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Soft tissue reconstruction of the lower extremity has evolved considerably over the last 25 years. We no longer have to rely only on awkward pedicle flaps, or ultimately, amputation in order to heal a leg wound. The following is a brief history of the flaps prior to the development and use of the operating microscope and an increased knowledge of the circulation distal to the knee.
Neuropathic injuries of the lower extremities in children due to meningomyelocele, congenital indifference to pain, and peripheral nerve damage were studied in 10 patients. The injuries fell into four categories: (a) fractures of the metaphysis and diaphysis of long bones, (b) epiphyseal separation, (c) Charcot joints, and (d) soft-tissue ulceration. These injuries are often unrecognized; untreated, they can lead to severe disability. For patients with impaired sensation, radiographs should be obtained at any sign of localized soft-tissue swelling, warmth, or hyperemia, especially near a joint. Following diagnosis, immobilization of the limb will lead to prompt healing of fractures and epiphyseal separation.
An alternate technique of performing lower extremity venography is described for use in patients in whom injection into a superficial vein of the foot is not possible.
Patients with extensive lower extremity ulcerations initially thought to be vascular disease were subsequently proved to have pyoderma gangrenosum and malignant lymphoma. Both patients died of sepsis; one patient exhibited hypogammaglobulinemia involving immunoglobulins IgA, IgG, and IgE; in the second patient, a polyclonal excess involving IgA and IgE was present.
Lower-extremity amputation for arterial insufficiency was performed in 282 cases ineligible for vascular surgery. In 203 cases (Group I), amputation was elective without previous vascular surgery. In 14 cases (Group II), amputation followed recent vascular reconstruction, and in 12 cases (Group III) amputation was performed after failed thromboembolectomy. In 53 cases (Group IV), amputation was done acutely, i.e., as a life-saving procedure because of septicemia. The results as regards both knee salvage and survival were much better in Groups I and II than in Groups III and IV. We conclude that knee salvage is poor and mortality high after acute amputations and after failed thrombembolectomy. These factors should be taken into account when comparing series from different centers.
Early rehabilitation of the lower extremity amputee has been achieved in 150 men and women with an average age of 63.2 years. Diabetes was present in 47 patients; all were smokers; 108 had associated cardiovascular disease; 32 had pulmonary disease. Ambulation began at 48 hours with a pneumatic externally supported device. It was total contact, equal pressure throughout (40 mmHg). There were no complications; all patients received a definitive prosthesis 21 to 93 days after amputation. The most common cause of delay in prosthetic use was financial.
Lower-extremity injuries have become increasingly common as sports performance demands have risen. Hyperbaric oxygen therapy is one method used to return athletes to competition as quickly as possible, but it has received criticism and lacks support. This review examines the literature on hyperbaric oxygen therapy and soft-tissue sports injuries. In the various studies, the location of the injury seemed to influence the effectiveness of treatment. Injuries at areas of reduced perfusion such as muscle-tendon junctions and ligaments seemed to benefit more from hyperbaric oxygen treatment than injuries at the muscle belly. Differences in the magnitude of the injury and in the time between injury and treatment may also affect outcomes. The authors sought to explore these variables as they relate to soft-tissue sports injuries and to weigh the benefits of hyperbaric oxygen therapy against its potential risks and high cost. More randomized controlled clinical trials with larger sample sizes must be conducted before hyperbaric oxygen can be established as a safe adjunctive therapy for soft-tissue sports injuries.
Ilizarov method for lower extremity lengthening has been employed in 107 patients. Some 25% of numerous complications are bony union disturbances. Dual energy X-ray absorptiometry (DEXA) for assessment of new bone formation was introduced to reduce these problems. Detailed densitometry methodology developed on the ground of 93 measurements in 11 patients is presented. Pre-operative measurement was followed by subsequent evaluations done every 3 weeks after the onset of distraction. DEXA was capable of showing the callus 3-4 weeks earlier than conventional radiography. DEXA allows for adjusting the pace of lengthening to the extent of new bone mineralization, evaluation of lengthening achieved, determining the timing for safe removal of the apparatus. The need for temporary rearranging of the apparatus and troublesome image analysis are among the drawbacks of the method.
Occlusive diseases of arteries of the lower extremities with underlying atherosclerosis present a serious medical problem. Despite some generally accepted principles, the diagnostic and therapeutic process in this disease keeps constantly developing. The author deals not only with verified therapeutic procedures such as reconstructive surgery of arteries, endarterectomy, profundoplastics, sympathectomy, but also with the diapeutic method of treatment, percutaneous transluminal angioplasty, which is being used ever more frequently. In indicated cases, percutaneous transluminal angioplasty is considered to be the alternative method to arterial reconstructive surgery. The algorithm of treatment applied in the author's department is presented.
DSA was applied to the lower extremity phlebography on 21 cases (36 legs). The patient lay in the supine position and a tourniquet was placed around the ankle. Forty ml of contrast medium, diluted to 25% of the original concentration with normal saline, was injected into the dorsal vein of the foot. The anterior tibial vein, posterior tibial vein, peroneal vein and muscular vein of the calf were identified in 24 (63.2%), 36 (94.7%), 37 (97.4%) and 7 legs (18.4%), respectively. The poor opacification of the anterior tibial vein was attributed partly to the compression effect of the tourniquet. The abnormal findings were deep vein thrombosis (5 legs), reflux from the deep to the superficial vein (14 legs) and irregularity of the venous wall (16 legs). The superficial varicose veins were not demonstrated in DSA phlebography. The examination was comfortable because the patient position was supine and the dilute contrast medium caused no burning sensation. We believe that DSA phlebography is a safe and useful method for diagnosing the deep venous system disorders.
Venous aberrations in the lower extremity, whether acute or chronic, have disastrous effects on individual patients, their families, and society in general. Whether the challenge is the treatment of varicose veins or that of maintaining patency of a venous reconstruction, it is obvious that many questions remain unanswered. Additional experimental research and clinical experience must be documented in carefully organized scientific studies.
One hundred thirty-four lower extremity amputees were evaluated from six months to 12 years postamputation by means of retrospective questionnaires. Patient population was similar to that of the "Amputee Census" in terms of sex, amputation level and cause of amputation. Information was gathered on activities generally considered essential for daily living, vocation and recreation, living arrangements and adjustments therein, as well as feedback on the patients' beliefs concerning what rehabilitation personnel should be doing to improve amputees' lifestyle. The relationship of functional outcome to age, amputation level, and cause of amputation was also evaluated. Results showed that most amputees did not resume a completely normal lifestyle and many modifications were made. The most popular recreational activities were fishing and swimming. Activities that amputees found most difficult were running and walking long distances. Patients requested better communication between professional staff and themselves. Below-knee amputees were significantly more independent than above-knee and bilateral amputees, but the differences between above-knee and bilateral amputees were statistically insignificant. Tumor patients did better than the other three etiologic groups. As age increased, functional independence decreased.
A review of lower-extremity length-discrepancy data in 803 patients demonstrated that not all discrepancies continue to increase at a constant rate with time. A classification of the developmental discrepancy patterns identified is presented: type I, upward slope; type II, upward slope-deceleration; type III, upward slope-plateau (type IIIA, downward slope-plateau; type IIIB, plateau); type IV, upward slope-plateau-upward slope; and type V, upward slope-plateau-downward slope. The patterns are dependent on the nature of the conditions causing the discrepancies and on the place and time of their occurrence. The distribution of the types of patterns in the various etiological groups is presented. The classification of developmental patterns illustrates the varying directional changes that can occur in these discrepancies and their dependence on underlying biological phenomena. Determination of the distribution of pattern types in the various conditions aids in planning the frequency of length-discrepancy studies. The patterns alone do not provide projections of final discrepancies, but when used in conjunction with the femoral-tibial length and growth-remaining charts of Green and Anderson they permit accurate projections of discrepancy to be made.
Judging the appropriate time for amputating lower extremities with open fractures and major soft tissue damage is a major problem for physicians. Limb salvage through vascular repair and external fixation is frequently unjustified. Attempts at saving a limb that should be amputated often are followed by renal failure, sepsis, and death. Much research remains to be done in this area.
Femoral fracture in patients with lower extremity amputations is relatively rare (reported incidence in 341 amputee patients, 2.35%). Lack of adequate support and balance, and osteoporosis on the amputation side, may explain the predisposition to fracture of the ipsilateral extremity. The prosthesis was in use at the time of the accident in only 3 of 9 cases studied, most falls occurring during transfer activity without a prosthesis. Proximal femoral fractures in below-knee amputee patients responded to open reduction with internal fixation and early ambulation. Others were treated with closed reduction and cast immobilization. Overall union was 100%, with all patients regaining their previous ambulatory levels and prosthesis skills.
27 patients with atherosclerotic occlusion of lower extremities were admitted from January 1988 to December 1992. Those patients underwent various kinds of bypass operations, with an effective rate of 86.8%. Some factors influencing the operative effect are discussed.
111 adult patients hospitalized with lower extremity fracture (LEF) at three teaching hospitals of Beijing Medical University were interviewed by using STAI and CES-D. The results showed that the prevalence of depression in this group using CES-D is 69.4%, and there was a high correlation between STAI scores and CES-D scores. Multivariante analyses indicated that physical status, financial crisis, age, knowledge about disease, especially the patients' perceived threat of fracture, and social supports were the main factors that contribute to the patients' emotional distress.
BACKGROUND: Postoperative epidural fibrosis may contribute to between 5% to 60% of the poor surgical outcomes following decompressive surgery. Correlations have been reported between epidural scarring and radicular pain, poor surgical outcomes, and a lack of any form of surgical treatment. The use of spinal endoscopic adhesiolysis in recent years in the management of chronic refractory low back and lower extremity pain has been described. METHODS: A prospective, randomized, double-blind trial was conducted to determine the outcome of spinal endoscopic adhesiolysis to reduce pain and improve function and psychological status in patients with chronic refractory low back and lower extremity pain. A total of 83 patients were evaluated, with 33 patients in Group I and 50 patients in Group II. Group I served as the control, with endoscopy into the sacral level without adhesiolysis, followed by injection of local anesthetic and steroid. Group II received spinal endoscopic adhesiolysis, followed by injection of local anesthetic and steroid. RESULTS: Among the 50 patients in the treatment group receiving spinal endoscopic adhesiolysis, significant improvement without adverse effects was shown in 80% at 3 months, 56% at 6 months, and 48% at 12 months. The control group showed improvement in 33% of the patients at one month and none thereafter. Based on the definition that less than 6 months of relief is considered short-term and longer than 6 months of relief is considered long-term, a significant number of patients obtained long-term relief with improvement in pain, functional status, and psychological status. CONCLUSION: Spinal endoscopic adhesiolysis with targeted delivery of local anesthetic and steroid is an effective treatment in a significant number of patients with chronic low back and lower extremity pain without major adverse effects.