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PubMed1998

Morphological and clinical aspects of scapular fasciocutaneous free flap transfer for treatment of venous insufficiency in the lower extremity.

We have recently shown that free scapular fasciocutaneous flaps transferred to the lower extremities of patients with chronic venous insufficiency and cutaneous ulcers have resulted in improvement in venous refilling times measured by photoplethysmography in the flap areas and that recurrent ulceration does not recur for up to 7 years. We hypothesized that the transferred flaps contained valves in their microvascular bed, which facilitated venous return, and using scanning electron microscopy of vascular corrosion casts and light and transmission electron microscopy of tissue sections prepared from human dorsal thoracic fascia, we showed that valves were most abundant in veins with a luminal diameter of 30-120 microm (59.3% of 905 valves). The depth of these valves increased with venous diameter, but the size of valve sinuses was not different for individual valves. Except for veins > 1,000 microm in diameter, there was no significant difference in the number of valves in different parts of an individual flap or between different flaps. Most valves were bicuspid; only in the vein Category 30-120 microm were unicuspid valves encountered. Valves were sometimes located in series in a short segment of a vein; occasionally they were found at the merging of two veins. Transmission electron microscopy showed that valve leaflets had collagen fibers that ascended toward the tip of the leaflet and were occasionally accompanied by elastic fibers. Myofibroblasts were regularly present in the valve leaflets. The present report reviews and updates these anatomic data about the human scapular region, focusing on venous valvular microstructure, and suggests that the high number of smaller-size valves contributes to improved hemodynamic of the leg and thus the clinical success of free scapular flaps used to treat cutaneous ulcerations in the lower extremity.

Adolescent↗

PubMed2001

Lower extremity strength deficits in peripheral arterial occlusive disease patients with intermittent claudication.

The purposes of this study were to quantify the degree and distribution of lower extremity weakness in patients with peripheral arterial occlusive disease (PAOD) compared to apparently healthy older patients and to determine if performance of a simple functional measure correlates with lower extremity strength. Older patients (n = 46), 31 with PAOD (mean age = 69.9 years; mean ankle-brachial index = 0.67) and 15 without PAOD (mean age = 62.6 years; mean ankle-brachial index = 1.20), underwent isometric strength testing of hip, knee, and ankle musculature. In patients with PAOD, dorsiflexion strength was 15% lower (p < 0.05) in the more affected limb (55 +/- 4 Newton-meters; mean +/- SE) versus the less affected limb (65 +/- 5 Newton-meters). Overall, the dorsiflexor muscles of the more affected extremity were 22% weaker (p < 0.05) in the PAOD group than in the non-PAOD group (73 +/- 6 Newton-meters). No other significant differences in strength were found between the PAOD and the healthy elderly groups or between the more affected and less affected limbs in the PAOD patients. The time to perform five sequential sit-to-stand transfers using an armless chair was 23% greater (p < 0.01) in the PAOD group (13.0 +/- 0.5 s) than in the healthy elderly (10.7 +/- 0.9 s). In the PAOD patients, dorsiflexor strength was correlated with chair stand time (r = -0.37, p < 0.05). The authors conclude that PAOD patients with intermittent claudication are functionally limited by dorsiflexion weakness, impairing their ability to perform tasks requiring distal lower extremity strength.

Aged↗

PubMed2006

Posterior tibial artery flap in poliomyelitis patients with lower extremity paralysis.

BACKGROUND: Poliomyelitis is a disease that can render affected individuals incapacitated to a variable degree. A normal lifespan is expected and therefore the patients deserve every effort at curative cancer resection and reconstruction. Those with lower extremity paralysis rely heavily on their upper limbs and torso for ambulation; therefore, their compromised limbs may be a better donor site for flaps. METHODS: All poliomyelitis patients with lower extremity paralysis over a 20-month period who underwent head and neck reconstruction were selected for a retrospective review. Perioperative complications were noted and outpatient follow-up was performed. RESULTS: Three patients underwent reconstruction of defects using the posterior tibial artery flap. Two patients required reconstruction of a buccal defect and one patient required soft palate reconstruction. All patients healed without complications and none required reexploration. At a mean follow-up of 10 months, there was no incidence of donor limb vascular compromise, cold intolerance, or long-term paresthesias. CONCLUSIONS: The posterior tibial artery free flap has been used successfully in the past; however, its popularity has been limited because of sacrifice of the posterior tibial artery. Nevertheless, in patients with lower extremity paralysis, this flap may fulfill the requirements of a thin, pliable flap with minimal hair that has a long pedicle and a reliable blood supply. Most importantly, the use of this flap obviates the need to use flaps that fulfill the same requirement, such as forearm flaps, that would be taken from patients' functioning limbs.

Adult↗

PubMed1997

Reliability of lower extremity functional performance tests.

Clinicians routinely have used functional performance tests as an evaluation tool in deciding when an athlete can safely return to unrestricted sporting activities. These practitioners assumed that these tests provide a reliable measure of lower extremity performance; however, little research has been reported on the reliability of these measures. The purpose of this investigation was to determine the reliability of lower extremity functional performance tests. Five male and 15 female volunteers were evaluated using the single hop for distance, triple hop for distance, 6-m timed hop, and cross-over hop for distance as described by Noyes (10). One clinician measured each subject's performance using a standardized protocol and retested subjects in the same manner approximately 48 hours later. The order of testing was randomly determined. Subjects' average and individual scores on each functional performance test were used for statistical analysis. Intraclass correlation coefficients (ICCs) and standard error of measurement (SEM) values based on average day 1 and day 2 scores were used to estimate the reliability of each functional performance test. Intraclass correlation coefficients were .96, .95, and .96, and SEMs were 4.56 cm, 15.44 cm, and 15.95 cm, respectively, for the single hop, triple hop, and cross-over hop for distance tests. An ICC of .66 and SEM of .13 seconds for the 6-m timed hop resulted from limited variability between measurements; however, its small SEM value inferred that the inconsistency of measurement would occur in an acceptably small range. A repeated measures analysis of variance revealed no significant difference ( p > .05) between individual trial scores except for the single hop for distance. We concluded that this difference represented a learning effect not found with the other tests. The results of this investigation demonstrate that clinicians can use functional performance testing to obtain reliable measures of lower extremity performance when using a standardized protocol.

Adult↗

PubMed2005

[Changes in core temperature associated with lower extremity tourniquet--the influence of ambient temperature and warming equipments].

BACKGROUND: We investigated changes in core temperature associated with lower extremity tourniquet (TQ) under two different ambient temperatures (1) and two different warming equipments (2) under general anesthesia combined with lumbar epidural anesthesia. METHODS: (1) The values of core temperature at ambient temperature of either 22 degrees C (n = 15) or 20 degrees C (n=15) were recorded after induction of anesthesia, at start of TQ application, at the termination of TQ application, and 14 minute after TQ release. (2) The values of core temperature using either air-forced warming or active heated i.v. at ambient temperature 20 degrees C were recorded at four points as mentioned above. RESULTS: (1) Changes in core temperature were not observed during TQ application at ambient temperature both 20 degrees C and 22 degrees C. Core temperatures in both groups decreased significantly after TQ release, and core temperatures at termination of TQ application and after TQ release at ambient temperature 20 degrees C were significantly lower than those at ambient temperature 22 degrees C. (2) Significant increases in core temperatures using two different warming equipments were observed at termination of TQ application and after TQ release at ambient temperature 20 degrees C. Core temperatures using air-forced warming were maintained during the investigation, though significant decrease in core temperature using active heated i.v. was recorded after TQ release. CONCLUSIONS: Air-forced warming maintains core temperature efficiently associated with lower extremity tourniquet.

Aged↗

PubMed1990

Techniques for color flow sonography of the lower extremity.

Color flow sonography permits noninvasive examination of the deep venous system in the lower extremity. In many patients, the modality is sufficiently accurate to serve as the sole diagnostic procedure for suspected deep venous thrombosis. Over 1,500 color flow sonographic examinations of the lower extremity have been performed at our institutions with various scanning techniques. For the inexperienced sonographer, we describe our current technique, which is easy, quick, accurate, and well tolerated by patients.

Color↗

PubMed2002

The role of ultrasound in lower extremity wound management.

Imaging and hemodynamic information are essential in determining the etiology of lower extremity wounds. Ultra- sound offers a noninvasive method of studying vessel walls and measuring blood flow, thereby providing reliable diagnostic data. This article reviews the role of ultrasound in the management of the lower extremity wound.

Journal Article↗

PubMed2002

Prediction of asymptomatically poor muscle perfusion of lower extremities in patients with type II diabetes mellitus using an objective radionuclide method.

Foot problems are the most common cause of hospital admission in patients with type II diabetes mellitus (DM). Poor muscle perfusion of lower extremities is thought to be the major component in the pathogenesis of foot problems. We used a well-established and non-invasive radionuclide method to objectively evaluate the anterior tibial muscle perfusion of 120 type II DM patients without symptoms/signs of peripheral vascular disease (PVD) in the lower extremities. The patients were separated into groups according to the duration of the disease and condition of blood sugar control. Meanwhile, 60 normal control males with a matched age distribution were also included for comparison. The muscle perfusion were of significant difference between (1) 120 type II DM patients and 60 normal controls, (2) 72 patients with good sugar control and 48 patients with poor sugar control, as well as (3) 64 patients with short disease duration and 56 patient with long disease duration. Based on the objective radionuclide method, we concluded that the muscle perfusion in the lower extremities of type II DM patients without symptoms/signs of PVD is significantly decreased and related to the duration of the disease and condition of blood sugar control.

Aged↗

PubMedDate not supplied

Efficacy and safety of becaplermin (recombinant human platelet-derived growth factor-BB) in patients with nonhealing, lower extremity diabetic ulcers: a combined analysis of four randomized studies.

The results of a combined analysis and separate analyses of four multicenter, randomized, parallel group studies that evaluated the effects of once-daily topical administration of becaplermin gel for the treatment of chronic, full thickness, lower extremity diabetic ulcers are presented. The four studies included a total of 922 patients with nonhealing lower extremity diabetic ulcers of at least 8 weeks' duration. Following initial complete sharp debridement of the ulcer, patients were randomized to receive a standardized regimen of good ulcer care alone, good ulcer care plus placebo gel, or good ulcer care plus becaplermin gel-30 microg/g, or good ulcer care plus becaplermin gel-100 microg/g, with various combinations of regimens used in the four studies. Safety was assessed by monitoring adverse events and by clinical laboratory evaluations. Meta-analytic statistical techniques were used in the combined analysis to establish homogeneity of treatment comparisons across studies. Based on an analysis of patients with baseline ulcer area common to all trials (</= 10 cm2), representing 95% of all patients, becaplermin gel-100 microg/g significantly increased (p = 0.007) the probability of complete healing compared with placebo gel. It was determined that for the median ulcer area of these patients, which was 1.5 cm2, the becaplermin gel-100 microg/g treatment group showed a 39% increase in complete healing compared with that of the placebo gel treatment group (50% vs. 36%, respectively, p = 0.007). Becaplermin gel-100 microg/g significantly decreased (p = 0.01) the time to complete healing compared with placebo gel, with the 35th percentile of time to complete healing being reduced by 30% (14.1 weeks vs. 20. 1 weeks, respectively). In patients with ulcers </= 5 cm2 at baseline (a more homogeneous group), becaplermin gel-100 microg/g also significantly increased the incidence of complete healing with a similar decrease in the time to healing. Adverse events reported during treatment or during a 3-month follow-up period were not unexpected for this patient population and were similar in nature and incidence across all treatment groups. We therefore conclude that treatment with becaplermin gel at a dose of 100 microg/g once daily, in conjunction with good ulcer care, is effective and well tolerated in patients with full thickness lower extremity diabetic ulcers.

Administration, Topical↗

PubMed2004

Walking ability and its relationship to lower-extremity muscle strength in children with idiopathic inflammatory myopathies.

OBJECTIVE: To describe gait deficits and their association with lower-extremity muscle strength in children with juvenile idiopathic inflammatory myopathies (IIM). DESIGN: Cross-sectional, descriptive study. SETTING: Clinical research center. PARTICIPANTS: Consecutive sample of 25 ambulatory children diagnosed with juvenile IIM. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Manual muscle test (MMT) of bilateral hip flexor, extensor, and abductor; knee extensor; and ankle plantarflexor strength, all measured on a 0- to 10-point scale and summary strength measures. Video-based movement analysis to determine walking speed; gait cycle time; right and left step time; stride length; right and left step length; and stance, swing, and double-limb support phase durations. RESULTS: Walking speed (1.03+/-0.27 m/s) was reduced because of shortened stride lengths (1.03+/-0.21 m) more than prolonged gait cycle times (1.05+/-0.22s). Walking speed highly correlated with the number of muscle groups weaker than grade 7 out of 10 (r=-.89) and the strength of the hip flexors (r=.85). CONCLUSIONS: Lower-extremity strength measures, including MMT scores of individual muscle groups and the number of weak muscle groups, were predictive of gait limitations in children with juvenile IIM.

Adolescent↗

PubMed1996

Prevalence of deep venous thrombosis in the lower extremities of children in the intensive care unit.

PURPOSE: To determine the prevalence of lower extremity deep venous thrombosis (LE-DVT) in children who spent at least 72 h in the pediatric intensive care unit (ICU). MATERIALS AND METHODS: Children up to the age of 17 years who spent at least 72 h in the ICU underwent lower extremity venous ultrasound at the end of their stay. Prevalence range for the sample size was calculated with a confidence interval of 95%. RESULTS: Among 76 children who spent 3-141 days in the ICU, the prevalence of acute (and silent) DVT was 4% (confidence interval 0-9%). All three affected children had femoral venous catheters in that leg during their ICU stay (17 unaffected children also had catheters). CONCLUSION: Children in an ICU setting are at significantly lower risk for thrombosis than adults in the same setting.

Acute Disease↗

PubMed1993

Efficacy of epidural anesthesia in free flaps to the lower extremity.

Epidural anesthesia is an effective means of providing pain control and chemical sympathectomy at the spinal nerve root level. The purpose of this study is to compare the efficacy of the combination of epidural and general anesthesia to general anesthesia alone in patients undergoing free flaps to the lower extremity. A retrospective review of 35 consecutive patients (36 operations) from November of 1988 to November of 1990 undergoing free tissue transfer to the lower extremity was undertaken. Sixteen patients had epidural and general anesthesia, and 19 (20 operations) had general anesthesia alone. There were no significant differences in the age or sex of the patients, the distribution between acute and chronic wounds, or the number of cigarette smokers in the two groups. There were no flap losses in the epidural group (100 percent success) and one major, but nonmicrovascular complication (6 percent). In the nonepidural group, there were one flap loss (95 percent success) and five major complications (25 percent). These included three microvascular complications (15 percent). There were significantly fewer patients with postoperative atelectatic fevers in the epidural group versus the nonepidural group. In this consecutive series of patients, epidural supplementation of general anesthesia for free flaps to the lower extremity was associated with uniformly successful flap survival and a lower rate of microvascular complications compared to general anesthesia alone.

Adult↗

PubMedDate not supplied

[Etiopathogenesis of varicosities of the lower extremities].

To investigate the significance of heredity in the development of varicosities of the lower extremities, and to establish the association between the sclerotherapy and the pathologic changes of the perforating and deep veins as well as the share of trauma in the development of perforating venous insufficiency of the lower part of the leg, the author studied 484 hospitalized patients. By using modern diagnostic procedures, the pathologic changes of the venous system were identified and located and varicosities were classified into five groups. A positive family anamnesis was found in 64.5% of the treated patients. The relationship between the heredity and the pathologic changes of the venous system is shown in tables. Of all the treated patients, 12.2% underwent sclerotization before the admission to the hospital. In 50.8% of these patients, the author found pathologic changes of the perforating veins and in 22% pathologic changes of the deep veins, as well. Due to perforating venous insufficiency 135 patients were operated. Among these patients, 21.4% reported positive history of trauma, while in 14.1% of surgically treated patients some degenerative changes of the fatty-connective tissue of the crural fascia were found. This speaks in favour of the assumption that trauma of the lower extremities may lead to perforating venous insufficiency.

Humans↗

PubMed1998

Treatment of non-healing ulcers of the lower extremity with free muscle flaps. Case reports.

The surgical management of ulcers in the lower extremity is traditionally conservative, and includes debridement and split thickness skin grafting. In the most intractable cases, however, this management is often not enough. In this report of three patients with non-healing ulcers of the lower extremity successfully treated with free muscle flaps, we advocate a more active surgical approach to the treatment of such conditions. This is also appropriate in patients for whom a microsurgical approach might not be considered because of advanced age, peripheral arterio-occlusive disease, or the presence of other risk factors.

Aged↗

PubMed2006

Partial weight bearing after surgery for fractures of the lower extremity--is it achievable?

Partial weight bearing is a generally accepted principle of rehabilitation following trauma or reconstructive surgery of the lower extremity. Individual dynamic loads during partial weight bearing to a given load level of 200 N were compared in 23 patients who had sustained a fracture of the lower extremity and 11 healthy volunteers using dynamic sole pressure measurements. Excessive dynamic loading compared with the statically pre-tested 200 N level was observed in all groups. Maximum force levels were up to 690 N in young patients and up to 580 N elderly patients beyond the prescribed static load. None of the healthy volunteers was able to keep within the given load of 200 N. The set load level was exceeded by at least 38 N (119%) in the elderly patient group. In comparison, elderly patients showed statistically significantly higher maximum forces than young patients during the first two test days (p=0.007 and 0.013). On the 3rd test day the maximum ground contact forces were on average 71 N higher than in the young patients group. Analysis of the force time integrals (impulses transferred to the ground) displayed higher values in the older again than in young patients. The differences were statistically significant during the first two test days (p=0.006 and 0.037). This study implies that the conventional concept of postoperative partial weight bearing starting from 200 N and a stepwise increase of the load level until full weight bearing is not valid during clinical practice.

Adolescent↗

PubMed1988

Lower extremity functional dynamics.

An overview of the normal and abnormal functional equilibrium of the lower extremity has been presented. The biomechanical and pathomechanical implications of activity and inactivity on this system have been discussed. Special emphasis has been placed on the effects of musculoskeletal imbalances on foot function. Evaluation and management guidelines for the restoration and rehabilitation of lower extremity functional equilibrium have been outlined. Familiarization with these concepts and techniques will enable the astute practitioner to prevent disruptions of extremity functional equilibrium and allow the individual to lead a more healthy, active lifestyle.

Biomechanical Phenomena↗

PubMed1998

Carotid atherosclerosis in patients operated for lower extremity ischemia before the age of 50: a case control study.

The purpose of this study was to investigate the presence of, and to identify factors associated with carotid atherosclerosis in patients, previously operated on for lower extremity ischemia before the age of 50. Forty-eight patients were compared to sex- and age-matched controls. All subjects were examined with duplex ultrasonography of the neck arteries and analysis of serum lipoproteins. History including smoking habits, family history of cardiovascular disease, and medication was also obtained. The patients were examined clinically and their preoperative angiograms were reevaluated. Thirty-one patients (64%) and 13 controls (23%) had a carotid lesion (p < 0.0001). Patients with suprainguinal or multilevel disease had a higher proportion of carotid lesions than those with only infrainguinal disease in whom the proportion was similar to the controls. A multiple regression analysis among the patients revealed that age, level of lower extremity arterial disease, presence of family history, and the ratio apolipoproteinB/apolipoproteinA discriminated significantly between those with and without carotid disease. It is concluded that a high proportion of patients operated on for lower extremity suprainguinal arterial occlusive disease at an early age have carotid lesions at follow-up, while patients operated on due to isolated infrainguinal disease have a prevalence similar to controls.

Arteriosclerosis↗

PubMed2003

Exercise Sandals Increase Lower Extremity Electromyographic Activity During Functional Activities.

OBJECTIVE: Anecdotal evidence suggests that use of Exercise Sandals results in a number of positive clinical outcomes. However, little research has been conducted to determine their efficacy objectively. Our purposes were to determine the effect of Exercise Sandals on lower leg electromyography (EMG) during activities in the Exercise Sandals and to compare EMG associated with Exercise Sandals with traditional lower extremity rehabilitation exercises. DESIGN AND SETTING: Two within-subjects, repeated-measures designs were used to identify differences in lower extremity EMG: (1) between activities with and without Exercise Sandals and (2) between Exercise Sandals activities and traditional rehabilitation activities. All data were collected in the Sports Medicine Research Laboratory. SUBJECTS: Eighteen subjects involved in rehabilitation using Exercise Sandals for at least 2 weeks within the year before data collection. MEASUREMENTS: Mean EMG amplitudes from the tibialis anterior, peroneus longus, soleus, and lateral gastrocnemius muscles were measured during single-leg stance, side stepping, and "high knees," all performed with and without the Exercise Sandals, as well as single-leg stance on a foam surface and T-band kicks in the sagittal and frontal planes. RESULTS: Exercise Sandals increased lower leg EMG activity, particularly in the ankle invertors and evertors. Also, activities involving the Exercise Sandals resulted in EMG activity similar to or exceeding that associated with traditional ankle-rehabilitation exercises. CONCLUSIONS: These results, coupled with the fact that Exercise Sandals are used in a functional closed kinetic chain manner, suggest that they are an effective means of increasing lower extremity muscle activity.

Journal Article↗