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PubMed2006

[Noninvasive diagnosis of the state of lower extremities arterial vascular bed in patients with diabetes of type 2].

Complex noninvasive investigation of arterial vascular bed and microcirculation of lower extremities was carried out in 87 patients with diabetes and 47 patients with atherosclerosis obliterans of lower extremities without diabetes. Color duplex scanning allowed to detect occlusive-stenotic and nonocclusive changes of arterial vascular bed in patients with type 2 diabetes. Calcinated atherosclerotic plaques in patients with type 2 diabetes more often localize in superficial femoral, popliteal arteries and arteries of the calf. Such plaques are twice as frequent among patients with atherosclerosis obliterans with diabetes compared with those without diabetes. Laser Doppler flowmetry with test of reactive postocclusion hyperemia and positional test in patients with atherosclerosis obliterans and type 2 diabetes allows to reveal more pronounced disturbances of microcirculation compared with patients without diabetes. In patients with type 2 diabetes with hemodynamically insignificant stenoses of arteries of lower extremities laser doppler flowmetry and transcutaneous measurement of oxygen tension in skin of a foot reveal disturbances of microcirculation.

Adult↗

PubMed2000

Correlations with patients' perspectives of the result of lower-extremity amputation.

BACKGROUND: Patients' perceptions of the result of lower-extremity amputation vary widely, yet the factors associated with this variability are not well understood. Our objective was to identify important correlations with the perceived result that may help to indicate the factors that deserve particular emphasis in the management of patients who have had an amputation. METHODS: In this retrospective study, 148 patients who had had a major lower-extremity amputation completed a standardized questionnaire designed to assess the demographic characteristics, comorbidities, amputation characteristics, prosthetic function, and social function at a mean of seven years after surgery. We correlated each of these variables with four result metrics: general satisfaction, quality of life, freedom from frustration, and walking distance. RESULTS: The four result metrics were significantly and strongly correlated with (1) the comfort of the residual limb; (2) the condition of the contralateral limb; (3) the comfort, function, and appearance of the prosthesis; (4) social factors; and (5) the ability to exercise recreationally (p < 0.0001). Interestingly, the level and laterality of the amputation were not significantly correlated with the patients' perceived result. CONCLUSIONS: The perceived result of amputation is not associated with the amount of the limb that was amputated but rather with factors that may be optimized by surgical, prosthetic, and social management.

Amputation, Surgical↗

PubMed2002

The ankle brachial index and change in lower extremity functioning over time: the Women's Health and Aging Study.

OBJECTIVES: To define the association between baseline ankle brachial index (ABI) level and subsequent onset of severe disability. DESIGN: Prospective cohort study. SETTING: Baltimore community. PARTICIPANTS: Eight hundred forty-seven disabled women aged 65 and older participating in the Women's Health and Aging Study. MEASUREMENTS: At baseline, participants underwent measurement of ABI and lower extremity functioning. Measures of lower extremity functioning included patient's report of their ability to walk one-quarter of a mile, number of city blocks walked last week, number of stair flights climbed last week, and performance-based measures including walking speed over 4 meters, five repeated chair stands, and a summary performance score. Functioning was remeasured every 6 months for 3 years. Definitions of severe disability were developed a priori, and participants who met these definitions at baseline were excluded from subsequent analyses. RESULTS: Participants with an ABI of less than 0.60 at baseline had significantly higher cumulative probabilities of developing severe disability than participants with a baseline ABI of 0.90 to 1.50 for walking-specific outcomes (ability to walk a quarter of a mile, number of city blocks walked last week, and walking velocity) but not for the remaining functional outcomes. In age-adjusted Cox proportional hazards analyses, hazard ratios for participants with a baseline ABI of less than 0.60 were 1.63 for becoming unable to walk a quarter of a mile (P = .044), 2.00 for developing severe disability in the number of blocks walked last week (P = .004), and 1.61 for developing severe disability in walking speed (P = .041), compared with participants with a baseline ABI of 0.90 to 1.50. Adjusting for age, race, baseline performance, and comorbidities, an ABI of less than 0.60 remained associated with becoming severely disabled in the number of blocks walked last week (hazard ratio = 1.97, P = .009) and nearly significantly associated with becoming unable to walk a quarter of a mile (hazard ratio = 1.54, P = .09). In fully adjusted random effects models, a baseline ABI of less than 0.60 was associated with significantly greater decline in walking speed per year (P = .019) and nearly significantly greater decline in number of blocks walked last week per year (P = .053) compared with a baseline ABI of 0.90 to 1.50. CONCLUSION: In community-dwelling disabled older women, a low ABI is associated with a greater incidence of severe disability in walking-specific but not other lower extremity functional outcomes, compared with persons with a normal ABI over 3 years.

Activities of Daily Living↗

PubMed2000

Chronic ergot toxicity: A rare cause of lower extremity ischemia.

Chronic ergot toxicity is a rare cause of lower extremity ischemia. The cornerstone of therapy in ergot toxicity is to discontinue the use of caffeine, cigarettes, and all ergot-containing medications. Although multiple different therapies have been recommended for acute toxicity, no specific treatment is uniformly recommended in chronic toxicity. We present a case of long-term ergot use for migraine headaches in a woman who had severe chronic lower extremity claudication. This case demonstrates the unique features associated with the diagnosis and management of chronic ergot toxicity. We recommend a conservative approach consisting of observation, antiplatelet agents, and the discontinuance of ergots. If symptoms progress to rest pain or gangrene, surgical treatment should be considered.

Adult↗

PubMed1994

Lower-Extremity Local Flaps.

Some soft-tissue defects of the lower extremities can be covered reliably with local flaps. Five such flaps--the tensor fascia lata, gastrocnemius, soleus, posterior tibial artery fasciocutaneous, and dorsalis pedis flaps--are described. If the indications for each flap are understood and the vascular pedicle is carefully preserved, these flaps can be used to provide relatively simple and reliable coverage of selected soft-tissue defects on the lower extremities. However, the indications must not be overextended in an attempt to avoid a free-tissue transfer. The gastrocnemius flap is most often used. It reliably covers common defects about the knee and the proximal tibia. A skin graft is required for the gastrocnemius flap, as well as the soleus flap, which covers the midportion of the tibia. The soleus requires deeper dissection of the calf for elevation. The tensor fascia lata flap and the more recently described posterior tibial artery fasciocutaneous flap are relatively easy to raise, but there are fewer orthopaedic indications for their use. The dorsalis pedis cutaneous flap is technically more demanding, but it can be used to cover difficult defects around the ankle.

Journal Article↗

PubMed2006

[Lower extremity nerves injuries in bone fractures and joint dislocations--etiopathogenesis, treatment].

Lower extremity nerve injuries accompanying bone fractures and joint dislocations lead to serious disturbances at the lower limbs and caused significant prolongation of the treatment time. Clinical material consisted of 73 patients treated surgically with lower extremity nerve injuries due to bone fractures and joint dislocation. Based on this material we analysed the most frequent localisations of the nerves lesions and the mechanism of injury. The indications to surgical treatment were also described.

Adolescent↗

PubMed1994

Lower extremity amputations in New Jersey.

We compared the incidence of nontraumatic lower extremity amputations in the diabetic and nondiabetic populations in New Jersey. The diabetes-related lower extremity amputation rate was 80.1/10,000 diabetic population, while the rate for nondiabetes-related amputations was 1.6/10,000 population.

Adolescent↗

PubMed2003

The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: a double-blind randomised-controlled trial.

OBJECTIVE: ischaemic lower-extremity ulcers in the diabetic population are a source of major concern because of the associated high risk of limb-threatening complications. The aim of this study was to evaluate the role of hyperbaric oxygen in the management of these ulcers. METHOD: eighteen diabetic patients with ischaemic, non-healing lower-extremity ulcers were recruited in a double-blind study. Patients were randomly assigned either to receive 100% oxygen (treatment group) or air (control group), at 2.4 atmospheres of absolute pressure for 90 min daily (total of 30 treatments). RESULTS: healing with complete epithelialisation was achieved in five out of eight ulcers in the treatment group compared to one out of eight ulcers in the control group. The median decrease of the wound areas in the treatment group was 100% and in the control group was 52% (p=0.027). Cost-effectiveness analysis has shown that despite the extra cost involved in using hyperbaric oxygen, there was a potential saving in the total cost of treatment for each patient during the study. CONCLUSION: hyperbaric oxygen enhanced the healing of ischaemic, non-healing diabetic leg ulcers and may be used as a valuable adjunct to conventional therapy when reconstructive surgery is not possible.

Aged↗

PubMed1989

The effect of distal anastomotic site on PTFE graft patency in lower extremity bypass.

The site of distal anastomosis of polytetrafluorethylene (PTFE) lower extremity bypass grafts may significantly affect results. We examined patency in 144 cases; 45 femoro-popliteal above knee (AK), 55 femoro-popliteal below the knee (BK) and 44 femoro-distal (D) PTFE bypasses, the groups being comparable with regard to other risk factors studied. Cumulative graft patency at 3 years was 71.3% for AK, 36.7% for BK, 16.4% for D and overall 35%. The site of distal anastomosis is an important determinant, of PTFE lower extremity bypass patency. We have abandoned the use of PTFE for BK and D, but feel that AK PTFE is a suitable alternative to autogenous reversed saphenous vein.

Aged↗

PubMed1999

Salvage after severe lower-extremity trauma: are the outcomes worth the means?

Advances in reconstructive surgery have allowed for impressive salvage after severe lower-extremity trauma but not without complications when compared with immediate below-knee amputation. Several amputation index scores have been developed to help predict successful salvage as defined by a viable rather than a functional extremity. The purpose of this study was to evaluate retrospectively the predictive value of the amputation index scores and to assess prospectively overall health status and specific dysfunction in successful limb salvage and primary and secondary amputation by administering standardized generic and specific outcomes questionnaires (Medical Outcomes Study 36-Item Short-Form Health Survey, Western Ontario and MacMaster Universities Osteoarthritis Index). A retrospective chart review identified 55 severe lower-extremity injuries (Gustilo Type IIIB and IIIC) over a 12-year period (1984 to 1996). Forty-six severe open tibial fractures in 45 patients underwent attempted salvage. All required soft-tissue coverage by either local or free flap or vascular repair for leg salvage. The attempted-salvage group was subdivided into successful salvage and secondary amputation. The other nine patients underwent a primary amputation. There were no statistically significant differences in terms of patient demographics or other injuries (Injury Severity Score) in the three groups. Forty-eight of 54 patients with an average 5-year follow-up completed a validated generic and specific outcomes health questionnaire. In the attempted-salvage group, 89 percent of patients had a successful salvage and 11 percent came to a secondary amputation. The amputation index scores correctly predicted an amputation in 32 percent of patients. The magnitude of the amputation index scores did not correlate with the physical outcomes scores and were not found to add any significant value of information to the surgeon's decision making. Patients undergoing primary and secondary amputation had a worse physical outcomes score (28 versus 38) than successful salvage (p < 0.007). Even so, the SF-36 (physical component score) outcomes score for this group of injured extremities, regardless as to whether salvaged or amputated, was as low as or lower than that of many serious medical illnesses, suggesting that severe lower-extremity trauma impairs health as much as or more than being seriously ill. The mental component score in this group was comparable to that of a healthy population (49 versus 50), which implies the disability is primarily physical rather than psychological. Ninety-two percent of patients preferred their salvaged leg to an amputation at any stage of their injury, and none would have preferred a primary amputation.

Activities of Daily Living↗

PubMed2004

Costs of lower-extremity ulcers among patients with diabetes.

OBJECTIVE: The objective of this study was to characterize health care costs associated with diabetic lower-extremity ulcers. RESEARCH DESIGN AND METHODS: Adult patients with diabetes who had a lower-extremity ulcer episode during 2000 and 2001 were identified using claims data. Ulcer-related direct health care costs were computed for each episode. Episodes were stratified according to severity level based on the Wagner classification. RESULTS: A total of 2,253 patients were identified. The mean age was 68.9 years, and 59% of the patients were male. The average episode duration was 87.3 +/- 82.8 days. Total ulcer-related costs averaged 13,179 dollars per episode and increased with severity level, ranging from 1,892 dollars (level 1) to 27,721 dollars (level 4/5). Inpatient hospital charges accounted for 77% (10,188 dollars) of the overall cost, indicating that hospitalization was a major cost driver. Total ulcer-related costs were significantly higher for patients <65 years of age compared with those of older patients (16,390 dollars vs. 11,925 dollars, P = 0.02) and for patients with inadequate vascular status compared with patients with adequate vascular status (23,372 dollars vs. 5,218 dollars, P < 0.0001). Patients who progressed to a higher severity level also had significantly higher ulcer-related costs compared with patients who did not progress (20,136 dollars vs. 3,063 dollars, P < 0.0001). CONCLUSIONS: The high costs of treating diabetic lower-extremity ulcers emphasize the value of intensive outpatient interventions designed to prevent ulcer progression.

Aged↗

PubMed1990

[The present state of surgical treatment of primary varices of the lower extremities].

Surgical treatment holds the chief place in treatment of varicosities of the lower extremities. Surgical treatment of varicosities of the lower extremities should be pathogenetic and based on pathophysiological findings and disorders of the venous system. The main principle of contemporary surgical treatment of varicosities is elimination of chronic venous insufficiency, elimination of the pathological venous reflux between the deep and superficial venous system and elimination of the altered insufficient superficial and connecting venous system.

Humans↗

PubMed2004

[Doppler ultrasound diagnosis of lower extremity deep vein insufficiency: Valsalva maneuver or pneumatic cuff?].

PURPOSE: To compare the efficacy of Valsalva maneuver and pneumatic compression techniques in detecting lower extremity deep venous and saphenofemoral insufficiency. MATERIALS AND METHODS: Eighty-one extremities evaluated in 43 patients who had undergone Doppler ultrasound examination of the lower extremity venous system were included in the study. Valsalva maneuver and pneumatic cuff techniques were used to elicit reflux in the standing position. Reflux was investigated with spectral Doppler in the superficial femoral vein, popliteal vein, the proximal segment of the great saphenous vein close to its junction with the femoral vein and in its caudal segment at the medial aspect of the knee. The same measurements were repeated after rapid deflation of the pneumatic cuff, which was applied to the calf and was initially inflated to 200 mmHg. Retrograde flow exceeding 1000 msec was regarded as insufficiency. The results of the two techniques at each venous segment were compared with the McNemar test. RESULTS: Deep venous and/or saphenofemoral insufficiency were detected in 61 of the 81 extremities. The cuff deflation technique was superior at the popliteal vein and caudal segment of the great saphenous vein. The Valsalva maneuver was superior at the superficial femoral vein. The statistical results did not change when the McNemar test was repeated for reflux exceeding 2000 msec. CONCLUSION: Combined application of Valsalva maneuver and pneumatic cuff techniques will lead to more accurate evaluation and increased detection of lower extremity venous insufficiency.

Adolescent↗

PubMed2000

Bicycle spoke injuries in the lower extremity.

This study reports the authors' 5-year experience with treating lower extremity injuries in bicycle passengers caused by the spokes. This patient group was selected from 716 lower extremity injuries that received treatment at our outpatient plastic surgery clinic. A total of 26 patients were treated during the study. Patients ranged from 2 to 19 years old, with a mean age of 5.6 years. The authors treated more female passengers (62 percent) than male passengers. The right foot (52 percent) was involved more often than was the left. Most patients were injured in the afternoon, from 2 to 7 PM (62 percent), and between May and October (77 percent). The rear wheel (89 percent) injured the majority of patients. The Achilles tendon was the most common site of injury (63 percent). The typical types of wounds observed included the following: type I, laceration with partial avulsion of skin and subcutaneous tissue (41 percent) and laceration forming a distally based flap (33 percent); type II, abrasions with ecchymoses and friction burn from the shearing effect of the spokes creating a partial- to full-thickness skin defect (26 percent). Of the type I injuries, full-thickness skin lacerations (33 percent) were closed primarily. Partial-thickness skin lacerations, abrasions, ecchymoses, and skin defects (67 percent) were treated conservatively with wound irrigation and dressing. The wound healing time for type I injuries was 29 days; for type II injuries, it was 27 days. These healing times were prolonged compared with healing by first intention. No significant difference was found in healing time when comparing both types of injury. Four patients required hospitalization. No patient required skin grafting. No fractures were noted because these patients were selected from the outpatient plastic surgery clinic and did not include patients from the emergency room. Since the first report of bicycle spoke injuries a half-century ago, prevention has not improved.

Achilles Tendon↗

PubMed2002

Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity.

Complex intra-articular and periarticular fractures of the lower extremity are challenging injuries to treat. Recently, the concept of utilizing a staged approach with temporary external fixation, a delay to allow soft-tissue healing followed by open reduction and internal fixation, has gained popularity. Historically high complication rates appear to be significantly improved with this strategy. Temporary external fixation is also useful in other settings, such as in the initial management of polytraumatized patients with multiple complex fractures, augmentation of internal fixation in osteoporotic bone, etc. This article reviews current indications, techniques, potential complications, and results of temporary external fixation for complex fractures of the lower extremity.

Clinical Protocols↗

PubMed1993

Treatment of lower extremity injuries with orthotic shoe inserts. An overview.

Orthotic shoe inserts are very effective in providing symptomatic relief of lower extremity complaints in running athletes. Inserts adjust the biomechanical-variables associated with running injuries and reduce the effect of high stresses produced by running activities. Orthotic treatment is based on an understanding of complex coupling of rotation of the lower extremity with pronation and supination of the subtalar joint. Orthotic fabrication is initiated by determining the neutral position of the foot and obtaining an accurate cast of this position. Successful treatment with orthotic shoe inserts is dependent on careful evaluation of the runner and formulation of a properly fitted orthosis. When correctly utilised, orthotic shoe inserts are beneficial for a broad range of disorders experienced by runners. Since biomechanical deficits may be related to injuries along the entire lower extremity, specific diagnoses may be of lesser indication; however, accurate identification of the underlying biomechanical deficit is critical. Problems related to excessive or prolonged pronation are most amenable to orthotic treatment. While treatment of the cavus foot with orthotic shoe inserts is sometimes worthwhile, the clinician should be aware of limited success in this instance. Finally, orthotics are only one facet in the overall treatment plan for injured running athletes. Most overuse syndromes will respond to rest, training modification, and a change in the running surface or shoe. Equally important is the use of a proper conditioning and stretching programme both for injury prevention and for treatment of specific injuries. Treatment with orthotic shoe inserts should not be used as a substitute for any of these approaches.

Athletic Injuries↗

PubMed2004

Alterations in lower extremity movement and muscle activation patterns in individuals with knee osteoarthritis.

OBJECTIVE: The purpose of this study was to investigate lower extremity movement and muscle activation patterns in individuals with knee osteoarthritis and healthy age- and gender-matched control subjects. DESIGN: This study utilized a non-randomized case-control design to compare 24 subjects with unilateral symptomatic knee osteoarthritis to 24 age- and gender-matched control subjects without knee osteoarthritis. BACKGROUND: It is hypothesized that knee osteoarthritis is associated with altered lower extremity movement and muscle activation patterns. METHODS: A gait analysis was performed to determine the lower extremity movement and muscle activation patterns when walking on a level surface at 1.12 to 1.34 m/s and while descending a 20 cm step. Paired t-tests were used to compare the average of five trials between the groups. RESULTS: Subjects with knee osteoarthritis demonstrated less excursion of the knee in the sagittal plane from heelstrike to peak flexion before midstance (i.e. during loading). Subjects with knee osteoarthritis also demonstrated reduced peak vertical ground reaction forces relative to body weight. The muscle activity patterns were also different between the groups. The vastus lateralis, medial hamstrings, tibialis anterior and medial gastrocnemius were on approximately 1.5 times longer than the same muscles in the control subjects. Additionally, significant increases in muscle co-activation were also observed in individuals with knee osteoarthritis during walking. Similar findings were observed when the subject descended a 20 cm step.

Aged↗

PubMed2004

Quality of life in patients with vascular malformations of the lower extremity.

With the exception of capillary malformations (port-wine stains), the adverse psychosocial effects of vascular malformations have not received much attention in the medical literature. We, therefore, studied health related quality of life of patients with vascular malformations located primarily on the lower extremity, who presented to us over a 10-year period. Patient's self-assessment of quality of life was measured by the Multiple Outcomes Study (MOS) Short Form Health Survey Questionnaire (SF-36). Several possible predictors were also examined. Eighty-one patients (33 male, 48 female), aged 14-61 years, completed the SF-36. Seventy-one patients (88%) had a low flow lesion. Twenty-three patients (28%) had hypertrophy of the lower extremity, while 11 patients (14%) had hypotrophy. Sixty-nine patients (85%) had the vascular malformation located only on the lower extremity. Six (7%) also had their upper extremity (hand) involved, and 20 patients (24.7%) had >10% TBSA affected. Eight patients (10%) needed special shoes. Fifty-one patients (63%) had a previously performed MRI, of which 62.7% (32/51) had muscle involvement. Fifty-one patients (63%) had been operated on. Of the 34 patients wearing elastic compression stockings, 25 patients (74%) indicated that they were satisfied with the stockings. Compared to the general population sample, the SF-36 questionnaire indicated that our vascular malformation patients reported impaired vitality and higher levels of pain, while no differences were seen regarding the other dimensions of quality of life. Demographic, clinical and therapy characteristics could explain quality of life only to a limited extent. Explained variability of the SF-36 dimensions ranged from 0% for mental health to 34.5% for role functioning physical. To our surprise, this study suggests that patients with vascular malformations located primarily on the lower extremity do not have a greatly decreased quality of life when compared to the general Dutch population.

Adolescent↗