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PubMed2001

Surgical repair of peripheral nerves in lower extremities.

OUTLINE: Present study reports the results of 48 operations performed on 48 nerves of lower extremities in 48 patients during the period of 15 years from 1985 to 1999. Basic lines of surgical treatment of various injuries of nerves in lower extremities are presented in the study. PATIENT POPULATION AND METHODS: 24 patients were treated by external neurolysis, 24 patients were treated by reconstruction operations. Reconstruction operations were performed either by suture of peripheral nerve (10 cases) or more frequently, by neural graft (14 cases). Complete and persisting neurological deficit and the absence of nerve action potentials were the indications for the surgical repair. The absence of nerve electrical properties potentials was an important criterion for the determination of the type of surgical intervention. Analysis of the effectiveness of surgical treatment was performed with respect to following parameters: period between the injury and operation, patient age, character of the injury, type of injured nerve, type of surgical intervention. RESULTS: The best results were observed for external neurolysis. Improved results of reconstruction operations were achieved for operation by suture compared to operations by nerve graft. Good and excellent results (not dependent on the character of surgical treatment, character and location of the injury, time period between the injury and surgical repair and on the age of the patient) were typical for treatment of n. tibialis. CONCLUSION: Early surgical revision associated with neurolysis and eventually with reconstruction surgery is very important in indicated cases. (Tab. 5, Ref. 10.)

Adult↗

PubMed2003

[Comparative clinical-economic analysis of antibiotic therapy in pyogenic inflammatory diseases of the lower extremities].

A randomized comparative investigation was carried out in two equal groups of patients with pyo-inflammatory diseases of lower extremities (the total number 50 patients) in order to study effectiveness and tolerance to Netilmycin (1st group) and Gentamycin (2nd group) given in combination with Cefasolin. Clinical symptoms were estimated immediately after operation, in 3, 6 and 10-12 days after it. Bacteriological investigations were fulfilled immediately after operation, in 72 h and in 6-10 days after the beginning of antibacterial therapy. Clinical and biochemical investigations of blood were fulfilled before and in 10 days after the beginning of the treatment. Effectiveness of the treatment in the first group was 100%, in the second group--80%. In the second group the antibiotics were changed in 20% of cases and the average duration of hospitalization among the patients of this group was reliably longer that in the first group. The eradication rating of Netilmycin was higher than that of Gentamycin (25 strains from 25 and 20 from 25 respectively). Gentamycin had a pronounced nephrotoxic effect (elevation of the level of creatinin and urea of blood in dynamics by 21% and 32%), as compared with Netilmycin (9% and 3%). Total expenses to antibiotic therapy in the first group made up 97,650 rub, and in the second group 106,245 rub. Netilmycin in combination with Cefasolin was more effective for acute pyo-inflammatory diseases of lower extremities than a combination of Gentamycin with Cefasolin, it more rapidly resulted in reduction of clinical signs of inflammation, was better endured and more economical.

Adult↗

PubMed1999

Frequency of pulmonary embolism in patients with low-probability lung scan and negative lower extremity venous ultrasound.

STUDY OBJECTIVES: To define the prevalence of pulmonary embolism (PE) in patients who are undergoing pulmonary arteriography because of a high clinical suspicion for PE but who have had a low-probability lung scan and a negative lower extremity venous ultrasound examination. DESIGN: A retrospective review of the medical records of 365 consecutive patients who underwent pulmonary arteriograms for suspected PE was undertaken. RESULTS: Of the 365 pulmonary arteriograms, 62 were performed in patients with suspected PEs despite a low-probability lung scan and a negative lower extremity venous ultrasound examination. In the latter group, five patients (8%; 95% confidence interval, 2.7% to 18%) had PEs revealed on the arteriogram. CONCLUSIONS: In patients whose presentation provokes a high clinical suspicion for PE despite having had a low-probability lung scan, a negative lower extremity venous ultrasound examination is insufficient to preclude proceeding to pulmonary angiography.

Adult↗

PubMedDate not supplied

Molten metal burns to the lower extremity.

In this study of ten consecutive patients sustaining molten metal injuries to the lower extremity who were treated with excision and grafting, treatment with compression Unna paste boot was compared with that with conventional dressing. Hospital stay was decreased from 12.2 days in the conventional dressing group (five patients) to 6.4 days in the Unna group (five patients). Ambulation was initiated on postoperative day (POD) 2.2 in the Unna group, compared with POD 8.0 in the conventional dressing group. Return to work was on POD 44.8 in the Unna group versus POD 86.3 in the conventional dressing group. Treatment of molten metal injuries to the lower extremity with Unna paste compression dressing resulted in shorter hospital stay, earlier ambulation, and more rapid return to work.

Accidents, Occupational↗

PubMed1995

[The blood pressure of upper and lower extremities in parturients under spinal anesthesia for cesarean section].

BACKGROUND: In clinical practice, we only measure the blood pressure of the arm during cesarean section. However, it can not accurately reflect the real image of pressure of the lower extremity in labor women. Therefore, we recorded simultaneously the arm and leg blood pressure in the term parturients undergoing cesarean section under spinal anesthesia. METHODS: After hydration with 1500 ml lactated Ringer's solution, all patients received spinal anesthesia with 2ml (0.5%) spinal heavy bupivacaine. The right hip was elevated 15 degree to insure left uterine displacement. Prior to spinal block blood pressure of the arm and leg was measured and recorded simultaneously using a Criticon Dinamap vital sign monitor 1846sx and was continued in determination every minute thereafter until uterine incision. RESULTS: We found that monitoring the lower extremity blood pressure might detect the onset of systemic hypotension more earlier and in some instances is disclosed hypotension that was not even detected by the arm cuff monitor. In addition, we found that the blood pressure in the leg was higher than that in the arm, but when hypotension occurred, it might fall even lower than that of the arm. CONCLUSIONS: We suggest that monitoring blood pressure in cesarean section under spinal anesthesia should be minute to minute for the first ten minutes and one had best monitor the lower extremity blood pressure in order to promptly detect hypotension.

Adult↗

PubMed2001

Efficacy and durability of autogenous saphenous vein conduits for lower extremity arterial reconstructions in preadolescent children.

OBJECTIVE: Limb length discrepancies (LLDs) in growing children may accompany extremity arterial occlusions. Revascularization with vein grafts has been questioned because of degenerative graft changes observed at other sites. This study was undertaken to define vein graft durability and efficacy in lower extremity revascularizations in preadolescent children. STUDY DESIGN: Fourteen children (10 boys, 4 girls) with a mean age of 7.3 years (range, 2-11 years) who underwent 16 lower extremity revascularizations with greater saphenous vein grafts were subjected to follow-up with graft ultrasonography, ankle/brachial indices (ABIs) with and without exercise, and limb length determinations. A mean of 5.7 years elapsed between the onset of ischemia and operation. Arterial occlusions resulted from cardiac catheterizations (11), arteritis (1), dialysis cannulation (1), and penetrating trauma (1). Indications for operation included LLD (6), claudication (4), both LLD and claudication (3), markedly diminished ABIs with a potential for LLD (2), and a traumatic transection with hemorrhage (1). The reconstructions with 15 reversed and one in situ vein grafts included iliofemoral (11), femorofemoral (1), aortofemoral (1), femoropopliteal (1), popliteal-popliteal (1), and popliteal-posterior tibial (1) arterial bypass grafts. RESULTS: Among patent grafts available for follow-up, 36% (5 of 14) remained unchanged, 50% (7 of 14) developed nonaneurysmal dilatation, and 14% (2 of 14) exhibited nonprogressive aneurysmal expansion. One graft became occluded, and one graft was lost to follow-up. Collectively, the grafts manifest an 11.2% expansion at an average of 10.7 years postoperatively. ABIs increased from 0.75 preoperatively to 0.97, at an average of 11.0 years postoperatively. LLDs were reduced from 1.66 to 1.24 cm, at an average of 11.4 years postoperatively. CONCLUSION: Vein graft reconstructions of lower extremity arteries in preadolescent children are durable. They provide an efficacious means of restoring normal blood flow, and in 70% of children their preexisting LLDs were reduced.

Angiography, Digital Subtraction↗

PubMed2006

Use of the tourniquet in reconstructive surgery in patients with previous ipsilateral lower extremity revascularization: is it safe? A survey.

Tourniquet use in the previously revascularized ipsilateral lower extremity varies among micro-reconstructive surgeons due to the possible complication of graft failure. Examination of evidence-based literature and a current standard of care is needed to establish guidelines for such tourniquet use. Surveys were sent to vascular surgery program directors of ACGME-accredited residency programs to assess prevailing tourniquet use instruction. The survey addressed issues, including tourniquet use in previous bypass surgery, previous angioplasty, and location relative to graft anatomy. Twenty-eight responses were received out of 87 surveys sent (32 percent response rate). Ninety-three percent considered tourniquet use inappropriate in the ipsilateral lower extremity with previous revascularization. Seventy-one percent indicated tourniquet use inappropriate in previous ipsilateral angioplasty. Sixty-one percent regarded graft conduit type to be important in tourniquet use. There remains a lack of prospective, randomized, controlled studies determining risks of occlusion and other complications to the preexisting bypass graft during tourniquet use. Until such studies are done, this survey recommends avoiding tourniquet use in this patient population.

Angioplasty↗

PubMed2006

Lower extremity physical performance and use of compensatory strategies for mobility.

OBJECTIVES: To compare measured lower extremity physical performance in the clinic with the methods used to carry out mobility tasks at home and to identify key factors influencing day-to-day task performance. DESIGN: Cross-sectional analysis of the Women's Health and Aging Study I. SETTING: Community-dwelling female residents of Baltimore, Maryland. PARTICIPANTS: One thousand two cognitively intact women aged 65 and older with moderate to severe physical limitations. MEASUREMENTS: Compensatory strategies reportedly used for mobility in the home, distinguishing between use of no compensatory strategies, behavioral changes only, durable medical equipment (DME) with or without behavioral change, and human help; measured lower extremity (LE) physical performance (gait speed, timed chair stands, balance). RESULTS: There was a statistically significant difference in LE physical performance between women using the four types of compensatory strategy (P < .001). Women who used DME for mobility in the home had worse performance than those using human help who in turn had worse performance than those with behavioral changes only; women reporting no compensatory strategies for in-home mobility performed best. Sequential multivariate logistic regressions identified several factors other than LE physical performance that were associated with use of specific compensatory strategies. Medical conditions, education, and environmental barriers influenced whether compensatory strategies were used at all, whereas income, contact with health providers, and availability of help in the home influenced the type of compensatory strategy. CONCLUSION: Physical abilities are an important factor influencing use of compensatory strategies for mobility, but several other factors also influence the ways that women adapt to mobility limitations.

Activities of Daily Living↗

PubMed1994

Vascular impairment and free tissue transfer in the lower extremity.

Fourteen patients with arteriosclerotic peripheral vascular disease and extensive tissue defects of the lower extremity, underwent microsurgical reconstruction using free tissue ("free flap") transfer. It was possible to provide coverage in ten of these patients. Analysis of this small series showed that only six of these ten patients were able to resume unassisted ambulation. The authors discuss technical aspects of microsurgical reconstruction in this unfavorable group of patients. Analysis of this small series suggest that: (1) inadequate patient motivation, and (2) inability to form granulation tissue in the soft tissue defect, either before or after a vascular reconstructive procedure, are both strong contraindications to microvascular free flap reconstruction in patients with arteriosclerotic peripheral vascular insufficiency of the lower extremity.

Aged↗

PubMed1983

Percutaneous transluminal angioplasty (PTA) for lower extremity arterial insufficiency.

Short term results of treatment with percutaneous transluminal angioplasty (PTA) for lower extremity arterial insufficiency are presented. During a two year period 54 PTA were attempted and 43 were successful. 42 patients were either free of symptoms or had objectively reduced ischemic symptoms and remained so during the follow-up period (mean 10.5 months). Successfully repeated PTA were performed in three patients for the management of occlusions within an arterial segment earlier dilatated. Reasons for unsuccessful PTA were mainly difficulties in passing the stenosis/occlusion with the guide wire or that dilation could not be completed because of extensive calcification in the arterial wall. The only complication requiring treatment was a bleeding from a puncture site in the femoral artery. PTA treatment of lower extremity arterial insufficiency is for many patients a good alternative or complement to reconstructive vascular surgery and a method that should be used to a greater extent in vascular surgery centers.

Aged↗

PubMed2002

Cost of routine screening for carotid and lower extremity occlusive disease in patients with abdominal aortic aneurysms.

OBJECTIVE: The burden of clinically relevant noncoronary atherosclerotic occlusive disease in patients with abdominal aortic aneurysms (AAAs) is poorly defined. Furthermore, the cost-effectiveness of routine versus selective preoperative noninvasive examination of the carotid and lower extremity arterial beds has not been established in patients who undergo elective AAA repair. METHODS: Diagnostic vascular laboratory study results were reviewed in 206 patients who underwent evaluation before AAA repair from 1994 to 1998. The patients underwent routine preoperative carotid duplex scan examinations and lower extremity Doppler scan arterial studies with ankle-brachial index (ABI) determinations. The medical records were reviewed for the identification of clinical evidence consistent with cerebrovascular or lower extremity arterial occlusive disease. The costs of routine screening and selective screening were determined with Medicare reimbursement schedules. RESULTS: The prevalence rate of advanced (80% to 100%) carotid artery stenosis (CAS) was 3.4%, and 18% of the patients had CAS between 60% and 100%. Advanced peripheral vascular occlusive disease (PVOD; ABI, <0.3) was found in 3% of the patients, and 12% of the patients had an ABI of less than 0.6. Most patients with advanced CAS (71%) or advanced PVOD (83%) had clinical indications of their disease. The absence of clinical evidence of disease had a negative predictive value of 99% for both advanced CAS and PVOD. The cost of routine screening for all patients for advanced CAS was $5445 per case. Routine screening for severe PVOD costs were $3732 per case discovered. In contrast, the costs for selective screening for advanced CAS or PVOD in patients with appropriate history or symptoms were $1258 and $785 per case found, respectively. CONCLUSION: Routine noninvasive diagnostic testing for the identification of asymptomatic CAS and PVOD in patients with AAA may not be justified. Preoperative screening is more clearly indicated for patients with AAAs who have clinical evidence suggestive of CAS or PVOD.

Aged↗

PubMed1991

[The clinico-instrumental evaluation of the efficacy of picotamide in treating chronic obstructive arteriopathies of the lower extremities].

In 25 patients (19 males and 6 females) suffering from chronic arteriopathy of lower extremities at Fontaine stage II, the clinical efficacy of picotamide was investigated in double blind, cross over placebo-controlled study. Patients were assigned randomly to the treatment with placebo or picotamide (900 mg/die) for three months and, after 15 days of wash-out, to the treatment with picotamide or placebo for the same period. Painfree walking distance and ankle/arm systolic pressure ratio improved significantly only during picotamide treatment. Laboratory monitoring revealed a significant decrease in platelet aggregation and an increase of fibrinogen degradation products only during picotamide treatment. Three patients during picotamide treatment referred transient gastrointestinal discomfort (nausea, vomiting and diarrhoea); however in no case the treatment was suspended because of the appearance of these symptoms. These results indicate that picotamide is an effective drug in the management of chronic arteriopathy of lower extremities.

Aged↗

PubMed1993

Is bilateral lower extremity compression sonography useful and cost-effective in the evaluation of suspected pulmonary embolism?

OBJECTIVE: Because deep venous thrombosis is clinically linked with pulmonary embolism and often treated similarly, we sought to assess the usefulness of obtaining bilateral lower extremity compression sonograms when findings on ventilation-perfusion lung scans indicate a low or indeterminate probability of pulmonary embolism. Demonstration of deep venous thrombosis would provide a rationale for treating both pulmonary embolism and deep venous thrombosis. MATERIALS AND METHODS: Two hundred twenty-three consecutive patients with suspected pulmonary embolism had ventilation-perfusion lung scans and concurrent bilateral lower extremity compression sonograms; 34 also had pulmonary arteriography. RESULTS: In 75 cases, the results of ventilation-perfusion lung scanning indicated an indeterminate probability of pulmonary embolism. Evidence of thrombosis was seen on sonograms in 11 of these 75. In the remaining 64, 17 underwent pulmonary arteriography and four (24%) had pulmonary embolism. Findings on lung scans indicated a low probability of pulmonary embolism in 70 of 223 patients. Evidence of thrombosis was seen on sonograms in 11 of these 70. Five of the remaining 59 underwent pulmonary arteriography and one (20%) had pulmonary embolism. According to the 1993 Medicare Fee Schedule, if all 145 patients whose lung scans were nondiagnostic had sonography and only those with normal sonograms had pulmonary arteriography, the professional and hospital charges would be $359,552. If all 145 had pulmonary arteriography without sonography, the charges would be $395,031. CONCLUSION: If ventilation-perfusion lung scans indicate a low or an indeterminate probability of pulmonary embolism and bilateral lower extremity compression sonography is performed, only those patients with normal sonographic findings would need further study. Thus, 15% (22/145) of patients could be spared pulmonary arteriography, and the estimated savings in cost would be 9%.

Algorithms↗

PubMedDate not supplied

Dynamic lower extremity alignment in children with achondroplasia.

The purpose of this study is to analyze lower extremity dynamic malalignment during gait using a 3-dimensional kinematics and kinetics in 13 children (3-17 years old) with achondroplasia and to compare measurements of alignment and malrotation between gait, radiographic, and clinical measures. Gait analysis in the coronal plane showed a varus malalignment of the knee (19 +/- 13 degrees) and variable tibial torsion abnormalities (13 [internal] +/- 15.7 degrees). Radiographs also showed knee varus malalignment (16 +/- 9 degrees); however, there was poor correlation with gait analysis measures (P > 0.05). In the sagittal plane, radiographs showed genu recurvatum deformity (23.5 +/- 13.2 degrees), although the sagittal plane knee kinematics were normal. Kinetic analyses of the knee showed high internal knee valgus moments (external varus moments, 0.48 +/- 0.25 N m/kg), which were significantly different from the normal population (P < 0.05). In conclusion, there is a 3-dimensional, complex, dynamic deformity of the lower extremity present in children with achondroplasia. We recommend a very careful assessment of the limb focusing on both the static and dynamic varus deformity and tibial torsion using a combination of radiographic, clinical, and gait analysis.

Achondroplasia↗

PubMed1999

Phantom limb, residual limb, and back pain after lower extremity amputations.

This study describes the sensations and pain reported by persons with unilateral lower extremity amputations. Participants (n = 92) were recruited from two hospitals to complete the Prosthesis Evaluation Questionnaire which included questions about amputation related sensations and pain. Using a visual analog scale, participants reported the frequency, intensity, and bothersomeness of phantom limb, residual limb, and back pain and nonpainful phantom limb sensations. A survey of medication use for each category of sensations also was included. Statistical analyses revealed that nonpainful phantom limb sensations were common and more frequent than phantom limb pain. Residual limb pain and back pain were also common after amputation. Back pain surprisingly was rated as more bothersome than phantom limb pain or residual limb pain. Back pain was significantly more common in persons with above knee amputations. These results support the importance of looking at pain as a multidimensional rather than a unidimensional construct. They also suggest that back pain after lower extremity amputation may be an overlooked but very important pain problem warranting additional clinical attention and study.

Adult↗

PubMed1990

Results of vein graft reconstruction of the lower extremity in diabetic and nondiabetic patients.

The results of 171 vein grafts of the lower extremity were evaluated. These were placed between January 1981 and December 1987 in 150 patients, 75 diabetic and 75 nondiabetic, to determine the influence of diabetes on the outcome of the procedure. One and four year patency rates were determined by a life table analysis. No statistical differences in primary patency were found between the patients with diabetes and those without diabetes for all indications of operations (one year, diabetic patients 95 +/- 3 per cent, nondiabetic patients 85 +/- 3 per cent; four years, diabetic patients 89 +/- 11 per cent and nondiabetic patients 80 +/- 12 per cent; p = n.s.). For those operated upon for salvage of the limb because of rest pain, ulceration or gangrene, patency in diabetic patients at one year approached a statistically significant advantage (diabetic patients 94 +/- 4 per cent versus nondiabetic patients 79 +/- 8 per cent; p = 0.056). We believe that arterial reconstruction of the lower extremity can be performed upon patients with diabetes with the same high degree of success for revascularization and salvage of the limb as can be accomplished in nondiabetic patients. This is true even though those with diabetes present with necrosis of the tissue and more often require bypass to distal tibial arteries.

Actuarial Analysis↗

PubMed1997

The effects of a 4-day march on the lower extremities and hormonal balance.

The functional strength, flexibility, and ranges of motion of the lower extremities, as well as hormonal balance, estimated by urinary excretion of adrenaline and noradrenaline and serum determinations of testosterone and cortisol, were studied with six physically active army officers participating in a 4-day march totaling 185 km. Catecholamine excretion rates showed cumulatively increased sympathoadrenal stress, and the effects on serum testosterone and cortisol concentrations were minor. Also, leg measurements showed no signs of edema, decreases in flexibility, or decreases in functional strength. Most pain (75%) experienced by the subjects was located in the feet and caused by abrasions and blisters. Only a small portion of perceived pains (25%) was associated with muscle soreness. Serum creatine kinase activity was slightly (ca. 400-650%) increased during the marching days. Thus, soldiers who are in good physical condition and are accustomed to marching are able to walk four marathons on successive days, while carrying 10-kg backpacks, without any major adverse effects on the musculature of their lower extremities.

Adult↗

PubMed1994

Validity and reliability of a new assessment of lower-extremity dysfunction.

BACKGROUND AND PURPOSE: A 20-variable assessment system for evaluation of lower-extremity dysfunction has been constructed with special consideration of the needs of the physical therapist. The variables are classified into five subgroups: hip impairment, knee impairment, physical disability, social disability, and pain. SUBJECTS: One hundred five patients with osteoarthrosis of the hip and knee, all accepted for total joint replacement arthroplasty, were tested. The mean age of the patients was 69 years (SD = 9.0, range = 46-91). METHODS: The original grouping of the variables was analyzed for content validity with a factor analysis. The results from a subgroup of 42 patients were tested for intertester reliability with the Goodman-Kruskal gamma coefficient. RESULTS: The factor analysis indicated a factor solution consistent with the primary grouping except for two variables. The correlation between two independent physical therapists was .99 to 1.00 for different variables, indicating excellent intertester reliability. CONCLUSION AND DISCUSSION: In the authors' opinion, the new assessment system provides a reasonably valid, reliable, inexpensive, and easy-to-use measurement and fulfills the needs of the physical therapist for functional evaluation of the lower extremity.

Activities of Daily Living↗