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The evaluation and surgical treatment of metastatic lesions of the lower extremity and pelvis are reviewed. The initial evaluation, biopsy considerations, treatment options, special techniques, and controversial areas are discussed.
The experience with treatment of 126 patients with ulcerous-necrotic lesion of the lower extremities of different genesis was summarized. A comparative evaluation of the effectiveness of treatment depending on a type of the magnetic field: the constant, alternating, or travelling impulse one was carried out. The most effective was the use of a travelling impulse magnetic field. The results of the investigation performed give grounds to recommend the wide use of magnetotherapy in the complex treatment of trophic ulcers of the lower extremities.
In 19 patients (male-female: ratio 10:9; median age 67.1 (42-90) years) with a critical ischaemia of the lower extremities either after failed attempt of revascularization (n = 4) or because of lacking possibility for vessel reconstruction measures (n = 16) a regional extremity perfusion with a fibrinolytic agent has been performed using a heart lung machine. In one patient both lower extremities were treated. In the first 30 minutes of the total 60 minutes perfusion time on average 31 mg (20-50 mg) of recombinant tissue-plasminogen activator (Actilyse) have been added to the perfusion solution. In order to enhance the fibrinolysis-activity the perfusion solution was warmed up to 40 degrees C. Systemic side effects have not been observed. Two patients died postoperatively because of their underlying diseases (mesenteric artery embolism, myocardial infarction), two patients experienced postoperative haemorrhage and one patient had a wound infection. In 11 cases (55%) an opening of the stem-arteries has been reached. Seven of these were successfully revascularized with a femoro-crural bypass in a following operation. Nine extremities (45%) remained without opening of the stem-arteries, however, in four cases (20%) an improved radiographic contrast of the collaterals has been reached. 11 (61%) of the followed-up extremities were successfully revascularized. Amputation has been performed in seven cases (39%). The regional hyperthermic perfusion with fibrinolytic drugs enables a reopening of the stem-arteries and the creation of accepting vessels for vascular procedures in primarily inoperable arterial occlusions.
Percutaneous transluminal angioplasty (PTA) has provided an alternative method of treatment for occlusive disease of the lower extremities. However, the long-term durability of PTA compared with that of surgical reconstruction has not been adequately evaluated. This study was undertaken to assess the long-term hemodynamic results of PTA. Thirty-four dilatations performed on 28 patients over a 30-month period and followed for 1 to 53 months were reviewed. Twenty-two dilatations were done in the iliac arteries, seven in the superficial femoral, three in the popliteal, one in the peroneal artery, and one at a bypass graft anastomosis. All patients underwent noninvasive measurements of lower extremity segmental pressure prior to dilatation and at scheduled follow-up intervals. Success was defined as an increase in the Doppler-derived segmental lower extremity/brachial index of greater than or equal to 0.15 or normalization of the index (greater than or equal to 0.90), measured at the closest level distal to the site of dilatation. Sixteen of 22 iliac dilatations (72.7%) were initially successful. However, long-term success was maintained in only six (27.6%). Cumulative hemodynamic success for the initially successful iliac dilatations was 28% at 3 years. Seven of 11 (63.6%) dilatations performed on infrainguinal arteries were initially successful; however, only two (18.2%) experienced continued success. Cumulative hemodynamic success for the initially successful infrainguinal dilatations in this group was 35% at 3 years. Although immediate patency and improvement in hemodynamic parameters are similar to comparable surgical procedures, these results demonstrate that PTA is not as durable as conventional surgical procedures.
The decision to perform free flap microanastomosis to clearly uninjured vessels proximal to the zone of injury for lower extremity reconstruction must be weighed against the anatomic and technical difficulties of performing such an anastomosis. Preserved blood flow through vessels traversing the zone of injury has been shown. The records of all patients who underwent lower extremity reconstruction with microvascular free flaps at NYU Medical Center and Bellevue Hospital Center from January 1979 through August 1995 were reviewed. Patients with free flap microanastomoses distal to the zone of injury were compared with those with proximally based anastomoses. The group of patients was subdivided further into acute (1-21 days), subacute (22-60 days), and chronic (greater than 60 days) reconstruction groups. Of 451 microvascular free flaps, 35 were performed with recipient vessels distal to the zone of injury. Time interval from injury to coverage ranged from 24 hours to 57 years. Of 35 distally based flaps, 33 (94 percent) were successful and 5 required reoperation (14 percent). There was a similar incidence of thrombotic complications throughout all after-injury phases. Of 416 free flaps performed with microanastomoses to vessels proximal to the zone of injury, 388 (93 percent) were successful and 62 (15 percent) required reoperation. There was no significant difference (p > 0.05) in outcome between distal and proximal anastomoses and no significant difference (p > 0.05) in rates of reoperation. Timing of operation after injury had no bearing on outcome. Distally based microvascular free flaps anastomoses may be technically less difficult with rates of survival equal to those of proximally based flaps. The consideration and use of microanastomoses distal to the zone of injury are encouraged in selected patients.
Relative tensility and resistivity of walls of superficial and deep veins were studied on 200 lower extremities in persona at the age of 4--86 years. The ability of valves to resist the retrograde liquor flow was studied on the same veins. The data on the valves "endurance" were compared with the character of their connective tissue framework. Relative lengthening of the venous walls increases up to 30--35 years of age, after that time these indices decrease. The wall resistivity is higher in the deep than in the superficial veins. The ability of the lower extremity valves to resist the retrograde liquor pressure is gradually increasing up to 60 years of age, and afterwards this ability is somewhat decreasing.
INTRODUCTION: The purpose of this study was to determine the effects of self-selected versus standardized running speeds on within-day and between-day repeatability of lower extremity kinematics and kinetics for running gait. METHODS: Subjects (six female, six male, age 18-35) were recreational athletes with no lower extremity injuries. The following study variables were analyzed using the coefficient of variation (CV): the peak angles for knee internal rotation, external rotation, varus, valgus, flexion, and extension; peak angles for ankle dorsiflexion and plantar flexion; peak impact force and propulsive force; and peak anterior, posterior, medial, and lateral ground reaction forces (GRFs). Data for the entire stance phase were analyzed using the coefficient of multiple correlation (CMC) for the following variables: anterior-posterior, medial-lateral, and vertical GRF; the angles and angular velocities for knee internal-external rotation, valgus-varus, flexion-extension, and ankle dorsiflexion-plantar flexion. Each variable was analyzed using a 2 x 2 (speed x day) repeated measures ANOVA (alpha = 0.05). RESULTS: The within-day repeatability for all of the significantly different variables was greater than the between-day repeatability. For variables with a significant difference based on speed, the standardized running speed had greater repeatability. CONCLUSIONS: Within-day repeatability is generally greater than between-day repeatability. Running speed had little effect on the repeatability of any study variable. Having subjects run at a standardized speed may not be as important as previously thought.
OBJECTIVE: Investigate the effect of relaxation training/thermal biofeedback on blood circulation in the lower extremities of diabetic subjects. RESEARCH DESIGN AND METHODS: Diabetic subjects (n = 40) aged 17-73 yr were volunteers recruited through the University of Wisconsin-La Crosse, the local ADA Chapter, and a medical clinic. A within-subjects experimental design was used. During phase 1, all subjects used a self-selected relaxation method and recorded toe temperatures daily. During phase 2, subjects were taught a biofeedback-assisted relaxation technique designed to elicit sensations of warmth in the lower extremities and increase circulation and temperature. Subjects relaxed at home with the use of a designated relaxation tape. They measured and recorded toe temperatures. Each phase lasted 4 wk. RESULTS: Toe temperature and blood volume pulse (BVP) data were gathered at the beginning and end of phases 1 and 2. Paired t tests compared the means of temperature percent change scores between 1 and 2. Mean temperature change scores were 8.73% (phase 1) and 31.38% (phase 2) (t = -8.00, df = 39, P less than 0.001). Mean BVP change scores were 2.33% (phase 1) and 22.47% (phase 2) (t = -9.24, df = 35, P less than 0.001). Based on eta squared, 71% of the BVP increase in phase 2 was attributed to the relaxation technique. A multiple regression analysis indicated that none of the other examined variables affected by diabetes were significant predictors of BVP increase. CONCLUSIONS: Data indicate that diabetic patients show significant increases in peripheral blood circulation with this technique. This noninvasive method could serve as an adjunct treatment for limited blood flow in some complications of diabetes.
BACKGROUND: The purpose of this study was to determine the extent to which measures of lower extremity strength and power contribute to the ability of older men and women to restore postural equilibrium using a single-step recovery following a large postural disturbance. METHODS: The postural disturbance, which has been used as a surrogate for forward-directed falls, involved a sudden release from a forward-leaning angle. The ability to recover using a single step was evaluated as the maximum recoverable lean angle for 56 healthy older women and men. Maximum voluntary isometric and isokinetic strength was measured for ankle plantarflexion and dorsiflexion, knee flexion and extension, and hip flexion and extension. Discriminant analysis was used to determine the strength measures that best classified participants as members of the highest (n = 14) or lowest (n = 14) quartiles of maximum recoverable lean angle. Those variables were subsequently entered into a regression analysis to characterize the relationship between strength and maximum recoverable lean angle for the entire participant sample. RESULTS: Maximum isokinetic dorsiflexion strength at 90 degrees /s satisfied the criteria of the stepwise discriminant analysis, and correctly classified 82.1% of the participants in the highest or lowest quartiles of maximum recoverable lean angle. The multiple regression procedure, performed on all participants (n = 56) revealed a significant quadratic relationship between maximum isokinetic dorsiflexion strength at 90 degrees /s and maximum recoverable lean angle (R2 = 0.295; p <.001). CONCLUSIONS: Lower extremity strength makes a small, but significant contribution to maximum recoverable lean angle. However, because 70% of the shared variability remained unaccounted for, it is suggested that other performance factors, such as coordination, may be of greater importance to performance of this time-critical motor task.
The paper is concerned with evidence for the choice of the treatment and rehabilitation policy of patients suffering from lower extremity stump ischemia. Altogether 446 patients with obliterating diseases of arteries and unilateral post-amputation defects of the lower extremities were examined. Of these, degree III-IV stump ischemia was verified in 90 patients, transient stump ischemia was present in 259 patients. In 30 patients, stump pains or defects of the skin were determined by defects and discuses of the stump; 67 patients were identified to have no clinical signs of ischemia and no defects or diseases of the stump, 43 patients underwent arterial reconstructions whereas reamputations of the extremity were undertaken in 29 patients. The remaining patients with stump ischemia received conservative therapy. The algorithm of the choice of the treatment policy and rehabilitation of patients was worked out depending on the severity of the clinical manifestations of stump ischemia and the level of post-amputation defect.
A comparative investigation has been performed on structural peculiarities of muscle arteries having various caliber in the lower extremities and in the anterior thoracic wall (section material, 40 observations). An essential predominance of the muscle tunic thickness and deterioration of blood supply has been stated in the arterial wall and in the distal parts of the lower extremities. The structural peculiarities revealed in the arteries of the extremities are connected with functional conditions of blood supply in the zone at the vertical position of the human body (orthostatic arterial hypertension).
Neuromuscular disorders must be considered when a patient presents with a pes cavus deformity; lower extremity weakness; difficulty in walking; or cramps, stiffness, fatigue, pain, or paresthesia in the extremities. In those instances in which a neurologic disease is considered, distinctions between central and peripheral nervous system origin, focal versus generalized pathology, and static versus progressive course are critical in the diagnosis and treatment of the disorder. The complexities of the nervous system often result in missed or delayed diagnosis of these syndromes. Patients affected with neurologic diseases often require diagnostic and therapeutic interventions from various specialists. This article presents a systematic approach to the patient with a neurologic disorder, with special emphasis on neuromuscular manifestations in the lower extremities. Key observations to aid in the recognition of neuromuscular dysfunction are presented, along with an approach to diagnostic evaluation and management for these patients.
Contrast-enhanced 3D MR angiography permits comprehensive assessment of the arterial system in the chest, abdomen und lower extremities. The method combines intravenous bolus application of a non-nephrotoxic, paramagnetic, extracellular contrast agent with the acquisition of a fast 3D data set. High contrast between the vascular lumen and surrounding tissues, inherent three-dimensionality and the ability to collect image data in the chest and abdomen under apnea conditions all contribute to excellent image quality. Contrast-enhanced 3D MRA is being employed in many centers throughout the world for the evaluation of various arterial pathologies. This review provides a technical overview and critically discusses the clinical applications in the chest, abdomen and lower extremities based upon the available literature and several clinical examples.
OBJECTIVE: To retrospectively analyze the experiences and results of the treatment on 62 patients with primary varicose of lower extremities with endovenous laser. METHODS: All patients were treated with endovenous laser. The laser treatment could begin when the fiber withdraw with 1 cm/2 s. The laser power was 10 - 12 w with the laser pulse duration and the interval 1 second respectively. RESULTS: The duration of follow-up varied from 2 months to 8 months. After endovenous treatment, the varicose veins and edema disappeared in all cases. The itching and uncomfortable feeling was dissipated. No morphine-like analgesic has been used and no serious complications occurred. CONCLUSION: Endovenous laser treatment of primary varicose of lower extremities is a safe and effective technique.
Results of application of preparation alprostan in 30 patients with chronic arterial insufficiency of lower extremities of III-IV stages were presented. Changes of regional blood flow and microcirculation of lower extremities under the influence of alprostan were studied. Positive result of treatment was achieved in more then 73% of patients.
Contrast lymphangiography has been the traditional radiographic method for imaging the lymphatic system of the lower extremities. Because of the difficulty in performing the procedure and its potential side effects, radionuclide lymphangiography is a safe and reliable alternative. Technetium-99m labeled to antimony trisulfide colloid was used in nine patients presenting with lymphedema of the lower extremities. The procedure was relatively simple to perform, and no adverse effects were noted.
We report the clinical features of two cases presenting metastatic neck tumors (in the anterior neck and submandibular regions) secondary to myxoid liposarcoma of the lower extremity. Both cases underwent repeated resection of primary legions of the lower extremities because of recurrences. Such repeated surgical procedures are thought to be a risk factor for distant metastasis resulting from hematogeneous dissemination of tumor cells, although there is considerable debate about multicentricity versus metastasis in liposarcomas. Where possible, therapy for liposarcomas should initially comprise complete and wide resection of the lesions. Combined therapy consisting of surgery and postoperative radiation and chemotherapy should be investigated in the future.
The records of 89,955 active duty Army officers were reviewed to determine their incidence of permanent upper and lower extremity profiles. Only 1,706 officers (1.897%) have permanent upper or lower extremity profiles. However, the incidence of such profiles varies with respect to rank, branch, and sex. Some officer groups have an incidence as high as 37%. Although the overall incidence of such profiles is quite low, the dramatically increased incidence in some officer groups demands scrutiny.