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PubMed1996

Sufentanil plasma concentrations following lower extremity tourniquet release.

STUDY OBJECTIVE: To investigate whether release of a tourniquet on the lower extremity affects plasma concentrations of sufentanil, as previously demonstrated with fentanyl and midazolam. DESIGN: Prospective. SETTING: University tertiary-care institution with residency program. PATIENTS: 20 ASA status I, II, and III patients undergoing total knee arthroplasty under a tourniquet using a sufentanil, nitrous oxide, relaxant regimen. INTERVENTIONS: Each patient received sufentanil 1 to 2 micrograms/kg at induction of anesthesia and in 12.5 to 25 microgram increments as needed thereafter, until 15 minutes prior to tourniquet release. MEASUREMENTS AND MAIN RESULTS: Plasma sufentanil concentrations were determined before tourniquet inflation, immediately before tourniquet deflation, and 1, 2, 5, 10, 20, 30, and 40 minutes following deflation. A 15% elevation of plasma sufentanil concentration above that predicted by elimination pharmacokinetics defined a secondary peak. Although the aggregate data did not indicate an overall statistically significant rise in plasma concentrations after deflation, 9 (45%) patients exhibited a secondary peak in sufentanil plasma concentration following tourniquet deflation (range of secondary peaks, 16% to 89% above predicted values). No patient experienced clinically significant respiratory depression. CONCLUSION: Release of a tourniquet on the lower extremity may yield a detectable rise in plasma sufentanil concentration.

Aged↗

PubMed1991

Thermal laser assisted balloon angioplasty in lower extremity occlusive disease.

Results of Nd:Yag thermal laser assisted balloon angioplasty (LABA) in lower extremity occlusive disease were reviewed retrospectively in 23 patients and 28 lesions over a 1 year period. Indications for intervention were progressive claudication in 74 per cent and gangrene and/or rest pain in 26 per cent. Twenty-four (86%) procedures were technically successful; however, there were only 15 (54%) clinical successes during the follow-up period (0.5-12.5 months). Complications occurred following ten (36%) procedures with one mortality (4%) unrelated to the procedure. Analysis of the nature and location of the lesions revealed five angiographic patterns with varying degrees of success. These are: Superficial Femoral and Popliteal: 1) short segment stenosis--2/3, 2) long multisegment stenosis--1/6, 3) total occlusion--7/9, 4) stenosis and occlusion--2/4; Iliac: 5) stenosis--3/4. The only subsets of patients who appeared to benefit from LABA were those with short segment stenosis or isolated occlusions. Patients with good runoff also did well. Patients with poor runoff or multiple stenoses associated with diffuse disease did poorly. It is concluded that LABA has limited applications in the treatment of lower extremity occlusive disease.

Adult↗

PubMed1981

[Evacuation function of a musculovenous "pump" of the leg in varicose veins of the lower extremities].

The investigation of average time of transport of radionuclide along the venous system of lower extremities was used by the authors to assess the evacuation function of the musculo-venous "pump" of the leg in 10 healthy people and 50 patients with varicose disease of lower extremities. The direct relation between the degree of incompetence of the musculo-venous "pump" and the degree of the varicose disease speaks of its obvious pathogenetical role in the development of venous pathology.

Humans↗

PubMed1991

Exercise testing and training in patients with peripheral vascular disease and lower extremity amputation.

Patients with peripheral vascular disease have a high risk of coronary artery disease. The risk is even greater when the peripheral vascular disease leads to lower extremity amputation. Exercise testing using lower extremity exercise has been the "gold standard" for screening for coronary artery disease, but many patients with peripheral vascular disease and those with amputations have difficulty doing this type of exercise. Arm exercise ergometry has been shown to be a safe and effective alternative for the detection of coronary artery disease in patients who cannot do leg exercise. This test has also been used to determine safe exercise levels and may be able to predict the ultimate level of prosthetic use in amputees. Exercise training with arm ergometry also improves cardiovascular efficiency and upper body strength in poorly conditioned patients. Studies are needed to appreciate fully the role of exercise testing and training in the recovery of these patients after amputation.

Amputation, Surgical↗

PubMed1999

Cardiac morbidity and operative mortality following lower-extremity amputation: the significance of multiple Eagle criteria.

The ability of the Eagle criteria (age >70 years, angina, diabetes, Q wave on EKG, history of congestive heart failure) to predict adverse cardiac events following major vascular surgery has previously been demonstrated. However, the utility of these criteria for lower-extremity amputation is not well established. To determine the value of the Eagle criteria for predicting cardiac morbidity and operative mortality following major lower-extremity amputation, we reviewed 214 consecutive procedures performed at two institutions over a 3-year period. Mean age was 62.7 years and 85% of the patients were male. Diabetes was the most frequent Eagle criterion (74%). The mean number of Eagle criteria was 1.6. Fifty-six percent of the amputations were below the knee, 24% were above the knee, and 20% were guillotine. On multivariate regression analysis, the presence of two or more Eagle criteria (16% vs. 4%, p = 0.04) and decompensated heart failure (39% vs. 7%, p = 0.003) were predictive of adverse cardiac events. The only predictor of postoperative mortality was the presence of two or more Eagle criteria (15% vs. 4%, p = 0.004). Our evaluation of the results of this study led us to conclude that patients requiring major lower-extremity amputation for major vascular disease who have multiple Eagle criteria or decompensated congestive heart failure are at high risk for adverse cardiac events and postoperative death. These findings should be used to guide perioperative cardiac evaluation and therapy.

Aged↗

PubMed2002

Measuring perceived activity limitations in lower extremity Complex Regional Pain Syndrome type 1 (CRPS I): test-retest reliability of two questionnaires.

OBJECTIVE: To assess the test-retest reliability of two questionnaires for measuring activity limitations in patients with Complex Regional Pain Syndrome type 1 (CRPS I) of the lower extremity. DESIGN: Patients filled out the Walking Stairs Questionnaire and the Questionnaire Rising and Sitting Down twice during a one-week period. SETTING: Outpatient pain clinic of a university hospital. PATIENTS: Twenty-one outpatients with CRPS I of the lower extremity. RESULTS: The Walking Stairs Questionnaire and the Questionnaire Rising and Sitting Down were reliable in terms of test-retest reliability as expressed by Spearman's r (range 0.79-0.90 and 0.85-0.89 respectively) and the ICC (range 0.78-0.84 and 0.84-0.87 respectively). CONCLUSION: Both questionnaires form a reliable tool for measuring activity limitations of patients with CRPS I of a lower extremity.

Activities of Daily Living↗

PubMed1996

Cardiovascular and metabolic responses to upper- and lower-extremity exercise in men with idiopathic Parkinson's disease.

BACKGROUND AND PURPOSE: The aerobic capacity of individuals with Parkinson's disease (PD) has not been characterized. This study (1) compared maximal exercise performance in individuals with and without PD, (2) compared exercise performance during upper- and lower-extremity exercise, and (3) described submaximal exercise responses. SUBJECTS: Eight men with PD (PD group) and 7 men without PD (control group) participated. METHODS: Subjects performed a lower-extremity ergometer test (LE test) and an arm-cranking ergometer test (AC test). Peak oxygen consumption, heart rate, respiratory exchange ratio, and power, as well as submaximal values of oxygen consumption and heart rate for each power level, were recorded. RESULTS: No differences were found between the groups for either test. Peak power was less for the PD group than for the control group for both tests. Submaximal heart rate and oxygen consumption were higher for the PD group than for the control group. CONCLUSION AND DISCUSSION: We conclude that individuals with mild to moderate PD can be tested with both exercise protocols to a peak exercise capacity and that there are differences in upper- and lower-extremity peak power and submaximal responses between persons with and without PD.

Aged↗

PubMed2003

[Changes in cell adhesion molecules under the influence of surgical treatment in patients with acute thrombophlebitis of the subcutaneous veins in the lower extremities].

The content of soluble molecules of intercellular adhesion-1 (sICAM-1) in 60 patients with an acute thrombophlebitis (TP) of the lower extremities subcutaneous veins was studied preoperatively and 7 days after the operation using method of a solid phase immunoenzymatic analysis (IEA). The sICAM-1 level before treatment in men was increased at average by 75.8% (P < 0.001), in women--by 81.5% (P < 0.001) in comparison with control group, after treatment it was lowered somewhat. The gender differences of patients for the average sICAM-1 concentration was not noted. In ascending TP sICAM-1 higher level preoperatively and its normalization on 7th day postoperatively were observed in patients, admitted to in surgical unit and operated 3-5 days after the beginning of disease. In patients, to whom conservative treatment was performed initially (anti-inflammatory and thrombolytic therapy), but its efficacy was minimal, the content of cell adhesion molecules preoperatively and before the treatment did not differ. Positive dynamic of index was revealed after the intervention. The results of investigation trust the important role of cell adhesion in pathogenesis of an acute TP of the lower extremities subcutaneous veins and perspective of application of the sICAM-1 method determination in dynamic of the patients treatment to estimate the surgical efficacy intervention.

Acute Disease↗

PubMed1999

Maximal strength and power characteristics in isometric and dynamic actions of the upper and lower extremities in middle-aged and older men.

Muscle cross-sectional area of the quadriceps femoris (CSAQF), maximal isometric strength (handgrip test and unilateral knee extension/flexion), the shape of isometric force-time curves, and power-load curves during concentric and stretch-shortening cycle (SSC) actions with loads ranging from 15 to 70% of one repetition maximum half-squat (1RMHS) and bench-press (1RMBP) were examined in 26 middle-aged men in the 40-year-old (M40) (mean age 42, range 35-46) and 21 elderly men in the 65-year-old age group (M65) (mean age 65, range 60-74). Maximal bilateral concentric (1RMHS and 1RMBP), unilateral knee extension (isometric; MIFKE and concentric; 1RMKE) strength and muscle CSA in M65 were lower (P < 0.001) than in M40. The individual values of the CSAQF correlated with the individual values of maximal concentric 1RMHS, 1RMKE and MIFKE in M65, while the corresponding correlations were lower in M40. The maximal MIFKE value per CSA of 4.54 +/- 0.7 N m cm-2 in M40 was greater (P < 0. 05-0.01) than that of 4.02 +/- 0.7 N m cm-2 recorded in M65. The maximal rate of force development of the knee extensors and flexors in M65 was lower (P < 0.01-0.001) and the heights in squat and counter-movement jumps as much as 27-29% lower (P < 0.001) than those recorded in M40. M65 showed lower (P < 0.001) concentric power values for both upper and lower extremity performances than those recorded for M40. Maximal power output was maximized at the 30-45% loads for the upper extremity and at the 60-70% loads for the lower extremity extensors in both age groups. Muscle activation of the antagonists was significantly higher (P < 0.01-0.001) during the isometric and dynamic knee extension actions in M65 than in M40. The present results support a general concept that parallel declines in muscle mass and maximal strength take place with increasing age, although loss of strength may vary in both lower and upper extremity muscles in relation to the type of action and that ageing may also lead to a decrease in voluntary neural drive to the muscles. Explosive strength and power seem to decrease with increasing age even more than maximal isometric strength in both actions but power was maximized at the 30-45% loads for the upper and at the 60-70% loads for the lower extremity action in both age groups. High antagonist muscle activity may limit the full movement efficiency depending on the type of muscle action, testing conditions and the velocity and/or the time duration of the action, especially in the elderly.

Adult↗

PubMed1993

Aortic occlusion and lower extremity exercise induced stress urinary incontinence.

An unusual case of intermittent stress urinary incontinence associated with lower extremity exercise in a patient with aortoiliac occlusive disease is reported. Preoperative noninvasive vascular testing revealed severe compromise of lower extremity and pelvic blood flow. Fluoroscopically guided preoperative urodynamic evaluation without exercise revealed a competent urethral sphincter mechanism that became incompetent following exercise sufficient to induce claudication. The claudication and exercise-induced incontinence resolved after aortobifemoral bypass, and postoperative urodynamic studies were normal.

Aged↗

PubMedDate not supplied

Infrapopliteal-lower extremity revascularization with prosthetic conduit: a 20-year experience.

The use of prosthetic conduits for lower extremity revascularization in the infrapopliteal location remains controversial. The objective of this report is to describe the immediate and long-term results in a series collected over two decades. Of the approximately 1,500 lower extremity revascularizations performed between 1978 and 1998, 81 infrapopliteal bypass cases using polytetrafluoroethylene (PTFE) as conduit in 77 patients were identified. Autogenous conduit was unavailable (86%) due to prior surgery: coronary artery bypass graft (25%), femoro-popliteal bypass (60%), or femoro-distal bypass (23%). All cases were done for critical ischemia using PTFE (6 mm, 95%; ring reinforced, 54%) under general (75%) or regional (25%) anesthesia. The distal anastomosis was to the anterior tibial artery (43%), posterior tibial artery (28%), tibioperoneal trunk (16%), or peroneal artery (12%), and vein patch was used in 25% of cases. Postoperative features included acute graft thrombosis in 11 cases (14%), all done under general anesthesia, perioperative death in 3 (4%), and a mean in-hospital stay of 17 days. Long-term follow-up has ranged from 1 to 144 months (mean, 22 months). At 36 months, primary patency was 20%, secondary patency 42%, and limb salvage 55% calculated by the Kaplan-Meier method. Univariate analyses revealed regional anesthesia was associated with prolonged primary patency (35% vs 15%, p=0.026) while the use of ring-reinforced PTFE conduit was associated with prolonged limb salvage (65% vs 40%, p=0.042). All other variables including gender, smoking, diabetes mellitus, renal failure, decade of operation, use of vein patch or postoperative warfarin were not significantly associated with either prolonged patency or limb salvage. Despite poor primary patency, distal prosthetic bypass can lead to long-term limb salvage. These data suggest distal anastomotic vein patches and postoperative anticoagulation may not be beneficial adjuncts. However, the use of regional anesthesia may decrease the incidence of perioperative thrombosis and the use of ring reinforced conduit may prolong limb salvage.

Aged↗

PubMedDate not supplied

Clubfeet associated with congenital constriction bands of the ipsilateral lower extremity.

The purpose of this study was to examine the outcome of treatment of clubfeet distal to a lower extremity constriction band. Eighteen patients with 21 clubfeet distal to a lower extremity constriction band were treated during the years 1946 to 1992. Three types of bands (I to III) were defined. Three grades of feet (A to C), based on the severity of the deformity, were recognized. After treatment, the feet were classified as good, fair, or poor. At follow-up, six of 18 feet were classified as good, six as fair, and nine as poor. These results were correlated with the type of band and the grade of the foot. A grade A foot associated with type III band had the best result.

Amniotic Band Syndrome↗

PubMed1987

Relative lower extremity length in Mexican American and in American black and white youth.

Stature, sitting height, estimated leg (subischial) length and the sitting height/stature ratio are compared in Mexican American, American White and American Black boys 9 through 14 years of age and girls 12 through 17 years of age. Mexican American youth are shorter in stature and have absolutely shorter lower extremities. The sitting height of Mexican American youth is similar to that of Black youth and shorter than that of White youth. The sitting height/stature ratio is virtually identical in Mexican American and White youth, indicating similar proportions of lower extremities to stature. In contrast, Black youth have absolutely and relatively longer lower extremities than Mexican American and White youth. These results would thus seem to suggest that reference data for the body mass index (BMI) based on American White youth can be used with Mexican American youth, while race-specific values may be necessary for American Black youth. However, ethnic variation in physique, perhaps frame size, may be a factor which should be more systematically considered in evaluating the utility of the body mass index.

Adolescent↗

PubMed1992

Magnetic resonance angiography of the lower extremity and renal arteries.

Magnetic resonance angiography (MRA) has been used to image the arteries to the lower extremities and to the kidneys, with promising initial results. In the case of the lower extremity arterial system, MRA provides a first opportunity to obtain anatomic images in a completely noninvasive fashion, including evaluation of the iliac and tibial vessels, to supplement the hemodynamic measurements that are a routine part of the preoperative evaluation. In the case of renal artery stenosis, MRA may soon become the initial screening modality of choice, especially in patients with renal insufficiency, in whom contrast scintigraphy may have limited accuracy and in whom contrast angiography is relatively contraindicated.

Arterial Occlusive Diseases↗

PubMed1990

Blood flow velocity waveforms from the fetal external iliac artery as a measure of lower extremity vascular resistance.

Blood flow velocities were recorded in the external iliac artery (EIA) and umbilical artery (UA) in 94 normal pregnancies and in 14 with intrauterine growth retardation (IUGR) between 25 and 36 weeks gestation. In normal pregnancy the pulsatility index (PI) in both vessels decreased significantly with advancing gestational age, reflecting a reduction in lower extremity and placental vascular resistance. The EIA PI/UA PI ratio also decreased significantly with gestational age suggesting that vascular resistance is more pronounced in the lower extremities. In the pregnancies with IUGR, PI values from both vessels were nearly always above the upper limit (+2 SD) of the normal curve reflecting increased vascular resistance at lower extremity and placental level. In two pregnancies, absent end-diastolic flow velocities in the umbilical artery were associated with reversed end-diastolic flow velocities in the external iliac artery.

Blood Flow Velocity↗

PubMed1978

131I-labeled fibrinogen in the diagnosis of deep vein thrombosis of the lower extremities.

Autologous 131I-labeled fibrinogen was administered to 17 patients during 19 episodes of suspected lower extremity deep vein thrombosis in an attempt to assess its diagnostic accuracy. Serial rectilinear scanning and probe counting of the lower extremities and pelvis were performed and compared with ascending contrast venography. The sensitivities of imaging and counting were 67% and 47%, respectively, and both had a specificity of 95%. The experience with evaluation of deep vein thrombosis of the pelvic and iliac veins was small but suggested that 131I fibrinogen will be of limited use in those vessels.

Fibrinogen↗

PubMed2000

A comparison of lower extremity muscle strength, obesity, and depression scores in elderly subjects with knee pain with and without radiographic evidence of knee osteoarthritis.

OBJECTIVE: To determine, in subjects with knee pain but no radiographic changes of tibiofemoral or patellofemoral compartment osteoarthritis (OA), whether mean body weight, quadriceps and hamstring strength, lower extremity muscle mass, depression scores, and perceptions of their general health status differed from those of subjects with symptomatic knee OA. METHODS: Subjects were 25 women and 10 men with knee pain and radiographic evidence of OA at the baseline examination, and 21 women and 16 men who had knee pain at the baseline examination but no radiographic evidence of knee OA at either baseline examination or followup evaluation performed, on average, 31 months later. These individuals were a subset of a cohort of 462 independently living elderly individuals recruited by telephone interview after random selection through random digit dialing of households in central Indiana. Data from an additional 134 subjects who had neither knee pain nor radiographic changes of OA at either the baseline or followup examination were analyzed for comparison. Lower extremity muscle strength was measured by isokinetic dynamometry, lean tissue (i.e., muscle) mass in the lower extremities by dual x-ray absorptiometry, depression by Center for Epidemiology Depression (CES-D) scale. knee pain by Western Ontario McMaster University OA instrument, and perceived general health status by the Medical Outcome Survey Short Form-36. RESULTS: In contrast to those with symptomatic knee OA, those who had knee pain but no radiographic evidence of OA were less obese, had hamstring as well as quadriceps weakness, and had CES-D scores high enough to qualify for a diagnosis of clinical depression. CONCLUSION: Among subjects with knee pain but no OA--and among women in this subset, in particular--knee pain may be a manifestation of depression. rather than of joint disease.

Aged↗

PubMed2000

Can a tissue-engineered skin graft improve healing of lower extremity foot wounds after revascularization?

A bilayered tissue-engineered skin graft composed of human neonatal foreskin fibroblasts and keratinocytes in a type I bovine collagen matrix has been developed. We sought to determine if this graft improves wound healing after lower extremity revascularization. Thirty-one previously ischemic foot wounds were randomly assigned to moist dressing changes or tissue-engineered skin graft within 60 days of revascularization. In the grafted group, 10 received meshed and 11 received unmeshed graft. Wound healing was followed by wound area measurements and photography. There were no statistically significant differences between groups in patient age, sex, diabetes or renal failure risk factors, revascularization procedure, or wound location or size. Treatment with tissue-engineered skin graft was significantly more effective than moist dressing in the percentage of wounds healed (62 vs. 0% at 8 weeks, 86 vs. 40% at 12 weeks, p < 0.01) and the median time to complete wound closure (7 vs. 15 weeks, p = 0.0021, rank-sum test). There was no difference in the wound closure rate of meshed and unmeshed graft at 4, 8, 12, or 24 weeks (p > 0.05). Three indolent localized wound infections in the tissue-engineered skin graft group were the only complication. Tissue-engineered skin grafting can be used safely in previously ischemic wounds after lower extremity revascularization. Treatment with this graft promotes healing more rapidly and in more patients than standard moist dressings. It obviates the risk, inconvenience, and expense of donor skin harvesting, anesthesia, and hospitalization associated with autologous skin grafting. This graft may represent an advance in the treatment of previously ischemic lower extremity foot wounds.

Aged↗