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PubMed1989

Low-dose fibrinolytic therapy for recent lower extremity thromboembolism.

Low-dose catheter-directed fibrinolytic therapy (LDCF) using streptokinase (35) and urokinase (7) was performed on 42 separate occasions in 36 patients for recent lower extremity thromboembolic occlusion. Twenty-seven grafts and 15 native arteries were treated. Causes of occlusion were known in 32 instances: native artery proximal or distal occlusive disease or both (18 vessels); bypass graft stenosis (6); aneurysm (2); embolus (4); and postangiography thrombosis (2). Twenty-nine infusions were technically successful, and patients were clinically improved by 26 of the treatments. Twelve patients had unsuccessful infusions and six underwent subsequent amputation. In all patients, infusions longer than 12 hours resulted in prolonged thrombin times and lowered plasma fibrinogen concentrations; one infusion was discontinued due to a low fibrinogen concentration. Complications occurred on 17 occasions and included hemorrhage (6), distal embolization (3), compartment syndrome (1), retrograde thrombosis during infusion (5), hypotension (1), and systemic fibrinogenolysis (1). The cumulative success rate was 44% +/- 9% at 24 months. Late rethrombosis (five instances) was more common in patients who had inflow or outflow structural lesions not corrected following successful fibrinolysis. LDCF is a useful alternative to other methods of treatment for recent onset lower extremity thromboembolic occlusion. Structural vascular lesions uncovered by successful infusion should be corrected immediately after infusion to ensure long-term patency.

Blood Vessel Prosthesis↗

PubMed2000

Functional status and walking ability after lower extremity bypass grafting or angioplasty for intermittent claudication: results from a prospective outcomes study.

OBJECTIVE: The purpose of this study was the prospective comparison of functional outcomes after lower extremity bypass grafting surgery, angioplasty, or medical management of intermittent claudication. METHODS: The study was designed as a prospective cohort study to compare functional outcomes for patients with interventional management to medical management, including a matched (younger, with more disability) subgroup, followed for a mean of 19 months. Sixteen Chicago-area vascular surgery clinics participated in the study. The subjects were consecutively enrolled patients with an abnormal ankle-brachial blood pressure index (ABI), without signs of rest pain, ulcer, or gangrene, and without prior lower extremity revascularization procedures. The main outcome measures were changes in physical functioning, community walking distance, bodily pain, leg symptoms, and ABI. RESULTS: Of the 526 study patients, 20% underwent revascularization procedures (60 surgical bypass grafting and 44 angioplasty only). The mean ABI improved significantly for the patients who underwent bypass grafting surgery (0.20; P <.001) and modestly for the patients who underwent angioplasty (0.09; P <. 05). Patients undergoing bypass grafting and angioplasty maintained highly significant (P <.001) improvements in mean physical functioning, (17%, 14%), bodily pain (18%, 13%), and walking distance (28%, 27%) scores and reported greater leg symptom improvement. The results were far superior for the patients with greater improvement in ABI. The conditions of the 277 unmatched patients who underwent medical management declined on all outcome measures, and the conditions of the 145 matched patients who underwent medical management improved 5% (P <.001) on walking distance score. Eighteen percent of the study patients failed to complete the full study follow-up period. CONCLUSION: Most of the functional improvement achieved by patients who underwent interventional management appears to be related to improved patency rather than to selection bias or placebo effects. The functional gains were approximately half those often reported for patients for hip arthroplasty and similar to patients who undergo elective coronary angioplasty.

Activities of Daily Living↗

PubMed1977

Clinically suspected deep venous thrombosis of the lower extremities. A comparison of venography, impedance plethysmography, and radiolabeled fibrinogen.

To define the utility of new diagnostic approaches in patients with clinically suspected deep venous thrombosis of the lower extremities, 42 legs of 33 patients were studied by fibrinogen labeled with radioactivie iodine (125I) impedance plethysmography (IPG), and contrast venography. The clinical diagnosis was confirmed in approximately two thirds of the legs and patients. In venogram-positive legs, fibrinogen 125I was positive in 70%, IPG in 61%, and one of the two in 78%. In venogram-negative legs, fibrinogen 125I was positive in four (21%) and IPG was negative in all. It was found that the size, age, and location of the thrombus, collateral vein development, heparin sodium therapy, and technical-interpretive choices can influence both IPG and fibrinogen 125I results. The data demonstrate that the fibrinogen 125I and IPG procedures can assist physicians in the diagnosis of clinically suspected deep venous thrombosis of the lower extremities.

False Negative Reactions↗

PubMed1982

[Compartment syndromes of the lower extremities (author's transl)].

A reduction of the arterial blood pressure of the muscles of the 4 tight fascial compartments of the shank may be initiated by: Trauma and operation of the lower extremities, spontaneous bleeding, occlusion of the arteries, general and local hypotonia due to elevation of the leg, as well as by drug abuse and increased stress of the muscles of the lower extremities. This is followed by an increased swelling and tension of the tissue with ischemia and consecutive paralyses of the nerves and muscles in the presence of almost simultaneous muscle contractures. We may encounter a double insult, a "rebound" effect, if f.i. following removal of a two thigh bandage of the shank the compartment again becomes too narrow due to a postischemic swelling. The anterior tibial syndrome is frequently caused by an increased exertion in sports and in the military service. The dorsal syndromes are often accompanied by Sudeck's dystrophy in the late stages. In treatment the early and extensive longitudinal incision of the respective fasciae is imperative in order to prevent the typical equino-varus deformity and hallux flexus.

Adult↗

PubMed1993

Kinetics of the lower extremities during drop landings from three heights.

In this study, the landing preferences of gymnasts (n = 6) and recreational athletes (n = 6) were determined by comparing the changes in lower extremity kinetics of drop landings performed from three heights (0.32-1.28 m). Net joint moments and work done on the extensor muscles of the ankle, knee, and hip were selected as variables representative of the demand placed on the muscles responsible for controlling flexion and dissipating the load. Kinematic and kinetic two-dimensional data were acquired simultaneously using high-speed film (202.4 fps) and a force plate (1000 Hz). Reaction forces and lower extremity joint motions were used to calculate net joint forces, net joint moments powers, and work done on the extensor muscles of the ankle, knee, and hip. Results indicated that the extensor joint moments tended to peak earlier after contact with increases in velocity, but the temporal sequence of events was maintained independently of velocity or group. As impact velocity increased, net peak extensor moments and work done on the extensor muscles significantly increased. Significantly larger ankle and hip peak extensor moments were observed for the gymnasts across velocities as compared to the recreational athletes. No significant differences in work done on the extensor muscles were noted between groups. Significant interaction effects indicate that gymnasts chose to dissipate the loads at contact by using larger ankle and hip extensor moments at higher impact velocities than the recreational athletes, whereas recreational athletes chose to adjust their strategy by using greater degrees of hip flexion (McNitt-Gray, Int. J. Sport Biomech, 7, 201-204, 1991) and longer landing phase durations than the gymnasts. The greater demands placed on the ankle and hip extensors by the gymnasts, as compared to the recreational athletes, may be explained by the need to maintain balance during competitive gymnastics landings or, perhaps, by the inability of recreational athletes to produce larger extensor moments at the ankle or hip during landings from great heights.

Ankle Joint↗

PubMed1990

Indirect revascularization of the lower extremity by means of microvascular free-muscle flap--a preliminary report.

We describe the treatment of a patient with end-stage peripheral vascular disease and ischemic ulceration of the lower extremity in whom an obliteration of the distal arterial bed precluded conventional arterial reconstruction. A nonhealing dorsal foot ulcer was debrided, and soft tissue reconstruction was accomplished by the free microsurgical transfer of a muscle flap to the distal lower extremity. Arterial inflow to this free flap was provided by a contralateral reversed saphenous vein graft from the proximal arterial tree of the leg. This procedure resulted in a healed wound, stable coverage, and limb salvage. The patient also noted complete relief of rest pain and improvement in his claudication symptoms. A follow-up arteriogram was done 2 months after surgery. Contrast injection directly into the artery of this flap showed new blood vessel growth from the muscle flap into the foot with anastomoses of these "new vessels" to the patient's native circulation. This experience suggests that limb salvage may be possible by the free microvascular transplantation of a muscle flap onto the limb in selected patients whose limbs are deemed "nonreconstructible."

Angiography↗

PubMedDate not supplied

The incidence and risks of failure to heal after lower extremity amputation for the treatment of diabetic neuropathic foot ulcer.

The primary goal of this retrospective cohort study was to determine the incidence of failure to heal after lower extremity amputation for the treatment of diabetic neuropathic foot ulcer, and the secondary goal was to identify risk factors associated with the outcome. We evaluated 1775 patients who underwent amputation for the treatment of 5314 neuropathic foot ulcers, and who were treated in a network of wound care centers. We calculated the incidence of failure to heal after the initial amputation, and used generalized estimation equations and generalized linear latent and mixed model regression to evaluate the association of failure to heal by the 20th week of care. The unadjusted incidence of failure to heal was 34.01%, and male sex, number of wounds, wound grade, and adjunct therapy were all significantly associated with failure to heal. With the exception of wound grade, the associations were not significantly affected by the treating wound care center, and a sensitivity analysis showed the results to be resistant to the theoretical influence of an unmeasured potential confounder. These findings should be useful to clinicians treating diabetic neuropathic foot ulcers, and should aid surgeons in the determination of the most appropriate level for lower extremity amputation.

Age Factors↗

PubMed1994

A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission.

BACKGROUND: A short battery of physical performance tests was used to assess lower extremity function in more than 5,000 persons age 71 years and older in three communities. METHODS: Balance, gait, strength, and endurance were evaluated by examining ability to stand with the feet together in the side-by-side, semi-tandem, and tandem positions, time to walk 8 feet, and time to rise from a chair and return to the seated position 5 times. RESULTS: A wide distribution of performance was observed for each test. Each test and a summary performance scale, created by summing categorical rankings of performance on each test, were strongly associated with self-report of disability. Both self-report items and performance tests were independent predictors of short-term mortality and nursing home admission in multivariate analyses. However, evidence is presented that the performance tests provide information not available from self-report items. Of particular importance is the finding that in those at the high end of the functional spectrum, who reported almost no disability, the performance test scores distinguished a gradient of risk for mortality and nursing home admission. Additionally, within subgroups with identical self-report profiles, there were systematic differences in physical performance related to age and sex. CONCLUSION: This study provides evidence that performance measures can validly characterize older persons across a broad spectrum of lower extremity function. Performance and self-report measures may complement each other in providing useful information about functional status.

Activities of Daily Living↗

PubMed1998

Development and validation of an exercise performance support system for people with lower extremity impairment.

OBJECTIVE: To identify innovative strategies to support appropriate, self-directed exercise that increase physical activity levels of people with arthritis. This article reports on one interactive, multimedia exercise performance support system (PSS) for people with lower extremity impairments in strength or flexibility. METHODS: An interdisciplinary team developed the PSS using self-report of lower extremity musculoskeletal impairments (flexibility and strength) to produce an individualized exercise program with video and print educational materials. Initial evaluation has investigated the validity and reliability of program assessments and recommendations. RESULTS: PSS self-report and professional assessments were similar, with more impairments indicated by self-report. PSS exercise recommendations were similar to those made by 3 expert physical therapists using the same exercise data base. Results of PSS impairment assessments were stable over a 1-week period. CONCLUSION: PSS exercise recommendations appear to be reliable and a valid reflection of current exercise knowledge in rheumatology. Furthermore, users were able to complete the computer-based program with minimal assistance and reported it to be enjoyable and informative.

Exercise Therapy↗

PubMed2004

[Deep venous thrombosis of the lower extremity. Ultrasonography should replace phlebography as first line diagnostic imaging].

In Sweden, there is a widespread use of ascending venography for the diagnosis of deep vein thrombosis of the lower extremities (LEDVT) instead of ultrasonography. The main reason for this is the inferiority of US in diagnosing LEDVT in the calf veins. In order to indirectly estimate the magnitude of this inadequacy, we reviewed all of the cases of attempts to perform venograms at our center during a four-month period. The results showed that only 4-5 per cent of requested and successful venograms were able to show signs of LEDVT in the calf veins (distal LEDVT). With regards to these results and a recent report by SBU (Swedish Council on Technology Assessment in Health Care), we believe that US with compression technique and Doppler should be considered as a replacement for venography of the lower extremities as the first line of diagnostic imaging modality.

Adolescent↗

PubMedDate not supplied

Fourier transformation of arterial Doppler waveforms of the lower extremity.

PURPOSE: Although it is well known that the normal, triphasic pulsatile arterial Doppler waveform changes in shape as flow is impaired, interpretation of the waveform has largely been subjective. We aimed to describe the Doppler waveforms of the lower extremity objectively using Fourier transformation. METHODS: Sixty-eight zero-crossing detector arterial recordings from 25 lower extremities were grouped as follows: group 1, no ischemic symptoms with an ankle-brachial index (ABI) > 0.9 (n = 17, 8 limbs); group 2, no ischemic symptoms with ABI < 0.9 (n = 18, 5 limbs); group 3, symptoms of claudication (n = 19, 7 limbs); group 4, rest pain or tissue loss (n = 14, 5 limbs). The waveforms were Fourier transformed and their amplitudes and phases were compared up to the third harmonic (H3). RESULTS: Amplitudes of both the fundamental (H1) and second harmonic (H2) were predominant in group 1. In contrast, amplitudes of the H2 and H3 decreased with altered flow (p < 0.0001 for group 1 versus others). The phases of the H1 and H2 were delayed with altered flow (p < 0.05 for group 1 versus others). Phases of the H1 were different between group 2 and 4 (p < 0.05). The difference of phase between the H3 and H1 was shortened with altered flow (p < 0.05 for group 1 or 2 versus group 4). Multivariate analysis revealed that the relative amplitudes of the H2 and H3, the phases of the H1 and H2, and the relative phase of the H3 were significant discriminators among the groups. CONCLUSION: Abnormal waveforms could be characterized by the predominant amplitude of the H1, phase delay of the H1 and H2, and shortening of the relative phase of the H3. These parameters may be useful in the evaluation of Doppler waveforms in patients with peripheral arterial disease.

Adult↗

PubMed1989

Digital venography of the lower extremity.

A digital 33-cm fluoroscopic system equipped with conventional spot-film and digital or video hard-copy capabilities was evaluated for its usefulness in diagnosing deep venous thrombosis of the lower extremities. The impact of different fluoroscopic field sizes, spatial resolution, and contrast variance was measured by using phantoms. The results indicate that the physical characteristics of the digital system are acceptable for lower-extremity venography. Digital fluoroscopic hard copy was compared with conventional spot films in 22 examinations. The digital examinations were as accurate as the conventional examinations. Procedure time, exposure to radiation, film costs, and repeated injections of contrast medium because of errors in exposure were reduced with the digital method. The need for extra technologists was eliminated. The advantages of digital radiographic displays, postprocessing, storage, and transmission were maximized. Digital fluoroscopic examinations were as accurate as conventional spot films and were found to have many advantages.

Fluoroscopy↗

PubMed1999

[MR angiography of the lower extremities with an automatic table translation (Mobitrak) compared to i.a. DSA].

PURPOSE: Comparison of the diagnostic information obtained by MRA using a moving bed ("MobiTrak") with i.a.DSA for angiography of the lower extremities. MATERIALS AND METHODS: In 20 patients, i.a.DSA and MRA were performed within a few days. The image quality and diagnostic information were evaluated by two radiologists and two surgeons. RESULTS: The radiologists assessed the quality of MRA higher for 18%, for 79% image quality was equal, for 3% the quality was graded as lower in comparison to i.a.DSA. The surgeons found the quality of MRA higher for 16%, equal for 75% and lower for 9%. In all cases, MRA was sufficient for planning of further treatment. CONCLUSIONS: For examinations of the arterial vessels of the lower extremities, MRA with a moving bed ("MobiTrak") can be used instead of i.a.DSA. The diagnostic information from MRA is sufficient for planning the further treatment. The advantages of MRA (no radiation, no i.a. puncture, no contrast medium with iodine) will lead to an increasing application of this method.

Adult↗

PubMed2002

Minimal clinically important rehabilitation effects in patients with osteoarthritis of the lower extremities.

OBJECTIVE: To estimate minimal clinically important differences (MCID) of effects measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in patients with osteoarthritis (OA) of the lower extremities undergoing a comprehensive inpatient rehabilitation intervention. METHODS: A prospective cohort study assessed patients' health by the WOMAC at baseline (entry into the clinic) and at the 3 month followup, and by a transition questionnaire asking about the change of "health in general related to the OA joint" during that time period. The WOMAC section score differences between the "equal" group and the "slightly better" and "slightly worse" groups resulted in the MCID for improvement and for worsening. RESULTS: In total 192 patients were followed up. The MCID for improvement ranged from 0.80 to 1.01 points on the continuous WOMAC numerical rating scale from 0 to 10, reflecting changes of 17 to 22% of baseline scores. The MCID for worsening conditions ranged from 0.29 (6%) to 1.03 points (22%). In the transition reply subjectively unchanged patients reported a "pessimistic bias" of 0.35 to 0.51 points, except for the stiffness section. Both MCID and pessimistic bias showed regression to the mean and baseline dependency. CONCLUSION: The assessment of MCID using the transition method is a heuristic and valid strategy to detect particular rehabilitation effects in patients with OA of the lower extremities with the use of the WOMAC, and it is worth implementing. The size of the MCID and of the systematic bias is comparable to that assessed by other methods and in other therapeutic settings.

Adult↗

PubMed1993

Management of deep vein thrombosis of the lower extremity in pregnancy.

Deep vein thrombosis (DVT) of the lower extremity during pregnancy is infrequent, but its complication, pulmonary embolism, remains an important cause of maternal mortality. To evaluate the best method of caring for patients with DVT, we reviewed the records of patients at the Charleston Area Medical Center from 1987-1992 who were treated for this condition. Twelve patients were treated with conventional continuous intravenous heparin for 7 days-10 days followed by subcutaneous heparin until 6 weeks-8 weeks after delivery. The other group consisted of nine patients who were treated with lower dose subcutaneous heparin for 7 days-10 days and maintained as the first group, but a Greenfield filter was inserted for patients with iliofemoral DVT. The patients who received low-dose heparin and Greenfield filters tended to do better than those who received high-dose conventional heparin treatment. However, since there were so few patients evaluated, further verification is needed.

Adult↗

PubMed2004

Multidetector CT angiography of arterial inflow and runoff in the lower extremities: a challenge in data acquisition and evaluation.

PURPOSE: To show the feasibility of acquiring homogenous 3-dimensional datasets with high temporal and spatial resolution from computed tomographic angiographic (CTA) scans of the lower extremities and to assess automated vessel-tracking techniques for vascular evaluation. METHODS: Eighteen men (mean age 67.0 years, range 43-83) with aneurysmal or occlusive vascular diseases underwent contrast-enhanced CTA of the lower limb arteries utilizing a 16-row CT imager. Curved multiplanar reformations were generated by manual selection of vessel centerlines in the infrarenal aorta and the arterial vasculature in the pelvis, thigh, and calf based on volume-rendering techniques. For each vessel, opacification and depiction were quantitatively evaluated. The manually segmented images were compared to datasets processed with automated vessel-tracking strategies by 5 radiologists, who evaluated diagnostic reliability and image quality. A Differential Receiver Operating Characteristic (DROC) analysis was performed. RESULTS: An increase in the temporal and spatial resolution led to acquisition of high quality CTA datasets. Significant homogeneity of the vascular contrast-to-noise ratios was achieved in the pelvic (coefficient of variance 1.5% to 10.1%), thigh (0.1% to 9.4%), and calf (3.3% to 19.2%) vessels. The assessment of vascular delineation revealed full-width-at-half-maximum contrast values of 96.4%, 95.5%, and 111.3% in the pelvis, thigh, and calf, respectively. Observers were not able to distinguish between manual and automated vascular segmentation, as represented by a 0.56 value for the area under the DROC curve. CONCLUSIONS: High-resolution CTA lower extremity datasets were acquired successfully, presenting vascular signal intensities of high homogeneity suitable for automated vessel-tracking techniques. Automated 3D visualization tools produced reliable, reproducible, and time-efficient centerline extractions that were comparable to manually defined centerlines.

Adult↗

PubMed2006

Ascorbic acid (vitamin C) and iloprost attenuate the lung injury caused by ischemia/reperfusion of the lower extremities of rats.

The objectives of this study were to compare the protective effects of ascorbic acid and iloprost on lung injury caused by ischemia reperfusion (I/R) of the lower extremities of rats. Wistar albino rats (n = 34) were divided into five groups. In the I/R group (n = 6), the aorta was cross-clamped for 3 hr, followed by 1 hr of reperfusion. In the vitamin C group (n = 8), animals were pretreated with 100 mg/kg ascorbic acid via the left jugular vein before aortic cross-clamping. In the iloprost group (n = 8), animals were pretreated with 20 ng/(kg x min) iloprost by constant intravenous infusion via the left jugular venous cannula. In the sham group (n = 6), the abdomen was left open at the same period and a juguler venous line was established. In the control group (n = 6), lungs were removed and blood samples taken immediately after sternotomy. No treatment was given in this group. After both lungs were removed, biochemical parameters were measured and histopathological evaluation was made. Although the arterial blood pO2 and HCO3 levels were statistically significantly high in both the vitamin C and iloprost groups compared to the I/R group, plasma malondialdehyde (MDA) levels were significantly low. Meanwhile, the MDA levels in the lung tissue were significantly low in the vitamin C group compared to the I/R group. The MDA level in the lung tissue in the iloprost group was also low compared to the I/R group, but it was not statistically significant. The lungs of the I/R group displayed intense interstitial leukocytic infiltration in histopathological examination compared to the other groups. Pretreatment of animals with iloprost and vitamin C significantly decreased the pulmonary injury characterized by decreased plasma leukocyte sequestration. The results suggest that both vitamin C and iloprost are useful agents for attenuating the lung injury caused by increased oxidative stress and neutrophil accumulation after a period of I/R of the lower extremities.

Animals↗

PubMed1994

[Changes in muscle activity of the lower extremities during forward-inclining-posture gait. Comparative study with free walking of healthy geriatric persons].

Using a force plate and electromyographic recordings, changes in the muscle activity of the lower extremities during forward-inclining-posture walking and the free walking of healthy young adults were studied and compared with the free gait of healthy geriatrics. The movement of the hamstring, and the tibialis anterior and calf muscles caused a negative quadric curve during the forward-inclining gait and a positive curve during the free walking. However, the movements of the rectus femoris muscle caused a positive curve during the forward-inclining gait and a negative curve during the free walking. It also was found that geriatrics are thrown off balance by changes in cadence while walking. Further, greater muscular activity of the lower extremities is needed by geriatrics than by young adults during free walking, and the muscular movements of geriatrics during free walking showed no relation to the forward-inclining muscular movements of the young adults.

Adult↗