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PubMed1993

Use of the osteocutaneous free scapular flap on the lower extremities.

Reports on the use of osteocutaneous free scapular flap transfers have focused primarily on mandible reconstruction. Yet the scapula is a nearly straight bone, and it is also useful in the reconstruction of long bones. We would like to report on 23 patients undergoing osteocutaneous free scapular flap transfers to the lower extremities in whom we obtained extremely satisfactory results. These 23 surgical patients included 10 with pseudoarthrosis with osteomyelitis, 3 with pseudoarthrosis due to trauma, and 5 with osteomyelitis of the lower extremities, as well as 5 with other miscellaneous problems. Surgery was successful in all patients. There was a recurrence of osteomyelitis in 2 patients. In 1 patient, the problem was minor and was treated on an outpatient basis. In the other patient, an infection arose in surgical dead space, and a second operation was required. The level of weight bearing achieved with the osteocutaneous free scapular flap is the same as obtained with a vascularized free fibular graft used for the treatment of pseudoarthrosis. We therefore believe that the osteocutaneous free scapular flap is extremely effective in the treatment of chronic and severe lower leg problems.

Adolescent↗

PubMed1981

Free flaps for reconstruction of the lower extremity.

Experience with the use of free flaps for lower extremity reconstruction during the period 1973 to 1980 is reviewed. From 1973 to 1977, 12 groin and 2 deltopectoral flaps were used, with 8 successes and 6 failures. From 1978 to 1980, 19 myocutaneous flaps (15 latissimus dorsi, 3 tensor fascia lata, and 1 osteocutaneous groin flap based on the deep circumflex vessels) were performed, 17 successfully and 2 unsuccessfully. The reasons for the improved results seem to be the longer and bigger vascular pedicle, the use of more end-to-side arterial anastomoses, and the choice of arterial trunks that are more distal and easier to work with. For these reasons, myocutaneous free flaps are the flap of choice for microsurgical soft tissue reconstruction of the lower limb.

Adolescent↗

PubMed1993

[The evaluation of blood perfusion of lower extremities in patients with NIDDM by 133Xe muscle clearance test: a preliminary report].

In this study, we collected twenty NIDDM patients with impaired sensation and clinically suspected angiopathy over both lower extremities. All the patients underwent testing by means of the ultrasonic Doppler technique and were separated into two groups, group 1 with impaired blood flow, and group 2 with no significant impairment of blood flow. Ten normal persons were also included in this study (group 3). The results of the 133Xe muscle clearance test showed that the Q value of group 1 was 0.85 +/- 0.24 [mean +/- SE, ml (100g tissue min-1)], 1.05 +/- 0.31 in group 2 and 1.78 +/- 0.23 in group 3 of normal controls. After statistical analysis, there were significant differences in groups 1 and 2 relative to group 3 (p < 0.05), respectively. This preliminary result indicates that the 133Xe muscle clearance test may be an effective and convenient method to evaluate angiopathy of lower extremities in patients with NIDDM.

Adult↗

PubMed1992

[Surgical indications for partial inpatient and ambulatory surgery of the lower extremities].

Outpatient (ambulatory) surgery has become widely accepted in free-standing outpatient surgery centres and in hospitals covering the field of hand surgery as well as, increasingly, the field of lower-extremity surgery. Three factors are decisive for secure ambulatory surgery: adequate material and personal resources guaranteeing a round-the-clock medical service, outpatient anesthesia which focuses mainly on the perioperative care of outpatient surgery, and a well-informed patient. Under these prerogatives the majority of surgical procedures of the lower extremities are performed on an outpatient basis without any undue risk. This includes also the diagnostic and operative arthroscopy of different joints.

Adult↗

PubMed1999

Duplex imaging of lower extremity bypasses, angioplasties, and stents.

Duplex scan surveillance after lower extremity bypass and endovascular interventions can have a favorable impact on outcome. Its application during an arterial intervention to exclude technical or hemodynamic abnormalities and as part of a postoperative surveillance program to detect stenosis has been shown to improve patency. Results of duplex imaging can identify the arterial reconstruction at high risk of failure/thrombosis, which requires more intensive surveillance. Based on stenosis severity and anatomy, duplex scanning can suggest which repair technique (open surgery vs percutaneous balloon angioplasty [PTA]) is more appropriate. The use of duplex imaging during PTA of graft or peripheral artery stenoses (duplex-monitored balloon angioplasty) is recommended to verify normalization of velocity spectra, because this end point is associated with improved stenosis-free patency. A duplex surveillance program combined with correction of progressively stenotic lesions is recommended after lower limb bypass and PTA.

Algorithms↗

PubMed2002

Psychosocial and physical factors associated with lower extremity injury.

With the increasing availability of modern occupant restraints, more drivers and passengers are surviving high-energy crashes. However, a large number, especially those involved in frontal and offset frontal crashes, incur disabling lower extremity injuries. In the past, not much attention was paid to these injuries, as they were usually not life threatening. Despite the low AIS scores associated with injuries to the lower extremities, they pose a major physical and psychological burden on patients' and their ability to return to pre-crash functioning. Associated injuries, such as mild brain injuries, and psychosocial factors such as depression, also influence the long-term outcome.

Accidents, Traffic↗

PubMed2003

Management and short-term patency of lower extremity venous injuries with various repairs.

BACKGROUND: Although several methods of repair of extremity venous injuries have been shown to be efficacious, patency rates have varied significantly from center to center. METHODS: A retrospective review was made of treatment outcomes of adult and pediatric patients with major venous injuries of the lower extremity. RESULTS: From 1997 to 2002, 82 patients sustained 86 major lower extremity venous injuries. Venous injuries were treated with primary repair in 27, complex repair in 37 (autogenous vein, 10, and ringed polytetrafluoroethylene [PTFE], 27) and ligation in 20. Prior to repair, temporary intraluminal venous shunts were used in 18 patients. Follow-up duplex imaging or venography or both were performed on 42 extremities at a mean of 10.9 +/- 7.1 days after repair with an overall patency rate of 73.8% (primary repair 76.5%; autogenous vein graft 66.7%; and PTFE 73.7%). CONCLUSIONS: Overall early patency rate of venous repairs performed by an experienced trauma team is similar irrespective of the type of repair. The use of temporary intraluminal shunts is acceptable in selected circumstances, while ringed PTFE grafts are reasonable alternatives when the contralateral saphenous vein is too small.

Adult↗

PubMed1987

Lower-extremity compartment syndromes associated with use of pneumatic antishock garments.

Pneumatic antishock garments (PASG) are frequently used to initially support and manage traumatic hypovolemic shock. PASG have been implicated in the development of complicating compartment syndromes of the lower extremities, but cause and effect have not been clearly defined. The present report documents the occurrence of bilateral compartment syndromes in uninjured lower extremities after using PASG and reviews similar reported cases.

Adult↗

PubMed1983

Lower extremity loads stimulate bone formation in the vertebral column: implications for osteoporosis.

Senile osteoporosis is a growing national health problem. The purpose of this study was to determine whether loads applied through the lower extremity would stimulate bone formation in the vertebral column, the site of most osteoporotic fractures. Female white New Zealand rabbits were divided into experimental (EG) and control (CG) groups. The right hind leg of the EG was repetitively loaded to 1.5 X body weight, 20 min/day for three weeks; the CG was "sham loaded". Bone formation in both groups was labeled using tetracycline. Labeled osteons, resorption spaces, surface bone formation, and porosity were measured in cross-sections from the right and left tibias and humeri, right femurs, and L6, L1, T12, T1, and C7 vertebrae. This experiment demonstrates that repetitive loading of the lower extremity increases osteonal bone formation in the vertebral column of rabbits extending at least up to the cervical spine, but not into the forelimbs. This finding supports the concept that exercise involving repetitive loading of the lower limbs (eg, walking) could be used to treat or prevent age-related osteoporotic changes in the vertebrae.

Aged↗

PubMed1997

Long-term results of lower-extremity venous injuries.

OBJECTIVES: To compare the long-term venous function of ligated, simple, and complex repairs and to assess long-term patency in repaired veins. DESIGN: A cohort study of patients with lower-extremity venous injuries treated during a 7-year period. SETTING: A level I urban trauma center. PATIENTS: Twenty-one of the 79 patients with a history of lower-extremity venous injury identified via the trauma registry consented to outpatient evaluation. INTERVENTION: Participating patients underwent a through vascular examination that included color flow duplex venous imaging and air plethysmographic assessment. MAIN OUTCOME MEASURES: The patency of venous repairs, the incidence of chronic deep venous thrombosis, and evidence of chronic venous insufficiency. RESULTS: The venous injuries included 5 iliac, 10 femoral, and 6 popliteal. Six of these injuries were ligated, 11 injuries were simply repaired (lateral venorrhaphy or end-to-end), and 4 were repaired with complex interposition grafts. All repairs were patent, with no evidence of deep venous thrombosis by color flow duplex venous imaging. Seventeen of the 21 patients had symptoms, color flow duplex venous imaging findings, and air plethysmographic data consistent with chronic venous insufficiency, including significant mean differences (P < .03) in outflow fraction, outflow fraction with compression, venous filling index, and residual volume fraction, when compared with the uninjured extremity. The most profound changes followed complex repairs and perioperative fasciotomies. CONCLUSIONS: While the long-term patency of venous repairs is excellent, most patients demonstrate evidence of chronic venous insufficiency after either ligation or repair. Complex venous repairs and fasciotomy are associated with the most severe functional changes.

Adult↗

PubMed2006

Persistent changes in interleukin-6 and lower extremity function following hip fracture.

BACKGROUND: A hip fracture often heralds a period of functional decline in elderly persons. Although an inflammatory reaction would be expected following a hip fracture, whether the degree of this response is associated with adverse functional outcomes is unknown. METHODS: In a cohort from the Baltimore Hip Studies, women aged 65 years or older with a hip fracture were evaluated at 3 or 10 days (baseline) and 2, 6, and 12 months (follow-up) postfracture. Serum was analyzed for interleukin-6 (IL-6) level. A score of timed performance of 9 tasks, the Lower Extremity Gain Scale (LEGS) was calculated at each evaluation. We divided participants into tertiles based on their cytokine levels at 2, 6, and 12 months, and examined the LEGS score trajectories as a function of IL-6 tertile using generalized estimating equations, adjusting for age, prefracture function, body fat, pain, cognitive function, type of surgical repair, the number of in-hospital complications, and the number of comorbid medical conditions. RESULTS: At baseline, 2, 6, and 12 months, respectively, 149, 95, 101, and 82 participants provided serum samples; of these participants 65, 78, and 59 also provided a LEGS measure at 2, 6, and 12 months, respectively. At 12 months postfracture the median (interquartile range) of serum IL-6 levels was 7.4 (4.0, 15.9) pg/mL. Participants in the lowest tertile of IL-6 level performed better on the LEGS than did those in the highest tertile (p =.008). At 12 months postfracture, participants in the lowest tertile scored 5.3 points better (95% confidence interval, 2.0-8.6) on the LEGS than did those in the highest tertile (p =.002). CONCLUSIONS: Higher IL-6 levels are adversely associated with recovery of lower extremity function after hip fracture. Factors that predict cytokine response and the potential mechanisms by which this effect is mediated warrant further study.

Aged↗

PubMed1975

Type of compression for reducing venous stasis. A study of lower extremities during inactive recumbency.

Determination of the optimal compression to reduce venous stasis was studied in terms of the amount of pressure and manner of application (graded or uniform pressure). Both lower extremities of seven inactive recumbent subjects were tested using transcutaneous Doppler ultrasonic measurement of femoral vein blood flow velocity. Optimal compression was defined as the externally applied pressure that produced the greatest increase in femoral vein flow velocity consistent with safety and the practicality of hospital use of elastic stockings. Optimal compression for elastic stockings to be used by hospitalized patients who spend substantial time in bed should be 18 to 8 mm Hg (ankle to midthigh). At this compression, average femoral vein blood flow velocity is increased to 138.4% of base line. Gradient compression at this level was found to produce a greater femoral vein flow velocity than the same amount of compression distributed uniformly over the lower extremity.

Adult↗

PubMed2001

Lower extremity isometric joint torque in children with juvenile chronic arthritis.

OBJECTIVE: To determine the intratester reliability of joint torque testing with a hand-held dynamometer (HHD) during contractions of four major lower extremity muscles in children with juvenile chronic arthritis (JCA) and to compare results for children with JCA to results for children without disability. METHODS: Eleven children with JCA and 14 children with normal musculoskeletal function were tested with a HHD using isometric muscle contractions of the right quadriceps, hamstrings, tibialis anterior and triceps surae. RESULTS: Intratester reliability values exceeded the 0.92 level, regardless of the number of trials, for all motions tested. Statistically lower joint torque values were found in a subgroup of children with JCA for contractions of the tibialis anterior (p=0.003) and triceps surae (p=0.05) muscles. CONCLUSIONS: HHD offers a reliable means of testing the joint torque generated with contraction of these lower extremity muscles in children with JCA. Findings in children with JCA compared to children without disability agree with previous reports concerning quadriceps muscle function, but also point to concerns for muscles associated with generating ankle joint torque.

Adolescent↗

PubMed1998

Radionuclide venography in the diagnosis of deep vein thrombosis of the lower extremities: a comparison to contrast venography.

Radionuclide venography (RNV) and contrast venography (CV) were compared in 72 limbs of 59 patients being clinically suspected of deep vein thrombosis (DVT) of the lower extremities. The criteria of positive RNV for DVT regarding flow pattern abnormality included (1) nonfilling or nonvisualization of a deep vein, (2) interruption of the flow, (3) irregular or asymmetric filling of a deep vein, and (4) presence of abnormal collateral vessels. The overall accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive likelihood ratio (LR+) were 90 per cent, 88 per cent, 96 per cent, 98 per cent, 79 per cent, and 20.8 respectively. These figures are even higher when we focused on the major veins of the thigh and pelvis. They were 97 per cent, 95 per cent, 98 per cent, 98 per cent, 95 per cent, and 61 respectively. The results indicate that radionuclide venography, while technically simple, is a reliable test for detection of DVT particularly of the major veins of the lower extremities. Combined radionuclide venography and perfusion lung scan can also be performed in the same setting if Tc99m-MAA is used. Contrast venography which is an invasive procedure, should be reserved for questionable cases of those with suspected isolated calf vein thrombosis.

Adolescent↗

PubMed1999

Diabetes mellitus and nontraumatic lower extremity amputation in black and white Americans: the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, 1971-1992.

BACKGROUND: The comparative long-term risk of non-traumatic lower extremity amputation (LEA) in black and white Americans, 2 groups with strikingly different rates of diabetes mellitus, is not known. OBJECTIVE: To examine the 20-year incidence of LEA in relation to race and diabetes mellitus. METHODS: The 14 407 subjects in the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study were observed prospectively between 1971 and 1992. Prevalent diabetes mellitus was ascertained at the baseline examination, and incident diabetes mellitus, during follow-up. Lower extremity amputation was ascertained from hospital discharge records. Cox regression analysis was used to estimate associations between race, diabetes mellitus, and risk of first LEA. RESULTS: During the study period, 158 LEAs occurred among 108 subjects. While black subjects constituted 15.2% of the cohort, they represented 27.8% of the subjects with amputation (P = .002). The 20-year age-adjusted rate ratio of first LEAs for black subjects-white subjects was 2.14. Regression analyses confirmed the importance of diabetes mellitus as a key LEA risk factor. The association between prevalent diabetes mellitus and LEA risk was substantially higher (relative risk [RR], 7.19; 95% confidence interval [CI], 4.61-11.22) than that for incident diabetes mellitus (RR, 3.15 [CI, 1.84-5.37]), highlighting the importance of diabetes mellitus duration on LEA risk. While preliminary analyses adjusted for age and diabetes indicated a significant association between race and LEA risk (RR, 1.93 [95% CI, 1.26-2.96]), the effect of race diminished (RR, 1.49 [95% CI, 0.95-2.34]) following adjustment for education, hypertension, and smoking. CONCLUSIONS: Although black subjects experienced higher age- and diabetes mellitus-adjusted rates of amputation than their white counterparts, a combination of social and environmental factors may account for the apparent ethnic difference. More research into nonbiological factors associated with LEA may reduce the occurrence of these procedures in both black and white individuals.

Adult↗

PubMed2006

Optimal management of uncomplicated skin and skin structure infections of the lower extremity.

Uncomplicated skin and skin structure infections of the lower extremity are almost always curable when properly diagnosed and promptly treated with antibiotics, but they can cause serious complications if not treated appropriately. These infections are caused often by Staphylococcus aureus and less commonly by Streptococcus pyogenes. Initial treatment is usually empiric. Although the most suitable oral treatment is likely cephalosporin, other options include beta-lactamase inhibitor-penicillin combinations and penicillinase-resistant penicillins. In some cases, incision and drainage or debridement may be required.

Journal Article↗

PubMed1998

A three-dimensional musculoskeletal database for the lower extremities.

A three-dimensional musculoskeletal database of the lower extremities has been developed for use in human musculoskeletal models. The locations of idealized muscle attachments on the pelvis, both femurs, both tibias and fibulas, and both feet were accurately digitized for 52 dried skeletal specimens. The mean specimen heights were 177.5 cm (male) and 166.2 cm (female) and the mean specimen age at the time of death was 48.8 yr. Statistical accumulation and scaling techniques were used to generate highly representative normative models, which were divided into groups and tested for differences based on gender and race. From the test results, the pelvis was divided into a male model (RMS = 8.6 mm), a black female model (RMS = 7.0 mm) and a white female model (RMS = 7.3 mm). The foot was separated into black (RMS = 3.7 mm) and white models (RMS = 3.6 mm). Single models were used for the femur (RMS = 6.5 mm) and the tibia/fibula (RMS = 3.7). Containing over 12000 anatomical landmarks digitized from 52 dried skeletons, this study represents an improvement over previous databases by an order of magnitude.

Black People↗

PubMed1997

Utility of magnetic resonance arteriography for distal lower extremity revascularization.

PURPOSE: Magnetic resonance arteriography (MRA) of the lower extremities affords several possible advantages over conventional contrast arteriography (CA). We hypothesized that MRA of the infrageniculate vessels was sufficiently accurate to replace CA before revascularization procedures in patients with limb-threatening ischemia. METHODS: Fifty-three extremities in 49 patients were prospectively evaluated before attempted infrageniculate revascularization procedures with preoperative infrageniculate time-of-flight MRA (cost, $170/study) and standard contrast arteriography (cost, $1310/study) of the aortoiliac and runoff vessels. Independent operative plans were formulated based on the MRA and CA results before the revascularization procedure. Intraoperative, prebypass arteriograms (IOA; cost, $46/study) were obtained in all patients to confirm the adequacy of the distal runoff. The preoperative plans formulated by the results of MRA and CA were compared with the actual procedure performed based on the IOA. All arteriograms (CA, MRA, IOA) were reviewed after the operation by two independent reviewers, and the number of patent vessel segments and those with < 50% stenosis was determined. RESULTS: Revascularization procedures were performed in 44 of 53 extremities (83%), and amputation was performed in nine extremities (17%) because of an absence of a suitable bypass target. The CA and MRA were equally effective in predicting the optimal operative plans as determined from IOA (CA, 42 of 53 [77%] vs MRA, 40 of 53 [75%]; p = 0.79). More patent vessel segments were seen on CA than MRA (reviewer A, 229 vs 174, kappa = 0.32; reviewer B, 321 vs 314, kappa = 0.46); however, a comparable number of segments were seen if the vessels of the foot were excluded. The accuracy (reviewer A, 78% vs 68%, p = 0.003; reviewer B, 75% vs 67%, p = 0.003) and sensitivity (reviewer A, 69% vs 51%, p = 0.001; reviewer B, 68% vs 46%, p = 0.0001) of CA relative to IOA were superior to those of MRA, although the specificity was comparable (reviewer A, 86% vs 90%, p = 0.31; reviewer B, 82% vs 87%, p = 0.52). The combination of MRA and IOA would have resulted in the optimal operative plan in 51 of the 53 cases (96%) and was comparable with CA and IOA (53 of 53; 100%; p = 0.50). Substitution of MRA and IOA for CA and IOA could potentially have saved an estimated $60,420. CONCLUSIONS: The combination of MRA and IOA provides an accurate, cost-efficient strategy for visualization of the infrageniculate vessels before revascularization procedures.

Aged↗