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PubMed2004

[Early treatment results with expandable intramedullary nails in lower extremity shaft fractures].

BACKGROUND: We investigated the use of expandable intramedullary nails, their efficacy, and short term results in the treatment of lower extremity shaft fractures. METHODS: The study included 23 patients (10 females, 13 males; mean age 33 years; range 17 to 60 years) who were treated with expandable intramedullary nails (the Fixion nail) for the lower extremity shaft fractures. Fourteen patients had femoral, nine patients had tibial fractures, all of which were closed. Eight patients had associated injuries. The mean duration from injury to surgery was 3.2 days (range 24 hours to 14 days). The results were evaluated using the Kalström-Olerud criteria. The mean follow-up was 15.3 months (range 10 to 20 months) for tibial fractures, and 13.1 months (range 10 to 19 months) for femoral fractures. RESULTS: Union was achieved in all the patients. In tibial fractures, the mean operation time was 50 minutes (range 25 to 90 min) and the mean time to union was 12 weeks (range 8 to 24 weeks). The results were excellent in six patients, and good in three patients. In femoral fractures, the mean operation time was 83.5 minutes (range 55 to 120 min) and the mean time to union was 13.2 weeks (range 10 to 20 weeks). The results were excellent in eight patients, good in three patients, fair in two patients, and poor in one patient. No complications were seen such as delayed union, early or late infections, compartment syndrome, or bone necrosis. CONCLUSION: Expandable intramedullary nails offer advantages in terms of ease of application and are less invasive than static nails and reamed applications. However, they may not provide adequate stability in metadiaphyseal regions and in fractures with fragments larger than 50 per cent.

Adolescent↗
PubMed2002

Lower extremity general muscle moment patterns in healthy individuals during recumbent cycling.

OBJECTIVE: The purpose of this study was to compare lower extremity generalized muscle moments across two workloads during recumbent bicycling in younger and older healthy adults. DESIGN: The study design was a comparative investigation of cycling patterns. BACKGROUND: Biomechanical data regarding muscle activation, kinematic, and kinetic patterns have been presented for upright cycling, but only a few studies have evaluated biomechanical patterns during the alternative configuration of recumbent cycling. METHODS: Twenty-four healthy adults, classified by age into two different groups, under 35 and over 50 years of age, rode a recumbent bicycle at a constant cadence (60-65 rpm) and at two different resistances (0.5 and 1.0 kg m) while kinematic and kinetic data were recorded. General muscle moments were calculated using joint kinematic and kinetic data via inverse dynamic equations. RESULTS: The ankle general muscle moment remained plantar flexor throughout the pedaling cycle; the knee general muscle moment remained flexor throughout the cycle, except during the power phase of the higher workload where an extensor general muscle moment was observed; and the hip general muscle moment was extensor with a transient flexor general muscle moment period during the recovery phase. Increased workload led to increases in ankle plantar flexor and knee extensor general muscle moment magnitudes, but no changes at the hip. Age had no effect on general muscle moment magnitudes or patterns. CONCLUSIONS: Configurational differences between the upright and recumbent bicycle do not affect patterns, but the total output requirements do affect the magnitudes of the general muscle moments. RELEVANCE: Based on previous studies, the recumbent bicycle appears to be a safe rehabilitation tool for post-cerebrovascular accident and cardiorespiratory patients, but in order to more properly and efficiently use the recumbent bicycle as a rehabilitation tool, normative biomechanical data are necessary. The current study is the first such investigation to report normative data of lower extremity general muscle moment patterns during recumbent cycling. Effects of age and workload were also demonstrated.

Adult↗
PubMed1996

Colour duplex ultrasonography versus angiography in the diagnosis of lower-extremity arterial disease.

Colour duplex scanning is reported to be an accurate non-invasive tool for the diagnosis of lower-extremity arterial disease. The authors at the South Coast Vascular Laboratory have conducted a prospective audit to determine the efficacy of colour duplex scanning in a vascular surgical practice. The aims of this prospective trial were to compare the accuracy of colour duplex scanning with intra-arterial digital subtraction angiography (DSA) in the localization and classification of aortoiliac and femoropopliteal artery disease. Ninety-one lower limbs in 50 patients were evaluated independently by colour duplex scanning and DSA. The lower-limb vasculature was divided into eight segments: infrarenal aorta, common iliac artery, external iliac artery, common femoral artery, proximal, middle and lower thirds of the combined length of the superficial femoral and above-knee popliteal artery, and lastly the below-knee popliteal artery. A total of 558 arterial segments were examined. The Kappa value of duplex scanning compared with 'gold standard' DSA was 0.57. For detecting haemodynamically significant arterial lesions of > 50% reduction in diameter, duplex scanning had a sensitivity of 75%, specificity of 90%, positive predictive value of 77% and negative predictive value of 89% compared with DSA. The level of accuracy obtained does not support the use of duplex as a sole method of investigation for lower-extremity arterial disease in the authors' case. However, the high negative predictive value of colour duplex may be useful in excluding haemodynamically significant disease. This study emphasizes the importance of prospective auditing to determine individual accuracy with duplex examination for arterial disease, and enables clinical decision making to be based on tests with a known accuracy.

Angiography, Digital Subtraction↗
PubMed2006

Unsuspected lower extremity deep venous thrombosis simulating musculoskeletal pathology.

OBJECTIVE: The purpose of this study was to highlight the critical role that MRI may play in diagnosing unsuspected lower extremity deep venous thrombosis and to stress the importance of scrutinizing MRI studies of the lower extremity showing apparently non-specific muscle edema for any evidence of intramuscular venous thrombosis. DESIGN AND PATIENTS: The imaging studies of four patients in whom deep venous thrombosis was unsuspected on clinical grounds, and first diagnosed on the basis of MRI findings, were reviewed by two musculoskeletal radiologists in consensus. In all four patients the initial clinical suspicion was within the scope of musculoskeletal injuries (gastrocnemius strain, n=3; ruptured Baker cyst, n=1), explaining the choice of MRI over ultrasound as the first diagnostic modality. RESULTS: All patients showed marked reactive edema in the surrounding soft tissues or muscles. Three patients showed MR evidence of branching rim-enhancing structures within intramuscular plexuses characteristic of venous thrombosis (gastrocnemius, n=1; sural, n=2); one patient showed a distended popliteal vein. Ultrasound was able to duplicate the MRI findings in three patients: one patient showed above-the-knee extension on ultrasound; neither of the two patients with intramuscular thrombosis demonstrated on ultrasound showed extension to the deep venous trunks. CONCLUSION: Intramuscular venous thrombosis can present as marked edema-like muscle changes on MRI, simulating primary musculoskeletal conditions. In the absence of clinical suspicion for deep venous thrombosis, only the identification of rim-enhancing branching intramuscular tubular structures will allow the correct diagnosis to be made.

Diagnosis, Differential↗
PubMed2006

Physical disability after severe lower-extremity injury.

OBJECTIVE: To investigate the use of a combined measure of decreased walking speed and gait deviation to identify high physical disability in patients with lower-limb salvage. DESIGN: Longitudinal study of patients with severe lower-extremity trauma. SETTING: Eight level I trauma centers. PARTICIPANTS: Patients (N=276) with lower-limb salvage from the Lower Extremity Assessment Project. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability from the physical dimension of the Sickness Impact Profile (SIP), walking speed, and gait deviation were measured at 24 months of follow-up. A 1-way analysis of variance and planned comparisons compared mean SIP scores across and between the following 3 outcome groups: no impaired speed and no gait deviation, impaired speed or gait deviation, and impaired speed and gait deviation. RESULTS: Mean SIP scores for the physical dimension and its 2 categories of ambulation and body care and movement differed statistically across the planned comparisons. The mobility category showed that the impaired speed or deviation group was statistically similar to the group without impaired speed and gait deviation. CONCLUSIONS: The combination of decreased walking speed and gait deviation appears to provide a valid measure of physical disability among patients with lower-limb salvage.

Analysis of Variance↗
PubMed1997

Surgical chemotherapy in the management of melanoblastoma of the lower extremities.

The therapy of advanced melanoblastomas of the lower extremities is limited. Surgery alone is insufficient due to the extent of the tumor, the radicality of mutilating surgery is questionable because of the existing or suspected subclinical metastasis. To avoid amputation, regional chemoperfusion and simultaneous hemofiltration may be the choice of treatment. Between 1993 and 1995 the authors performed surgical chemotherapy on 21 occasions in 14 patients with advanced melanoblastoma of the lower limb. Partial remission of 4 to 11 months developed in 10 patients, 3 patients achieved subjective improvement for 3 to 6 months, 1 patient had disease progression. Simultaneous application of surgical regional chemotherapy and hemofiltration offers an alternative approach in the management of patients suffering from advanced melanoblastoma.

Antibiotics, Antineoplastic↗
PubMed1979

[Interrelationship of the venous and arterial blood flows in chronic venous diseases of the lower extremities].

The data obtained evidence that the tone of the arterial vessels increases in 55% of patients with decompensated varicose dilatation of the lower extremity veins. In the postthrombophlebitic disease the arterial tone is disturbed in 80% of patients. It is supposed that the spasm of the arterial vessels of the lower extremities in chronic phlebopathology is a compensatory-adaptational response to the deteriorated venous outflow.

Adult↗
PubMed2002

A quantitative approach to lower extremity vein repair.

OBJECTIVE: We prospectively investigated the patency of venous repair in a quantitative fashion with measurement of vein blood flow velocities after lower extremity injuries caused by either military or civilian trauma. MATERIAL AND METHODS: During a 10-year study period (March 1990 to December 2000), surgical intervention was performed after lower extremity vascular injuries in 130 patients. Most of these patients were men (n = 125), with a mean age of 23 +/- 5 years (range, 17 to 44 years). One hundred ten direct venous injuries were identified in 97 patients, involving the common femoral vein in seven, the deep femoral vein in three, the superficial femoral vein in nine, the popliteal vein in 46, and the posterior tibial (n = 21), anterior tibial (n = 17), or peroneal veins (n = 7) in 45. Popliteal vein thrombosis without apparent venous injury was found in seven patients. Bone fractures (n = 45), nerve injuries (n = 27), or extensive tissue loss (n = 7) often were associated with vascular injuries. Duplex color ultrasonography was used to evaluate patency and to measure blood flow velocity in repaired veins during the early postoperative period and at the time of late follow-up examinations. RESULTS: Significant differences were seen in venous blood flow velocities between severe (extremity diameter more than twice normal) and moderate (diameter 1.5 to 2 times normal) reperfusion injuries. The mean flow velocity in repaired popliteal veins was 15 +/- 2 cm/s with severe reperfusion injuries compared with 8.4 +/- 1.1 cm/s with moderate reperfusion injuries (P <.0001). Flow velocities were lower than 5 cm/s in repaired infrapopliteal veins, and most of these veins occluded on the first postoperative day. Amputations were necessary in 11 patients, all of whom had both tibial fractures and extensive tissue loss. Sodium warfarin therapy was routinely administrated before hospital discharge. The mean follow-up period was 6.2 years (range, 1.3 to 10 years). Repaired common femoral and superficial femoral veins had relatively high patency rates (100% and 89% at 1 year, 100% and 78% at 6 years, respectively), whereas the patency rates for repaired popliteal veins were disappointing (86% at 1 year, 60% at 6 years). All seven popliteal veins that required thrombectomy in the absence of direct injuries remained patent, however. Patch angioplasty had the highest 6-year patency rate (75%) in comparison with all other techniques that were used for venous injuries (lateral repair, 58%; end-to-end anastomosis, 43%; saphenous vein graft interposition, 36%). CONCLUSION: Venous repair has a high patency rate at the femoral and popliteal levels, but the patency rate for infrapopliteal venous repair is extremely poor because of low flow velocities. Therefore, we conclude that repair of infrapopliteal venous injuries is unnecessary.

Adolescent↗
PubMed1989

Physeal arrest about the knee associated with non-physeal fractures in the lower extremity.

The cases of seven patients who had a physeal arrest about the knee in association with nonphyseal fractures in the lower extremity were reviewed. The patients were between ten and twelve and one-half years old at the time of injury, and the physeal arrest involved either the posterolateral part of the distal femoral physis or the anterior part of the proximal tibial physis. There was no evidence of iatrogenic trauma to the physis. Recognition of the physeal injury was delayed for an average of one year and ten months until a gross angular deformity appeared. Adolescents who have fractures of the lower extremities that do not appear to involve a physeal plate should nevertheless be evaluated and followed for possible physeal injury about the knee that can be detected only after additional growth has taken place.

Child↗
PubMed1988

Comparison of the reliability of the Orthoranger and the standard goniometer for assessing active lower extremity range of motion.

The purpose of this study were to determine 1) the reliability of the Orthoranger for assessing active lower extremity joint range of motion, 2) specific methods for applying the Orthoranger, and 3) whether a correlation exists between the measurements obtained with the Orthoranger and those obtained with a standard goniometer. Ten men and 10 women, mean ages 28.3 +/- 5.1 and 30.0 +/- 10.1 years, respectively, participated in the study. Random selection was used to determine testing sequences. The Orthoranger and the goniometer were used to measure each joint three times during the five sessions. Results indicated that both instruments were reliable for assessing active lower extremity joint ROM. The goniometer showed greater intraclass correlations and confidence levels for all movements except hip lateral rotation, which demonstrated a higher intraclass correlation for the Orthoranger. In addition, all motions except hip adduction and knee extension demonstrated a positive relationship between instruments. Compared with a manual goniometer, the added costs for purchase and use of the Orthoranger appear to be unnecessary until such time that factors enhancing its inherent reliability are identified.

Adult↗
PubMed1985

Distribution and symmetry of arteriosclerotic lesions of the lower extremities: an arteriographic study of 200 limbs.

Lower-extremity arteriograms of 100 candidates for vascular surgery were reviewed. All the arteries in the 200 limbs were visualized and graded as normal, irregular, stenotic, or occluded. The occurrence of hemodynamically significant disease (stenosis or occlusion) was markedly different in various arteries: iliac--37%, common femoral--9%, superficial femoral--58%, deep femoral--19%, popliteal--17.5%, tibialis anterior--27.5%, tibialis posterior--28.5%, and peroneal--16.5%. A remarkable symmetry was observed between the two lower limbs. In 53-76% of contralateral vessels the arteriographic picture was identical. When one degree of difference in arteriosclerotic involvement was allowed, the symmetry increased to 80-96%.

Angiography↗
PubMed2003

Functional outcome in a contemporary series of major lower extremity amputations.

PURPOSE: We undertook this study to document the functional natural history of patients undergoing major amputation in an academic vascular surgery and rehabilitation medicine practice. METHODS: A retrospective review was conducted of consecutive patients undergoing major lower extremity amputation and rehabilitation in a university and Department of Veterans Affairs hospital. Main outcome variables included operative mortality, follow-up, survival, median time to incision healing, secondary operative procedures for wound management, and conversion from below-knee amputation (BKA) to above-knee amputation (AKA). For surviving patients, quality of life was determined by degree of ambulation, eg, outdoors, indoors only, or no ambulation; use of a prosthesis; and independence, eg, community housing or nursing facility. RESULTS: From August 1997 through March 2002, 154 patients (130 men; median age, 62 years) underwent 172 major amputations, 78 AKA and 94 BKA, because of either critical limb ischemia (87%) or diabetic neuropathy (13%). Thirty-day operative mortality was 10%. Mean follow-up was 14 months. Healing at 100 and 200 days, as determined with the Kaplan-Meier method, was 55% and 83%, respectively, for BKA, and 76% and 85%, respectively, for AKA. Twenty-three BKA and 16 AKA required additional operative revision, and 18 BKA ultimately were converted to AKA. Survival was 78% at 1 year and 55% at 3 years. Function in surviving patients at 10 and 17 months, respectively, was as follows: 21% and 29% of patients ambulated outdoors, 28% and 25% ambulated indoors only, and 51% and 46% of patients were nonambulatory; 32% and 42% of patients used prosthetic limbs; and 17% and 8% of patients who lived in the community before amputation required care in a nursing facility. CONCLUSIONS: We were surprised to find that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite infrequent prosthesis use and outdoor ambulation. Although any hope for postoperative ambulation in this population requires salvaging the knee joint, because of the morbidity incurred in both wound healing and rehabilitation efforts, aggressive effort should be reserved for selected patients at good risk. Ability to predict ambulation after BKA in the vascular population is poor.

Activities of Daily Living↗
PubMed1990

Profundaplasty as the only reconstructive procedure in patients with severe ischemia of the lower extremity.

Twenty-one profundaplasties were performed as the only reconstructive procedure. All of the patients had severe ischemia of the lower extremity with serious symptoms, such as rest pain or gangrene, or both. There was no postoperative mortality. Two patients had a crural amputation, and one patient, a femoral amputation performed during the first three months postoperatively. All of the other patients improved, and there was a significant rise in distal blood pressures after one week, further increasing after three months. At follow-up study, 15 of the patients had considerably less symptoms than preoperatively or were free of symptoms. There was a limb salvage rate of 83 per cent after 60 months. The operation is recommended whenever possible in patients with severe ischemia of the lower extremity when the possibilities of other reconstructive procedures are considered to be poor.

Aged↗
PubMed2000

Optimization of combined CT pulmonary angiography with lower extremity CT venography.

OBJECTIVE: We wanted to determine the time delay for maximum enhancement of the deep venous system of the lower extremities after standard CT pulmonary angiography. SUBJECTS AND METHODS: In 20 patients who had undergone standard CT pulmonary angiography, we measured arterial and venous enhancement at the level of the greater trochanter. These measurements were obtained at 30-sec intervals immediately after completion of CT pulmonary angiography. Ten measurements were obtained in 5 min. Time-density curves were plotted. RESULTS: We found that the median and average peak venous enhancements were 92 and 95 H, respectively. Time to peak enhancement was variable. Because of the broad shape of the venous time-density curve, near peak enhancement could be achieved in most patients at 2 min after CT pulmonary angiography. CONCLUSION: CT of the deep venous system of the lower extremities after standard CT pulmonary angiography, performed with appropriate timing considerations, allows near maximal enhancement of the venous system in most patients without altering the optimum CT pulmonary angiography protocol.

Female↗
PubMed1995

Prevalence and risk factors of varicose veins in lower extremities: mini-Finland health survey.

OBJECTIVE: To study the prevalence and risk factors of clinically important varicose veins in the lower extremities. DESIGN: Cross-sectional study with self-administered questionnaire. SETTING: A national health examination survey, Finland. SUBJECTS: 8000 people from 40 geographical areas representing the adult population aged 30 years and over. RESULTS: The prevalence of varicose veins diagnosed by a physician was 25% in women and 7% in men. Twenty-nine per cent of the men and 53% of the women with diagnosed varicose veins had been treated surgically. Age, height, body mass index (weight/height2), standing at work, and the number of births were expected risk factors associated with varicosities. Unexpectedly, signs of osteoarthrosis were positively, and diabetes negatively, associated with varicose veins. Urban dwelling and high income correlated positively with varicose veins treated surgically in women. CONCLUSIONS: Varicose veins in the lower extremities are common, and demand considerable health service resources. The aetiology of varicose veins is still incompletely understood and more research is needed to develop possible preventive measures.

Adult↗
PubMed1991

Prevention of complications and correction of postoperative problems in microsurgery of the lower extremity.

Prevention of complications in microsurgery of the lower extremities begins with proper patient selection and patient preparation. Complications are highest in elderly patients who have had multiple trauma, smokers, patients with arterial or venous insufficiency, and those with hypercoagulability. Some patients may be best served by primary amputation. If multiple flaps are required, a higher success rate can be achieved with simultaneous rather than sequential transfers. However, for simultaneous transfers, a higher re-exploration rate must be anticipated. The key to avoiding long-term problems with infection is adequate preparation of the wound. Multiple debridements may be necessary. If early coverage can be obtained in trauma cases, a lower rate of chronic osteomyelitis has been observed. Attention to details in the operating room, such as patient warmth and perfusion, will increase the success rate. Recipient vessels must be out of the "zone of injury" and normal in appearance and pulsatility. It is safer to use normal recipient vessels and vein grafts than to attempt anastomoses to vessels affected by "post-traumatic vascular disease." If thrombosis occurs in the early postoperative period, prompt re-exploration can result in flap salvage, with a high degree of predictability if the cause of the thrombosis can be determined and corrected.

Adult↗
PubMedDate not supplied

Intraoperative SSEP monitoring during external fixation procedures in the lower extremities.

The efficacy of somatosensory evoked potentials (SSEPs) to detect acute peripheral nerve injury during external-fixator application in the lower extremities was evaluated in 40 children with 42 Ilizarov surgical procedures. The study included patients who were either clinically normal or who had preexisting neuropathy but consistent and reliable SSEP responses preoperatively. SSEPs were recorded from the popliteal fossa and lumbar regions after alternating stimulation of the peroneal and posterior tibial nerves at the ankle. SSEP changes due to anesthesia, Ilizarov apparatus application, and other intraoperative variables are described. Significant deterioration or total loss of SSEP response during surgery occurred in four cases. Two of these patients were normal preoperatively and had symptoms of neurologic deficit postoperatively; the other two had exacerbations of pre-existing neuropathy. In general, the peroneal nerve was at greater risk for injury during surgery. SSEP monitoring proved to be technically feasible in external-fixation procedures on the lower extremities and may be a practical tool for detection of intraoperative nerve compromise.

Acute Disease↗