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PubMed2002

An early intervention plan for identification and control of chronic lower extremity edema.

Chronic lower extremity edema is one of the most common medical problems; every second person has the problem, and every eighth has advanced problems that require treatment.(1) Treatment interventions for wounded patients and prevention plans to prevent recurrence abound in the literature. However only one reference could be found that identified the need to intervene before wounding occurs, and no plan for intervention was proposed. The purpose of this article is to present a plan for early intervention designed to identify and prevent disease progression for patients who suffer from chronic edema. An advanced practice nurse identified the need, devised the plan, and coordinated the implementation, and now wishes to share the information and tools with other advanced practice nurses. The first of its kind to be proposed, the plan consists of the following components: education sessions for medical professionals, patients, and caregivers that explain the rationale for early intervention, the need to identify and treat patients, and program guidelines and expected outcomes; and guidelines of treatment, health assessment, and patient outcomes. Successful implementation of the plan is measured by the increase in the number of patients sent to the program, and by the number of patients successfully controlling their edema.

Anthropometry↗
PubMed1996

Effect of purified eicosapentaenoate ethyl ester on fibrinolytic capacity in patients with stable coronary artery disease and lower extremity ischaemia.

BACKGROUND: Lower extremity ischaemia is often complicated by coronary artery disease (CAD). Patients with CAD often have impaired fibrinolytic capacity. Plasma plasminogen activator inhibitors (PAI) levels are known to be associated with levels of atherogenic lipids. Purified eicosapentaenoic acid reduces atherogenic lipid levels. OBJECTIVE: To examine the effect of purified eicosapentaenoic acid ethyl ester (EPA) on the fibrinolytic capacity in patients with stable CAD and arteriosclerosis obliterans (ASO). METHODS: Plasma levels of PAl activity and tissue-type plasminogen activator (t-PA) antigen were measured. We administered 1800 mg/day EPA for 8 weeks to 25 patients. RESULTS: Mean baseline plasma PAI activity (P < 0.01) and t-PA antigen (P < 0.01) levels were higher in the patient group than they were in the control group. At the conclusion of EPA administration, significant reductions in PAI activity (P < 0.01), t-PA antigen (P < 0.01) and serum levels of triglyceride (P < 0.01), total (P < 0.05) and low-density lipoprotein (P < 0.05) cholesterols were observed. Changes in PAI activity levels caused by EPA administration showed positive linear correlations with those in low-density lipoprotein cholesterol (r = 0.411, P < 0.05) and triglyceride (r = 0.652, P < 0.01). CONCLUSION: These findings indicate that the fibrinolytic capacity in patients with CAD and ASO is decreased by increased PAI activity, but that EPA may correct this fibrinolytic impairment by decreasing PAI activity via its inhibitory effect on atherogenic lipids.

Administration, Oral↗
PubMed1978

Simplified outpatient lower extremity venography.

Improved lower extremity venography has been achieved by a distally directed superficial foot venipuncture. Supine position and short procedure time afford excellent patient acceptance. Dilute contrast is believed responsible for eliminating venospasm and postvenography phlebitis; the low sodium concentration permits safe evaluation of cardiac patients. Sequential imaging (and the use of anteroposterior and lateral projections) eliminates false positive and negative interpretations. Skip areas are avoided by the use of 90-cm (36-inch) cassettes.

Ambulatory Care↗
PubMed1991

Judgment and approach for management of severe lower extremity injuries.

Severe lower extremity injuries are devastating in their impact on the patient, his or her family, and the future. A critical evaluation of the results of previous salvage efforts provides the basis for the formulation of a treatment strategy. Success can be measured only in terms of functional outcome. The type of therapy is perhaps less important than the effectiveness of establishing a coordinated multidisciplinary approach to these injuries.

Amputation, Surgical↗
PubMed1989

Limb reconstruction versus amputation decision making in massive lower extremity trauma.

Massive lower extremity trauma, in particular open tibial fractures with associated vascular injuries, presents an immediate and complex decision-making challenge between a limb salvage attempt and primary amputation. Unfortunately, the literature to date is deficient in providing sound and defensible guidelines for primary amputation. Individual patient variables, specific extremity injury characteristics, and associated injuries must all be weighed before a decision can be reached. Further prospective studies are necessary before a well-defined protocol for primary amputation can be properly developed.

Amputation, Surgical↗
PubMed1990

Tc-99m human serum albumin lymphoscintigraphy in lymphedema of the lower extremities.

Edema of the lower extremities is a difficult clinical problem. It can be due to stasis, obstruction of the lymphatic channels, increased production of lymph beyond the drainage capacity of the lymphatic vessels. It is often difficult to differentiate between these varieties. Lymphoscintigraphy was performed on 164 patients complaining of swelling of the lower extremities and on 5 volunteers. All patients were injected with 1 mCi of Tc-99m human serum albumin (HSA) intradermally in the medial web of the dorsum of each foot. Data were acquired dynamically for both inguinal regions for 45 minutes, and static images of the legs, thighs, and pelvis were taken at 90 minutes. Time activity curves were generated for the equal regions of inguinal nodes on both inguinal sides. The following patterns were recognized: normal (5 volunteers and 57 patients), enhanced (17 patients), stasis with mild obstruction (70 patients), and marked stasis with obstruction (20 patients).

Adult↗
PubMed1992

Longitudinal growth and growth-plate activity in the lower extremity.

Teleroentgenograms of the lower extremity in 244 children (123 boys and 121 girls) were made at six-month intervals from age seven until skeletal maturity. Lengths were measured to determine the growth remaining in the femur and tibia. The subjects were healthy, well-nourished, middle class Americans, mostly of Northwest European descent. The percentage of growth occurring at each lower extremity growth plate was determined by roentgenstereophotogrametric analysis. The growth occurring at the distal femoral and proximal tibial growth plates was determined by multiplying the proportion of growth occurring at each age by the longitudinal growth remaining. The proportion of growth occurring at each growth plate is not equal. Also, growth-plate activity is not constant or average throughout growth. Overall, approximately 70% of growth in the femur occurs at the distal growth plate. The proportion of growth occurring in the distal femoral growth plate in girls varies from 60% at seven years of age to 90% at age 14. Similarly, the contribution of the distal femoral growth plate in boys varies from 55% at seven years of age to 90% at age 16. Overall, the contribution of the proximal tibial growth plate is approximately 57%. In girls, this varies from 50% at seven years of age to 80% at age 14. In boys it varies from 50% at seven years of age to 80% at age 16. From the age of seven to skeletal maturity, the distal femur contributes approximately 1.3 cm per year to femoral growth, except in the last two years, when it contributes half that amount.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

[Characteristics of diabetic macroangiopathy of the lower extremities].

Macroangiopathy of the lower extremities is one of the most frequent complications of diabetes and has a very adverse impact on the quality of life of the patients. It affects approximately as much as half the diabetics with the duration of the disease for more than 15 years. It is encountered in two forms. The first type of affection--obliterating atherosclerosis--reminds of affections of the arteries of the lower extremities in the non-diabetic population, although some differences in the site of affection, morphology of sclerotic changes as well as the spectrum of risk factors were found, when compared with obliterating atherosclerosis in non-diabetics. Risk factors of this form of macroangiopathy include cholesterol, triacylglycerols, reduced values of HDL-cholesterol, hypertension, fibrinogen, smoking and apparently also albuminuria. The second form of macroangiopathy--mediocalcinosis--is not associated with the mentioned risk factors of atherosclerosis but is probably the consequence of diabetic neuropathy. Contrary to atherosclerosis, it does not lead to the development of obliteration but has also an adverse effect on the function of blood vessels. Its incidence correlates with the duration and compensation of diabetes as well as deteriorated perception of vibrations. With regard to the high incidence of gangrenes requiring amputation, it seems rational to influence in diabetics all known risk factors of macroangiopathy although convincing results of long-term intervention studies are still lacking.

Diabetic Angiopathies↗
PubMed1995

The current status of prosthetic-vein composite grafts for lower extremity revascularization.

When infrageniculate lower extremity vascular reconstructions are required in the face of inadequate or insufficient autogenous vein, prosthetic-vein composite grafts remain a viable alternative. Graft patency and limb salvage for composite grafts are intermediate between those of completely autogenous and prosthetic bypasses alone. The sequential technique may offer superior patency in patients with the appropriate anatomy. The addition of adjunctive techniques such as a distal arteriovenous fistula and/or anticoagulation may further improve results. An algorithm illustrating the proper role of composite grafts for distal lower extremity reconstructions is shown in Figure 6. Any significant interval of patency is important in this group of patients in whom limb salvage can often be achieved by healing ischemic lesions and in whom overall life expectancy is limited.

Arterial Occlusive Diseases↗
PubMedDate not supplied

A prospective comparison of intra-arterial digital subtraction and conventional angiography prior to lower extremity revascularization.

Prior to lower extremity revascularization, patients underwent CA or IADSA as the only radiologic study. A total of 30 patients were entered into each group and subsequently underwent a reconstructive procedure. Each study in the CA group was deemed accurate at the time of surgery, in assessing suitability of vessels for anastomosis. Of the patients undergoing surgery based exclusively on IADSA, 5 were noted in whom this examination provided insufficient detail or were misleading, resulting in attempted reconstructions at inappropriate sites. These results were statistically significant and indicate that IADSA should not be used as the only imaging technique in the preoperative evaluation of lower extremity vascular disease. IADSA is most useful as a complementary technique to CA and should be performed during the same examination when the latter fails to identify distal runoff vessels. In the majority of cases, CA alone will provide sufficient information and should be used as the initial contrast study.

Angiography↗
PubMed2000

Measures of success and health-related quality of life in lower-extremity vascular surgery.

Lower-extremity vascular surgery is most often indicated for patients with critical leg ischemia but has increasingly been used for patients with disabling intermittent claudication. This article reviews indications, follow-up protocols, and procedure-related outcomes including perioperative and late mortality, complications, and long-term patency rates, which vary with patient risk factors, vascular disease severity, and hospital volume. Population-based studies have yet to establish whether rates of limb-preserving bypass surgery are related to overall amputation rates, partly because of the continued high rate of primary amputation. The functional benefits of vascular surgery have been traditionally assessed by treadmill protocols and batteries of physical tests. Claudication treatment is increasingly being measured by both generic and disease-specific functional and health-related quality-of-life questionnaires. Patient self-reported measures of physical functioning and walking ability are reviewed. Finally, conclusions are presented about trends in lower-extremity bypass surgery rates.

Exercise Test↗
PubMed2004

Impairments of muscles and nerves associated with peripheral arterial disease and their relationship with lower extremity functioning: the InCHIANTI Study.

OBJECTIVES: To define the relationships between lower extremity peripheral arterial disease (PAD), pathophysiological findings in lower extremity muscles and nerves, and lower extremity performance. DESIGN: Cross-sectional. SETTING: Two communities in Italy. PARTICIPANTS: Nine-hundred seventy-nine community-dwelling men and women aged 60 and older (109 with PAD). MEASUREMENTS: Presence and degree of lower extremity arterial obstruction were determined using the ankle-brachial index (ABI). Lower extremity muscle cross-sectional area was measured using computed tomography. Peroneal nerve conduction velocity (NCV) and leg power were also determined. Measures of lower extremity functioning were fast walking speed over 4 meters, time required to walk 400 meters, and the summary performance score. RESULTS: Participants with PAD had significantly poorer performance on functional outcomes than participants without PAD. Adjusting for age and sex, presence of PAD was associated with reduced leg muscle power (83.69 vs 103.51 watts, P<.001), reduced muscle cross-sectional area (61.5 vs 63.5 cm2, P=.14), and reduced NCV (43.0 vs 44.2 m/s, P=.003). Adjustment for leg power diminished the independent association between ABI and the functional outcomes measures. CONCLUSION: In community-dwelling individuals, PAD is associated with reduced NCV and reduced muscle power in the lower extremities. Muscle power may mediate the association between lower ABI levels and poorer functional performance.

Adult↗
PubMed1976

Rotational problems of the lower extremity.

Rotational abnormalities in the lower extremities are common in the growing child, but they seldom represent any serious handicap in adult life. When confronted with such a problem, the physician should carefully rule out any underlying pathologic abnormality and should approach the problem in a step-wise fashion. The component parts of the lower extremity should be examined carefully and individually to assess their role in the rotational problem. The usual causes of internal rotation problems, or toeing in, are metatarsus adductus, internal tibial torsion, and femoral anteversion. External rotation problems are infrequent and pose fewer problems. These include calcaneovalgus, external rotation of the tibia, and external rotatory contractures of the lower extremity. The natural history of these conditions favors improvement with time. However, some patients may require conservative treatment, such as stretching and splints. Rarely, a patient may require surgical intervention.

Child↗
PubMed2002

Peripheral artery disease, diabetes, and reduced lower extremity functioning.

OBJECTIVE: To characterize lower extremity function and dysfunction in peripheral artery disease (PAD) patients with and without diabetes. RESEARCH DESIGN AND METHODS: In this cross-sectional study, 460 men and women with PAD (147 with diabetes) were recruited from three academic medical centers. Assessments included ankle brachial index (ABI), neuropathy score, 6-min walk distance, 4-m walking velocity, Walking Impairment Questionnaire (0-100 scale, 100 = best), and summary performance score (SPS) (0-12 scale, 12 = best). RESULTS: The mean ABI was similar in PAD patients with and without diabetes. PAD patients with diabetes were younger, had a higher BMI, had a worse neuropathy score, and had a greater number of cardiovascular comorbidities compared with those without diabetes. Participants with diabetes were less likely to report classical symptoms of intermittent claudication and more likely to report exertional leg pain, which sometimes started at rest. After adjusting for age, those with diabetes had a shorter mean 6-min walk distance (1,040 vs. 1,168 feet, P < 0.001), slower fast-pace 4-m walk velocity (0.83 vs. 0.90 m/sec, P < 0.001), and a lower SPS (7.3 vs. 8.6, P < 0.001) than those without diabetes. Patients with diet-controlled diabetes performed better than those on diabetes medications. Differences in lower extremity functioning between patients with and without diabetes were largely attenuated but not abolished for SPS and fast-pace 4-m walk velocity after adjustment for type of exertional leg pain, neuropathy score, and number of cardiovascular comorbidities. CONCLUSIONS: Subjects with PAD and diabetes have poorer lower extremity function than those with PAD alone. This difference in functioning appears to be largely explained by diabetes-associated neuropathy, differences in exertional leg symptoms, and greater cardiovascular disease in patients with diabetes.

Arterial Occlusive Diseases↗
PubMed2003

Using a Y-shaped vein graft with drain-out branches to provide additional arterial sources for free flap reconstruction in injured lower extremities.

BACKGROUND: Reconstruction of the distal lower extremity with poor arterial circulation is a challenge for reconstructive surgeons, especially when a microsurgical free tissue transfer is necessary. One may face the problem of having no suitable recipient artery to be used except the main one. To overcome this difficult situation, utilization of a Y-shaped vein graft (YVG) was developed. METHODS: We report on 3 successful reconstructions of the lower extremities with free flaps using YVG to supply the arterial inflow and in which the distal circulation of the lower extremity was preserved at the same time. The therapeutic goals, design, surgical technique, and outcomes are clarified. The indications, advantages, and disadvantages are also discussed. RESULTS: All 3 patients achieved successful reconstruction of the affected limbs with uneventful surgery. Special microsurgical skills are unnecessary in this method. It can provide an additional arterial source, which is useful and reliable for revascularizing various kinds of free tissue. Utmost care must be taken to examine the direction of flow during harvesting since only the drainout branches can serve as an ideal YVG. CONCLUSION: We concluded that Y-shaped vein grafting is a good alternative technique to achieve free flap reconstruction of a distal lower extremity with simultaneous preservation of the distal circulation in selected difficult cases.

Ankle Injuries↗
PubMed2005

Effect of walking speed on lower extremity joint loading in graded ramp walking.

Lower extremity joint loading during walking is strongly affected by the steepness of the slope and might cause pain and injuries in lower extremity joint structures. One feasible measure to reduce joint loading is the reduction of walking speed. Positive effects have been shown for level walking, but not for graded walking or hiking conditions. The aim of the study was to quantify the effect of walking speed (separated into the two components, step length and cadence) on the joint power of the hip, knee and ankle and to determine the knee joint forces in uphill and downhill walking. Ten participants walked up and down a ramp with step lengths of 0.46, 0.575 and 0.69 m and cadences of 80, 100 and 120 steps per minute. The ramp was equipped with a force platform and the locomotion was filmed with a 60 Hz video camera. Loading of the lower extremity joints was determined using inverse dynamics. A two-dimensional knee model was used to calculate forces in the knee structures during the stance phase. Walking speed affected lower extremity joint loading substantially and significantly. Change of step length caused much greater loading changes for all joints compared with change of cadence; the effects were more distinct in downhill than in uphill walking. The results indicate that lower extremity joint loading can be effectively controlled by varying step length and cadence during graded uphill and downhill walking. Hikers can avoid or reduce pain and injuries by reducing walking speed, particularly in downhill walking.

Acceleration↗