between von Willebrand antigen (vWF) and CRP, also in this case the relationship was dependent on the findings in patients with diabetes. It is concluded that there is a difference between diabetic and nondiabetic patients with lower limb ischemia with the former showing stronger signs of inflammation.

Aged↗
PubMed1985

Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity.

Most lower extremity amputations result from complications of diabetes and arterio-sclerotic occlusive diseases below the inguinal ligament. Improved limb salvage has been achieved by an aggressive approach to distal revascularization in the severely ischemic lower extremity. There remains, however, a high incidence of amputation resulting from progression of the ulceration or gangrene into deeper and less well-vascularized tissues, such as tendon and bone. Even in the nonischemic extremity, such wounds rarely heal without flap coverage. Microvascular free tissue transfers promote healing by providing coverage with healthy, nondiseased, well-vascularized tissue for these difficult defects. Successful free flap transfer requires a high-pressure recipient inflow vessel. In contrast to individuals with nonarteriosclerotic lesions, many individuals with nonhealing ischemic lesions have no acceptable artery demonstrated on high-resolution angiography to serve as a recipient vessel. Limb salvage has been achieved in four candidates for amputation utilizing distal revascularization followed by free tissue transfer coverage of the ischemic lower leg defects.

Aged↗
PubMed2005

Vascular function in patients with lower extremity peripheral arterial disease: a comparison of functions in upper and lower extremities.

Peripheral arterial disease (PAD) is caused by atherosclerosis. Assessment of endothelial function in patients with PAD has been limited to that in forearm circulation in previous studies. The purpose of this study was to evaluate vascular function in upper and lower extremities in patients with PAD and to determine the relationship between the ankle-brachial pressure index (ABPI) and endothelial function in forearm and leg circulation. Forearm blood flow (FBF) and leg blood flow (LBF) responses to reactive hyperemia and sublingual administration of nitroglycerin (NTG) were measured using strain-gauge plethysmography in 57 PAD patients and 24 control patients. LBF during reactive hyperemia was significantly less in PAD patients than in control patients (p<0.001). FBF during reactive hyperemia in PAD patients was similar to that in control patients. NTG-induced vasodilation in upper and lower extremities was similar in the two groups. There was a significant relationship between the maximal LBF response to reactive hyperemia and the ABPI in both the patients with PAD and control patients (r=0.384, p<0.001), whereas maximal FBF response to reactive hyperemia was not correlated with ABPI (r=0.182, p=0.12). These findings suggest that LBF response to reactive hyperemia is impaired in PAD patients compared with that in control patients. Impairment of vascular reactivity of leg circulation may occur before impairment of vascular reactivity of forearm circulation in PAD patients and may be a better indicator of the degree of PAD than impairment of vascular reactivity of forearm circulation.

Administration, Sublingual↗
PubMed1998

Pitfalls in the radiologic evaluation of extremity trauma: Part II. The lower extremity.

Fractures of the lower extremity are common reasons for visits to family physicians. Some lower extremity fractures are especially likely to be missed. Examples of lesions that commonly go unrecognized include sacral insufficiency or fatigue fracture, fracture of the femoral neck (especially if the fracture is nondisplaced and/or impacted), tibial plateau fracture, Segond fracture (vertical fracture of the lateral tibia), patellar fracture, calcaneal fracture of the foot, Lisfranc fracture/dislocation of the tarsometatarsal apparatus, and Jones fracture of the fifth metatarsal. Lower extremity fracture in children may suggest the possibility of child abuse, especially in the case of multiple or bilateral fractures.

Child↗
PubMed1999

[On the legality of the term "diabetic angiopathy of the lower extremities". Part III. The influence of the stage of the lower extremities' main artery occlusion on the severity of microangiopathy].

In 40 patients with diabetic angiopathy of lower extremities in terminal stage during investigation of cutaneous biopsies using electronic microscopy it was established that changes in femoral skin are more pronounced than in a foot skin, showing more severe signs of microangiopathy in a preserved main blood flow zone. The author proposes a concept, according to which the angiopathy stage reflects the diabetes mellitus stage.

Adult↗
PubMed2006

Factors affecting perioperative mortality and wound-related complications following major lower extremity amputations.

Major lower extremity amputations continue to be associated with significant morbidity and mortality, yet few recent large series have evaluated factors associated with perioperative mortality and wound complications. The purpose of this study was to examine factors affecting perioperative mortality and wound-related complications following major lower extremity amputation. A retrospective review was conducted of all adult patients who underwent nontraumatic major lower extremity amputations over a 5-year period at a single tertiary-care center in southern West Virginia. Demographic and clinical data, perioperative data, and outcomes were collected and analyzed to identify any relationship with perioperative mortality, as well as wound complications and early revisions (within 90 days) to a more proximal level. Variables were examined using chi-squared, two-tailed t-tests, and logistic regression. Three hundred eighty patients (61% male) underwent 412 major lower extremity amputations during 1999-2003. The initial level of amputation included 230 below-knee (BKA), 149 above-knee (AKA), and one hip disarticulation. Perioperative mortality was 15.5% (n = 59). From a regression model, age, albumin level, AKA, and lack of a previous coronary artery bypass graft (CABG) were independently related to mortality. Patients who did not have a previous CABG were nearly three times more likely to die than those who did (p = 0.038). Overall early wound complications were noted in 13.4% (n = 51). Four factors were independently related to experiencing a 90-day wound complication: BKA, community (rather than care facility) living, type of anesthesia, and preoperative hematocrit >30%. Major lower extremity amputation in patients with peripheral vascular disease continues to be associated with considerable perioperative morbidity and mortality. Even though the surgical procedure itself may not be challenging from a technical standpoint, underlying medical conditions put this group at high risk for perioperative death. Wound-healing problems are frequently encountered and must be minimized to facilitate early mobilization and hospital discharge.

Age Factors↗
PubMed1996

Surgical revascularization versus thrombolysis for nonembolic lower extremity native artery occlusions: results of a prospective randomized trial. The STILE Investigators. Surgery versus Thrombolysis for Ischemia of the Lower Extremity.

PURPOSE: Early results of a prospective study that compared surgical revascularization and thrombolysis for lower extremity arterial and graft occlusions have been published. This report details the final results in patients who have native artery occlusions. METHODS: Two hundred thirty-seven patients who had lower extremity ischemia as a result of iliac-common femoral (IF; 69 patients) or superficial femoral-popliteal (FP; 168 patients) occlusion, and had symptomatically deteriorated within the past 6 months were randomized to catheter-directed thrombolysis (150 patients) or surgical revascularization (87 patients). After diagnostic arteriographic examination but before randomization, the optimal surgical procedure was determined. Lytic patients were randomized to recombinant tissue plasminogen activator (rt-PA; 84 patients) or urokinase (UK; 66 patients). Recurrent ischemia, morbidity, amputation, and death rates were determined at 30 days, 6 months, and 1 year, and were analyzed on an intent-to-treat basis. RESULTS: For patients randomized to lysis, a catheter was properly positioned and the lytic agent delivered in 78%. This provided a reduction in the predetermined surgical procedure in 58% of patients who had an FP occlusion and 51% of those who had an IF occlusion. rt-PA and UK were equally effective and safe, but lysis time was shorter with rt-PA (8 vs 24 hr; p < 0.05). At 1 year, the incidence of recurrent ischemia (64% vs 35%; p < 0.0001) and major amputation (10% vs 0%; p = 0.0024) was increased in patients who were randomized to lysis. Factors associated with a poor lytic outcome included FP occlusion, diabetes, and critical ischemia. No differences in mortality rates were observed at 1 year between the lysis and surgical groups. CONCLUSION: Surgical revascularization for lower extremity native artery occlusions is more effective and durable than thrombolysis. Thrombolysis used initially provides a reduction in the surgical procedure for a majority of patients; however, long-term outcome is inferior, particularly for patients who have an FP occlusion, diabetes, or critical ischemia.

Arterial Occlusive Diseases↗
PubMed2004

Consequences and costs of lower extremity injuries.

Lower extremity injuries resulting from motor vehicle crashes are common and have become relatively more important as more drivers with newer occupant restraints survive high-energy crashes. CIREN data provide a greater level of clinical detail based on coding guidelines from the Orthopedic Trauma Association. These detailed data, in conjunction with long-term follow-up data obtained from patient interviews, reveal that the most costly and disabling injuries are those involving articular (joint) surfaces, especially those of the ankle/foot. Patients with such injuries exhibit residual physical and psychosocial problems, even at one year post-trauma.

Abbreviated Injury Scale↗
PubMed2001

Design and intermediate results of the Lower Extremity Arterial Disease Event Reduction (LEADER)* trial of bezafibrate in men with lower extremity arterial disease [ISRCTN4119421].

BACKGROUND: Raised levels of both triglycerides and fibrinogen, each of which are reduced by bezafibrate, may contribute to lower extremity arterial disease (LEAD). This condition is characterized by a particularly high incidence of coronary heart disease (CHD) and stroke, but is little studied thus far in randomised controlled trials. METHOD: Patients were recruited through 85 practices in the British Medical Research Council General Practice Research Framework and through nine hospital vascular clinics. The treatment regimen, which is double-blind and placebo-controlled, is bezafibrate 400 mg/day. The 1568 patients recruited represent 86% of those eligible at screening. RESULTS: None of the anticipated side effects (mainly gastrointestinal) differed between the two groups. Nearly 80% of the total person-years accrued at 3 years were spent on trial treatment. Bezafibrate significantly reduced total cholesterol by approximately 8.0% and low-density lipoprotein (LDL)-cholesterol by approximately 9.0%, and increased high-density lipoprotein (HDL)-cholesterol by approximately 11.0% initially, falling to about 6.0% at 3 years. Triglycerides were significantly reduced by about 23.0% and fibrinogen by about 14.0%. Plasma creatinine rose by approximately 11% in those on active treatment. All of these effects were highly significant (P < 0.0001). Bezafibrate had no effect on the level of C-reactive protein (CRP). CONCLUSION: The trial recruited an unusually high proportion of eligible patients, ensuring the general applicability of its results. The fibrinogen-lowering and lipid-modifying effects of bezafibrate were confirmed. Although bezafibrate lowers fibrinogen, it has no effect on CRP; this suggests that the reduction in fibrinogen is due to an effect on its metabolism rather than suppression of an inflammatory response.

Journal Article↗
PubMed1988

[Excessive stress damage of the lower extremity caused by sports. The value of sonographic diagnosis in stress damage of the lower extremity].

150 sportsmen with lesions and diseases of the lower extremity served as basis for demonstrating the possibilities offered by diagnosis via sonography. Main indications were articular and paraarticular diseases of the large joints (hip and knee) to demonstrate effusions, ganglia, bursae and tendon ruptures, diseases and injuries of the musculature at the thigh and lower leg, as well as the Achilles tendon with its various changes such as rupture, achillodynia and peritendinitis. Muscular and tendon ruptures can be differentiated via sonography in respect of extension, type, age and localisation. This makes differentiated treatment possible. Intraarticular lesions of the knee joint remain the domain of arthroscopy. Sonographic findings should always be supplemented by anamnesis, clinical findings and x-ray film so as not to overlook any bony injuries and damage of the capsular ligaments.

Adolescent↗
PubMed2006

Loading modalities and bone structures at nonweight-bearing upper extremity and weight-bearing lower extremity: a pQCT study of adult female athletes.

This cross-sectional study of adult female athletes assessed whether the apparent loading-related differences in bone structure are primarily associated with the loading type or the muscle performance-related joint moments. Several structural variables at shaft sites of the tibia, radius and humerus, and distal sites of the tibia and radius were measured with peripheral quantitative computed tomography (pQCT) among 113 female national level athletes (representing hurdling, volleyball, soccer, racket-sports and swimming) and their 30 nonathletic referents. For the weight-bearing lower extremities, the loading modalities of the above sports were classified into high-impact (hurdling, volleyball), odd-impact (soccer, racket-sports) and repetitive, nonimpact (swimming) loadings; and for the nonweight-bearing upper extremities into high magnitude (functional weightlifting in hurdling and soccer), impact (volleyball, racket-sports) and repetitive, nonimpact (swimming) loadings. As expected, athletes' bone mass was substantially higher at loaded bone sites compared with the nonathletic referents, but more pertinently to the locomotive perspective, the loading-induced additional bone mass seemed to be used to build mechanically strong and appropriate bone structures. Compared with controls, the weight-bearing bone structures of female athletes (swimmers excluded) were characterized by larger diaphysis, thicker cortices and somewhat denser trabecular bone. The athletes' bones at the nonweight-bearing upper extremity were generally larger in cross-sectional area. The estimated indices of joint moment (muscle force x estimated lever arm) were explained from 29% to 50%, and the loading modalities from 8% to 25%, of the variance in most bone variables (P < 0.05) of the tibia (shaft and distal site). In contrast to the weight-bearing tibia, only the estimated joint moment was positively associated (P < 0.05) with the structural characteristics of the radius and humerus, accounting for 6% to 26% of the variance in bone variables of the shafts of these bones. Such association was not observed at the distal radius. In conclusion, at the weight-bearing lower extremity, the strong bone structure of the female athletes was attributable to muscle performance-related estimated joint moments and impact loading modality. At the shaft sites of the nonweight-bearing upper extremity, the strong bone structure was mainly attributable to the estimated joint moments. Thus, different loading history and other features of loading seemed to govern the skeletal adaptation at the upper and lower extremity.

Absorptiometry, Photon↗
PubMed1988

[Venous diseases of the lower extremities--methods and results of phlebography of the lower extremity--the superficial and deep systems].

The vena saphena magna is the most important arterial vascular substitute in today's vascular surgery. That is why modern varicose vein surgery is performed very carefully and cautiously with an aim to preserve the vessels as much as possible. This can be done only if the radiologist visualises both the healthy and the diseased superficial and deep venous systems as completely and a easily appreciable as possible when diagnosing varicosis. It is not enough to merely produce contrast images of the deep venous system when attempting to clarify varicosis via phlebography. The conditions obtaining at the points where the great saphenous vein and the small saphenous vein open into the femoral and popliteal veins, respectively, must be clearly visible. The maximum possible number of insufficient venae perforantes must be shown and the side branches of the great saphenous vein that have undergone varicose changes, must be visualised. It goes without saying that the deep venous system must be shown in a manner that it can be safely assessed. An extended thrombosis of the deep veins of the leg and pelvis does not present any diagnostic pitfalls when assessing the phlebogram. On the other hand, a beginning deep leg thrombosis is easily overlooked. Phlebographically it is quite difficult to clarify a relapsing thrombosis. This requires detailed knowledge of the patterns of signs in deep leg vein thrombosis.

Humans↗
PubMed2000

Lower extremity nerve blocks.

Lower extremity nerve blocks have not become as popular as upper extremity blocks for anesthesia; however, the use of lower extremity nerve blocks will become more widespread, as teaching programs are now providing more regional anesthesia experiences for their trainees so that the anesthesia provider will have the familiarity to use these blocks. To increase the enthusiasm among our surgical colleagues, we must begin to use these blocks for surgery, and if the block must be supplemented with local anesthetic or a light general anesthetic, we must educate them that the block is not a failure but a success, as it will provide analgesia after surgery in a method of multimodal pain control. Lower extremity nerve blocks will become more popular when it is realized that they are an effective way of increasing operating room efficiency. Because the block may be placed in an induction room, there is no induction or emergence in the operating room. Patients may be discharged without the need for pain medications, thus lowering the incidence of nausea postoperatively and decreasing PACU and discharge times.

Humans↗