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PubMed2007

A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma.

BACKGROUND: Comparison of functional mobility and quality of life is performed in patients with lower-extremity bone sarcoma following either amputation, limb-sparing surgery, or rotationplasty with four different types of outcome measures: (1) an objective functional mobility measure that requires patients to physically perform specific tasks, functional mobility assessment (FMA); (2) a clinician administered tool, Musculoskeletal Tumor Society Scale (MSTS); (3) a patient questionnaire, Toronto Extremity Salvage Scale (TESS); and (4) a health-related quality of life (HRQL) measure, Short Form-36 version 2 (SF-36v.2). PROCEDURE: This is a prospective multi-site study including 91 patients with lower-extremity bone sarcoma following amputation, limb-sparing surgery, or rotationplasty. One of three physical therapists administered the quality of life measure (SF-36v.2) as well as a battery of functional measures (FMA, MSTS, and TESS). RESULTS: Differences between patients who had amputation, limb-sparing surgery, or rotationplasty were consistently demonstrated by the FMA. Patients with limb sparing femur surgery performed better than those patients with an above the knee amputation but similarly to a small number of rotationplasty patients. Several of the more conventional self-report measures were shown to not have the discriminative capabilities of the FMA in these cohorts. CONCLUSION: In adolescents with lower-extremity bone sarcoma, it may be advantageous to consider the use of a combination of outcome measures, including the FMA, for objective functional mobility assessment along with the TESS for a subjective measure of disability and the SF-36v.2 for a quality-of-life measure.

Adolescent↗

PubMed2000

Initial results of reteplase in the treatment of acute lower extremity arterial occlusions.

PURPOSE: To assess the feasibility and efficacy of reteplase in transcatheter arterial thrombolysis for lower extremity occlusive disease. MATERIALS AND METHODS: Fifteen consecutive patients with acute lower extremity ischemia due to occlusive disease were treated by means of catheter-directed thrombolysis with reteplase. Following diagnostic angiography, thrombolysis was started either from an antegrade puncture site in cases of femoropopliteal occlusions, or from the contralateral groin in cases of thrombosis of the iliac artery, common femoral artery, or infrainguinal bypass grafts. Reteplase was infused at a rate of either 0.5 U/h (six patients) or 1.0 U/h (nine patients). RESULTS: Complete thrombolysis was achieved in all of the nine (100%) patients in the 1.0 U/h group and in four of six (66%) patients in the 0.5 U/h group for a combined success rate of 13 of 15 (87%). Clinical success was achieved in 11 of 15 patients overall (73%). Major bleeding complications occurred in none of the 9 patients in the 1.0 U/h group and in one (16%) of the six patients in the 0.5 U/h group for an overall rate of 6%. CONCLUSIONS: Reteplase shows promise as an alternative to urokinase in the treatment of lower extremity ischemia due to arterial occlusive disease.

Acute Disease↗

PubMed1993

Ethnic differences in the incidence of lower extremity amputation secondary to diabetes mellitus.

Patients of Asian ethnic origin with diabetes mellitus living in the United Kingdom (UK) have been shown to have a higher prevalence of coronary heart disease and renal disease. Little is known about the incidence of lower extremity amputation in this racial group. The incidence of lower extremity amputation was estimated for patients of Asian ethnic origin and White Caucasians with diabetes mellitus in the county of Leicestershire from 1980 to 1985. The age and sex-adjusted incidence rate of lower extremity amputation for the estimated population of patients with diabetes mellitus in patients of Asian ethnic origin was 3.4 (95% CI, 1.1-10.7) cases per 10,000 patients year-1, compared to 14.2 (12.6-15.9) in White Caucasians. Similarly, a lower incidence rate of lower extremity amputation was recorded in patients of Asian ethnic origin without diabetes mellitus (0.4 (0.2-0.6) vs 1.5 (1.4 to 1.6) cases per 10,000 persons year-1). These findings contrast markedly with the high rates of coronary heart disease and renal disease previously reported in patients of Asian ethnic origin residing in the UK.

Adult↗

PubMed2002

The utilization of a new yellow light laser (578 nm) for the treatment of class I red telangiectasia of the lower extremities.

BACKGROUND: A dual-wavelength approach is necessary in order to achieve consistent results when utilizing lasers and intense pulsed light sources to treat red and blue lower extremity vessels. In this regard, short-wavelength technologies (500-800 nm) may be employed to treat red telangiectasia of less than 2 mm on the lower extremities. OBJECTIVE: To demonstrate a new yellow light laser utilizing a copper bromide medium and its potential efficacy in the treatment of red lower extremity telangiectasia of less than 2 mm. METHODS: Forty-six women (mean age 37 years) were treated in two private practice settings with a 578 nm yellow light laser with a circulating cooling window (1-4 degrees C). Class I red telangiectases of the thighs 1.5 mm or less in diameter were considered for treatment. Patients were treated with up to three treatments at 6-week intervals on a 5 cm2 surgical area of vessels utilizing a fluence of 50-55 J/cm2. Results were analyzed by macrophotographic imaging, double-blinded observer evaluation/optical chromatography, and a patient evaluation scale. RESULTS: An average of 1.7 patient treatment sessions produced significant clearing of 75-100% in 71.8% of patients. The mean erythema index showed significant lightening (51-65a+) in the study population. Finally, 76.1% of patients reported great satisfaction with the results of their treatment session. CONCLUSION: A new 578 nm copper bromide (CuBr) yellow light laser produces excellent results in eradicating red telangiectases of the lower extremities that are less than 2 mm in diameter.

Adult↗

PubMed1977

Cervical spondylotic myelopathy with reversible fasciculations in the lower extremities.

Cervical spondylosis and motor system disease can appear in a similar manner with upper and lower motor neuron signs. Four patients with spasticity and fasciculations in the upper and lower extremities had surgical decompression for cervical spondylosis. Postoperative examinations at 24 to 48 months, including electromyographic studies, disclosed neurological improvement in all patients and loss of fasciculations in the lower extremities in three. Three mechanisms by which cervical spondylosis might cause fasciculations in the lower extremities are vascular insufficiency, cord traction, and denervation.

Adult↗

PubMed2003

Major lower extremity amputations at a Veterans Affairs hospital.

BACKGROUND: This study was made to evaluate the experience at a Department of Veterans Affairs (VA) hospital with consecutive major lower extremity amputations over a period of 7 years. METHODS: The records of 229 patients (221 male and 8 female) who underwent 296 consecutive major lower extremity amputations (119 above-knee amputations [AKA] and 177 below-knee amputations [BKA]) over a period of 86 months (September 1994 to October 2001) were retrospectively analyzed. All amputations were performed by members of the vascular surgery department. RESULTS: Forty of the 229 patients (17%) eventually required a contralateral amputation, 27 patients (12%) had BKAs that eventually necessitated conversion to AKA, and 44 amputations (15%) required an initial guillotine amputation. The 30-day mortalities for BKA, AKA, and BKA to AKA operations were 12%, 17%, and 7%, respectively. Eighty-eight of the amputations (30%) developed wound complications, and required 137 revisions. Seventy-seven of the amputations (26%) had undergone prior revascularization, of which 31 (48%) had an early failed bypass. The average preoperative ankle/brachial index (ABI) was 0.57. Of the patients undergoing amputation, 97 (42%) complained of rest pain, 91 (40%) complained of claudication, and 158 (69%) had tissue loss or gangrene at the time of their operation. One hundred and forty-six patients (64%) were diabetic. Twenty-two patients (9%) were dialysis dependent and 81 patients (35%) admitted to smoking. Of the known causes of death, 21 resulted from myocardial infarction, 22 from congestive heart failure, 14 from respiratory failure, 13 from disseminated cancer, 10 from sepsis, 7 from stroke, and 6 from renal failure. Preoperative functional status determinations revealed that of 272 patients with enough information to assess functional status, 43 were totally dependent, 97 were partially independent, and 132 were independent. Of the 229 patients, 168 (73%) were ambulatory prior to their amputation, and at the completion of this review only 53 patients (23%) were ambulatory. CONCLUSIONS: Most patients undergoing major lower extremity amputations have many comorbidities; hence morbidity and mortality rates are high, with the most common causes of death being cardiac and respiratory in nature. These data suggest that major lower extremity amputations highlight a very high-risk population with only 39% survival at 7 years, as well as a costly subset secondary to prolonged hospitalization times (average 15 days, range 3 to 105), in addition to the extraordinary cost associated with diminished functional status.

Amputation, Surgical↗

PubMed1994

Functional status and mobility among elderly women with lower extremity arterial disease: the Study of Osteoporotic Fractures.

OBJECTIVE: To investigate the relationship between lower extremity arterial disease, functional status, and mobility among elderly women. DESIGN: Cross-sectional study. SETTING: Community. PARTICIPANTS: 1492 healthy white women, 65 years of age or older, residing in a rural community, able to walk without the assistance of another person, and enrolled in the Pittsburgh clinic of the multicenter Study of Osteoporotic Fractures. Those with bilateral hip replacement were excluded. MEASUREMENTS: Ankle/arm index (AAI); instrumental activities of daily living (IADLs); measures of recent physical activity, muscle strength, gait and balance; general demographic, lifestyle, and physical variables. RESULTS: Women with lower extremity arterial disease (defined as an AAI of 0.9 or less) were more likely to report difficulty with one or more IADLs than were women free of this disease. After adjusting for age and other potential confounders, only difficulty with walking 2-3 blocks remained highly correlated with disease (relative risk (RR) 2.8, 95% confidence interval (CI) 1.6, 4.8). Several measures of physical activity were inversely and independently related to a low AAI. Muscle strength in the hip, arm, knee, and hand and measures of static and dynamic balance were correlated with low AAI in the univariate analysis, but most of these trends were not statistically significant after adjustment for age and other confounders. Exclusion of women with symptomatic arterial disease did not substantially affect the results obtained. CONCLUSION: Women with mild, predominantly subclinical, lower extremity arterial disease living in the community have decreased functional status and mobility.

Activities of Daily Living↗

PubMed1997

Utility of carotid duplex in young adults with lower extremity atherosclerosis: how aggressive should we be in screening young patients?

The purpose of this study was to determine the prevalence and degree of carotid disease in patients with premature lower-extremity atherosclerosis. Seventy-six young men (mean age at onset of symptoms 42+/-0.5 years with premature lower extremity atherosclerosis who underwent complete carotid duplex scans were studied. The mean lowest ankle: brachial index was 0.49+/-0.02. Forty-seven patients (62%) required interventions to treat advanced leg symptoms, and 18 (24%) experienced disease progression during the study period. Carotid duplex scans showed internal carotid occlusions in eight (11%); advanced or critical plaque disease (60-99% diameter loss) in 14 (18%); moderate plaque disease (40-59% diameter loss) in 16 (21%); mild plaque disease (intimal thickening or 1-39% diameter loss) in 18 (24%); and normal carotid arteries in 20 (26%). Comparing the 20 subjects with normal carotid arteries to the S6 with any evidence of disease, there were no differences in age of onset, risk factors, coronary artery disease, mean ankle: brachial index, number of interventions, disease progression, amputation, or death. Fifteen (27%) of the patients with carotid atherosclerosis ultimately developed transient ischemic attack or stroke; 13 of these had advanced carotid stenoses or carotid occlusions. In conclusion, carotid plaque disease is prevalent among patients with premature atherosclerosis of the lower extremity. The presence of carotid atherosclerosis is not related to the degree of lower extremity atherosclerosis, nor to the rate of disease progression. Carotid duplex scans are indicated to screen these young patients for compelling lesions that might warrant prophylactic carotid endarterectomy.

Adult↗

PubMed1995

The accuracy of duplex ultrasonography in the planning of skin flaps in the lower extremity.

The septocutaneous perforators represent one of the major sources of the blood supply to the skin of the lower extremity. Despite several well-described anatomic accounts, the location of lower leg septocutaneous perforators, as they originate from each of the three main infrapopliteal vessels in the leg, remains inconsistent as a result of individual anatomic variations. With the aid of duplex ultrasonography (color Doppler imaging), preoperative, mapping and size determination of these perforators can be provided. The skin paddle can then be designed to lie exactly over these perforators, ensuring blood supply to the skin paddle. The location and distribution of medial septocutaneous perforators in the leg, which originate from the posterior tibial artery, were mapped using anatomic dissections (29 lower extremities). These findings were then compared with duplex ultrasonographic data in 9 living volunteers (18 lower extremities). The medial septocutaneous perforators were chosen for this study because they course directly over the posterior tibial artery, making their location difficult to assess with standard Doppler techniques. The hand-held Doppler is incapable of distinguishing flow originating from the perforators versus the posterior tibial artery. No significant difference existed between cadaver and duplex distributions. "Large" perforator vessels (> 1 mm outer diameter) were evenly distributed with a central tendency at 140 to 150 mm from the medial malleolus. The distribution of "small" perforator vessels (< 1 mm outer diameter) was skewed. Fifty percent were found within 80 mm of the medial malleolus and the remainder spread proximally in the leg.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1987

Strength testing with a portable dynamometer: reliability for upper and lower extremities.

This study was designed to determine intraobserver and interobserver reliability of maximal muscle strength for upper and lower extremity muscle groups. Four healthy subjects were tested with a portable muscle dynamometer on two separate occasions by three separate examiners to determine maximal isometric strength of lateral pinch between thumb and index finger, elbow flexion, elbow extension, shoulder flexion, hip flexion, hip extension, hip abduction, knee flexion, and ankle dorsiflexion. A break test was also used to evaluate the strength of cervical flexor muscles and extensor hallucis longus. Pearson correlation coefficients for inter- and intraexaminer testing was good for upper extremity test values from 0.85 to 0.99. The variation coefficient of the methodology error (CV) in all upper extremity muscle tests was between 5.1% and 8.3%. These results seemed reliable for clinical muscle strength testing. However, correlation coefficients for lower extremity testing were poor, with values ranging from -0.20 to 0.96. The CV in these tests was much greater than in the upper extremities and ranged from 11.3% to 17.8%. Both break tests also had high CV, with each being greater than 17%. Our results demonstrate that although the dynamometer is reliable for testing upper extremity muscle groups, it is unreliable for testing lower extremity muscle groups. Further work is needed to evaluate muscle strength quantitatively in the clinical setting in an accurate, valid, and reliable manner.

Arm↗

PubMed1998

Quality of life issues in patients with diabetes and lower extremity ulcers: patients and care givers.

The impact of lower extremity ulcers on the quality of life (QoL) of patients with diabetes and their care givers was assessed in a series of focus groups. Fourteen patients with diabetes and lower extremity ulcers and 11 care givers participated in the focus groups. Semi-structured discussions identified the issues relating to four broad QoL domains and subdomains: social (daily, leisure, family and social life), psychological (emotional health and positive consequences), physical (physical health and treatment impact) and economic (employment and finances). The patients and care givers experienced a negative impact on all domains of QoL because of the limitations in mobility caused by the ulcer which required an adaptation to a different lifestyle. A reduction in social activities, increased family tensions, lost time from work and a negative impact on general health were experienced by both groups. It is necessary to separate the impact of the ulcer from the general condition of diabetes on both patients' and care givers' QoL. The results from this disease-specific focus will allow for an improved clinical understanding with targeted interventions and contribute to the development of a disease-specific instrument to understand and measure QoL better in these individuals.

Adult↗

PubMed2004

Effect of lower-extremity muscle fatigue on postural control.

OBJECTIVE: To examine the effects of fatigue of the lower extremity on postural control during single-leg stance. DESIGN: Pretest-posttest. SETTING: University research laboratory. PARTICIPANTS: Fourteen healthy volunteers (age, 21+/-2y) with no history of lower-extremity injury or neurologic deficits. INTERVENTIONS: Testing consisted of isokinetically fatiguing the sagittal plane movers of the ankle, knee, or hip with measures of static postural control. Postural control was assessed with three 30-second trials during unilateral stance with eyes open. MAIN OUTCOME MEASURES: Center of pressure excursion velocity (COPV) in the frontal and sagittal planes. RESULTS: Fatigue at the knee and hip led to postural control impairment in the frontal plane, whereas fatigue at the ankle did not. In the sagittal plane, fatigue at all 3 joints contributed to postural control impairment. CONCLUSIONS: Our results suggest that there is an effect of localized fatigue of the sagittal plane movers of the lower extremity on COPV. It appears that fatigue about the hip and knee had a greater adverse affect on COPV.

Adult↗

PubMed1998

[On the legal aspects of the term "diabetic angiopathy of the lower extremities". Part I. Clinico-morphological parallels of the lower diabetic angiopathy].

The clinico-morphological data analysis was done in 100 examined patients with diabetic angiopathy of the lower extremities. The morphological changes revealed have corresponded to severity of the disease clinical symptoms in 70% only. Purulent affection of extremities have characterized not the end stage of angiopathy only but it was observed in another stages of the disease.

Diabetic Angiopathies↗

PubMedDate not supplied

Does repeat duplex ultrasound for lower extremity deep vein thrombosis influence patient management?

The clinical significance of lower extremity deep vein thrombus (DVT) propagation in the setting of anticoagulation therapy remains unclear. The purpose of this study is to compare results of thrombus outcome found with repeat duplex ultrasonography to the incidence of pulmonary embolism and mortality. During a recent 18-month period, 457 patients were diagnosed with lower extremity DVT with duplex ultrasonography and their data were retrospectively analyzed. Repeat examinations were available for review in 118 patients (51 men, 67 women). Results of repeat duplex exams were divided into 4 groups: resolved, improved, unchanged, or extended proximally. All patients received heparin and warfarin therapy. Ventilation-perfusion (V/ Q) scans were obtained only for signs and symptoms of pulmonary embolism (n=30). Mortality, the prevalence of high-probability V/ Q scans, frequency of intracaval filter insertion, gender, mean age, mean prothrombin time (PT), mean partial thromboplastin time (PTT), mean number of repeat ultrasounds per patient, and mean time over which the repeat ultrasounds took place were compared among the 4 groups. Patients who had proximal extension of DVT (19%) on repeat duplex ultrasound had an increased prevalence of pulmonary embolism (p<0.05). Also, patients whose DVT resolved were younger (p<0.05). There was no difference among the 4 groups in mortality, placement of Greenfield filters, mean PT, mean PTT, mean number of ultrasound exams per patient, or mean follow-up time over which the exams took place. Proximal extension of DVT documented by repeat duplex ultrasound is a significant risk factor for pulmonary embolism. Repeat duplex ultrasound can identify a group of patients who may benefit from insertion of an intracaval filter device.

Adult↗

PubMed2006

Influence of a custom foot orthotic intervention on lower extremity dynamics in healthy runners.

OBJECTIVE: To investigate the influence of a custom foot orthotic intervention on the lower extremity dynamics in healthy runners. DESIGN: Three-dimensional kinematics and kinetics were collected on 15 female runners (>15 miles per week) while each performed the over-ground running trials in either a shoe only or a shoe+custom foot orthotic condition. Kinematic and kinetic variables were analyzed using Paired Sample t-tests. BACKGROUND: Custom foot orthotics are frequently prescribed treatment modality for the management of overuse running injuries. Although it is generally accepted that a custom foot orthotic intervention produces positive clinical outcomes, it remains unclear what influence this therapeutic modality has on the dynamics of the lower extremity. METHODS: Each subject performed five acceptable over-ground running trials (3.6 m s(-1) +/-5%) with and without the custom foot orthotic intervention in a running shoe. Selected maximum ankle and knee joint angles and moments were measured during the stance phase. RESULTS: While wearing the custom foot orthotic, subjects exhibited significantly decreased maximum values in rearfoot eversion angle, rearfoot eversion velocity and internal ankle inversion moment. CONCLUSIONS: In this sample of healthy female runners, the custom foot orthotic intervention led to significant decreases in maximum values for ankle dynamics in the frontal plane and in the sagittal plane of the knee joint. Relevance It remains unclear how a custom foot orthotic intervention influences lower extremity dynamics to produce positive clinical outcomes. Furthering our understanding of the dynamic influence will not only inform improved prescription and manufacturing practices but may provide insight into the mechanisms that cause overuse injuries.

Adult↗

PubMed1996

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage.

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries.

Adolescent↗

PubMed2000

Lower-extremity edema associated with gene transfer of naked DNA encoding vascular endothelial growth factor.

BACKGROUND: Vascular endothelial growth factor (VEGF) promotes angiogenesis and vascular permeability. The extent to which VEGF may cause tissue edema in humans has not been established. OBJECTIVE: To evaluate patients undergoing VEGF gene transfer for evidence of lower-extremity edema. DESIGN: Prospective consecutive case series. SETTING: Hospital outpatient clinic. PATIENTS: 62 patients with critical limb ischemia and 28 patients with claudication. INTERVENTION: Gene transfer of VEGF DNA. MEASUREMENTS: Semiquantitative analysis of lower-extremity edema. RESULTS: Lower-extremity edema was observed in 31 of 90 (34%) patients. Edema was less common in patients with claudication than in those with pain at rest (P = 0.016) or ischemic ulcers (P < 0.001), and it was less common in patients with pain at rest than in those with ischemic ulcers (P= 0.017). Treatment was typically limited to a brief course of oral diuretics. CONCLUSIONS: Vascular endothelial growth factor may enhance vascular permeability in humans. At the doses of plasmid DNA used in this study, lower-extremity edema responded to oral diuretic therapy and did not seem to be associated with serious sequelae.

Administration, Oral↗

PubMed2004

Basics of computed tomography angiography of the lower extremity vessels.

Complete noninvasive, angiographic evaluation of the abdominal aorta and lower extremity vessels using the latest generation of multidetector row computed tomography (CT) scanners can now be accomplished in a single scan lasting less than a minute. The high spatial resolution of these new scanners and their more efficient use of contrast permit accurate depiction of disease in the smaller tibial and pedal vessels, as well as the larger diameter iliac and femoral arteries; nevertheless, many challenges and obstacles remain to its more widespread acceptance. Foremost among these, is the difficulty in accurately reconstructing the smaller leg and pedal vessels from individual CT slices, a process that must to a very great extent be done manually, and the potential nephrotoxicity of iodinated contrast material. Future advances in imaging software that could more fully automate accurate three-dimensional reconstructions of the lower extremity vasculature, and detector technology to allow for even finer resolution of the vasculature will further enhance an already powerful and clinically useful tool.

Angiography↗