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PubMed1998

Failure of reducing lower extremity amputations in diabetic patients: results of two subsequent population based surveys 1990 and 1995 in Germany.

BACKGROUND: A 50% reduction of lower extremity amputations during the subsequent 5 year period has been targeted by the St. Vincent-Declaration issued in 1989/90 for a better care of diabetic patients across Europe. PATIENTS AND METHODS: In two adjacent counties far off major city areas 10 hospitals without specialised diabetes centers in the area provide care to about 300,000 inhabitants. Based on the official operation books and verified by the individual patient file all patients amputated in the 10 hospitals during the years 1990 and 1995 were evaluated retrospectively. RESULTS: A total of 119 patients (66 males, 53 females, age median 72 years) were amputated in the 10 hospitals 1990, and 162 (89 males, 73 females, age median 74 years) in 1995. The proportion of diabetic amputees amounted to 70.6 and 62.3%, respectively. A trend towards more toe amputations in diabetic versus nondiabetic patients was seen in both surveys which reached significance in 1995 (59 vs. 41%; p < 0.05). Based on the total population and the estimated number of diabetic patients (5% of the population) 1.4 and 2/10,000 nondiabetics were amputated in 1990 and 1995, respectively, in contrast to 61 and 66/10,000 diabetic individuals, indicating a 44 fold and 33 fold excess risk of diabetic patients. CONCLUSION: It is concluded that these 2 surveys 5 years apart reveal a failure of reducing lower extremity amputations in people with diabetes--despite the objectives of the St. Vincent-Declaration.

Adolescent↗

PubMed2000

Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden.

OBJECTIVE: To quantify changes in variables of inflammation, coagulation, and fibrinolysis in blunt trauma patients with lower extremity fractures who underwent different types of surgical procedures. DESIGN: Prospective, cohort study. SETTING: Level I university trauma center. PATIENTS: We allocated 83 blunt trauma patients in stable condition and 22 patients eligible for elective hip replacement to four treatment groups. INTERVENTIONS: In 34 multiply traumatized patients with femoral fracture (group PTFF) and in 28 patients with an isolated femoral fracture (group IFF), primary unreamed intramedullary nailing for stabilization of the femoral shaft fracture was performed. In 22 patients, an elective uncemented total hip arthroplasty (group THA) was inserted for osteoarthritis, and in 21 control patients, an isolated ankle fracture (group AF) was acutely stabilized. MEASUREMENTS AND MAIN RESULTS: From serially sampled central venous blood, the perioperative concentrations of interleukin (IL)-6, of tumor necrosis factor-alpha, of prothrombin fragments 1 + 2, and of D-dimer cross-linked fibrin degradation products were evaluated. Intramedullary instrumentation for an isolated femur fracture caused a significant perioperative increase in the concentrations of IL-6 (preoperative IL-6, 52 +/- 12 pg/mL; IL-6 30 mins postinsertion, 78 +/- 14 pg/mL; p = .02). This increase was comparable with group THA (preoperative IL-6, 46 +/- 16 pg/mL; IL-6 30 mins postinsertion, 67 +/- 11 pg/mL; p = .03). A positive correlation occurred between both groups (r = .83, p < .0004). Multiple trauma patients demonstrated significantly (p = .0002) higher IL-6 concentrations than all other groups throughout the study period and showed a significant increase after femoral nailing (preoperative IL-6, 570 +/- 21 pg/mL; IL-6 30 mins postinsertion, 690 +/- 24 pg/mL; p = .003), whereas no perioperative change was seen in group AF. The highest IL-6 increases were associated with a longer ventilation time (group PTFF) and a longer period of positive fluid balances (groups PTFF, IFF, THA). The coagulatory variables demonstrated similar perioperative increases in groups IFF and THA, but not in groups PTFF and AF. The IL-6 concentrations and the prothrombin fragments 1 + 2 concentrations correlated between groups THA and IFF at 30 mins and at 1 hr after surgery (r2 = .64, p < .02). In all patients the clinical variables were stable perioperatively. CONCLUSIONS: Major surgery of the lower extremity causes changes to the inflammatory, fibrinolytic, and coagulatory cascades in patients with stable cardiopulmonary function. The inflammatory response induced by femoral nailing is biochemically comparable to that induced by uncemented total hip arthroplasty. In multiple trauma patients, increases, which occurred in addition to those induced by the initial trauma, were measured. Definitive primary femoral stabilization by intramedullary nailing imposes an additional burden to the patient with blunt trauma. A careful preoperative investigation is required to evaluate whether primary definitive stabilization can be performed safely.

Adult↗

PubMed1980

An improved approach for performance evaluation in lower extremity involvement.

An investigation has been carried out to confirm the relationship between heart rate and energy expenditure in case of normal and lower extremity handicapped persons and, to explore the difference, if any, between both the relationships. Studies have been made on 8 below-knee amputees fitted with patellar-tendon-bearing (PTB) prostheses and 10 normal subjects, taken as two separate groups and also, on 1 below-knee amputee and 1 control subject as individuals. It has been found that a significant difference exists between both the relationships and hence, separate heart rate-energy expenditure relationship is needed to evaluate the performance of lower extremity handicapped in clinics and in industry without going into the cumbersome, clumsy and time consuming methods of estimating physiological cost.

Amputees↗

PubMed2000

Assessment of CO2 arteriography in arterial occlusive disease of the lower extremities.

PURPOSE: To compare the diagnostic ability and usefulness of carbon dioxide arteriography with that of angiography using iodinated contrast medium in ischemia of the lower extremities. METHODS: Between April 1997 and February 1998 arteriography was performed systematically in 50 consecutive patients (42 men, eight women; average age, 65 years), who presented with peripheral vascular disease of the arteries of the lower extremities, with use of both CO2 and iodinated contrast medium. Untoward events that occurred during the examinations and the resulting clinical problems were recorded. Subsequently, two radiologists carried out a double-blind evaluation of the images obtained for each segment (aorta, pelvis, thighs, knees, legs, and feet) using the two different contrast agents to diagnose the arterial condition (normal, aneurysm, stenosis, and occlusion). Afterward, the two types of study performed for each patient were compared to assess the overall quality of CO2 arteriography as opposed to arteriography performed with use of iodinated contrast material. RESULTS: Forty-eight percent of the patients reported discomfort during the CO2 examinations and 18% of the studies had to be discontinued as a result. When problems relating to poor image quality were included, only 36% of the arteriograms obtained with use of CO2 were complete. Evaluation was possible in only 25% of CO2 studies of the feet. On average, the overall quality of the arteriograms obtained with use of CO2 was insufficient for diagnosis. CONCLUSION: In the authors' experience, CO2 arteriography cannot replace procedures performed with use of iodinated contrast medium for routine examination of ischemia of the lower limbs. In most cases, because of lower tolerance to the procedure and poorer image quality, CO2 imaging was not of sufficient quality to permit diagnosis, particularly at the infrapopliteal level.

Aged↗

PubMed1991

[Clinical aspects of using extremely high frequency electromagnetic radiation in the complex treatment of occlusive vascular diseases of the lower extremities].

A method of local influencing with the extremely high frequency electromagnetic irradiation on the points of acupuncture was used in the complex treatment of 44 patients with obliterative diseases of the vessels of the lower extremities at the age of 34-75 years. Obliterative atherosclerosis was diagnosed in 15 of them, obliterative endarteritis --in 29. A high effectiveness of the method even in late stages of vascular pathology was noted. No complications were observed.

Adult↗

PubMed1981

Improvement of amputation level by lower extremity revascularization.

Improvement of amputation level, with a resulting increase in the ambulatory rehabilitation potential, was achieved in ten patients requiring extirpation of the lower extremity because of gangrene. Arterial reconstruction, percutaneous transluminal dilation or chemical lumbar sympathectomy, or a combination of these modalities, was used to achieve primary healing at an amputation site at least one level below that initially suggested by clinical and noninvasive diagnostic means. Patients requiring amputation of the lower extremity who are good candidates for ambulatory rehabilitation should undergo an aggressive diagnostic and therapeutic search for treatable proximal arterial lesions, thereby preserving limb length and increasing the likelihood of independent prosthetic use.

Amputation, Surgical↗

PubMed1986

[Valvular substitution of the popliteal vein in deep venous insufficiency of the lower extremity].

Substitute valve operation by Technique II provides a valve-like mechanism in the popliteal vein and has been performed on 105 patients (119 lower extremities) with chronic venous insufficiency. Results were verified clinically, phlebographically as well as by means of Doppler ultrasound and venous pressure measurement. Follow-up checks by Technique II were applied to 115 lower extremities, within one to five years from surgery, and substantive clinical improvement was recorded from 108 of them. Evidence was found to reduction of ambulatory venous pressure, elimination of popliteal reflux, and good phlebographic function of substitute valves.

Follow-Up Studies↗

PubMed2005

Changing dynamics in lower-extremity amputation in China.

OBJECTIVE: To evaluate the current pattern of lower-extremity amputation (LEA) in a Chinese population and to identify independent risk factors for failure to ambulate in the community after LEA. DESIGN: Retrospective study. SETTING: Tertiary hospital. PARTICIPANTS: Consecutive Chinese adults (N=189) who underwent LEA from 1995 to 1997. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pattern of LEA in comparison with previous data and risk factors for failure to ambulate in the community after LEA. RESULTS: The mean age at amputation was 74.1 years. Vascular occlusive disease and infection accounted for most of the reasons for the LEA. The pattern of LEA had changed significantly. The proportion of patients who were able to ambulate in the community decreased from 66.1% before the LEA to 29.9% 12 months after LEA. Logistic regression analysis showed that major amputation level, presence of diabetes mellitus, hypertension, inability to ambulate in the community before LEA, and failed use of prosthesis were significant independent risk factors for failure to ambulate in the community after LEA. CONCLUSIONS: A more aggressive rehabilitation approach, together with efforts targeted at various levels is required to achieve better functional ambulation level and to improve reintegration into the community after LEA.

Adult↗

PubMed2005

Measurement of central venous pressure from a peripheral intravenous catheter in the lower extremity.

OBJECTIVES: The measurement of central venous pressure (CVP) is used to assess intravascular status. Although this is usually accomplished by placement of a central venous catheter (CVC), there are circumstances when placement of a CVC may be technically difficult or impossible. The current study investigates the feasibility of measuring CVP from a peripheral intravenous catheter. METHODS: CVP was simultaneously measured from a CVC and from a peripheral intravenous site. The continuity of the peripheral intravenous catheter with the central venous system was evaluated by noting the change in the pressure measured from the peripheral catheter during a sustained inspiratory effort and during occlusion of the extremity (arm or leg) above the catheter. RESULTS: The cohort for the study included 37 adult patients. In 8 of the 37 patients (22%), there was no increase in the peripheral venous pressure (PVP) in response to a Valsalva maneuver or occlusion of the extremity above the intravenous site. For the upper extremity intravenous sites without a PVP increase, the PVP-CVP difference was 11.2 +/- 6.2 mm Hg versus 2.7 +/- 2.2 mm Hg in the patients in whom the PVP increased with these maneuvers (P < 0.0001). For the lower extremity intravenous sites without a PVP increase, the PVP-CVP difference was 7.6 +/- 4.0 mm Hg versus 2.6 +/- 1.9 mm Hg in the patients in whom the PVP increased (P < 0.0001). No variation in the accuracy of the technique was noted, depending on the size of the intravenous cannula, its location (upper versus lower extremity), CVP value, or patient positioning (supine, prone, lateral). CONCLUSIONS: Provided that the PVP increases to a sustained inspiratory breath and occlusion above the intravenous site, there is a clinically useful correlation between the PVP and the CVP.

Adolescent↗

PubMed1993

Clinical significance of routine imaging of iliac and calf veins by color flow duplex scanning in patients suspected of having acute lower extremity deep venous thrombosis.

BACKGROUND: Because duplex ultrasonography is used increasingly to evaluate patients suspected of having acute deep venous thrombosis of the lower extremity, the clinical significance of limiting venous duplex scanning to the common femoral, superficial femoral, and popliteal veins becomes an important question. METHODS: We prospectively studied by venous color flow duplex ultrasonography 181 patients referred for evaluation to rule out acute deep venous thrombosis to determine (1) the frequency with which the iliac and calf veins could be imaged adequately to determine the presence or absence of acute deep venous thrombosis, (2) the frequency of acute venous thrombosis in these venous segments, and (3) the time required to scan these additional segments. RESULTS: In 79% of the patients studied, one segment of the iliac venous system was imaged adequately to determine the presence or absence of venous thrombosis. In the lower extremity, the common femoral vein, the superficial femoral vein, and the popliteal vein were imaged adequately in 94% of the patients. In 76% of the patients all three calf veins were imaged adequately to determine whether acute deep venous thrombosis was present or absent. The anterior tibial vein was the most difficult vein to image consistently and was imaged adequately in 76% of the patients referred. The mean time to scan the affected limb was 8 minutes 37 seconds. Forty-seven patients (26%) of the 180 patients studied had positive venous scans. Twenty-three percent of the patients who had positive scans were found to have iliac vein involvement. Thirty-two percent who had positive venous scans were found to have thrombosis of the calf veins. Fifteen percent of the 47 patients who had positive scans had either an isolated iliac or calf vein thrombosis. CONCLUSIONS: We believe this frequency of isolated iliac or calf vein thrombosis coupled with the frequency of successful imaging of these venous segments and the short additional time required to image these segments justifies the inclusion of routine imaging of the iliac and calf veins in patients undergoing venous duplex scanning to rule out acute deep venous thrombosis.

Acute Disease↗

PubMed2026

Smart crutch tipsTM real-time feedback improves adherence to partial weight-bearing protocols following lower extremity fracture surgery: a pilot study.

PURPOSE: To evaluate the effectiveness of Smart Crutch Tips™ in promoting adherence to prescribed early partial weight-bearing (PWB) protocols and to assess patient experience with real-time weight-bearing feedback during home rehabilitation. METHODS: Twenty patients with lower extremity fractures prescribed partial weight-bearing (PWB) were randomized into two groups utilizing real-time feedback crutch tips (RFC). The Intervention group (n = 10) used Smart Crutch Tips™ (ComeBack Mobility Inc., Kiev, Ukraine), which provided real-time feedback on weight-bearing compliance. The Control group (n = 10) also used crutches equipped with Smart Crutch Tips™, but notifications were disabled, allowing passive data collection without patient feedback. Weight-bearing compliance was defined as the percentage of steps within ± 10% of the prescribed target. Secondary outcomes included patient satisfaction and device usability assessed using the System Usability Scale (SUS) throughout the home rehabilitation period. RESULTS: The Intervention group demonstrated significantly greater PWB compliance compared with the Control group (73.6% vs. 21.1%, p < 0.01). The Intervention group reported a mean SUS score of 84.25, indicating excellent usability. No device-related complications or adverse events were observed. Patient satisfaction, assessed through video interviews, was high, with participants in the Intervention group expressing a strong willingness to recommend the device to others with similar injuries and rating it 10 out of 10. CONCLUSION: Smart Crutch Tips™ significantly improved adherence to prescribed partial weight-bearing protocols following lower extremity fracture surgery. The RFC device demonstrated high usability, excellent patient satisfaction, and no device-related complications during home rehabilitation throughout the study period.

Humans↗

PubMed2003

Lower extremity injuries in lateral impact: a retrospective study.

ABSTRACT A retrospective analysis of the NASS/CDS database from 1993 to 2000 was used to investigate lower extremity injury in lateral impact. The analysis includes the study of the injury patterns, crash characteristics and the interactions between the occupant and the vehicle interior, including injuries to the farside occupants. The findings include significantly different injury patterns for the nearside and farside impacts. In particular, while the proportion of pelvis/hip injuries, with respect to AIS2 and AIS3 lower extremity skeletal injuries and 2-4 and 10-8 o'clock side impacts, was higher in nearside (70.4%) than farside (38.3%), the opposite trend was observed for the thigh (2.8% vs 4.5%), knee (6.2% vs 16.7%), leg (10.1% vs 19.5%) and foot/ankle (5.6% vs 14.7) injuries. Analysis of the PDOF suggested that a large proportion the impacts occurred obliquely, at approximately 10 and 2 o'clock, with a rearward component of force. It is hoped that the findings of the current study can help to investigate injury mechanisms.

Abbreviated Injury Scale↗

PubMedDate not supplied

Use of a ramp surface for lower extremity exercise with burn-injured patients.

The use of a ramp surface in our Burn Center has demonstrated benefits in improving gait, standing postures, and lower extremity muscle length. This technique has been effective with a wide age range of patients and is most useful as part of an overall treatment program including prestretching of lower extremities.

Burns↗

PubMed1999

Long-term functional status and quality of life after lower extremity revascularization.

OBJECTIVE: The objective of this study was to assess the longer term (up to 7 years) functional status and quality of life outcomes from lower extremity revascularization. METHODS: This study was designed as a cross-sectional telephone survey and chart review at the University of Minnesota Hospital. The subjects were patients who underwent their first lower extremity revascularization procedure or a primary amputation for vascular disease between January 1, 1989, and January 31, 1995, who had granted consent or had died. The main outcome measures were ability to walk, SF-36 physical function, SF-12, subsequent amputation, and death. RESULTS: The medical records for all 329 subjects were reviewed after the qualifying procedures for details of the primary procedure (62.6% arterial bypass graft, 36.8% angioplasty, 0.6% atherectomy), comorbidities (64% diabetics), severity of disease, and other vascular risk factors. All 166 patients who were living were surveyed by telephone between June and August 1996. At 7 years after the qualifying procedure, 73% of the patients who were alive still had the qualifying limb, although 63% of the patients had died. Overall, at the time of the follow-up examination (1 to 7.5 years after the qualifying procedure), 65% of the patients who were living were able to walk independently and 43% had little or no limitation in walking several blocks. In a multiple regression model, patients with diabetes and patients who were older were less likely to be able to walk at follow-up examination and had a worse functional status on the SF-36 and a lower physical health on the SF-12. Number of years since the procedure was not a predictor in any of the analyses. CONCLUSION: Although the long-term mortality rate is high in the population that undergoes lower limb revascularization, the survivors are likely to retain their limb over time and have good functional status.

Activities of Daily Living↗

PubMed1998

Transient lower extremity neurapraxia associated with radical perineal prostatectomy: a complication of the exaggerated lithotomy position.

PURPOSE: We assess the incidence and risk factors associated with lower extremity neurapraxia following radical perineal prostatectomy. MATERIALS AND METHODS: The medical records of 111 consecutive patients undergoing radical perineal prostatectomy at Duke University Medical Center between June 1994 and June 1995 were retrospectively reviewed. Patients were interviewed by telephone to ascertain whether symptoms had resolved. RESULTS: Neurapraxia developed in 23 patients (21%). Symptomatology was variable, including sensory and motor deficits of the lower leg and foot. Although lower extremity neurapraxia occurred in a significant number of patients undergoing radical perineal prostatectomy, it appeared to resolve in most. CONCLUSIONS: Careful attention to detail when positioning the patient and limiting the time in the exaggerated lithotomy position appear to be the most critical aspects to prevent neurapraxia.

Aged↗

PubMed1998

Lower extremity manifestations of cardiovascular disease. An update.

Cardiovascular disease is one of the leading causes of morbidity and mortality, and its system-wide complications are numerous and complex. Many signs and symptoms of cardiovascular pathology are expressed in the lower extremities. This article addresses new research that relates the lower extremity with cardiovascular disease.

Arterial Occlusive Diseases↗

PubMed1990

Pitfalls in lower extremity venous duplex scanning.

Results of scans performed on 1074 patients over an 18-month period were evaluated to define the limitations of lower extremity venous duplex scanning. Eighty-four patients had confirmatory phlebography performed within 24 hours of their venous duplex scanning. In 71 patients scans were considered diagnostic (sensitivity 91%, specificity 95%). Eighteen studies (13 equivocal, 5 misinterpretations) were scrutinized to determine the limitations of venous duplex scanning compared to phlebography and are the focus of this analysis. Seven patients had phlebograms documenting only infrapopliteal thrombus, seven had normal phlebographic findings, and four had findings consistent with chronic thrombosis. In the seven patients with infrapopliteal thrombus, four had normal imaging outcomes but abnormal Doppler flow patterns, whereas three had both normal imaging results and flow patterns. All four patients with chronic thrombosis had identifiable thrombus and abnormal flow patterns by venous duplex scanning, but in each case thrombus age was indeterminate. Of the seven patients with normal phlebographic results, five had incompressible segments of the superficial femoral vein on imaging, one had abnormal Doppler flow without visualized thrombus and without apparent reason, one had venous duplex scanning visualized thrombus with a normal outcome on phlebography. These data suggest that the diagnostic yield of lower extremity venous duplex scanning may be improved by (1) meticulous infrapopliteal vein examination, (2) better estimation of the age of the thrombotic process, and (3) recognizing segmental incompressibility of the superficial femoral vein within the adductor canal as a normal finding especially in the absence of abnormal Doppler flow or imaged thrombus.

Chronic Disease↗

PubMed1996

Outcomes and resource utilization in a managed care setting for lower extremity vein bypass grafts.

BACKGROUND: This 17-year review was undertaken to examine clinical outcomes and the changing trends in resource utilization for lower extremity bypass grafts performed in a managed care setting. PATIENTS AND METHODS: Between 1979 and 1995, 338 bypasses in 276 patients (199 men, 77 women; 62% diabetics) were carried out for limb salvage. Autogenous vein bypasses (AVB) were performed in 324 (96%) of the cases, which included 150 (43%) femoropopliteal (FP) and 174 (57%) femoro-tibial (FT) bypasses. There were 32 secondary AVB reconstructions included in the study group. RESULTS: The 30-day mortality rate was 2.2% and patient survival was 46% and 21% at 5 and 10 years. At 1 and 5 years, primary patency rates for the AVB were 87% and 79% for FP; 80% and 67% for FT AVB, whereas the limb salvage rates at those intervals were 96% and 94% for FP; 87% and 77% for FT, respectively. Despite an average annual inflation rate of 8%, significant reductions in hospital charges were noted during the study period. These were made possible by decreasing lengths of hospital stay, the development and application of guidelines and protocols for the management of leg ischemia, and the implementation of angioscopy for improving the surgical technique for in situ AVB. CONCLUSIONS: High-quality outcomes for lower extremity AVB are possible in a managed care setting with demonstrated improvements in the efficiency of resource utilization.

Aged↗