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The use of local transposition muscle flaps for coverage of the lower extremity has been overshadowed in recent years by the development of microsurgical techniques for tissue transfer. There are still definite indications for local muscle flaps in reconstruction of the lower extremity. An outline of criteria of selectivity as it applies to specific wounds and practical pitfalls of their use is presented.
A revascularization procedure for extensive arterial occlusive lesions of the lower extremity, namely "A-V shunt procedure" was devised. The occluded popliteal artery is recanalized by open endarterectomy in association with E-PTFE bypass for occlusion of the superficial femoral artery, and the patency of reconstructed arterial segments is ensured by an arterio-venous shunt created at the distal end of the recanalized tibio-peroneal trunk. The branches of the genicular arterial network are also reopened by a technique of thrombectomy. Numerous collaterals develop through the reopened genicular network increasing blood flow to the ischemic distal areas. From 1967 to 1980, 63 extremities in 57 patients, which had extensive arterial occlusions of lower extremities with impending ulcer and/or severe rest pain in their feet or toes, underwent this procedure. Remarkable improvement of ischemic symptoms resulted in 76.2% of extremities at the time of the hospital discharge and 57.1% in follow-up.
The results and complications of lower extremity bone reconstruction using microvascular fibula transfer were retrospectively compared with reconstruction using microvascular iliac crest transfer. Seventeen patients matched as much as possible in regard to location of defect (femur, tibia, ankle) and aetiology (traumatic defect, osteomyelitis) were studied in each group. Data collected included number of prior operative procedures, length of bony defect, presence or absence of associated soft tissue loss, the final clinical and radiographic result, technique of bone immobilisation and duration to union, complications including patency of microvascular anastomoses (if known) and nature and number of additional operative procedures. The outcome of this study suggests that, for reconstruction of the femur or tibia bridging a defect greater than 10 cms, fibula transfer yielded a satisfactory outcome. For defects less than 10 cms resulting from debridement for osteomyelitis, iliac crest transfer yielded a more favourable result. Moreover, the iliac crest appeared to be more optimal than the fibula for reconstruction about the ankle regardless of aetiology.
In bone fractures in the lower extremities a high blood loss must be taken into consideration. An adequate blood transfusion should be given before and during diagnostic procedures. Diagnostic measures should proceed quickly and be limited to the necessary treatment. Operative setting of closed fractures can be programmed when conditions are optimal. Immediate setting of open fractures has proven to be valuable not only because the blood loss may be controlled, but also because extensive soft tissue distraction and possible infection can be prevented. The crush-syndrome can be caused by crushing injuries, pluck-out injuries and traumatic amputation and endanger the patient's life.
Eleven patients with lower extremity atheromatous microembolization are described. The diagnostic feature of sudden, often repetitive, episodes of focal ischemia, patent major arteries of the legs, and arteriographic demonstration of nonocclusive atheromas of the proximal arterial tree are characteristic. Successful removal of the causative lesion in these patients has prevented further ischemic episodes.
Postoperative management of the lower extremity amputation continues to evolve as a crucial first step in amputee rehabilitation. Although the major goals of early rehabilitation remain fairly constant, external forces continually pressure the rehabilitation team to complete these goals within shorter time frames. The atmosphere of rapid rehabilitation for amputees stresses return to normal function as quickly as possible. Early ambulation is the obvious goal for most new amputees.
The lower extremity is the most commonly injured anatomic area in sports. An appropriate history and physical examination is sufficient to diagnose most injuries. By knowing the position where a joint has the greatest and least bony stability, one can predict the likelihood of bony and ligament injury. Such information is helpful in determining which structures are most susceptible to injury as well as identifying when radiographs or other diagnostic studies are indicated. An accurate diagnosis is crucial for planning effective therapy and in determining the need for surgical referral. An understanding of common injury patterns is also helpful in differentiating sources of musculoskeletal pain that are not injury related.
UNLABELLED: Although function after lower extremity amputation and limb salvage has been compared, no study has assessed individual functional variables by surgical level. Our aim was to determine whether risks of long-term psychologic and physical limitations were associated with amputation or limb salvage at four levels: below-knee, above-knee, hip, and pelvis. We included 408 patients with sarcomas and postoperative followup of 2 years or greater who had completed a quality-of-life self-report questionnaire. The mean length of followup was 8.91 +/- 5.15 years (range, 2-27 years). Relative risk analysis was done on 12 dichotomous general health, psychologic, and physical function variables. At the below-knee level, outcomes were similar after both procedures. At the above-knee level, amputation was associated with increased risk of limp (RR = 1.6), walking aid use (RR = 2.1), anxiety (RR = 2.4), and inability to drive (RR = 3), and decreased risk of muscle weakness (RR = 0.57). At the hip and pelvic levels, outcomes were descriptively compared because of the small number of amputations. At these higher levels, limitations were more common after amputation. The difference in results between the below-knee and above-knee levels supports the importance of distinguishing surgical levels. Limb salvage offers a functional advantage at proximal tumor locations. LEVEL OF EVIDENCE: Therapeutic study, Level III (retrospective, comparative study). See the Guidelines for Authors for a complete description of levels of evidence.
The neuromuscular function of the lower extremity in 40 normal and 100 anterior cruciate ligament-deficient volunteers was evaluated by physical examination, KT-1000 arthrometer measurements, isokinetic strength and endurance testing, subjective functional assessment, and an anterior tibial translation stress test. A specially designed apparatus delivered an anteriorly directed step force to the posterior aspect of the leg while anterior tibial translation was monitored and electromyographic signals were recorded at the medial and lateral quadriceps, medial and lateral hamstrings, and gastrocnemius muscles. Testing was done at 30 degrees of knee flexion with the foot fixed to a scale to monitor weightbearing, while the tibia remained unconstrained. Results indicate that muscle timing and recruitment order in response to anterior tibial translation are affected by anterior cruciate ligament injury. These alterations in muscle performance change with time from injury, correlate with an individual's physical activity level, affect subjective functional parameters, and are directly related to the degree of dynamic anterior tibial laxity seen with stress testing.
Three hundred thirty-seven lower extremities of 256 patients, both symptomatic and asymptomatic, underwent ascending positive contrast venography. Certain anatomic variations were noted to be related to the location and development of deep venous thrombosis (DVT). The thrombus was located entirely in the calf in 44% of asymptomatic limbs and 17% of symptomatic ones (p less than 0.001). There were multiple superficial femoral veins (SFVs) in 31% of the limbs examined, and 40% of those limbs had DVT. This percentage (40%) represented a statistically higher incidence of DVT (p less than 0.001) than those limbs with a single SFV, where the incidence was only 19%. When limbs with multiple SFVs had DVT, only 41% were symptomatic, whereas in those with a single SFV, 72% of the limbs were symptomatic (p less than 0.001). This difference may be the result of internal collaterals due to multiple SFVs. When there were more than five valves in the deep veins between the popliteal fossa and the ischial spine, there was a higher incidence of DVT (35%) as compared to the incidence when there were five or fewer valves (13%) (p less than 0.001).
Patients requiring amputation of the lower extremity for arteriosclerosis are at high risk for the development of venous thrombosis and pulmonary embolism. Inapparent venous thrombosis was discovered in the amputated leg at operation in eight patients. Pulmonary embolism was documented by angiogram or at autopsy in ten patients. The majority of emboli discovered in this study was not suspected by the physician responsible for the care of the patient. The perfusion lung scan in this elderly group of patients had a false-positive rate of 60 per cent, while a normal lung scan was strong evidence against pulmonary embolsim. Although imperfectly randomized, the prophylactic use of low molecular weight dextran in this study did not decrease the incidence of pulmonary embolism. The pulmonary arteriogram proved a safe procedure in the elderly and should be used before therapy is initiated for suspected pulmonary embolism.
PURPOSE: Reversed lower-extremity vein grafts (LEVGs) frequently require operative revisions to maintain patency. Identifying grafts that are at risk, however, requires an intensive duplex scanning-based surveillance program. Excellent 5-year graft patency and limb-salvage rates have previously been reported in patients undergoing graft revisions, but results beyond 5 years are essentially unknown, a factor that is of importance in an increasingly aging population. This study was performed to determine the results of surgical revisions of LEVGs after a follow-up as long as 10 years. METHODS: All patients undergoing placement of a LEVG were observed in a program of duplex scanning-based surveillance as long as the patient remained a candidate for graft revision. Grafts were considered for revision on the basis of the presence of focal areas of increased velocity, a prestenotic to intrastenotic velocity ratio more than 3.0, or uniformly low velocities throughout the graft. All lesions were confirmed with preoperative arteriography before revision. Assisted primary patency, limb-salvage, and survival rates were determined by means of Kaplan-Meier analysis in all patients who underwent LEVG revision from January 1990 to December 2000. RESULTS: A total of 1498 LEVG procedures were performed during the study period. A total of 330 surgical graft revisions were performed on 259 extremities in 245 patients. The median follow-up period was 38 months. The assisted primary patency rate of all grafts, the limb-salvage rate for patients undergoing surgery for limb-salvage indications, and the survival rate of all patients were 87.4%, 88.7%, and 72.4%, respectively, 5 years after the original bypass grafting procedure, 85.7%, 83.4%, and 67.8%, respectively, 7 years after the original bypass grafting procedure, and 80.4%, 75.4%, and 53.4%, respectively, 10 years after the original bypass grafting procedure. A total of 180 revisions (55%) were performed during the first year, 110 (33%) between the first year and the fifth year, and 40 revisions (12%) were performed on grafts older than 5 years. LEVGs revised within the first year after bypass grafting had lesions within the graft in 78%, in the native arterial inflow in 10%, and in the native arterial outflow in 12%. This differed significantly from the location of lesions in revisions performed between 1 and 5 years and after 5 years (graft, 63% and 62%; inflow, 20% and 19%; outflow, 17% and 19%; P >.05, Chi-square). CONCLUSION: Excellent assisted primary patency and limb-salvage rates can be achieved for as long as 10 years in LEVGs that require revision, with only a 7% drop in overall patency and limb-salvage rates between the fifth and 10th years. Although most revisions were required within the first year, 34% were performed between the first year and the fifth year, and 11% after 5 years. These data support the growing body of evidence that favors an aggressive regimen of duplex scanning surveillance of LEVGs for the life of the graft. Revised grafts have excellent patency through 10 years.
Animal bite wounds of the lower extremity are considered high-risk wounds for infection, especially in the medically compromised individual. Management should be aggressive. Copious irrigation and debridement of the wound clearly proves to be of greater value in the prevention of infection than the indiscriminate use of so-called "prophylactic" antibiotic agents. Frankly infected wounds must also be managed aggressively, incorporating the use of antibiotics to eradicate the infection. Empiric use of an agent containing clavulanic acid or sulbactam is suggested until results are obtained from the bacterial culture and sensitivity. Tetanus prophylaxis should be considered for every bite wound, whereas rabies prophylaxis is warranted in selected cases.
Nerve compression syndromes of the lower extremity present a challenge in differential diagnosis. Compression of the common peroneal nerve occurs relatively frequently; compression of the sciatic nerve occurs infrequently. The pattern of weakness helps distinguish lumbar root entrapment from peripheral compression syndromes. Compression syndromes must also be differentiated from diabetic, alcoholic or vasculitic neuropathy. Recovery correlates with the degree and duration of nerve injury. Thus, early diagnosis and treatment are important.
Range of motion of the lower extremity joints from the hip to the digits will be discussed including both active and passive axis of motion and their planes of motion. The author believes that the interpretation of these ranges of motion is essential in order to properly diagnose and to execute a treatment plan.
When assessing injuries to the lower extremity, they can best be discussed if divided into two groups: (1) vehicular or crushing injuries; and (2) nonvehicular, torsion, or overuse injuries. Vehicular injuries require speedy, accurate assessment as they are often complex and frequently involve other systems. The patient is initially stabilized, then assessment of orthopedic problems is begun. The nurse's role is an assistive one. If the patient is admitted to the hospital, orthopedic care involves prevention of complications, reduction of pain, and assisting the patient in daily activities. Nonvehicular injuries are more chronic in nature. The patient may have unsuccessfully ignored the problem, tried home remedies, or attempted to work with it. At this point, they are seen in the physician's office, hoping for a cure. After diagnosis, proper instruction for a rehabilitation program is begun. Treatment for a sprain, strain, or overuse syndrome can often be done at home. An active program should be encouraged and the patient should be taught why the problem occurred initially and how it can be prevented in the future.
In 4 patients with lower extremity pain and either negative or equivocal radiograhic findings, the bone scan was definitely positive for stress fracture in all, accurately localized the lesion, and permitted proper therapy. The condition in all instances proved to be a microfracture at the origin or insertion of a muscle. The pain was always intensified by physical activity.
The prevalence of lower-extremity ulcers is expected to increase as the U.S. population ages. Although these ulcers are often difficult to diagnose, the proper etiologic diagnosis can be useful in guiding treatment.