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BACKGROUND AND HYPOTHESIS: Lower extremity symptoms accompanying dissecting hematomas of the aorta are well described. Isolated lower extremity ischemia as the presenting syndrome of aortic dissection is rare and frequently misinterpreted so that the diagnosis of aortic dissection is delayed or missed, often with catastrophic results. This study was undertaken to determine its common characteristics and to reinforce recognition of this life-threatening phenomenon. METHODS: After the first patient in our series presented with isolated lower extremity ischemia due to aortic dissection, a prospective search for similar presentations was undertaken over 2 years. We also conducted a retrospective search for all aortic dissections at our hospital for the past 10 years and a MEDLINE search for all reported aortic dissections in the literature of the past 20 years, as well as for all reports of isolated ischemia of the lower extremities due to aortic dissection. RESULTS: Three patients with isolated ischemia of the lower extremities due to aortic dissection were found prospectively after the index case. Over 10 years, 40 patients with acute aortic dissection were diagnosed at our hospital. The MEDLINE search revealed 1,751 aortic dissections of which 10% had lower extremity symptoms. Only 10 cases of aortic dissection were reported as lower extremity ischemia with symptoms isolated to one or both lower extremities. Smoking, hypertension, male gender, hypercholesterolemia, and recent history of coronary artery bypass grafting were common predisposing risk factors for this rare presentation. CONCLUSION: Symptomatic isolated ischemia of the lower extremities due to aortic dissection is rare and often missed. Awareness of its characteristics, aided by the acronym ILEAD, made it possible to suspect the true origin of this misleading syndrome.
Lower extremity symptoms are caused by lesions at any level of the neuraxis, from cortex to muscle. HIV affects virtually every level of the nervous system, either directly or indirectly. The presence of pathology at multiple levels and by multiple processes further complicates the bedside diagnosis of a patient with AIDS and neurologic symptoms. Many neuropathies and other conditions that affect the lower extremities can be identified with careful history and physical examination, confirmed with limited testing, and can be treated successfully. Distal symmetric polyneuropathy is the most common lower extremity disorder, but it must be distinguished from similar-appearing neuropathies caused by medications, B12 deficiency, or vasculitis. Diffuse infiltrative lymphocytosis syndrome also causes a painful peripheral neuropathy that must be distinguished from distal symmetric polyneuropathy. Inflammatory demyelinating polyneuropathies are characterized by muscle weakness. They occur in early, asymptomatic HIV infection and respond to plasmapheresis or steroids. Mononeuropathies in patients with CD4 counts more than 200 often resolve on their own. Multiple mononeuropathies, which occur in patients with CD4 counts less than 50, are often associated with cytomegalovirus infection and may follow a rapidly progressive course unless treated promptly and aggressively. Progressive polyradiculopathy occurs late in the course of AIDS, is often caused by cytomegalovirus, is rapidly progressive, and generally is fatal unless recognized and treated promptly. Muscle weakness, myalgia, and fatigue are common in HIV and have multiple causes. Lower extremity spasticity may be caused by treatable etiologies such as spinal cord abscess, tumor, disc compression, B12 deficiency, or ischemia. Gait disturbances are common but nonspecific and may be caused by treatable neurologic disorders at any level of the neuraxis.
OBJECTIVES: To determine if race/ethnicity is independently associated with an increased risk for nontraumatic lower extremity amputation versus lower extremity bypass revascularization among patients with peripheral arterial disease (PAD). METHODS: Data were analyzed from the National VA Surgical Quality Improvement Program (NSQIP) and from the Veterans Affairs Patient Treatment File (PTF). Race/ethnicity was defined as non-Hispanic white, black, or Hispanic. Variables that were univariately associated (P < or = 0.05) with the outcome of amputation were placed into a multiple logistic regression model to determine independent predictors for the dependent variable, lower extremity amputation versus lower extremity bypass revascularization. RESULTS: Three thousand eighty-five lower extremity amputations and 8409 lower extremity bypass operations were identified. Among all cases included, there were 416 Hispanic patients (3.6%), 2337 black patients (20.3%), and 8741 non-Hispanic white patients (76.1%). Among all variables within the model, Hispanic and black race were each associated with a greater risk for amputation than a history of rest pain/gangrene (Hispanic race 1.4, 95% CI 1.1, 1.9; black race 1.5, 95% CI 1.4, 1.7; rest pain/gangrene 1.1, 95% CI 1.0, 1.3). The final model had a c statistic of 0.83. CONCLUSION: Hispanic race and black race were independent risk factors for lower extremity amputation in patients with PAD. Although the burden of certain atherosclerotic risk factors (eg, diabetes and hypertension) is higher in minority patients, the impact of this burden does not account for the increased risk for the outcome of lower extremity amputation in these two populations. Further research is needed to better understand the reason(s) why race/ethnicity is independently associated with poor outcomes in PAD.
BACKGROUND: Although stroke and lower extremity fracture are often viewed as distinct medical rehabilitation conditions, they share similarities in that they are both experienced primarily among older adults, and are often accompanied by gero-psychological problems such as dementia and depression. In spite of these similarities, actual comparisons of these prevalence rates have been rare in the previous literature, most likely due to obvious differences in the nature of the injuries involved (neurological vs. peripheral injury). METHODS: One hundred and one stroke and 198 lower extremity fracture patients were assessed with neuropsychological tests from the Normative Studies Research Project test battery. The prevalence rates of dementia and depression were then compared between these two patient groups. RESULTS: Overall, 34.7% of stroke and 27.8% of lower extremity fracture patients met the criteria for dementia. In addition, 33.3% of stroke and 25.1% of lower extremity fracture patients scored in the depressed range on the Geriatric Depression Scale. The prevalence rates for dementia and depression did not differ significantly between these two patient groups. CONCLUSIONS: Although rehabilitation efforts focus mainly upon the primary diagnoses of geriatric patients, these findings suggest that stroke and lower extremity fracture should be considered within the context of the geriatric issues (e.g., dementia, depression, and comorbid medical illness) which accompany them.
BACKGROUND AND PURPOSE: This study examined the validity of the clinical tenet that poststroke recovery of the upper extremity is less rapid and complete than poststroke recovery of the lower extremity. Previous studies comparing upper and lower extremity recovery have evaluated disability rather than motor impairment. Individuals with lower extremity impairments may be more functional and appear less disabled than individuals with upper extremity impairments. Function of the upper extremity requires finer motor control, for which the patient can less readily compensate. Therefore, impairments and disability would predictably be more highly correlated in this area. We tested the hypothesis that upper and lower extremity motor recovery are similar. METHODS: The 95 patients selected for this study were enrolled in the Durham County Stroke Study and had been diagnosed with anterior circulation ischemic stroke. Each subject received Fugl-Meyer assessments within 24 hours of admission and then 5, 30, 90, and 180 days after stroke. We used these assessments to compare the time course and patterns of motor function of the upper and lower extremities. RESULTS: Repeated-measures ANOVA revealed that percent maximal motor recovery was significantly (P < .001) affected by time after stroke but not by extremity (upper extremity versus lower extremity) (P = .32). When stroke severity level is controlled, the upper and lower extremities continue to show no difference in percent motor recovery (P = .19). CONCLUSIONS: In patients with anterior circulation ischemic stroke, the severity of motor impairment and the patterns of motor recovery are similar for the upper and lower extremities. The most rapid recovery for both extremities occurs within 30 days.
OBJECTIVES: Multiple (> 1) revisions of lower extremity vein grafts may be required to maintain patency. Characteristics of recurrent lower extremity vein graft lesions and the patency achieved after multiple revisions have not been emphasized in reports on infrainguinal vein graft stenosis. This study was performed to determine (1) the patency of multiply revised lower extremity vein grafts and (2) the timing, location, and angiographic and duplex features of the recurrent lesions. METHODS: Lower extremity vein grafts that were followed in a duplex surveillance protocol and required revisions from January 1990 through December 1998 were identified. All revisions were preceded by angiography. In multiply revised lower extremity vein grafts, the immediate preoperative angiogram and duplex examination findings, as well as the angiogram made before the previous revision and the duplex study done after the previous revision, were reviewed to characterize recurrent lesions at the time of previous and current graft revision. The patencies of grafts undergoing single and multiple revisions were compared. RESULTS: A total of 233 lower extremity vein graft revisions were performed; of these, 50 (21%) were repeat revisions. Of grafts requiring more than one revision, 98% were normal on duplex examination after the initial revision. Five-year assisted primary patency of multiply revised grafts (91%) was not different from that of grafts with a single revision (89%; P not significant). Of 60 lesions repaired in the 50 repeat revisions, 29 (48%) were at the previously revised site, and 31 (52%) were at new sites. The time between revisions was less if the same site was revised (11 +/- 2 months) than if a different site required revision (20 +/- 4 months; P <.05). Arteriographic evidence of a minor (< 50% diameter) lesion was present at the time of the initial revision in 23% of cases in which revision of a second site was subsequently required. CONCLUSION: In our experience, 21% of lower extremity vein grafts requiring initial revision ultimately require additional revisions. Multiply revised lower extremity vein grafts have excellent long-term patency. Lesions occur with equal frequency at the site of prior revision and new sites. Lesions prompting revision at new sites occur significantly later and are infrequently detected on prior imaging studies.
BACKGROUND: Despite the significant public health burden of lower-extremity amputations in diabetes mellitus, few data are available on the epidemiology of lower-extremity amputations in diabetes mellitus in the community setting. METHODS: A retrospective incidence cohort study based in Rochester, Minn, was conducted. RESULTS: Among the 2015 diabetic individuals free of lower-extremity amputation at the diagnosis of diabetes mellitus, 57 individuals underwent 79 lower-extremity amputations (incidence, 375 per 100,000 person-years; 95% confidence interval, 297 to 467). Among the 1826 patients with non-insulin-dependent diabetes mellitus, 52 underwent 73 lower-extremity amputations, and the subsequent incidence of lower-extremity amputation among these residents was 388 per 100,000 person-years (95% confidence interval, 304 to 487). Of the 137 insulin-dependent diabetic patients, four subsequently underwent five lower-extremity amputations (incidence, 283 per 100,000 person-years; 95% confidence interval, 92 to 659). Twenty-five years after the diagnosis of diabetes mellitus, the cumulative risk of one lower-extremity amputation was 11.2% in insulin-dependent diabetes mellitus and 11.0% in non-insulin-dependent diabetes mellitus. When compared with lower-extremity amputation rates for Rochester residents without diabetes, patients with non-insulin-dependent diabetes mellitus were nearly 400 times more likely to undergo an initial transphalangeal amputation (rate ratio, 378.8) and had almost a 12-fold increased risk of a below-knee amputation (rate ratio, 11.8). In this community, more than 60% of lower-extremity amputations were attributable to non-insulin-dependent diabetes mellitus. CONCLUSIONS: These population-based data document the magnitude of the elevated risk of lower-extremity amputation among diabetic individuals. Efforts should be made to identify more precisely risk factors for amputation in diabetes and to intervene in the processes leading to amputation.
Lower extremity equipment-related injuries are the most significant injury group in alpine skiing. The lower extremity equipment-related injuries occurring at four Norwegian ski resorts were studied during the winter of 1985 to 1986. A total of 132 skiers with injuries were included (40% of all injured skiers) and compared with a randomly selected control population of 316 uninjured skiers. The most common lower extremity equipment-related injuries were knee sprains (56%) and lower leg fractures (14%), usually caused by no or late binding release. Significantly more lower extremity equipment-related injuries (33%) than other skiing injuries (19%) needed hospital admittance. Children below 10 years had a risk of lower leg fractures nine times that of skiers beyond 20 years. Beginners were six times more at risk for a lower extremity equipment-related injury than skiers of higher skiing abilities. The following factors were also associated with a significantly increased risk for a lower extremity equipment-related injury: less than three skiing seasons, no skiing instruction, and no self-testing of the bindings.
Completely independent application of lower extremity prostheses and clothing is essential but often difficult to accomplish in optimal rehabilitation of the bilateral above-knee amputee. This paper suggests an occupational therapy treatment plan for above-knee amputations, discusses reasons for dependency and decreased use of lower extremity prostheses and clothing, and describes a bilateral lower extremity dressing frame designed for independent application of prostheses and lower extremity clothing. The cost of rehabilitation can be justified once independence in application of prostheses and clothing is accomplished and functional ambulation is achieved.
OBJECTIVE: Lower-extremity amputation is a common complication among patients with diabetes throughout the world. However, few data exist on the actual impact of the recent moves to improve the management of diabetic foot ulcers to reduce the incidence of lower-extremity amputations. The aim was to determine the incidence of lower-extremity amputations among diabetic patients from 1991 to 2000 in The Netherlands. RESEARCH DESIGN AND METHODS: A secondary database containing information regarding all hospital admissions in which a lower-extremity amputation occurred for the years 1991-2000 was obtained from the Dutch National Medical Register. Because a patient-unique identifier was included, multiple amputations and hospitalizations for a single individual could be identified. Furthermore, age- and sex-specific diabetes prevalence rates were calculated using a 3-year average for every year, calculating the total diabetic population in the Netherlands at risk for every year. RESULTS: In 1991, a total of 1,687 patients with diabetes had been admitted 1,865 times for 2,409 amputations. In 2000, a total of 1,673 patients with diabetes were admitted 1,932 times for 2,448 amputations. The overall incidence rates of the number of patients who underwent lower-extremity amputation decreased over the years from 55.0 to 36.3 per 10,000 patients with diabetes (P < 0.05). Both in men (71.8 vs. 46.1, P < 0.05) and women (45.0 vs. 28.0, P < 0.05) with diabetes, a significant decrease could be observed. Mean duration of hospitalization decreased from 45.0 days (SD 44.4) in 1991 to 36.2 days (SD 38.4) in 2000; decreases were observed for both men and women. CONCLUSIONS: Over the years observed in this study, the incidence rates of diabetes-related lower-extremity amputation in The Netherlands was found to decrease in both men (36%) and women (38%) with diabetes. Furthermore, the duration of hospitalization decreased over time.
Lower extremity injuries are among the most common injuries sustained by motorcycle riders in crashes and often lead to extended and costly medical treatment and permanent disability. This study characterizes lower extremity injuries in a group of 700 motorcycle riders in crashes in Los Angeles County from July 1, 1988, through October 31, 1989. Motorcycle crash fatalities (n = 163) were identified through the Los Angeles County Coroner's office, and nonfatally injured riders (n = 537) were identified at four of the ten level I and level II trauma centers in the county. Lower extremity injuries were diagnosed in 301 (56%) of nonfatally injured and in 75 (46%) of fatally injured riders. Fractures were the most common lower extremity injury and were diagnosed in 52% and 42% of riders with nonfatal and fatal injuries, respectively. Over a third of all fractures were to the tibia or fibula. Drivers and passengers did not differ in their risk for lower extremity injuries. Multiple-vehicle collisions resulted in a higher risk of lower extremity injuries than did single-vehicle collisions. The highest risk for lower extremity fractures was observed among riders in broadside collisions in which another vehicle struck the motorcycle (risk ratio = 2.7). Modifications in vehicle design and rider apparel may prevent some lower extremity injuries in motorcycle crashes.
Successful revascularization of the severely ischemic lower extremity can be achieved by femorotibial as well as femoropopliteal bypass. The incidence of delayed graft occlusion after salvage of the severely ischemic lower extremity is low in patients with femorotibial or femoropopliteal bypass. Femorotibial bypass was performed in over one-third of patients undergoing bypass. Tibial bypasses resulted in effective prolonged revascularization of the severely ischemic lower extremity. An aggressive diagnostic and therapeutic approach to revascularization of the severely ischemic lower extremity can result in prolonged limb salvage by tibial or popliteal bypasses in lieu of primary amputation.
Soft-tissue infection following lower extremity trauma has not been studied in detail in light of recent data on biology of infection. This article examines specific problems in lower extremity trauma that allow the wound to become susceptible to wound infection. It also illustrates the various principles of wound management in lower extremity trauma that serve to prevent infection. Two case examples are used to illustrate principles of management. Other wound problems in lower extremity trauma are also discussed, such as rabies, necrotizing soft-tissue infection, tetanus, and diabetic foot infections.
Lower-extremity wounds with exposed tendon, bone, or orthopedic hardware present a difficult treatment challenge. In this series of patients, subatmospheric pressure therapy was applied to such lower-extremity wounds. Seventy-five patients with lower-extremity wounds, most of which were the result of trauma, were selected for this study. Dressings made of sterile open-cell foam with embedded fenestrated tubing were contoured to the wound size and placed into the wound. The site was covered with an adhesive plastic sheet. The sheet was placed beneath any external fixation devices, or the fixation device was enclosed within the sheet. The tubing was connected to the vacuum-assisted closure pump. Continuous subatmospheric suction pressure (125 mmHg) was applied to the wound site. The wounds were inspected and the dressings were changed every 48 hours.Vacuum-assisted closure therapy greatly reduced the amount of tissue edema, diminishing the circumference of the extremity and thus decreasing the surface area of the wound. Profuse granulation tissue formed rapidly, covering bone and hardware. The wounds were closed primarily and covered with split-thickness skin grafts, or a regional flap was rotated into the granulating bed to fill the defect. Successful coverage was obtained without complication in 71 of 75 patients. Wounds have been stable from 6 months up to 6 years.
BACKGROUND AND OBJECTIVES: Lower-extremity spider veins are a cosmetic problem that poses formidable clinical difficulty for laser removal. They are significantly harder to remove than facial telangiectasias. A new-generation, pulsed-dye laser (PDL), capable of administering pulses that clinically behave like true 40-millisecond pulses has been developed, by doubling the number of sub-pulses comprising each laser pulse. STUDY DESIGN/MATERIALS AND METHODS: Fifteen subjects with Fitzpatrick skin types I-III were enrolled in the study and treated to 35 sites. Subjects were treated three times at 6-week intervals using an average fluence of 20.4 J/cm(2), a 3 x 10 mm spot, and a dynamic cooling device to protect the epidermis. Digital photographs were taken before initiating treatment and 8 weeks following the final treatment. RESULTS: Mean improvement scores using a 4-point scale as rated subjectively by the treating physician were 0.92 (<25%), 2.7 (approximately 40-50%), and 3.6 (approximately 65-75%), 6 weeks following 1st and 2nd treatments and 8 weeks following the 3rd and final treatment, respectively. Improvement was also determined by three physicians, rating digital photographs and blinded as to which photographs were pre- or post-treatment. They rated improvement as mild (0-25%) in 10.5% of photographs, moderate (26-50%) in 15.2%, marked (51-75%) in 38.1%, and excellent (76-100%) in 6.3%. There was no textural change in any treatment site. CONCLUSIONS: The new-generation, high-energy, 595 nm, long pulse-duration, PDL effectively removes lower-extremity spider veins in subjects with skin types I-III.
BACKGROUND: Patients undergoing lower extremity revascularization have associated cardiovascular risks: smoking, hypertension, dyslipidemia, and diabetes. This study evaluated the impact of cardiovascular risk factors on proximal versus distal arterial occlusive disease in patients undergoing lower extremity revascularization as adjusted to a control group without vascular disease. STUDY DESIGN: We performed a retrospective, case-control study that included 151 patients undergoing lower extremity revascularization and 229 patients undergoing knee and hip replacement (controls). Risk factors were determined for each of three separate groups undergoing revascularization for different levels of occlusive disease: aortoiliac, superficial femoral, and popliteal-tibial. Comparisons to controls were tested using t-tests or chi-square tests and multiple logistic regression. RESULTS: Dyslipidemia was associated with a significant risk of aortoiliac (odds ratio [OR]=3.4; p=0.0006) and superficial femoral occlusion (OR=2.8; p=0.01) but was less strongly associated with popliteal-tibial occlusion (OR=2.1; p=0.09). Smoking was strongly associated with aortoiliac (OR=4.5; p=0.004) and superficial femoral disease (OR=4.6; p=0.0007) but not popliteal-tibial disease (OR=1.3; p=0.53). In contrast, diabetes mellitus and chronic renal insufficiency were strong risk factors for popliteal-tibial occlusion (OR=5.4, p=0.0002; OR=3.9, p=0.01, respectively), but were not significant risk factors for aortoiliac or superficial femoral occlusion. CONCLUSIONS: These data, which use revascularization level as a surrogate marker for lower extremity arterial disease, suggest that the risk factor profile for proximal disease differs from that of distal disease. These findings may reflect differences in the biology of disease and indicate that different risk factors have various anatomic influences on arterial disease formation.
Authors have done a retrospective analysis of 94 lower extremities in 88 patients examined from 1996 to 2002 for recurrence of varices in lower extremities. The goal was to find out the most frequent causes of recurrence of varices in lower extremities in patients with history of varices surgery referred to venous guidance clinic because of another onset of varices in lower extreminites or clinical signs of chronic venous insufficiency. Reflux was proved in 78 lower extremities from the total number of 94 (83%) in our sample. Isolated reflux was discovered in 59 extremities in saphenofemoral junction (39 extremities), in saphenopopliteal junction (14 extreminies), and in perforators (6 extremities). Combined reflux detected simultaneously in two or three places (SFJ, SPJ, perforators) was found in 19 extremities. In 11 cases the reflux was proved in two places and in 8 cases even in 3 places simultaneously. The main cause of recurrence of varices in lower extremities in our sample was reflux especially in saphenofemoral junction and saphenopopliteal junction. Reflux in perforators was usually accompanied with saphenofemoral and/or saphenopopliteal junctions incompetence. Isolated reflux in perforators was found very rarely (6.4%). The cause of varices recurrence was not disclosed in 17% of cases.