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PubMed2005

[Surgery for fractures of the lower extremities in cases of chronic spinal cord injury].

According to the literature, the need for surgical treatment of fractures of the lower extremity in patients with chronic spinal cord injury (SCI) is very limited. Conservative management is usually presented as the treatment of choice. We present the results of a retrospective review of 55 fractures in 44 patients from 1996 to 2000 which were managed surgically. Rating of the outcome was based on basic clinical and radiological criteria. The results of the radiological investigation on bone remodeling and bone positioning after healing were rated as good or excellent in 43 and fair in five limbs. In five cases, the treatment failed. For 53 of the 55 fractures, the patients regained their normal level of independence. Comparing our results to those presented in the literature, we clearly had fewer complications as well as better clinical and radiological results. We therefore advocate surgical treatment as an appropriate choice of treatment for lower extremity fractures of patients with chronic SCI.

Adolescent↗

PubMed1992

Quality of life in bone tumor patients comparing limb salvage and amputation of the lower extremity.

In 33 long-term survivors of lower extremity bone cancer quality-of-life data were studied following limb salvage compared to amputation. Self-report questionnaires, semistructured interviews and visual analog scales were used to measure psychoneurotic and somatical distress, activities of daily living, self-esteem, and adjustment to illness. Fourteen patients with limb salvage (age 13-56 years, median 24) and 19 patients with an amputation (age 21-53 years, median 27) were evaluated 2-17 years (median 10 years) after surgery. The differences between the two groups were not statistically significant. However, physical complaints were reported more often by limb salvage patients, whereas the amputees showed a trend toward lower self-esteem and isolation in social life, due to their disability. Both groups felt equal diminution of quality of life and disability as measured on the visual analog scale. These findings could support the cosmetic advantage of limb salvage compared to amputation.

Adolescent↗

PubMed2006

First successful lower-extremity transplantation: technique and functional result.

Composite tissue transplantation has emerged as a viable alternative to prosthetics and complex reconstructive surgery. Thus far it is reserved for cases which cannot be effectively reconstructed and where it offers some benefits over prostheses. It has been used in the upper extremity with encouraging results and, most recently, in the face. This report outlines what is believed to be the first such use in the lower extremity. A normal lower limb in a 3-month-old ischiopagus twin who was not going to survive was transplanted to the appropriate pelvic position, revascularized, and reinnervated in an otherwise healthy sister. The limb survived and, because of the immune compatibility, did not require immune suppressive therapy. The return of muscle function in the transplanted limb is encouraging. The transplanted limb appears to be fully sensate. In addition to reinnervation, the limb is now spontaneously under the cortical control of the recipient.

Abdominal Muscles↗

PubMed2002

Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography.

HYPOTHESIS: Abandoning mandatory angiography in patients with blunt lower-extremity trauma and normal neurovascular examination results does not affect limb salvage. DESIGN: Retrospective, nonrandomized cohort study. Mean follow-up (31 of 52 patients) of 9.5 months (range, 0-96 months). SETTING: Single-institution, academic level I trauma center. PATIENTS: Medical records of patients presenting on an emergency basis with knee dislocation, distal femoral fractures, or proximal tibial fractures during a 20-year period were reviewed. Fifty-three injuries occurred in 52 patients. Patients were predominantly male (81%) and young (mean age, 32.7 years). Mechanisms and side of extremity injury, coincident injuries, and neurovascular status on admission were recorded. Hard signs of arterial insufficiency or compartment syndrome were identified. INTERVENTIONS: Angiographic findings and operative and nonoperative interventions were recorded to identify whether angiographic data would alter therapy dictated by clinical findings alone. MAIN OUTCOME MEASURES: Limb salvage rate and necessity for vascular surgical intervention based on angiographic data in patients with normal neurovascular examination results. RESULTS: Multiorgan trauma occurred in 11 patients. Pulses were normal in 35, absent in 16, and diminished or identified by Doppler signal in 2. Arterial insufficiency or compartment syndrome was present in 29%. Twenty-seven patients (28 limbs) underwent angiography at the discretion of the attending surgeon. Of 13 abnormal arteriograms, 2 occurred in patients with normal pulses and 11 in patients with abnormal examination results. Thirteen of 36 patients with normal pulses underwent angiography; none had clinically significant arterial injuries that necessitated intervention. No vascular interventions were necessary in 23 patients with normal pulses who did not undergo angiography (P<.001). Normal neurovascular status bore a 100% negative predictive value in determining the necessity of vascular intervention. CONCLUSIONS: Angiography is unnecessary in the routine evaluation of the patient with blunt lower-extremity trauma who presents with a normal neurovascular examination result and can be used selectively for patients with diminished pulses who lack associated indications for mandatory operative exploration.

Adult↗

PubMed1994

Twin-barrelled vascularized fibular grafting to the pelvis and lower extremity.

From 1988 to 1992, 17 patients were treated for a large bone defect or established nonunion of the pelvis or lower extremities with twin-barrelled vascularized fibular grafts. There were 13 men and four women whose average age at operation was 39 years (range, 13-73 years). The reconstructed site was the pelvis in two patients, the femur in 12, the tibia in two, and the ankle in one. The mean length of the bone defect was 8.5 cm, and the mean length of the harvested fibula was 22 cm. Free grafts were transferred in 14 patients and pedicle grafts in three patients. The mean duration of the operation was six hours 46 minutes (range, 3.5-10.6 hours). Average blood loss was 1949 ml (range, 268-5308 ml). In one patient, the vascularized transfer failed, and recurrence of local infection was encountered in another. In the remaining 15 patients, the postoperative course was uneventful; the mean period to bony union was 5.1 months (range, two to 12 months). The mean time to full weight bearing was four months in pelvic reconstruction, 10.6 months in femoral reconstruction, and 6.3 months in leg reconstruction. Only one patient had a fracture of the fibular graft. This method is well suited for patients with a bone defect up to 13 cm in length of the pelvis or lower extremities.

Adolescent↗

PubMed1996

Anatomic and physiologic changes in lower extremity venous hemodynamics associated with pregnancy.

PURPOSE: The purpose of this study was to describe the physiologic effects of pregnancy on lower extremity venous hemodynamics. METHODS: Eight pregnant women, six with no known venous disease (NVD) and two with documented deep venous obstruction (DVO), were identified in the first trimester (TM) and studied monthly until delivery and once postpartum (pp) by air plethysmography and duplex scan. RESULTS: None of six women in the NVD group (12 extremities) had obstruction or elevated ambulatory venous pressures as estimated by air plethysmography. In addition, despite significant increases in common femoral vein and saphenofemoral junction diameters, no woman in the NVD group had reflux by either test. Venous filling index increased significantly during pregnancy and decreased significantly pp, but all values remained within the normal range (0.55 +/- 0.2 ml/sec first TM, 1.01 +/- 0.38 ml/sec late third TM, 0.58 +/- 0.08 ml/sec pp; p < 0.03 both comparisons). Common femoral vein diameters increased and decreased in similar fashion (0.99 +/- 0.25 cm first TM, 1.21 +/- 0.25 cm late third TM, 0.80 +/- 0.11 cm pp; p < 0.0005 first vs late third TM, p < 0.005 late third TM vs pp). Saphenofemoral junction vein diameters similarly increased and decreased in size (0.46 +/- 0.07 cm first TM, 0.68 +/- 0.19 cm late third TM, 0.50 +/- 0.10 cm pp; p < 0.01 first vs late third TM, p < 0.03 late third TM vs pp). Neither of the two women in the DVO group showed deterioration of outflow fraction or venous filling index as pregnancy progressed, and neither had thromboembolic complications despite moderate to severe preexisting obstruction. Both women in the DVO group delivered uneventfully. No woman in either group developed varicose veins. CONCLUSIONS: Pregnancy-induced changes in lower extremity venous hemodynamics in the NVD and DVO groups were detected but were small. Hormonal or other systemic factors must play a significant role in the development of postpartum varicose veins.

Adult↗

PubMed1995

On the assumption of bilateral lower extremity joint moment symmetry during the sit-to-stand task.

This study examined the validity of the assumption of bilateral lower extremity joint moment symmetry during the sit-to-stand motion for a group of young (n = 7) and a group of elderly (n = 7) female subjects. Two force plates and a motion analysis system were used to determine peak joint moments at the ankles, knees, and hips following liftoff from a chair. Statistically, bilateral asymmetries in peak joint moments were found at the knee joint in the young group [a right to left difference of 0.43% BW x BH (body weight x body height)] and at the hip joint in both subject groups (differences of 0.20% BW x BH and 1.09% BW x BH for the young and elderly subjects, respectively). Subsequent data analysis, using an algorithm that assumed bilateral ground reaction force (GRF) symmetry, was performed to determine whether the bilateral differences were a result of kinematic or GRF asymmetry. It was concluded from these results that both the kinematic and GRF data account for the bilateral asymmetry. The results of the subsequent analysis also showed that the method which assumed bilateral GRF symmetry underestimated the peak joint moments at the ankles, knees, and hips, with the greatest difference between methods being 0.10% BW x BH for the ankle joint. The results of this study suggest that the assumption of bilateral symmetry of lower extremity joint moments during the sit-to-stand is not valid. However, the biomechanical significance of the errors associated with assuming symmetry must also be taken into account.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1996

Lower extremity blood flow and responses to occlusion ischemia differ in exercise-trained and sedentary tetraplegic persons.

OBJECTIVE: To test whether lower extremity blood flow and hyperemic responses to vascular occlusion differ among electrically stimulated exercise trained and sedentary tetraplegic persons and subjects without tetraplegia (control). DESIGN: Blinded cross-sectional comparison, control group. SETTING: Academic medical center. PARTICIPANTS: Ten sedentary tetraplegic men, 10 tetraplegic persons previously habituated to electrically stimulated cycling exercise for 0.4 to 7 years, and 10 nondisabled controls. OUTCOME MEASURES: Subjects underwent quantitative Doppler ultrasound examination of the common femoral artery (CFA). End-diastolic arterial images and arterial flow-velocity profiles obtained at rest and following five minutes of suprasystolic thigh occlusion were computer digitized for analysis of heart rate (HR), CFA peak systolic velocity (PSV), CFA cross-sectional area (CSA), flow velocity integral (FVI), and computed CFA inflow volume (IV). RESULTS: No group main effects were observed for resting HR or FVI. At rest, trained tetraplegic men had 14.9% greater PSV, 29.8% larger CSA, and 51.3% greater IV (p values < .05) than sedentary tetraplegic subjects. Resting PSV and IV of the trained subjects did not differ from controls, although CSA was smaller than controls (p < .05). Following occlusion, PSV, CSA, and IV averaged 16.5%, 33.4%, and 65.1% greater for trained tetraplegics persons, respectively, than sedentary tetraplegic subjects (p values < .05). Only CSA differed between the control and the trained groups (p < .05). CONCLUSION: Tetraplegic persons conditioned by electrically stimulated cycling have greater lower extremity blood flow and hyperemic responses to occlusion than do their sedentary counterparts.

Adult↗

PubMed1999

Management of deep vein thrombosis of the lower extremity in pregnancy: a challenging dilemma.

This study reviews our experience in the management of deep vein thrombosis (DVT) of the lower extremity during pregnancy and analyzes the outcome of various treatment alternatives, including conventional full-dose heparin therapy and Greenfield filter insertion. Twenty-four patients treated over an 8-year period were reviewed. Fifteen patients were treated with conventional full-dose intravenous heparin therapy for 5 to 10 days, followed by subcutaneous low-dose heparin until labor, and continued for 6 weeks postpartum (Group A); Eleven patients had Greenfield filters inserted, followed by the same low-dose subcutaneous heparin regimen (Group B). There were 18 femoral or iliofemoral, 5 femoropopliteal, and 1 popliteal and below-knee DVT. The indications for Greenfield filter insertion included two patients in Group A (one with pulmonary embolism, despite adequate heparin therapy, and one with significant bleeding). Nine other patients had prophylactic indications: two for free-floating iliofemoral DVT, three with iliofemoral DVT (occurring just 1-2 weeks before labor), and four with femoropopliteal DVT. There were three immediate major complications (pulmonary embolism, bleeding, or death) in Group A; two with pulmonary embolism, one of which was fatal, and one with significant bleeding (3 of 15 patients; 20%). No major complications occurred in Group B. On long-term follow-up (mean, 61 months), 4 of 12 patients (33%) in Group A had significant leg swelling, with partial resolution of DVT in 2 patients and venous occlusion in 2 patients by duplex ultrasound. This is in contrast to 3 of 11 patients (27%) in Group B with significant leg swelling. There was no fetal morbidity or mortality in either group. Conventional full-dose heparin therapy for DVT of the lower extremity in pregnancy can carry significant morbidity and mortality. Greenfield filters may be used safely in some of these patients.

Adolescent↗

PubMed2006

MR angiography versus intra-arterial digital subtraction angiography of the lower extremities: activity-based cost analysis.

PURPOSE: The aim of this study was to analyse the costs pertaining to the radiology department of magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA) in the evaluation of arterial disease of the lower limbs. MATERIALS AND METHODS: The differential cost of the two procedures, i.e. the sum of equipment costs (amortisation and service contract), variable costs (supplies and related services) and personnel costs (radiologist, radiographer and nurse) was determined. The common cost (auxiliary personnel and indirect internal costs) was also calculated. Finally, the full cost of the two procedures was obtained (sum of differential and common costs). RESULTS: The differential cost of MRA was 186.14 euro (equipment costs: 50.80 euro, variable costs: 75.04 euro, personnel costs: 60.30 euro) while the differential cost of intra-arterial DSA was 238.18 euro (equipment costs: 57.60 euro, variable costs: 90.13 euro, staff costs: 90.45 euro). The estimated common cost was 5.62 euro. Therefore, the full cost of MRA was 191.76 euro and the full cost of intra-arterial DSA was 243.80 euro (27.1% higher). DISCUSSION AND CONCLUSIONS: Intra-arterial DSA costs more than MRA, mainly because of the higher costs of supplies used during the procedure and higher personnel costs (as a result of the longer duration of intra-arterial DSA). It should be noted that our evaluation considers costs pertaining to the radiology department only. It is evident that an economic analysis considering hospital costs as well would result in much higher costs for DSA if post-procedure hospitalisation is required. Our results cannot be simply exported to other radiology departments since they refer to the technology and organisation adopted in our department. However, our cost analysis model can be easily applied to other environments. MRA provides good diagnostic accuracy in the evaluation of arteries of the lower extremities, and its biological cost is far lower than that of intra-arterial DSA (MRA is noninvasive, it does not use ionising radiation, and the contrast medium is safe). Its lower cost is another argument in favour of the use of MRA instead of intra-arterial DSA in the evaluation of lower-extremity arterial disease.

Angiography, Digital Subtraction↗

PubMedDate not supplied

[Clinical assessment of treatment results for atherosclerotic ischemia of the lower extremities with intraarterial ozone injections].

Ten injections of O3 into femoral arteries were administered to 50 patients with atherosclerotic ischemia of the lower extremities and to 49 diabetic patients. All patients were assessed clinically with the ankle-arm index, measurement of intermittent claudication distance prior to and after the treatment. The treatment showed a significant improvement in both groups manifested by an increase in ankle-arm index, and prolongation of the intermittent claudication distance by more than twice. The treatment of atherosclerotic ischemia of the lower extremities with O3 is both valuable and safe.

Arteriosclerosis↗

PubMed1993

Lower-extremity arterial disease in older hypertensive adults.

Lower-extremity arterial disease (LEAD) is common in older adults, particularly those with systolic hypertension. In a subgroup of 1,775 participants of the Systolic Hypertension in the Elderly Program, LEAD was assessed noninvasively by the ratio of the ankle to arm blood pressure, the ankle-arm index (AAI). LEAD was defined as an AAI of < or = 0.9 in either leg. The prevalence of LEAD was 25% in white men, 38% in black men, 23% in white women, and 41% in black women. About half of those with LEAD had mild disease (AAI, 0.8-0.9), and only 1-3% had a positive Rose questionnaire for intermittent claudication. The prevalence increased with age (p < 0.01) and was consistently higher in blacks than whites (p < 0.01), although there were no significant differences between men and women. Even in the absence of risk factors such as smoking and diabetes, blacks had a higher prevalence of LEAD than whites. Associations of LEAD with cardiovascular risk factors (high density lipoprotein cholesterol, systolic blood pressure, and smoking) appeared to be similar in blacks and whites, although relations were not always statistically significant in subgroups stratified by race and sex. Independent factors associated with the presence of LEAD included age, black race, smoking, diabetes mellitus, history of myocardial infarction or angina, systolic blood pressure, lower high density lipoprotein cholesterol, and body mass index. LEAD is common in older men and women with systolic hypertension, particularly blacks. However, very few have symptoms of claudication.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed2005

Ultrasound appearance of tendon tears. Part 2: lower extremity and myotendinous tears.

Traumatic tears of the musculotendinous complex at the lower limb are common in clinical practice but can be difficult to detect and to evaluate because of swelling and pain that can limit proper physical examination. They can affect sedentary subjects or active sports participants involved in amateur or professional activities. In the first group tendons are more commonly affected, while myotendinous tears are common in sports players. The aims of this review article are to review the aetiology and pathomechanism of the most common ruptures affecting the tendons and the main myotendinous junctions of the lower extremity and to describe their ultrasound findings as well as to correlate ultrasound appearance with that of the other imaging modalities.

Humans↗

PubMed1975

The natural history of bilateral aortofemoral bypass grafts for ischemia of the lower extremities.

Analysis of the immediate and long-term results in 180 patients undergoing aortofemoral bypass grafts for occlusive disease of the lower extremities showed the immediate graft limb patency in 360 graft limbs to be 99.2%. The cumulative ten-year graft limb patency was 66%. Factors associated with thrombosis of the graft limb revealed correlations for localized atherosclerotic disease of either the profunda femoris artery or the tibial trifurcation vessels. The highest correlation for graft limb thrombosis was with simultaneous lesions involving both the profunda femoris artery and tibial trifurcation vessels. The acute lower extremity salvage rate was 94%, and the ten-year cumulative extremity salvage for legs at risk of amputation was 85%. Postoperative symtpoms correlated well with patency. Overall operative mortality was five patients out of 180 (2.5%).

Adult↗

PubMed1988

Ultrasonography of the popliteal fossa and lower extremities.

In this article, the numerous proven applications of diagnostic ultrasound to the assessment of disease processes affecting the popliteal fossa and lower extremities have been discussed. Popliteal cysts and aneurysms, hematomas, cellulitis, abscesses, soft tissue neoplasms, and other space-occupying fluid collections are readily identified using this technique. In addition, post-traumatic and inflammatory disorders affecting tendons, synovial thickening and effusion, derangement of articular cartilage, meniscal tears, and alterations in soft tissue thickness as well as foreign bodies are amenable to detection by sonography. With future technologic improvements in transducer design and computerized image reconstruction, diagnostic capabilities of this method in the lower extremities should continue to expand.

Aneurysm↗

PubMed2004

Thrombolysis for lower extremity deep venous thrombosis.

Catheter-directed thrombolysis (CDT) has been proposed as an alternative mode of therapy to anticoagulation in patients with massive, symptomatic deep vein thrombosis of the extremity. The major goal of therapy is to rapidly restore venous blood flow, reduce the pain and edema of the extremity, preserve venous valve function, and reduce chronic symptoms related to chronic venous hypertension (postthrombotic syndrome). In patients with iliofemoral deep venous thrombosis (DVT) standard angiographic techniques are used to instrument a lower extremity vein (popliteal) and venography is performed followed by catheter-directed infusion of a plasminogen activator directly into the thrombus. Following lytic infusion, the interventionalist must evaluate the venous drainage to determine if there is an anatomic lesion that requires further endovascular treatment (eg, iliac vein compression syndrome). Posttreatment therapy usually consists of warfarin therapy and venous compression stockings for at least 3 to 6 months. The purpose of this article is to review the technical approach used in treating iliofemoral DVT and highlight the hurdles that face interventionalists in attempting to broaden this procedure to most types of lower extremity DVT.

Catheterization, Peripheral↗

PubMed2004

[Endovenous therapy for varicose veins of the lower extremities].

Endovenous treatment for varicose veins of the lower extremities is an old technique. New technologies such as radiofrequency and laser have revived its indications. Thermal energy which is delivered to the vein wall results in a fibrous retraction and eventually complete obstruction of the vessel.

Equipment Design↗

PubMed2004

Soft-tissue injuries of the lower extremity.

A diverse set of conditions affect the lower extremities in athletes. Good history taking and knowledge of the anatomy of the affected areas can aid in accurate diagnosis. Most conditions can be treated conservatively with great success. Familiarity with rehabilitation strategies can assist physicians in working with physical therapists. New advances, especially in the therapy of plantar fasciitis, may aid physicians in more rapid treatment of conditions of overuse. Surgery can provide definitive relief from symptoms for athletes with whom conservative measures have failed.

Fasciitis, Plantar↗