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Successful treatment of massive degloving lower extremity requires a flexible approach with adherence to basic surgical principles. There should be aggressive therapy with extensive debridement guided by direct observation and fluorescein vital dye staining. Wound closure, either primary or delayed, should be carried out using autogenous tissues when local and systemic tissue conditions permit.
A patient with lower extremity reconstruction is presented with a radial forearm free flap designed using the cluster analysis method of cutaneous perforators. The cutaneous vascular anatomy of fasciocutaneous flaps is discussed as well as the application of the mathematical model of analysis of the vascular territories within specific flaps to assist in "custom" flap design. The ultimate goal of this technique is the creation of flaps that provide a more precise and anatomical reconstruction of the proposed defect.
Ten patients who had amputations of a lower extremity for high-grade sarcomas underwent bone augmentation with either allograft or autograft between 1988 and 1996. There were eight transfemoral amputations and two transtibial amputations. The transferred segments consisted of one proximal tibia and six distal tibia autografts, two allografts, one autograft talar dome and first metatarsal, and one with a patellar cap of a supracondylar amputation. The average length of followup was 54 months. There were no nonunions of any of the grafts. There were three wound problems requiring additional operations. One autograft resorbed, and one autograft had a late infection. There was one local recurrence. Augmentation to provide length resulted in a 42% increase in bone length in those performed purely for length. All patients were able to use standard prostheses. Functional outcome was appropriate to the amputation level. Half of the patients avoided more proximal levels of amputation because of the ability to augment the osteotomy. The use of nonvascularized structural autografts or allografts is a simple procedure that can produce a superior residual limb in patients undergoing amputation. Its use should be considered in patients for whom traditional amputation techniques will result in poor function, difficulty in fitting a prosthesis, or greater than necessary anatomic loss.
Patients with burns of the lower extremity that require skin grafting were randomized into three groups to determine when postgraft ambulation could be safely resumed. Dangling protocol was initiated on postoperative day 6, 8, or 10, and ambulation was started on the next day. Grafts were evaluated at six stages on a five-point scale. In the 22 patients who completed the study, there was no significant difference in scores of the three groups. There was a significant difference in length of hospital stay when patients who dangled on postoperative day 6 were compared with patients who dangled on postoperative day 10.
BACKGROUND: Lower extremity injuries (LEIs) sustained in vehicular crashes result in physical problems and unexpected psychosocial consequences. Their significance is diminished by low Abbreviated Injury Scale scores. METHODS: Drivers who sustained LEIs were identified as part of the Crash Injury Research and Engineering Network (CIREN) and interviewed during hospitalization, at 6 months, and at 1 year. All were occupants of newer vehicles with seatbelts and airbags. RESULTS: Sixty-five patients were followed for 1 year. Injuries included mild brain injury (43%), ankle/foot fractures (55%), and bilateral injuries (37%). One year post-injury, 46% reported limitations in walking and 22% with ankle/foot fractures were unable to return to work. Depression (39%), cognitive problems (32%), and post-traumatic stress disorder (18%) were significant in the mild brain injury group. CONCLUSIONS: Long-lasting physical and psychological burdens may impede recovery and alter the lifestyle of patients with LEI. These issues need to be addressed by trauma center personnel.
Chronic ulceration of the skin of the lower extremities continues to be a difficult therapeutic problem. Pinch grafting of ulcers of the legs from a variety of causes, has proved to be highly successful. The success rate and complications of this procedure performed in the Department of Dermatology at the University of Iowa over a five-year period (1971-1975) are reviewed. The basic technique and pre-operative and post-operative care are outlined. Management of difficult cases by using such techniques as the Jobst pump, heterograft skin dressings, and sublesional steroid injection is also discussed.
A simple device is described for lower extremity phlebography. With the patient standing or recumbent, simultaneous injection of contrast material can easily be achieved by one person.
Revision of lower extremity bypass graft stenoses identified by surveillance duplex scanning is frequently required in diabetic patients. The authors evaluated (1) the value of routine angiography before graft revision in diabetics, (2) factors that predict patients in whom angiography alters management, and (3) the incidence of recurrent stenosis and factors that might predict it. Forty-two infrainguinal primary vein bypasses undergoing primary revision were retrospectively studied. The initial graft stenosis was detected at a mean of 11.5 +/-3.6 months after the original bypass. Angiograms were obtained in 38 cases, revealing additional findings in 29 of 38 cases (76%), with a resultant alteration of the operative plan in 27 cases (71%). The most frequent additional angiographic finding was the identification or localization of a lesion in the inflow or outflow tracts (18 of 27 cases). Cases where the angiogram altered the management plan had a mean systolic velocity ratio across the stenosis (Vr) of 7.3 +/-6.1, versus a Vr of 4.8 +/-1.3 for cases where the angiogram did not alter the management plan (p<0.04). Duplex scanning identified 4 lesions that were not seen on angiography; 3 of 4 were confirmed as webs at surgery. Twenty of 42 grafts (48%) developed recurrent stenoses at a mean of 4.9 +/-3.8 months from initial revision. Restenosis occurred in 69% of female limbs as compared to 38% of male limbs (p=0.06). Recurrent stenosis was not a predictor of ultimate graft failure, unless left untreated. Four of 10 untreated grafts ultimately failed. A total of 9 of the 42 grafts eventually failed (21%), leading to 3 amputations (7%). The authors conclude that failing infrainguinal bypass grafts identified by duplex in diabetics should undergo a detailed angiographic evaluation. This frequently leads to an alteration in the management plan, especially in the presence of a high Vr across stenoses. High rates of limb salvage (93%) and assisted primary graft patency (79%) despite a high recurrent stenoses rate (48%) justify routine duplex surveillance, preoperative angiography, and aggressive graft revision in diabetic patients with infrainguinal grafts.
Nineteen patients with complex injuries of the lower extremities were treated with emergency free flap reconstruction after radical débridement, bone stabilisation, and primary repair of injured structures (nerves, tendons, vessels, and muscles). Two patients sustained complete below knee amputation associated with avulsion of soft tissue and had salvage free flap transfer to preserve length of stump and function of knee joint. Long-term follow up ranged from four months to eight years (median 3.5 years) No flaps failed and there were no serious complications of wound healing. Procedures were associated with minimal morbidity, a reduced number of secondary operations, shorter hospital stay, and good functional results.
The lower extremity has a mechanical axis with joint orientation that allows joint longevity and efficiency in bipedal gait. When normal alignment is lost because of trauma or other conditions, deviations from this anatomic norm may be deleterious to long-term joint function. In fractures that have healed with angular malunion, all facets of the deformity must be carefully considered, including alteration in length, rotation, alignment, and translation. Once all elements are fully defined, the effects of the malunion on mechanical axis and joint orientation can be understood. Techniques for surgical correction include wedge, dome, and oblique osteotomies and distraction osteogenesis. Each method possesses characteristics appropriate for certain clinical situations. Judicious patient selection and thoughtful preoperative planning may allow restoration of normal mechanics.
The reliability of biomechanical measurements of the lower extremities, as they are commonly used in podiatric practice, was quantified by means of intraclass correlation coefficients (ICCs). This was done not only to evaluate interrater and intrarater reliability but also to provide an estimate for the accuracy of the measurements. The measurement protocol involved 30 asymptomatic subjects and five raters of varying experience. Each subject was measured twice by the same rater, with the retest immediately following the test. The study demonstrated that the interrater ICCs were quite low (< or =0.51), except for the measurements of relaxed calcaneal stance position and forefoot varus (both 0.61 and 0.62 for left and right, respectively). However, the intrarater ICCs were relatively high (>0.8) for most raters and measurement variables. Measurement accuracy was moderate between raters.
In 20 patients with diabetic angiopathy of lower extremities and purulent-necrotic complications, in whom the diagnosis of chronic syndrome of disseminated intravascular blood coagulation (DIC-syndrome), preparation vobenzym (Mucos Pharma & Co, Germany) was applied. High efficacy of the preparation was noted: more rapid healing of purulent-necrotic wounds, elimination of symptoms, stabilization of the hemodynamics indexes.
Lower extremity amputation (LEA) is a costly and disabling procedure that disproportionately affects persons with diabetes. One of the national health objectives for 2000 was to reduce the LEA rate from a 1991 baseline of approximately eight per 1,000 persons with diabetes to a target of approximately five per 1,000 persons with diabetes. Review of 1996 data indicated an LEA rate of approximately 11. To estimate the national rates of hospital discharges for LEA among persons with and without diabetes and to assess the excess risk for LEA among persons with diabetes, CDC and the Agency for Healthcare Research and Quality (AHRQ) analyzed data from the 1997 Nationwide Inpatient Sample (NIS) and the 1997 National Health Interview Survey (NHIS). This report summarizes the findings of the analysis, which indicated that the age-adjusted rates of hospital discharges among persons with LEA who had diabetes were 28 times that of those without diabetes. This higher rate underscores the need to increase efforts to prevent risk factors (e.g., peripheral vascular disease, neuropathy, and infection) that result in LEA among persons with diabetes.
Rational method of surgery for lower extremities varicosis are developed. Method consists of Babkok's extirpation of greater and minor (if it is necessary) saphenous veins with spiral device; preliminary transcutaneous-supracutaneous temporary caprone ligation of changed superficial veins, subcutaneous dissection of ligated veins with minimal blood loss. Original flexible spiral saphenoextractor, inflatable hemostatic device, phlebotoms of simple construction are used. These devices permit to simplify surgery, to decrease tissues trauma and to achieve good cosmetic effect. Recurrence over 1-8 years was seen in 145 operated patients.
Ulcers of the lower extremities, particularly in individuals >65 years old, are a common cause for visits to the podiatrist, wound care specialist, primary care physician, vascular surgeon, or dermatologist. When an ulcer does not respond to adequate medical and wound care, the potential for an underlying malignancy should be considered. Cutaneous malignancies that may masquerade as ulcers include nodulo-ulcerative basal cell carcinoma, squamous cell carcinoma, keratoacanthoma, nodular melanoma, tumor stage mycosis fungoides, lymphomatoid granulomatosis, lymphomatoid papulosis, angiosarcoma, and cutaneous metastases from internal malignancy. It is crucial for healthcare providers to recognize these presentations and render appropriate therapeutic intervention.
Reconstructive surgery on the vessels of the lower extremities accompanied by ischemia and the following tissue oxygenation leads to the activation of lipid peroxidation causing the destruction of cellular membranes and formation of toxic products, namely medium mass oligopeptides. The accumulation of lipid peroxidation metabolites in the blood correlates with the onset of renal-hepatic failure complicating the postoperative period.
Defects in the soft tissues of the lower extremities after burns and traumas in 10 patients were managed by plastic surgery using ++cutaneo-fascial grafts formed from the leg of the same or contralateral side. The operation was performed in two or three stages. ++Cutaneo-fascial grafts formed on the posteromedial or posterolateral surface of the leg may have a width:length ratio of 1:3. In cross plastics the proximal one third of the graft is folded like a tube. Inclusion of the vena saphena magna in the graft and measures aimed at prevention of separation of the fascia from the layer of fat increase the viability of the graft. Secondary deformity is significantly reduced by modelling the edges of the donor wound and closing it with an unperforated graft of split skin.
The etiology of back and lower extremity pain can, at times, be difficult to differentiate. This is especially true in cases where two pain-producing conditions coexist. Such difficulties have been reported in cases of coexisting vascular and neurogenic claudication. We report the case of a 66-year-old woman with concurrent musculoskeletal pain and hip claudication. Her arterial insufficiency was initially masked by her diffuse pain complaints and only became apparent to us after successful treatment of her soft tissue problems. We caution physicians to be aware of coexisting musculoskeletal pain that may mask significant underlying pathology.