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Vascular surgeons are often consulted on the management of lower extremity ulcerations and gangrene which are commonly due to atherosclerotic arterial occlusive disease or to chronic venous insufficiency. The following report describes an unusual case of severe lower extremity cutaneous gangrene associated with secondary hyperparathyroidism and a review of the literature.
The purpose of this study was to evaluate physical impairment and functional outcome in a group of patients who had a fracture of a lower extremity after age 65. The 30 subjects participating were treated between January 1992 and February 1998, for a unilateral fracture of the lower extremity. At the return examination, the patients' lower extremities were evaluated for range of motion (ROM) and strength. The participants also completed the Short Form 36 (SF-36) questionnaire, and their scores were compared with those of age-matched controls to determine relative disability. There were no statistically significant differences in ROM or muscle strength of the injured versus noninjured extremities, except in the case of knee flexion. The Mental Component Score (MCS) of the SF-36 in our study population was statistically different from that of controls, and there was no statistical difference in the Physical Component Score (PCS). A moderate correlation was found between the PCS and physical impairment.
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Functioning hemodialysis grafts were used as access sites for peripheral vascular arteriography and interventional procedures. In 11 patients with end-stage renal disease and ischemia, upper extremity (n = 8) or lower extremity (n = 3) arteriography was performed successfully. Angioplasty and other interventional procedures were performed via the same route in two of the patients. No bleeding complications occurred, and all patients were ambulatory immediately after the procedure.
The use of saphenous vein in situ bypass for limb salvage has increased the need for adequate visualization of distal lower extremity vessels. Preoperative angiographic techniques are often inadequate, requiring multiple films, extensive patient manipulation, or excessive dye loads. Intraoperative prereconstructive angiography permits adequate distal vessel visualization, but at a significant waste of time and expense if no usable distal vessels are found. There is a need for a reliable means of preoperative angiography in patients being evaluated for saphenous vein in situ bypass. Preoperative balloon occlusion femoral angiography was compared to preoperative standard angiography of the lower extremity in 39 patients referred to the University of Minnesota for limb salvage. Balloon occlusion femoral angiography significantly improved the preoperative ability to visualize lower extremity vessels distal to the superficial femoral artery in this group of patients.
PURPOSE: This study was performed to clarify the role of intraarterial thrombolytic therapy (IATT) in the management of acute lower extremity ischemia. METHODS: A retrospective review of 77 patients undergoing 84 courses of high-dose regional urokinase IATT from July 1981 to June 1991 was performed. The group included patients with acute thrombosis of lower extremity bypass grafts (n = 48) or native arteries (n = 36), presenting with ischemic but viable limbs, minimal or no motor dysfunction, and an absence of muscle rigor or compartment syndrome. The data were then examined individually by site of thrombosis to evaluate patient selection for IATT. RESULTS: Complete lysis, complications (either distal thromboembolism or bleeding), and early limb loss occurred in 59.5%, 11%, and 6% of infusions, respectively. IATT precluded the need for operative intervention in 49% of acutely ischemic limbs. When surgery was required, successful IATT precisely localized responsible lesions and reduced the magnitude of operation. A subset of 13 patients were identified in whom either no intrinsic abnormality or poor runoff were evident after lysis and were treated with anticoagulation alone. CONCLUSIONS: These data show IATT to be especially suitable for thrombosis of native iliac or femoropopliteal arteries and infrainguinal vein grafts. IATT serves primarily as an adjunct in management of acute lower extremity ischemia. After successful IATT, subsequent therapy can be tailored to the anatomic cause of thrombosis.
The purpose of this study was to establish the correlation between the intensity of atherosclerosis of the lower extremities found in the course of the Doppler examination, and type of hyperlipoproteinaemia. An attempt was undertaken to analyse the relation of the risk factors of obliterative atherosclerosis to the condition of the arteries in the lower extremities. 53 men at the age of 37 to 63 years (mean age 51 years) were examined. HLP type IIa, IIb, IV, was found in 16, 19, 18 patients respectively. The control group consisted of 30 healthy non-smoking men. The examination was performed using ACUSON 128 with a linear probe 5 and 7 MHz. The Doppler spectrum was registered from the external iliac, common femoral, superficial femoral, deep femoral and popliteal arteries. Simultaneously, a two-dimensional color picture of contrasted vessels, and the Doppler spectrum of blood velocity were recorded. Blood velocity spectrum was quantitatively assessed according to the classification suggested by Jager et al. The results of the Doppler examination confirmed the unfavourable influence of the so called risk factors on the progress of atherosclerosis, especially low serum concentration of HDL cholesterol and cigarette smoking. Besides, the examination has proved the possibility to diagnose even asymptomatic atherosclerotic lesions of the arteries of lower extremities.
INTRODUCTION: Intra-arterial thrombolysis is commonly used as the initial treatment of acute or subacute lower extremity ischemia. METHODS: To evaluate the efficacy and cost of thrombolysis, we retrospectively analyzed 100 consecutive cases (87 patients) in which intra-arterial lysis (urokinase) was used as the initial treatment for native arterial lower extremity occlusive disease. The mean age of patients was 67 years, 57% of the patients were male, and preexisting peripheral vascular disease was present in 74%. Presenting symptoms were limb-threatening ischemia (53%) and claudication (47%). Acute symptoms (< 2 weeks' duration) were present in 48%. RESULTS: The 30-day morbidity rate was 31%, and four patients died. Complications were significant bleeding (23%), ischemic stroke (1%), and renal failure with (2%) and without (2%) dialysis. Concomitant angioplasty was performed in 63%. Complete or significant lysis as demonstrated with angiography was achieved in 75% of iliac, 58% of femoropopliteal, and 41% of crural vessels (P <.001). Within 30 days of lysis, 9% of patients underwent major amputation and 20% surgical revascularization (in 3 patients the extent of revascularization was lessened by the lytic therapy). Amputation-free survival was 83% and 75% at 6 months and 2 years, respectively. Relief of ischemia (defined as relief of claudication or limb salvage without major surgical intervention) was achieved in only 70% and 43% of patients at 30 days and 2 years, respectively (Kaplan-Meier analysis; mean follow-up, 31 months). Patients with aortoiliac disease had significantly better outcomes than those with infrainguinal disease (P =.03). Duration or type of presenting symptoms did not predict outcome. The cost of the initial hospitalization per patient for thrombolysis was $18,490. CONCLUSION: Thrombolysis can be as or more costly than surgery and is associated with a suboptimal outcome in a significant number of patients. These data lead us to caution against a uniform policy of initial thrombolysis for patients who present with lower extremity ischemia.
OBJECTIVES: To evaluate prosthetic costs of pediatric lawnmower amputations; to see if reducing the incidence of pediatric lawnmower amputations could result in significant cost savings; and to consider if a cost analysis could be useful to implement more safety features (voluntarily or legislatively). DESIGN: Pediatric lawnmower amputees from 1980 to 2000 were reviewed to determine age at time of injury, level of amputation, number of prostheses, and lifetime per prosthesis. A standard prosthetic program beginning at amputation and ending at age 18 years was constructed. An aggregate cost was calculated according to the proportion of amputation levels. The cost burden for prosthetic care was estimated from the statistics of US pediatric lawnmower injuries. SETTING: Referral pediatric orthopedic center. PATIENTS: Fifty-three lower extremity amputees with 58 lower extremity amputations at a mean +/- SD age of 4.7 +/- 2.5 years were reviewed. RESULTS: The percentage of amputee children injured by riding lawnmowers was 80%; the percentage injured by riding lawnmowers engaged in reverse was 39%. Prosthetic costs from the time of injury to the age of 18 years range from 73,140 dollars to 116,040 dollars per single lower extremity amputation. With 600 to 650 new childhood amputations per year due to lawnmowers, the new annual burden for prosthetic costs thus ranges from 43.88 to 75.42 million dollars, or (600)(73,140 dollars) to (650)(116,040 dollars). CONCLUSIONS: Further encouragement of lawnmower manufacturers to install improved safety devices (such as those to disengage power while in reverse mode of operation), new research on improved safety measures, and continued promotion of educational campaigns regarding the dangers of children being around and/or operating riding lawnmowers and garden tractors should be pursued. This will result in significant cost savings as well as incalculable health savings.
PURPOSE: The purpose of this study was to investigate the lower-extremity kinematics when walking on potentially slippery surfaces in simulated construction worksite environments. METHODS: A survey was conducted to select two types of footwear, two floorings, and four contaminants to represent the local construction worksite environments, making 16 simulated conditions. A mechanical slip-resistance test was conducted to evaluate the slipping potential of the 16 conditions by the value of the dynamic coefficient of friction. The 16 conditions were classified into three groups by slipping potential. Fifteen harnessed Chinese male subjects were instructed to walk and avoid slips on each of the 16 simulated 5-m walkways 10 times at their natural cadence. The movements in the sagittal plane were videotaped, digitized, and analyzed by a motion analysis system. Gait pattern parameters were obtained. Lower-extremity kinematic data were time-normalized from foot strike (0% stance) to take-off (100% stance) and were extracted from foot strike to midstance (50% stance) at 10% stance intervals. RESULTS: ANOVA showed that with increased slipping potential, changes in gait pattern parameters included increased stance and stride time, shortened stride length, decreased propagation speed, and gentle heel strike. In lower-extremity kinematic parameters, significant differences were found mainly at the ankle joint rather than the knee joint. CONCLUSION: Strategies to prevent slips included increased stance and stride time, shortened stride length, decreased propagation speed, and gentle heel strike. The ankle joint played the most important role in adaptation strategy. Such strategy included reducing range of motion, maintaining a stiff joint, and achieving flatfoot landing or a plantarflexed ankle joint during the first 10% stance.
High-resolution B-mode ultrasonography of the carotid arteries is used to investigate the signs of early atherosclerotic vessel wall disease. To assess whether carotid artery findings reflect atherosclerosis elsewhere, we studied the association between common carotid intima-media thickness and lower extremity arterial atherosclerosis among the first 1000 participants of the Rotterdam Study. The Rotterdam Study is a single-center population-based prospective follow-up study of 7983 subjects, > or = 55 years old. Baseline measurements include ultrasound imaging of intima-media thickness of the distal common carotid artery and determination of the ankle-to-arm systolic blood pressure index. Lower extremity arterial disease was defined as an ankle-arm index < 0.90 in at least one leg. An increase of 0.1 mm in common carotid artery intima-media thickness was associated with an age- and sex-adjusted reduction of the ankle-arm index of 0.026 (95% confidence interval [CI]: 0.018 to 0.034). The age- and sex-adjusted odds ratio of lower extremity arterial disease for subjects with an intima-media thickness > or = 0.89 mm (upper quintile) to that of subjects with an intima-media thickness < 0.89 mm was 3.4 (95% CI: 2.2 to 5.2). Analysis among subjects free from symptomatic cardiovascular disease yielded a reduction in ankle-arm index per 0.1 mm increase in intima-media thickness of 0.018 (95% CI: 0.008 to 0.28) and an odds ratio for lower extremity arterial disease of 3.0 (95% CI: 1.7 to 5.1). Adjustments for differences in serum lipids, hypertension, and current smoking status only slightly attenuated the results.(ABSTRACT TRUNCATED AT 250 WORDS)
This study examined specific types of lower extremity injuries, their treatment, and trends in length of stay (LOS) as seen in an academic community hospital. The authors' trauma registry was queried for lower extremity injuries requiring surgical intervention from 1992 to 2000. A total of 5567 patients were identified. A total of 574 patients with 857 injuries met the criteria. The only significant difference in injury severity score among various injury types was found between traumatic amputations and open fractures (P = 0.006). However, there was no statistical difference between these 2 groups with regard to LOS. Patients requiring 1 or 2 procedures had a significantly shorter LOS than those requiring 3 procedures (P = 0.002 and P = 0.021 respectively). In this population of patients, it was not the manner of initial reconstruction, but the number of reconstructive procedures required that had an impact on LOS. LOS reduction might be possible when patients with lower injury severity scores can be treated in a more efficient manner.
Increased number of overuse injuries, particularly of the lower extremity, occurs in exercise. It is important for the physician who prescribes exercise to understand the mechanism of injury-repetitive microtrauma-and the risk factors for occurrence of these injuries. In the lower extremity, risk factors include inappropriate progression of the rate, intensity and duration of training; anatomic malalignment; muscle-tendon imbalances of strength, endurance, or flexibility; shoewear; surface; and pre-existent disease states. Specific recommendations for training progression, technique, and sports equipment may have to come from the physician, since the recreational athlete often does not have access to coach or athletic trainer. These are described.
A retrospective review of 304 consecutive microvascular free flaps to the lower extremity was done to identify the patterns of usage, results, and problems. The most common indication (91%) was for the replacement of extensive tissue loss caused by motor-vehicle injuries. Most of the defects were below the mid-tibia (73%). The associated compound fractures were predominantly gradable as Gustilo type IIIb&c. The latissimus dorsi, the rectus abdominus, and the scapular skin were the flaps used most commonly for coverage (77%). The overall flap failure rate was 8%, compared with 3% for our series of non-lower extremity cases, and 0% for the non-traumatic lower extremity cases. The magnitude of the traumatic insult was the most significant factor associated with anastomotic failure. The rate of anastomotic thrombosis doubled in the presence of vascular trauma, increased threefold in the presence of larger bony defects, and increased fivefold when vein grafts were needed. Experience was important in reducing the complications and improving the results. Fourteen patients (6%) underwent an amputation within the first 3 months, ten of them because of flap failure. Of 85 patients followed up for over one year, 91% had recovered good to excellent leg function. The ability to add healthy and well vascularized tissue to the traumatized limb is critical for the achievement of: 1) early definitive wound healing and restoration of function; 2) salvage of many impending amputations; 3) better prosthetic stump reconstructions; 4) better esthetic results.
BACKGROUND: We evaluated the use of distally based neurocutaneous flaps in the reconstruction of soft tissue defects in the lower extremity caused by trauma or other reasons. METHODS: Sixty-six patients (49 males, 17 females; mean age 42 years; range 16 to 75 years) underwent reconstruction of lower extremity soft tissue defects with the use of neurocutaneous flaps. The defects were in the external (n=11) and internal malleolus (n=10), Achilles tendon (n=6), heel (n=11), foot (n=7), distal (n=9) and middle (n=7) third of the anterior tibia, the mid-plantar region (n=3), and the popliteal region (n=2). Sural and saphenous neurocutaneous flaps were used in 34 and 32 patients, respectively. The mean flap area was 135 square centimetres (range 54 to 286). The mean follow-up period was 32 months (range 11 to 58 months). RESULTS: Of sixty-six patients treated with neurocutaneous flaps, complete survival was achieved in 57 flaps (86.4%). Partial necrosis was encountered in six patients (9%). Total flap loss occurred in three patients (4.6%) who had diabetes, hypertension, and electrical burns, respectively. The most common complication during the postoperative period was venous congestion seen in 14 patients (21%), the majority of whom had diabetes (n=5), hypertension (n=3), and electrical burns (n=3), predisposing them to microcirculation disorders. This complication was successfully managed by leech therapy in 78.6%. CONCLUSION: Neurocutaneous flaps offer maximum reconstruction capacity with minimum donor site morbidity, making them a successful alternative in the treatment of soft tissue defects of the lower extremity in recent years.
OBJECTIVES: To better understand disablement and transitions from impairment to disability, discrete valid measures of functional limitation are needed. This study reports the development and criterion-related validity of scales that quantify severity of upper and lower extremity functional limitation. METHODS: Data are from 3,635 cognitively intact community-dwelling women aged 65 years and older and 1,002 moderately to severely disabled participants in the Women's Health and Aging Study. Scales assessing severity of upper and lower extremity functional limitation were constructed from commonly available questions on functional difficulty. Criterion-related validity was evaluated with self-report and performance-based measures. RESULTS: The upper and lower extremity scales range from 0 to 6 and 0 to 9, respectively. Scale scores were well distributed in the disabled group and discriminated limitations in the broader community. For both scales, rates of difficulty for all ADL and IADL increased (p<.001) with increasing severity score, and percent able and mean performance on respective upper and lower extremity tasks decreased (p<.01). DISCUSSION: These scales, constructed from commonly used self-report measures of function, provide discrete measures of upper and lower functional limitation. Because these scales are distinct from measures of disability and impairment, their use should facilitate increased understanding of the disablement process.
BACKGROUND: Literature shows that landing with great impact forces may be a risk factor for knee injuries. The purpose of this study was to examine the relationships among selected lower extremity kinematics and kinetics during the landing of a stop-jump task. METHODS: Landmark coordinates and ground reaction forces during a stop-jump task were collected. Lower extremity joint angles and resultants were reduced. Pearson correlation coefficients among selected lower extremity kinematics and kinetics were determined. FINDINGS: The hip flexion angular velocity at the initial foot contact had significant correlation with peak posterior and vertical ground reaction forces (r = -0.63, P < 0.001, r = -0.48, P < 0.001) during the landing of the stop-jump task. The knee flexion angular velocity at the initial foot contact also had significant correlation with peak posterior and vertical ground reaction force (r = -0.49, P < 0.001, r = -0.06, P < 0.001) during the landing of the stop-jump task. Peak proximal tibia anterior shear force and peak knee extension moment during landing of the stop-jump task had significantly correlation with the corresponding posterior and vertical ground reaction forces (r > 0.51, P < 0.001). INTERPRETATION: A large hip and knee flexion angles at the initial foot contact with the ground do not necessarily reduce the impact forces during the landing of the stop-jump task, but active hip and knee flexion motions do. Hip joint motion at the initial foot contact with the ground appears to be an important technical factor that affects anterior cruciate ligament loading during the landing of the stop-jump task.
The purpose of this study was to clarify the lower extremity function in terms of the shock absorption during unsynchronized-foot landings. The characteristics of the supination and pronation in the ankle joint at landing were investigated, assuming that the measurements of the impact force on the body could be demonstrated by the changes that occurred during 3 different landing motions: -unsynchronized-foot landings, synchronized-foot landings, and one-foot landings. Subjects jumped to the floor from 10-cm footstools 3 times for each type of landing. For the synchronized-foot landing, the rear foot angle was 92.2 degrees at the start of landing and did not change significantly from landing start to 100 msec. For the one-foot landing, rear foot angle was 95.1 degrees at the start of landing and decreased rapidly to 87.1 degrees by 75 msec, and then increased rapidly to 90.8 degrees by 140 msec. For the unsynchronized-foot landing, the rear foot angle was 93.8 degrees at the start of the landing, decreased rapidly to 88.0 degrees by 75 msec, and then increased rapidly to 89.9 degrees by 115 msec. It was clarified that the lower extremity function for the shock attenuation during landing with the unsynchronized-foot was similar to that with one-foot landings, and the lower extremity function for supporting the body after another foot landing was similar to that after the synchronized-foot landings in this study.