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PubMed1996

Clinical syndromes associated with disproportionate weakness of the upper versus the lower extremities after cervical spinal cord injury.

Patients with cervical spinal cord injuries who present with weakness or paralysis of the hands and arms with relative preservation of lower extremity strengths are often categorized as having two clinical syndromes, cruciate paralysis and acute central cervical spinal cord injury. The explanation for the pathophysiological findings of the dissociated strength in the upper versus the lower extremities has relied on the assumption that there is a localized injury within a somatotopically organized corticospinal tract. This article summarizes the evidence that there is no somatotopic organization within the corticospinal tract in the medulla or cervical spinal cord in primates. An alternative hypothesis for these two syndromes is presented and is based on evidence that has demonstrated that the corticospinal tract in primates is critical for hand function but not for locomotion. Other prevailing theories are reviewed. Thus, we propose that a syndrome consisting of relatively greater hand and arm weakness compared with leg weakness can occur after an injury to the corticospinal tracts in the medulla or the cervical cord. The proposed mechanism, based on the function of the corticospinal tract, unifies a spectrum of injuries of the lower medulla and cervical spinal cord, which produce similar clinical syndromes (cruciate paralysis and acute central cervical spinal cord injury).

Animals↗

PubMed1992

The influence of vascular certification on lower extremity revascularization at one institution.

The potential impact of vascular certification on the practice of vascular surgery at Maricopa Medical Center (Phoenix, AZ) was analyzed by comparison of lower extremity revascularization results over consecutive 2-year periods before (Period I) and after (Period II) institution of vascular surgery service. The overall setting (county hospital, surgical residency) and ancillary services (Anesthesia, Intensive Care Unit, Radiology) were unchanged, except for the authors' use of invasive hemodynamic support. In Period I, there were 49 cases (30 inflow, 19 outflow) with 14 per cent (7/49) mortality, 32 per cent (21/67) limb thrombosis or embolus, and 10 per cent (5/49) graft infection; 80 per cent (39/49) of operations were done for claudication; 20 per cent (10/49) were done for inappropriate indications (P less than 0.005). In Period II, there were 110 cases (47 inflow, 63 outflow). The increase in cases was predominantly due to increased use of extra-anatomic inflow and complex infrapopliteal outflow reconstructions. Seventy per cent (77/110) of operations were done for limb salvage; of 17 aortic cases, 3 were "re-do's" and 5 underwent simultaneous renal revascularization. There was a 3 per cent (4/110) mortality (P less than 0.025), 11 per cent (13/137) limb thrombosis or embolus (P less than 0.005), and no graft infections (P less than 0.001). Lower extremity revascularization delivered by certified vascular surgeons was offered to more patients with lower overall mortality and morbidity rates after more thorough diagnostic work-up and for more appropriate indications, with concomitant use of more refined vascular techniques/procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗

PubMed1976

Postoperative deep vein thrombosis in the lower extremity amputee: A prospective study with Doppler ultrasound.

The incidence of postoperative venous thrombosis and pulmonary embolism was assessed in 87 patients undergoing 96 major lower extremity amputations for ischemia. Prospective surveillance for deep leg vein thrombosis was carried out by Doppler ultrasound in 35 patients. There was no instance of major leg vein thrombosis and only one episode of a small non-fatal pulmonary embolus in a patient suffering trauma to the amputation stump after discharge from the hospital. This study suggests that clinically significant venous thromboembolism following current techniques of lower extremity amputation is not as common as previously reported. Doppler ultrasound is the most suitable technique for surveillance of venous thrombosis in these patients.

Adult↗

PubMed2005

[Plasma lipids oxidation in patients with occlusive atherosclerosis of lower extremities and ischemic heart disease].

Dynamics of lipoprotein oxidation in blood plasma was studied by Cu-induced plasma oxidation in 114 patients with atherosclerosis of lower extremities of various severity with and without ischemic heart disease. Preparedness of plasma lipoproteins to oxidation in patients was higher than in healthy subjects. Degree of oxidizeability increased with increase of severity and extent of atherosclerosis and was highest in patients with atherosclerosis of lower extremities and ischemic heart disease. There were no significant differences between groups of patients with various severity and extent of atherosclerosis in levels of total cholesterol and triglycerides as well as in other parameters of lipid spectrum. Correlation analysis revealed no relationship between age of patients and degree of plasma oxidizeability.

Aged↗

PubMed2000

Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: a systematic overview and meta-analysis.

OBJECTIVE: To determine the effect of reamed versus nonreamed intramedullary (IM) nailing of lower extremity long bone fractures on the rates of nonunion, implant failure, malunion, compartment syndrome, pulmonary embolus, and infection. DESIGN: Quantitative systematic review of prospective, randomized controlled trials. DATA IDENTIFICATION: MEDLINE and SCISEARCH computer searches provided lists of published randomized clinical trials from 1969 to 1998. Extensive hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files identified additional studies. STUDY SELECTION AND DATA EXTRACTION: Of 676 citations initially identified, sixty proved potentially eligible, of which four published and five unpublished randomized trials met all eligibility criteria. Each of three investigators assessed study quality and abstracted relevant data. RESULTS: The pooled relative risk of reamed versus nonreamed nails (nine trials, n = 646 patients) was 0.33 [95% confidence interval (CI), 0.16 to 0.68; p = 0.004]. The absolute risk difference in nonunion rates with reamed IM nailing was 7.0 percent (95% CI, 1 to 11 percent). Thus, one nonunion could be prevented for every fourteen patients treated with reamed IM nailing [number needed to treat (NNT) = 14.28]. The risk ratios for secondary outcome measures were: implant failure, 0.30 (95% CI, 0.16 to 0.58; p < 0.001); malunion, 1.06 (95% CI, 0.32 to 3.57); pulmonary embolus, 1.10 (95% CI, 0.26 to 4.76); compartment syndrome, 0.45 (95% CI, 0.13 to 1.56); and infection, 0.98 (95% CI, 0.21 to 4.76). Sensitivity analyses suggested that reported rates of nonunion and implant failure were higher in studies of lower quality. The type of long bone fractured (tibia or femur), the degree of soft tissue injury (open or closed), study quality, and whether a study was published or unpublished did not significantly alter the relative risk of nonunion between reamed and nonreamed IM nailing. CONCLUSIONS: There is evidence from a pooled analysis of randomized trials that reamed IM nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing.

Bone Nails↗

PubMed1990

[Dynamic measuring of blood pressure in the gastrocnemius muscle for evaluation of the status of venous hemodynamics in the lower extremity].

The work presents results of measuring the intramuscular pressure in musculus gastrocnemius in healthy people and patients with a pathology of major venous vessels of lower extremities (varicose dilatation of the veins, ++post-thrombophlebitic syndrome with recanalization of profound veins, acute iliofemoral venous thrombosis). It was found that the intramuscular pressure indices correlate with indications of phlebotonometry and may be used for the assessment of the state of venous hemodynamics in lower extremities.

Femoral Vein↗

PubMed1997

Relationship between functional exercise capacity and general quality of life in nonsurgical patients with lower-extremity peripheral arterial disease.

The purpose of this study was to examine the relationship between functional exercise capacity and general quality of life in patients with lower-extremity peripheral arterial disease (PAD) whose conditions are managed without surgical intervention and to establish new ways of measuring functional exercise capacity and general quality of life in this population. This descriptive survey examined 29 nonsurgical patients with lower-extremity PAD. Functional exercise capacity was measured with the 6-minute walk test. Quality of life was measured with the Medical Outcomes Study Short Form 36 (SF-36). All participants were either present or former smokers. Age ranged from 42 to 81 (M = 65). Walk test performance improved significantly from appointment 1 to appointment 2 (p = 0.01) but not from appointment 2 to appointment 3 (p = 0.9). All participants were able to finish all three walk tests for a total of 87 tests; however, in 30% (n = 26) of tests breaks were required because of leg pain. No one reported angina, and no syncope was observed. The SF-36 revealed significantly lower scores on the physical dimension scales and physical component summary (PCS) score in study participants as compared with a general population. Three physical dimension scales correlated significantly with walk test performance, as did the PCS score (r = 0.57, p = 0.001). In conclusion, functional exercise capacity correlated significantly with physical domains of general quality of life, whereas mental domains were unaffected. The 6-minute walk test was a safe, reliable measure of functional exercise capacity in the nonsurgical PAD population. By improving functional exercise capacity, physical abilities may improve. Thus the 6-minute walk test and SF-36 provide additional methods for objective measurement of the therapeutic impact of the nonsurgical management of PAD.

Activities of Daily Living↗

PubMed1993

Multiple relaxing skin incisions in orthopaedic lower extremity trauma.

The purpose of this study was to evaluate the efficacy of using multiple relaxing skin incisions (MRSIs) to facilitate the closure of difficult lower extremity wounds. Such wounds are caused by direct trauma or by surgical intervention for management of bone and soft tissue injury that result in wound closure under tension. Common alternatives include closure by secondary intention, delayed primary closure, split thickness skin grafting, or flap coverage. The technique of MRSI involves numerous small (5-10 mm) incisions through the dermis arranged in 1-cm-wide rows parallel to the primary wound or incision. Multiple relaxing skin incisions were utilized in 22 cases of orthopaedic lower extremity trauma to facilitate primary or delayed primary closure. Wounds were evaluated for dehiscence, skin slough, superficial and deep infection, and neurovascular compromise in the early postoperative period. Cosmesis was evaluated long term. Patients were followed postoperatively for > or = 1 year. There were no cases of wound dehiscence, skin slough, infection, or neurovascular compromise. Multiple relaxing skin incisions were preferred by all patients when compared to split thickness skin grafting, open wound management, or flap coverage. Cosmetic results were excellent. The use of MRSIs is a safe, simple, and reliable technique where wound closure is complicated by swelling due to trauma or soft tissue defects. No specialized training or equipment is required, and postoperative wound care is greatly simplified.

Adolescent↗

PubMed1982

Lower extremity ischemia due to combined drug therapy for migraine.

Three days after initiation of migraine headache therapy with ergotamine tartrate and propranolol, severe acute arterial insufficiency of the lower extremities developed in a 48-year-old woman who had been in general good health. Angiography revealed hypoplastic aortoiliac arteries, with tubular narrowing of the leg arteries. Lower extremity blood pressures rapidly returned to normal with a single intraarterial injection of 25 mg of tolazoline. Cases of peripheral ischemia due to either ergotamine or propranolol have been reported. Combined use of these two drugs may enhance the risk of acute arterial compromise.

Drug Therapy, Combination↗

PubMed1998

Bolus-chase MR digital subtraction angiography in the lower extremity.

A bolus-chase magnetic resonance (MR) angiographic technique performed with a prototypic stepping table and coil holder and a 15-20-mL injection of contrast material was developed to depict the entire lower extremity. Image acquisition was synchronized with passage of the contrast medium bolus through the lower extremity. Ten subjects underwent the examination, which was performed in less than 1 minute. All major arteries were well demonstrated in all cases.

Adult↗

PubMed1982

[Outpatient management of lower extremity fractures (author's transl)].

Although a large part of patients are hospitalized and treated operatively by modern traumatology, the absolute majority of bone fractures -- including the lower extremity -- are still managed on an outpatient basis. In this respect, they have to be strictly specified according to concomitant injuries, localization, type of fracture, possibilities of transportation and rehabilitation. Treated -- reposition and fixed -- fractures of the lower extremity require to be checked repeatedly with the rehabilitation exercise also being systematically controlled. Special demands are made concerning anaesthesia. Strict selection has to be observed in leg fractures. On an outpatient basis they can be managed in a plaster bandage.

Adolescent↗

PubMed2005

Functional decline in lower-extremity peripheral arterial disease: associations with comorbidity, gender, and race.

PURPOSE: To identify comorbidities associated with increased rates of functional decline in persons with lower-extremity peripheral arterial disease (PAD). We also determined whether female sex and black race were associated with greater functional decline than male sex and white race, respectively, in PAD. METHODS: Three-hundred ninety-seven men and women with PAD were followed prospectively for a median of 36 months. The presence of comorbid illnesses was determined with medical record review, patient report, medications, laboratory values, and a primary care physician questionnaire. Functional outcomes, measured annually, included the 6-minute walk, usual-paced and fast-paced 4-meter walking speed, and summary performance score. The summary performance score is a composite measure of lower-extremity functioning (score range, 0 to 12; 12 = best). RESULTS: Adjusting for known and potential confounders, PAD patients with pulmonary disease had a significantly greater average annual decline in 6-minute walk performance of -34.02 ft/y (95% confidence interval [CI], -60.42 to -7.63; P = .012), rapid-paced 4-meter walk speed of -0.028 m/s/y (95% CI, -0.054 to -0.001; P = .042), and summary performance score of -0.460/y (95% CI, -0.762 to -0.157; P = .003) compared with those without pulmonary disease. PAD patients with spinal stenosis had a greater average annual decline in 6-minute walk performance of -77.4 ft/y (95% CI, -18.9 to -35.8; P < .001) and usual-paced 4-meter walking velocity of -0.045 m/s/y (95% CI, -0.081 to -0.009; P = .014) compared with participants without spinal stenosis. CONCLUSION: At 3-year follow-up, pulmonary disease and spinal stenosis were each associated with a significant decline in functioning among persons with PAD. In contrast, female sex and black race were not associated with functional decline among persons with PAD.

Aged↗

PubMed1997

Delay in improvement of ankle-arm index and ankle waveforms after lower-extremity revascularization.

Ankle-arm index (AAI) and pulse volume recording (PVR) are commonly used in the early postoperative period to measure the outcome after lower-extremity revascularization. They are also used in addition to duplex scan for long-term follow-up of these patients. We noticed that in some patients the AAI and/or PVR after revascularization procedures did not improve immediately after surgery, but took 24 hours or longer to do so. We retrospectively reviewed the records of 47 patients who underwent various lower-extremity revascularization procedures and found that out of 20 patients who had AAI and/or PVR measured in the recovery room, 8 patients took 24 hours and 1 patient took more than 24 hours for maximal improvement of their AAI and/or PVR. This may be related to vascular spasm, and knowledge of this delayed improvement is important in preventing errors during follow-up.

Aged↗

PubMed1992

Lower-extremity amputation with immediate postoperative prosthetic placement.

To study the efficacy of an immediate postoperative prosthesis (IPOP) program, a retrospective review of 167 major lower-extremity amputations was performed. Patient enrollment in the IPOP program was based on the individual's potential for rehabilitation and participation in an aggressive postoperative physical therapy regimen, as determined by the surgeon, prosthetist, physical therapist, and social worker. Indications for amputation were intractable infection and/or severe unreconstructable arterial insufficiency. Sixty-five patients underwent 69 amputations with IPOP (59 below knee; 10 above knee). Successful program completion was defined as independent ambulation and occurred in 86% of those patients enrolled. The average interval from amputation to ambulation was 15.2 days for the below-knee amputees and 9.3 days for the above-knee amputees. Failure to complete the program occurred in 14% of patients and was due to noncompliance, stump infection, stump trauma, and death. The results of this review support the use of IPOP after major lower-extremity amputation.

Adult↗

PubMed1986

A comparison of techniques for improved visualization of the arteries of the distal lower extremity.

Intraarterial prostaglandin E1, tolazoline, nitroglycerin, and tourniquet-induced reactive hyperemia were directly compared by paired analysis for their efficacy in improving visualization of distal lower extremity vessels during routine arteriography in 101 limbs (52 patients). Nitroglycerin and reactive hyperemia were equal in their effect and statistically superior to both tolazoline and prostaglandin E1. Tolazoline was superior to prostaglandin E1, which had little or no effect. Intraarterial nitroglycerin in a dose of 200 micrograms appears to be the method of choice for augmenting visualization of the distal arterial vascular system in lower-extremity arteriography.

Alprostadil↗

PubMed1996

A prospective study comparing duplex scan and venography for diagnosis of lower-extremity deep vein thrombosis.

This study was designed to compare duplex scanning with contrast venography for the diagnosis of acute deep vein thrombosis of the lower extremity, both at the femoropopliteal (above-knee) and tibioperoneal (below-knee) levels. A total of 216 patients with 220 limbs suspected of acute deep vein thrombosis underwent duplex scanning followed within 24 h by ascending venography. The two studies were interpreted independently by two physicians who were blinded to the results of the corresponding alternative study. Venography was positive for deep vein thrombosis in 44.5% of cases (98/220). Duplex scanning was inadequate at the above-knee level in two cases (0.9%) and at the below-knee level in 17 cases (7.7%). Sensitivity and specificity of duplex scanning at above-knee level were 98.7% and 100% respectively while corresponding values were 85.2% and 99.2% at below-knee level. By excluding technically inadequate duplex studies, the sensitivity at below-knee level was clearly improved (93.8%). It is concluded that with meticulous technique, duplex scanning is highly accurate in diagnosing acute deep vein thrombosis of symptomatic lower extremities, avoiding contrast venography in over 90% of the cases, even at the tibioperoneal level.

Adult↗

PubMed1985

Statistical determinants of success and complications of thrombolytic therapy for arterial occlusion of lower extremity.

In this prospective study, we have documented the limited usefulness of thrombolytic therapy in the management of all patients with arterial occlusion of the lower extremities. We have also emphasized the significant rate of recurrent thrombosis unless an underlying obstructive lesion is corrected surgically after clot dissolution. Because thrombolytic drugs can lyse clots of a duration of several weeks, we recommend consideration of fibrinolytic therapy for subacute graft occlusions and segmental arterial thromboses. In such instances, thrombolysis is likely to reveal a focal underlying lesion that is correctable by a limited anastomotic revision or balloon angioplasty. Without fibrinolytic therapy, these older occlusions generally require more extensive bypass grafting or graft replacement. In contrast, we are less enthusiastic about thrombolytic therapy for distal small vessel thrombosis or embolism because complete clot lysis was achieved in only one of five patients. The primary problems with regional arterial low dosage thrombolytic infusions are bleeding at the angiographic catheter entry site and distal thromboemboli of the lysing clot. These difficulties may discourage wide acceptance of fibrinolytic therapy. However, they can be minimized by careful technique. Although its usefulness is limited and complications are common, catheter directed arterial low dosage thrombolytic therapy can be an important initial step in the diagnosis and treatment of selected arterial occlusion of the lower extremities.

Aorta, Abdominal↗

PubMedDate not supplied

Characterization of patients with high-energy lower extremity trauma.

PURPOSE: (a) to report the demographic, socioeconomic, behavioral, social, and vocational characteristics of patients enrolled in a study to examine outcomes after high-energy lower extremity trauma (HELET) and to compare them with the general population; (b) to determine whether characteristics of patients undergoing limb salvage versus amputation after HELET are significantly different from each other. DESIGN AND STUDY POPULATION: A prospective study of 601 patients admitted with high-energy lower extremity trauma to eight Level I trauma centers. PROCEDURES: Patients were evaluated during the initial hospitalization. They are being followed up for 24 months postinjury. Study patients are compared with the general population by using census information, population survey data, and published norms. Characteristics of patients undergoing limb salvage versus amputation are also compared. RESULTS: Most patients were male (77 percent), white (72 percent), and between the ages of twenty and forty-five years (71 percent). Seventy percent graduated from high school (compared with 86 percent nationally) (p < 0.05). One fourth lived in households with incomes below the federal poverty line, compared with 16 percent nationally (p < 0.05). The percentage with no health insurance (38 percent) was also higher than in the general population (20 percent) (p < .05). The percentage of heavy drinkers was over two times higher than reported nationally (p < 0.01). Study patients were slightly more neurotic and extroverted and less open to new experiences. When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found among any of the variables (p > 0.05). CONCLUSION: In conclusion, LEAP patients differ in important ways from the general population. However, the decision to amputate verus reconstruct does not appear to be significantly influenced by patient characteristics.

Adolescent↗