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PubMedDate not supplied

Extravascular incidental findings at multislice CT angiography of the abdominal aorta and lower extremity arteries: a retrospective review study.

PURPOSE: To assess the frequency and clinical impact of extravascular incidental findings on routine CT angiography of abdominal aorta or lower extremity arteries. MATERIALS AND METHODS: From January 2002 to July 2004, a total of 692 patients underwent CT angiography of abdominal aorta and lower extremity arteries. Two radiologists retrospectively reviewed by consensus cross-sectional images for the presence and clinical impact definition of extravascular findings. The revision of hospital charts, medical records, and all procedures' reports performed before and after CT angiography represented the standard of reference (SOR). RESULTS: Only 373 out of 605 patients in whom extravascular findings were found had a SOR; in these patients CT angiography obtained a true-positive incidental rate of 98.9% (369/373). For the clinical impact definition of CT-angiography incidental findings, a concordance with SOR was obtained in 56.3% of patients, whereas a subsequent investigation was required in 183 patients (183/369, 49.6%). Among clinically relevant incidental findings, a total of 35 malignancies (35/894, 3.9%) were detected in 20 patients (20/423, 4.7%); in 15 patients (15/423, 3.5%) malignancy was unknown before CT-angiography exam. CONCLUSIONS: A careful observation of cross-sectional images, even if "time consuming", is mandatory not only to assess vascular findings but also to avoid a misdiagnosis of clinical relevant extravascular findings.

Aged↗

PubMed1982

Identification of human lower extremity dynamics in torsion.

A four degrees of freedom, damped, linear oscillator model of the lower extremity in torsion was identified through laboratory frequency response tests. The foot was rotated sinusoidally in the medial-lateral plane through the 1-20 HZ frequency band at the constant amplitudes 2, 4 and 6 degrees. Weight bearing on the foot, muscle-induced bias torsion and knee flexion were also test variables. Identification was undertaken by minimizing the squared difference between the measured and predicted transfer functions of the pelvis and foot. The model specification and the laboratory identification procedures were the focus of this work. Variations greater than 30% in the identification stiffness, damping and inertia values were predicted over the test variable ranges. The transfer functions recorded in these tests indicated the lower extremity can be modeled as a compliance between a foot inertia and the pelvis-torso inertia. Joint compression, induced by weight bearing, and muscle contraction, measured by the bias torsional moment at the foot, increased the torsional stiffness of the knee, ankle and pelvis model elements, and they had an indeterminate influence on the hip stiffness. The model knee and hip stiffnesses and the model pelvis-torso inertia were maximized, and the model ankle stiffness was minimized at the maximum foot rotation amplitude.

Adult↗

PubMedDate not supplied

[Corrective osteotomies of the lower extremities following posttraumatic deformities].

PURPOSE: As part of a retrospective analysis of posttraumatic malunions of the lower extremity, the causes for deformity, as well as indications and methods for corrective osteotomies are reviewed. METHODS: From January 1992 until December 1996, a total of 115 patients underwent corrective osteotomies of the lower extremity secondary to posttraumatic deformities. The 89 adult patients with tibial (n = 54) or femoral (n = 35) malunion were analyzed as part of this study. RESULTS: The primary fracture treatment consisted of an intramedullary stabilization in 19 instances, a plate osteosynthesis in 22 and an external fixateur in 14 cases. Other forms of treatment were choosen in the remaining (n = 34) instances. Torsional deformities were seen after primary intramedullary nailings, while plate osteosynthesis lead to angulation in the frontal plane in the majority of the treated patients. In 43 instances uniplanar and in 46 cases multiplanar deformities had to be corrected. The correction was carried out with the help of an Ilisarow-ring fixator in 37 instances. As an internal stabilizer, 9 nails, 2 dynamic compression screws and 38 AO-plates were used. A bone graft was carried out primarily 33 times. CONCLUSIONS: The review of the literature, as well as of our own results, shows that deformities in the frontal plane should be corrected if they exceed 10 degrees of varus or 15 degrees of valgus. Malunions of more than 15 degrees in the sagittal and 15-20 degrees in the transverse plane should also be considered for correction, while a shortening of more than 3 cm represents an indication for corrective osteotomy. Callus distraction techniques have proven valuable in the correction of posttraumatic malunions of the lower leg, especially when soft tissue compromise is evident.

Adolescent↗

PubMed2004

[Necrotizing fasciitis in the lower extremity secondary to diabetic wounds].

OBJECTIVES: The aim of this retrospective study was to evaluate patients who developed necrotizing fasciitis (NF) in the lower extremity secondary to diabetic wounds. METHODS: The study included sixteen patients (11 men, 5 women; mean age 63 years; range 50 to 82 years) who were treated for NF arising from diabetic wounds. Associated diseases were coronary heart disease in three patients, and chronic renal failure due to diabetic nephropathy in three patients. The patients were evaluated by physical examination, direct radiographs, blood pressure measurements, and cultures, and with respect to treatment methods and results. The mean hospitalization period was 26 days (range 5 to 59 days). RESULTS: Necrotizing fasciitis was confined to the leg in four patients, extended to the thigh in 10 patients, and was bilateral in two patients. Pain was encountered in 10 patients (68.8%). Fourteen patients (87.5%) had increased creatine kinase levels. Direct radiographs showed gas appearance in soft tissues in seven patients (43.8%). Cultures showed a single microorganism in four patients (25%), and multiple microorganisms in five patients (31.3%). Of seventeen microorganisms isolated, 10 (58.8%) were Enterobacter species. Eleven patients (68.8%) underwent above-the-knee, and three patients (18.8%) underwent below-the-knee amputations. Disarticulation of the hip was performed in four patients. The mean number of debridements was five (range 2 to 21) following the initial surgical intervention. Nine patients developed septic shock. Seven patients (43.8%) died due to multiple organ failure. Increased creatine kinase levels were significantly associated with mortality (p<0.05). CONCLUSION: Early and accurate diagnosis and prompt surgical treatment may be life-saving in diabetic patients with NF of the lower extremity.

Aged↗

PubMedDate not supplied

An experience with free scapular flap for reconstruction of lower extremity defects at Aga Khan University Hospital Karachi.

BACKGROUND: Reconstruction of large composite tissue defects with exposed vital structures and weight bearing surfaces are extremely difficult for reconstructive surgeons. Coverage of such difficult defects can be achieved with free tissue transfer provided microsurgical expertise is available. This study was carried out to determine the outcome of free scapular flaps performed for lower extremity defects. METHODS: Clinical records of the patients were reviewed and important variables included demographic data, etiology of soft tissue defects, site and size of defect, complications and percentage of wound coverage by flap. Patient satisfaction and objective assessment of flap coverage and motion of involved joints was made. RESULTS: There were 13 male patients with mean age of 30.46 years. The causes of tissue defects were road traffic accident in 8 cases, industrial accidents in 2 and 3 cases had bomb blast, gunshot and gas gangrene one in each case respectively. Nine scapular flaps were performed to reconstruct the defects around the foot, ankle and lower leg; two flaps for amputation stumps and two flaps for defects around the knee and popliteal fossa. Post flap surgery, 3 cases had vascular compromise which required urgent exploration of anastomosis. Two cases were revived and one flap did not survive. With respect to cosmetic appearance, coverage of required defect, performance of activities of daily living and functional range of motion of involved joints, 6 cases were graded excellent and 7 cases were good. CONCLUSION: In our cases of lower extremities defects, scapular flap helped to salvage the limb. In conclusion scapular flap is a versatile flap which can be used for lower extremity defects.

Accidents, Occupational↗

PubMed2005

Evaluation of simple non-invasive techniques for assessment of lower extremity arterial disease.

OBJECTIVE: To evaluate the reproducibility and precision of three, simple, non-invasive methods to measure blood pressure (BP) in the lower extremities by comparing reproducibility and sensitivity in finding abnormally low BP between ankle blood pressure (ABP) and toe blood pressure (TBP), by studying the concordance between TBP in toe 1 and 2 and evaluating the pole-pox method in patients with diabetes and lower extremity arterial disease (LEAD). SUBJECTS AND METHODS: The BP was measured twice, 1 week apart, in arms and legs in 13 controls and 12 patients with diabetes. ABP was assessed by using a Doppler pen for pulse registration. TBP was obtained by using a small cuff and a pulse oximetry sensor at toe 1 and 2. In eleven patients with diabetes and previously known LEAD ABP was obtained through the pole-pox method. RESULTS: No significant difference in reproducibility between absolute BPs and indices (coefficients of variation <9%) was found. A non-significant improvement with 4-8% in the sensitivity in detecting LEAD was seen when BP indices were used instead of absolute BP. A significant correlation in the variation over time for systemic and TBP (r = 0.34, P = 0.015) and a strong correlation was found between TBP measured at toe 1 and 2, respectively (r = 0.99, P < 0.001) was found. TBP measured with pole-pox method were significantly correlated with measurements made by the ordinary cuff technique (r = 0.75, P < 0.001). CONCLUSIONS: The use of TBP and ABP indices instead of absolute BP does not improve the reproducibility but may improve the sensitivity with respect to detection of LEAD, especially in patients with diabetes. The pole-pox method may be used as an alternative screening method in patients with diabetes and LEAD.

Adult↗

PubMed2001

Lower extremity compartment syndrome in an adolescent with spinal cord injury.

OBJECTIVE: Describe the unusual complication of lower extremity compartment syndrome occurring in an adolescent with spinal cord injury (SCI). METHODS: Case presentation. RESULTS: A 17-year-old male with C5 ASIA A complete SCI developed a compartment syndrome of his lower leg on the ninth day postinjury. Presenting signs included an equinus deformity of the foot, blackened induration over the anterior tibia, circumferential erythematous markings over the calf, large urticarial lesions over the knee, and calf swelling. The presumed etiology of the compartment syndrome was excessive pressure from elastic wraps, which were placed over gradient elastic stockings. Pressures were 51 mmHg in the superficial posterior, 50 mmHg in the deep posterior, 33 mmHg in the anterior, and 34 mmHg in the peroneal compartments. The patient also developed rhabdomyolysis with myoglobinuria. In addition to supportive care, the patient underwent a dual incision fasciotomy for compartment release. CONCLUSIONS: The development of lower extremity compartment syndrome was probably a result of excessive pressure applied by elastic wraps. Elastic wraps should be used with caution in individuals with SCI.

Adolescent↗

PubMed2003

Quantitative assessment of the degree of deep venous reflux of the lower extremities.

OBJECTIVE: We sought to quantitatively evaluate the degree of deep venous reflux of the lower extremities using colour Doppler velocity profile (CDVP) technology. METHODS: Deep venous reflux volume was examined using CDVP in 79 limbs of 66 patients who were admitted to our hospital between July 1999 and July 2000 with primary, deep venous, valvular incompetence. Reflux data were statistically described and analyzed. RESULTS: Of 79 limbs, 20 had grade I reflux, with a mean reflux volume of 29.79 +/- 5.89 mL/min; 19 had grade II reflux, mean reflux volume, 43.87 +/- 4.86 mL/min; 23 had grade III reflux, mean reflux volume, 70.67 +/- 5.77 mL/min; and 17 had grade IV reflux, mean reflux volume, 105.07 +/- 14.8 mL/min. There were significant differences among grades I, II, III and IV (p < 0.05), except between grades I and II (p > 0.05) for analysis of variance and Student-Newman-Keuls analysis, although the 95% confidence interval (CI) of grade I was different from grade II. Every degree of reflux volume showed close correlation with the reflux index. Other indices were less sensitive. CONCLUSIONS: Venous reflux volume is a more accurate non-invasive quantitative assessment of the degree of deep venous reflux in the lower extremities than current methods.

Adolescent↗

PubMedDate not supplied

Efficacy of concentrated autologous platelet-derived growth factors in chronic lower-extremity wounds.

The efficacy of concentrated autologous platelet-derived growth factors in the healing and closure of chronic lower-extremity wounds was evaluated in 24 patients with 33 lower-extremity wounds treated previously for at least 6 months using traditional methods. Surgical wound debridement was performed to convert chronic ulcers into acute wounds. Concentrated autologous platelet-derived growth factors and thrombin were applied to the wound bases and protected with a nonadhering compression dressing that remained intact for 7 days. Wounds were evaluated and the concentrate was reapplied every 2 weeks. Wound closure and complete epithelialization was achieved in 20 wounds. Seventy-five percent or greater wound closure was obtained in three wounds, 50% to 74% closure in three wounds, and 25% to 49% closure in two wounds. Five wounds displayed no improvement. Mean time to complete closure was 11.15 weeks. The application of concentrated autologous platelet-derived growth factors and thrombin resulted in substantial wound healing and wound-diameter reduction. This technique constitutes a safe and effective treatment option and avoids lengthy treatment periods that increase the potential for infection.

Adult↗

PubMedDate not supplied

Diabetes-related lower extremity amputations in Ontario: 1987-88 experience.

Lower extremity amputee rates were estimated for diabetic persons living in Ontario. The rates were specified for age, sex and six Health Regions. The 1987-88 Hospital Records Institute database supplied the information regarding the amputations and the prevalence of diabetes in Ontario was estimated from age/sex specific diabetic rates of the U.S. The crude amputee rate for Ontario is 40 amputees/year/10,000 diabetics and the amputation rate is 44 amputations/year/10,000. These rates are lower than the 101 amputees/year/10,000 reported in the U.K. and are reasonably close to those of the U.S. (59.7 amputations/year/10,000). Age and sex Standardized Morbidity Ratios indicated that Region 1 and 6 have significantly higher and Region 2 significantly lower amputee rates than the Province. There is an almost two-fold difference between the highest and the lowest DRLEA rates of the six regions. (Range: 60-30). These results should be interpreted with caution, since actual prevalence rates of diabetes are not available.

Adult↗

PubMed2001

Prevalence and significance of unrecognized lower extremity peripheral arterial disease in general medicine practice*.

OBJECTIVE: To determine the prevalence of unrecognized lower extremity peripheral arterial disease (PAD) among men and women aged 55 years and older in a general internal medicine (GIM) practice and to identify characteristics and functional performance associated with unrecognized PAD. DESIGN: Cross-sectional. SETTING: Academic medical center. PARTICIPANTS: We identified 143 patients with known PAD from the noninvasive vascular laboratory, and 239 men and women aged 55 and older with no prior PAD history from a GIM practice. Group 1 consisted of patients with PAD consecutively identified from the noninvasive vascular laboratory (n = 143). Group 2 included GIM practice patients found to have an ankle brachial index less than 0.90, consistent with PAD (n = 34). Group 3 consisted of GIM practice patients without PAD (n = 205). MEASUREMENTS AND MAIN RESULTS: Leg functioning was assessed with the 6-minute walk, 4-meter walking velocity, and Walking Impairment Questionnaire (WIQ). Of GIM practice patients, 14% had unrecognized PAD. Only 44% of patients in Group 2 had exertional leg symptoms. Distances achieved in the 6-minute walk were 1,130, 1,362, and 1,539 feet for Groups 1, 2, and 3, respectively, adjusting for age, gender, and race (P <.001). The degree of difficulty walking due to leg symptoms as reported on the WIQ was comparable between Groups 2 and 3 and significantly greater in Group 1 than Group 2. In multiple logistic regression analysis including Groups 2 and 3, current cigarette smoking was associated independently with unrecognized PAD (odds ratio [OR], 6.82; 95% confidence interval [95% CI], 1.55 to 29.93). Aspirin therapy was nearly independently associated with absence of PAD (OR, 0.37; 95% CI, 0.12 to 1.12). CONCLUSION: Unrecognized PAD is common among men and women aged 55 years and older in GIM practice and is associated with impaired lower extremity functioning. Ankle brachial index screening may be necessary to diagnose unrecognized PAD in a GIM practice.

Age Factors↗

PubMed1996

Lower extremity free flaps: a review.

OBJECTIVE: To identify factors related to free-flap coverage of lower extremity fractures that are linked to a negative outcome. DESIGN: A chart review. SETTING: A large microsurgical referral centre. PATIENTS: From 1981 to 1989, the records of all patients who underwent free-tissue transfer to the lower extremity with more than 1 year of follow-up were selected. From this was drawn a subgroup of 49 patients (mean age, 36 years) who had tibial fractures (55% were motor vehicle injuries) and in almost all cases established soft-tissue or bony defects. They formed the study group. INTERVENTION: Free-flap transfer. OUTCOME MEASURES: Factors that might be associated with free-flap failure: mechanism of injury, grade of tibial fracture, history of smoking, diabetes, peripheral vascular disease, ischemic heart disease, vascular compromise in the leg preoperatively, recipient artery used, type of anastomosis, and hypertension or hypotension intraoperatively. RESULTS: Type IIIB tibial fractures were the most frequent (67%) and carried a significantly (p = 0.02) higher risk of free-flap failure than other types of fracture. Patients underwent a mean of four procedures before referral for free-tissue transfer. The mean time from injury to flap coverage was 1006 days. Stable, long-term coverage of the free flaps was achieved in 78% of patients. Wound breakdown was most often caused by recurrent osteomyelitis (65%). Seventy-four percent of the fractures healed. The amputation rate was 10%. Four patients required repeat free-flap transfer for limb salvage. CONCLUSIONS: Only the grade of tibial fracture could be significantly related to postoperative free-flap failure.

Adolescent↗

PubMedDate not supplied

[The biomechanical diagnosis of the venous hemodynamics of the lower extremities].

Based on examinations of 147 patients the authors consider that tonometry, myography, radiothermometry and rheography of lower extremities allow diagnosing venous insufficiency at the prehospital stage. The method of mathematical analysis of the dependence of biomechanical parameters of lower extremities on the degree of venous insufficiency is proposed.

Biomechanical Phenomena↗

PubMed2002

[Somatometric and impedance measurements of the lower extremities in orthopedics].

PURPOSE OF THE STUDY: The objective was to demonstrate the contribution of somatometry and vascular impedance measurement to the evaluation of somatic status and nutrition, particularly the state and function of the vascular system of lower extremities, in patients with arthropathy of the weight-bearing joints. MATERIAL: Impedance plethysmography and impedance phlebography appeared to be the best methods for assessment of vascular hemodynamics; pulse oxymetry, carried out on toes, was most convenient for measurement of haemoglobin saturation with oxygen (HbO2). The state of vessels was determined according to the CEAP classification. Somatometric methods included measurement of the circumference and volume of calves, and assessment of body height, at the anthropometric wall, and weight to calculate the body mass index (BMI). RESULTS: The lower extremities affected by arthropathy were compared with the unaffected ones by means of CEAP classes and related to the body mass values of patients. It was found that only 15 men and 26 women had normal body mass. The rest of the patients were overweight or obese (grade I and II). Only 14 men and 17 women were free of signs of vascular insufficiency, the others were classified in the range of C1 to C4 of the CEAP system. Impedance measurements showed lower mean values for affected extremities and for overweight or obese patients. A comparison of the parameters of arterial and venous hemodynamics between the affected and unaffected extremity by means of the paried t-test gave statistically significant results in patients with higher BMI grades and higher classes of vascular insufficiency, regardless of their gender. The results of HbO2 saturation measurement showed normal values in both men and women. DISCUSSION: To meet the requirements of orthopaedists, the Biophysical Laboratory carried out non-invasive measurements of somatometric parameters and vascular impedance values in patients with arthropathy of the weight-bearing joints of lower extremities. The results were similar to those of a large Framingham cohort study on knee arthropathy and obesity. The data derived from measurement of basic impedance, specific impedance and pulse-related impedance changes show that it is important to record and evaluate skin lesions and oedema because they are related to vascular disease. The finding that an increasing volume the calf was indirectly related to a decreasing basic impedance of calf vessels was confirmed by our results. This information is important for the evaluation of impedance measurement results in order to make diagnosis in individual patients. CONCLUSIONS: Our results showed that, in the group investigated, (i) there was a high proportion of overweight and obese patients; (ii) assessment by CEAP classification revealed higher grades of vascular insufficiency; (iii) affected extremities showed a significant decrease in arterial and venous haemodynamics, particularly in women with higher-grade vascular insufficiency; (iv) there was no difference in HbO2 saturation measured on toes.

Adolescent↗

PubMed1980

[Continuous epidural blockade for frostbite of the lower extremities (author's transl)].

We describe the case of a patient suffering from freezing of the lower extremities, for which continuous epidural-blockade, over a period of four days, was conducted. By this means it was possible to relieve the vessel-spasm caused by the freezing and the patient was spared bilateral upper-thigh amputation. As the lower extremities are concerned in many cases of freezing, a continuous epidural-blockade as described here, seems to be the therapy to choose.

Anesthesia, Epidural↗

PubMedDate not supplied

Treatment of complex regional pain syndrome of the lower extremity.

Complex regional pain syndrome, formerly known as reflex sympathetic dystrophy or causalgia, is a difficult therapeutic problem for the orthopaedic surgeon treating an affected lower extremity. Despite many divergent and often conflicting theories, the cause of the severe pain, alterations in regional blood flow, and edema is unknown. Interventions that have proved successful for treating similar conditions in the arm and hand frequently do not relieve pain similarly in the lower extremity. Common treatment regimens target individual components of this symptom complex, namely, sympathetic or afferent nerve hyperactivity, vasomotor instability, or regional osteoporosis. Despite widespread use of some of these treatments, few controlled clinical trials quantify their effectiveness. This challenging syndrome is best managed by a multidisciplinary team, including chronic pain management specialists, physical therapists, and orthopaedic surgeons.

Complex Regional Pain Syndromes↗

PubMed1993

Magnetic resonance arteriography of the pelvis and lower extremities.

Reconstructive vascular surgery is the last resort for limb salvage in patients with vascular insufficiency. Planning the sites of arterial bypass grafts depends on an exact knowledge of the angiographic anatomy. Currently, conventional contrast angiography is the primary preoperative study for surgical planning. Recently, magnetic resonance (MR) arteriography has been shown to be an accurate technique for the evaluation of slow arterial flow in the lower extremities. The purpose of this review will be to show how MR arteriography can be used as both an adjunct to and in some cases instead of conventional angiography for the preoperative assessment of lower-extremity vascular reconstruction. The derivation of common artifacts, the many pitfalls of interpretation, and the evaluation of peripheral arterial occlusion and percentage stenosis will be discussed. MR arteriography of the lower extremities is an important advance for the noninvasive evaluation of disease of the peripheral vasculature.

Algorithms↗

PubMedDate not supplied

Time-resolved contrast-enhanced magnetic resonance angiography of the lower extremity.

The aim of this prospective study was to evaluate the feasibility and clinical use of time-resolved magnetic resonance angiography (MRA) of the lower extremity compared to intraarterial digital subtraction angiography (IA-DSA). Twenty-two patients suffering from peripheral arterial occlusive disease underwent MRA and IA-DSA. MRA examinations were performed on a 1.5 T system equipped with a 4-element-array coil. The area from the distal abdominal aorta to the distal lower limb was covered by 2-3 examination steps. A T1-weighted gradient echo sequence with a temporal resolution of 7-10 s was used. Single-dose contrast material (0.1 mm/kg) was injected with a flow rate of 2 mL/s, followed by a 40 mL saline flush. Pre and post contrast images were subtracted, and the subtracted data set was postprocessed with maximum intensity projection (MIP). In all patients diagnostic images could be obtained. Problems with venous overlay or incomplete arterial filling were not present. Sensitivity for the detection of relevant stenoses (>50%) was 96.7%, specificity was 97%. Concerning the detection of occlusions, sensitivity was 97.8%, specificity was 99.2%. Time-resolved contrast-enhanced MRA of the lower extremity is a robust procedure with high accuracy in the detection of relevant stenoses and occlusions.

Aged↗