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PubMed1993

A prospective, randomized, blinded, and placebo-controlled trial of intraoperative intra-arterial urokinase infusion during lower extremity revascularization. Regional and systemic effects.

OBJECTIVE: This study was designed to evaluate the safety and regional and systemic effects of three doses of urokinase (UK) infused into the distal arterial circulation during routine operative lower extremity revascularization. METHODS: One hundred thirty-four patients were prospectively randomized to receive one of three bolus doses of UK (125,000, 250,000, or 500,000 U) or placebo (saline) infused into the distal circulation before lower extremity bypass for chronic limb ischemia. Regional (femoral vein) and systemic (arm) blood was sampled before drug infusion, prereperfusion, and postreperfusion, and systemic blood samples were obtained 2 hours postreperfusion. Assays evaluated plasma levels of fibrinogen, fibrin(ogen) degradation products (FDP), fibrin breakdown products (D-dimer and fragment B-beta 15-42), and plasminogen. Patients were monitored for clinically evident bleeding complications. The Wilcoxon rank-sum test was used to compare different drug doses with the placebo. RESULTS: Intraoperative bolus UK infusions produced no significant fibrinogen breakdown compared with placebo. There was a dose-related decline in plasminogen levels, which became significant at a dose of 500,000 U of UK (p < 0.001). There were dose-related increases in plasma FDP, which became significant at dose of 250,000 and 500,000 U (p < or = 0.005), and in plasma D-dimer, which were significant at all UK doses (p < 0.001). The changes in plasma fibrinogen and markers of fibrin breakdown were similar in the regional and systemic circulations. There was no increase in operative blood loss, blood replaced, or wound hematoma formation. There was an unexplained increased mortality in the placebo group (21.1% vs. 2.0%, p = 0.033). CONCLUSIONS: Intraoperative bolus UK infusion is safe, with no significant fibrinogen depletion or increased operative blood loss or wound hematoma formation. Dose-related plasminogen activation resulted in significant breakdown in cross-linked fibrin in the distal circulation. Intraoperative bolus UK infusion may be valuable as an adjunct in patients with chronic occlusive disease who are undergoing revascularization. Detailed randomized studies are indicated to establish clinical efficacy.

Aged↗

PubMed2005

Lower extremity coupling parameters during locomotion and landings.

During ballistic locomotion and landing activities, the lower extremity joints must function synchronously to dissipate the impact. The coupling of subtalar motion to tibial and knee rotation has been hypothesized to depend on the dynamic requirements of the task. This study was undertaken to look for differences in the coupling of 3-D foot and knee motions during walking, jogging, and landing from a jump. Twenty recreationally active young women with normal foot alignment (as assessed by a licensed physical therapist) were videotaped with high-speed cameras (250 Hz) during walking, jogging, hopping, and jumping trials. Coupling coefficients were compared among the four activities. The ratio of eversion to tibial rotation increased from the locomotion to the landing trials, indicating that with the increased loading demands of the activity, the requirements of foot motion increased. However, this increased motion was not proportionately translated into rotation of the tibia through the subtalar joint. Furthermore, the ratio of knee flexion to knee internal rotation increased significantly from the walking to landing trials. Together these findings suggest that femoral rotation may compensate for the increase in tibial rotation as the force-dissipating demands of the task increase. The relative unbalance among the magnitude of foot, tibial, and knee rotations observed with increasing task demands may have direct implications on clinical treatments aimed at reducing knee motion via controlling motion at the foot during landing tasks.

Adult↗

PubMedDate not supplied

Lower extremity neuromuscular recovery following anterior cruciate ligament reconstruction; a 2-week case study.

The lower extremity neuromuscular recovery of a 31-year-old male physical therapy student during the initial 2-weeks following anterior cruciate ligament reconstruction was evaluated by measuring involved side vastus medialis (VM), gluteus maximus (GMAX) and gastrocnemius (GASTROC) electromyographic (EMG) signals (1000 Hz), plantar forces (50 Hz), and knee pain as the subject performed a series of volitional, maximal effort unilateral, isometric leg presses (6 sec) in a modified continuous passive motion device. Data were standardized to pre-operative values and graphically plotted for split middle technique, celeration line assessment. From 1-8 hours post-surgery, EMG amplitudes and plantar forces decreased, pain increased, and plantar force location shifted toward the forefoot. From 9-12 hours post-surgery, EMG amplitudes and plantar forces increased and pain decreased. By 24 hours post-surgery, pain decreased to pre-operative levels. From 24-72 hours post-surgery, EMG amplitudes and plantar forces increased. From 1-2 weeks post-surgery, EMG amplitudes and plantar forces increased. From 9 hours-2 weeks post-surgery, plantar force location shifted toward the pre-operative location. Sequential increases were observed for GMAX, GASTROC, and VM EMG amplitudes. By 2 weeks post-surgery, plantar forces and VM EMG amplitudes remained reduced. Reduced plantar forces and VM EMG amplitude at 2 weeks post-surgery suggest a need for greater focus on restoring VM function before attempting closed kinetic chain exercises that require the full shock absorption capabilities of the quadriceps femoris muscle group.

Adult↗

PubMed1982

Compartment syndrome after anti-shock trouser use without lower-extremity trauma.

The use of anti-shock trousers is widely advocated for the treatment of hypovolemic shock. Despite its frequent use, few complications have been reported in the medical literature. Although speculation exists that anti-shock trouser application may result in ischemic injury to the lower extremities, this complication has only recently been reported. Our report describes a patient with no lower extremity trauma who developed bilateral anterior and lateral compartment syndromes after the application of anti-shock trousers.

Adolescent↗

PubMed2003

Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.

OBJECTIVE: Neurological injury associated with present day labor and delivery is thought to be unusual. The purpose of this study was to estimate the incidence, severity, and duration of postpartum lumbosacral spine and lower extremity nerve injury and identify factors related to nerve injury. METHODS: All women who delivered a live-born infant from July 1997 through June 1998 were asked about symptoms of lumbosacral spine and lower extremity nerve injury the day after delivery. Women with symptoms were examined by a physiatrist to confirm injury, and their cases were then followed by telephone until the symptoms resolved. Maternal variables (including prospective documentation of time spent pushing in various positions) and fetal variables that might be associated with risk of nerve injury were compared between women with injury and those without. RESULTS: Six thousand fifty-seven women delivered live-born infants; 6,048 were interviewed and 56 had a confirmed new nerve injury, an incidence of 0.92%. Factors found by logistic regression analysis to be associated with nerve injury were nulliparity and prolonged second stage of labor. Women with nerve injury spent more time pushing in the semi-Fowler-lithotomy position than women without injury. The median duration of symptoms was 2 months. CONCLUSION: The estimated incidence of postpartum nerve injury was greater than reported from previous studies and is associated with nulliparity and prolonged second stage of labor.

Adult↗

PubMed2004

Assessment of the patient's quality of life in the long-term postoperative period after reconstructions on lower extremity arteries.

The study accrued 28 male patients provided reconstruction for atherosclerotic lesion of lower extremity arteries. Their ages ranged from 36 to 69 years, with a mean of 57.73+/-8.75 years. Degree IIB ischemia according to the R. Fontaine classification modified by A. V. Pokrovsky was present in 10, degree III in 17 patients, and degree IV in one patient. The level end degree of lesion were assessed using contrast angiography and Doppler ultrasound. Before and after operation all the patients underwent measurements of the painless walking distance and regional systolic pressure on the shoulder and ankle as well as of the ankle/brachial pressure index. The quality of life was evaluated in all the patients with the aid of a MOS SF36 questionnaire before and 3 months after operation. The individual and typological personality properties were defined by the psychodiagnostic test (PDT). Operation was followed by a significant rise of the pressure index, painless walking index, and an improvement of the patient's quality of life according to the scales "physical function" and "physical pain". The correlation was established between the painless walking distance and indicators of the "physical function" scale (r=0.48, p<0.05) and "physical pain " (r=0.44, p>0.05) as well as between the ankle/brachial pressure index and general health status (r=0.58, p<0.02). The relationship was revealed between the change in the patient's quality of life after operation and individual-typological personality properties. The correlation coefficient between the scales of "neurotism" according to the PDT: and "physical function", "physical role" and "emotional role" according to the SF36 constituted -0.47, -0.54 and - -0.49 respectively (p<0.05) that between psychotism and the general health status was -0.49 (p<0.05), and that between mental instability and physical and emotional role -0.66 and -0,61 respectively (p<0.01).

Adult↗

PubMed2004

The role of the endovascular surgeon for lower extremity ischemia.

UNLABELLED: Since the data investigating endovascular therapy performed by surgeons is scarce, we retrospectively reviewed our experience of endovascular procedures performed by vascular surgeons in the operating room for lower extremity ischemia due to stenotic lesions. METHODS: A total of 14,424 procedures were performed by our division between January 1990--October 2003. Of these, 500 involved a balloon angioplasty. These made up 3.5% of the total caseload. The median age of the patients who underwent these 500 balloon angioplasty was 72+/-0.5 years old; 65% were male; 50% had a history of diabetes mellitus, and 6% had ESRD. Indications for the procedures included acute ischemia (47 cases), critical ischemia (rest pain, gangrene, or ischemic ulcers in 254 cases), failing bypass (64 cases), severe claudication (134 cases), and preoperative for a popliteal artery aneurysm repair. RESULTS: 244 of the procedures were percutaneous, and the remaining 256 were combined with some type of open procedure. Those performed as an open technique were in combination with a bypass (135 cases) and in combination with a patch angioplasty (31cases). Balloon angioplasties were performed of the aorta (5 cases), iliac arteries (281 cases), the superficial femoral artery (SFA) (101 cases), the popliteal artery (44 cases), the tibial vessels (77 cases), the subclavian/axillary artery (5 cases) and failing grafts (26 cases). Balloon angioplasty was attempted in eight cases and failed due to inability to cross the lesion with a guidewire. Intraoperative complications included 4 dissections, inability to dilate the lesion adequately (2 cases), and rupture of two iliac lesions that underwent open repair (1 case) or repair with a stent graft (1 case). Stents were initially used highly selectively but recently are now being deployed more liberally in the iliac arteries (total 251 cases with stents). CONCLUSIONS: Based on these data, we suggest that balloon angioplasty is a useful tool that can be performed by vascular surgeons safely. The advantages to the patients include one combined procedure to treat lower extremity ischemia.

Aged↗

PubMed2004

[Prophylaxis of purulent-septic complications after amputation of lower extremity for atherosclerotic gangrene].

Results of treatment of 78 patients, in whom atherosclerotic gangrene of lower extremity had occurred, were analyzed. There was proposed the method of the extremity amputation on level of femur, using two flaps, and apparatus for formation of cutaneomuscular flap as well, introduction of which have allowed to reduce frequency of purulent-septic complications to 7.1%. Lethality had lowered from 13.1 down to 5.3%.

Abscess↗

PubMed1981

A prognostic model for clinical stage I melanoma of the lower extremity. Location on foot as independent risk factor for recurrent disease.

Thirteen variables were studied to determine their usefulness in predicting recurrent disease in 158 patients with stage I melanoma of the lower extremity. A Cox proportional hazards analysis demonstrated that three variables were independent risk factors for recurrent disease in these patients: (1) thickness, in millimeters, of the primary tumor (P = 0.000009), (2) primary tumor location on the foot (P = 0.0003), and (3) the number of mitoses/mm2 (P = 0.0244). Life-table analyses of patient subgroups defined by different combinations of these three variables demonstrated that thick (greater than or equal to 3.0 mm) melanomas of the foot were associated with recurrent disease much more frequently than tumors of similar thickness located on the thigh or calf. These data provide guidelines that can be used to evaluate results of surgical and/or adjuvant therapy studies for patients with melanoma of the lower extremity.

Foot Diseases↗

PubMed1993

The potential for lower extremity revascularization without contrast arteriography: experience with magnetic resonance angiography.

PURPOSE: We report an initial experience with 24 patients studied between March 1990 and April 1992 with magnetic resonance angiography (MRA) for lower extremity occlusive disease. METHODS: All patients underwent vascular intervention with either balloon angioplasty or bypass grafting, and in six patients this intervention was based on MRA findings alone. Eighteen patients were studied with both MRA and contrast arteriography, and there was observed agreement between the two studies in 98% of all arterial segments examined. RESULTS: Agreement between MRA and contrast arteriography was uniform for arterial segments below the inguinal ligament. Intraoperative findings and favorable early results of seven bypass grafts performed in six patients after MRA alone suggested this was a valid approach for patients at prohibitive risk of complications from contrast arteriography. CONCLUSIONS: Magnetic resonance angiography is accurate in demonstrating relevant anatomy in peripheral arterial occlusive disease and in selected patients may eliminate the need for contrast arteriography before lower extremity revascularization.

Angiography↗

PubMed1999

Isolated limb perfusion with tumour necrosis factor-alpha and melphalan for unresectable bone sarcomas of the lower extremity.

AIMS: Isolated limb perfusion (ILP) with recombinant tumour necrosis factor-alpha (rTNF-alpha) and melphalan has recently been reported to induce major tumour responses and permit limb salvage in over 80% of patients with unresectable soft-tissue sarcomas of the extremities. We investigated whether TNF-based ILP could allow limb-sparing surgery in patients with primary, recurrent or metastatic bone sarcoma to the lower extremity who met the criteria for an amputation and had failed or refused chemotherapy. METHODS: From August 1992 to December 1997, we employed ILP with rTNF-alpha and melphalan in 13 patients with unresectable bone sarcoma of the lower extremity, all of whom were candidates for amputation. The aim was to reduce tumour size and allow the performance of a limb-sparing surgery (LSS). RESULTS: Following ILP, none of the patients had severe local toxicity and only one patient experienced significant systemic side-effects. LSS was subsequently performed in nine of the 13 patients. LSS was feasible in an additional three patients but was not performed because of the emergence of diffused metastatic disease. CONCLUSIONS: ILP with rTNF-alpha and melphalan can allow limb salvage in patients wih locally advanced bone sarcomas who had failed standard treatment options. Its potential role in the treatment of unresectable bone sarcomas of the extremities merits further evaluation.

Adolescent↗

PubMed1999

Superior responsiveness of the pain and function sections of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as compared to the Lequesne-Algofunctional Index in patients with osteoarthritis of the lower extremities.

OBJECTIVE: To compare the responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and a questionnaire format of the Lequesne-Algofunctional Index in patients with OA of the lower extremities. METHODS: Longitudinal analysis of the instruments' responsiveness [standardized response mean (SRM), effect size (ES)] in ambulatory patients undergoing hip or knee arthroplasty. RESULTS: At six months 36, and at one year 40 out of 43 patients undergoing hip (N=30) or knee arthroplasty (N=13) could be examined. Both responsiveness statistics revealed the same order of responsiveness. For both indices and for both locations, the pain sections were more responsive than the function sections. However, the WOMAC scales and the WOMAC global index (hip at 12 months: SRM=2.4; knee at 12 months: SRM=2.0 ) were more responsive than the comparable Lequesne sections and Lequesne index (hip at 12 months: SRM=2.1; knee at 12 months: SRM=1.5). CONCLUSIONS: Although our results are based on a German version using a self-report format, the WOMAC scales appear to be more responsive than the Lequesne index in patients with OA of the lower extremities.

Adult↗

PubMed1998

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans.

BACKGROUND: Ketamine in sub-dissociative doses has been shown to have analgesic effects in various pain conditions, including neuropathic and phantom-limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood. METHODS: Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS). RESULTS: Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all the patients at the highest dose (0.45 mg/kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. These 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/kg ketamine doses than for morphine 10 mg. CONCLUSION: We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.

Aged↗

PubMed1997

[Personal experience with radical treatment of varicose veins in the lower extremities, the present status and future perspectives of therapy].

In 1989-1993 at the Surgical department of the Central Military Hospital 815 patients were operated on account of primary and relapsing varicosities of the lower extremities. Based on evaluation of the therapeutic outcome, after radical surgery very satisfactory short-term as well as long-term results can be expected with a low incidence of relapses of the disease. The operation assumes a careful diagnosis of the affection, radical surgery with regard to the cosmetic effect incl. treatment of all affected veins of the lower extremities.

Adult↗

PubMed2005

The effects of plyometric versus dynamic stabilization and balance training on lower extremity biomechanics.

BACKGROUND: Neuromuscular training that includes both plyometric and dynamic stabilization/balance exercises alters movement biomechanics and reduces ACL injury risk in female athletes. The biomechanical effects of plyometric and balance training utilized separately are unknown. HYPOTHESIS: A protocol that includes balance training without plyometric training will decrease coronal plane hip, knee, and ankle motions during landing, and plyometric training will not affect coronal plane measures. The corollary hypothesis was that plyometric and balance training effects on knee flexion are dependent on the movement task tested. STUDY DESIGN: Controlled laboratory study. METHODS: Eighteen high school female athletes participated in 18 training sessions during a 7-week period. The plyometric group (n = 8) performed maximum-effort jumping and cutting exercises, and the balance group (n = 10) used dynamic stabilization/ balance exercises during training. Lower extremity kinematics were measured during the drop vertical jump and the medial drop landing before and after training using 3D motion analysis techniques. RESULTS: During the drop vertical jump, both plyometric and balance training reduced initial contact (P = .002), maximum hip adduction angle (P = .015), and maximum ankle eversion angle (P = .020). During the medial drop landing, both groups decreased initial contact (P = .002) and maximum knee abduction angle (P = .038). Plyometric training increased initial contact knee flexion (P = .047) and maximum knee flexion (P = .031) during the drop vertical jump, whereas the balance training increased maximum knee flexion (P = .005) during the medial drop landing. CONCLUSION: Both plyometric and balance training can reduce lower extremity valgus measures. Plyometric training affects sagittal plane kinematics primarily during a drop vertical jump, whereas balance training affects sagittal plane kinematics during single-legged drop landing. CLINICAL RELEVANCE: Both plyometric and dynamic stabilization/balance exercises should be included in injury-prevention protocols.

Adolescent↗

PubMed1992

Lower extremity fracture fixation in head-injured patients.

Compared with nonsurgical management or delayed repair, early fracture fixation can reduce the incidence of pulmonary complications in patients with long-bone fractures of the lower extremities. Blunt trauma victims often have multiple nonskeletal injuries that might influence the risk of pulmonary complications, and when head injuries are present it has been a common practice to delay nonemergent operations for several days to protect the injured brain. We conducted a retrospective review of 114 patients with multiple trauma whose injuries included head trauma and a fracture of the neck or shaft of the femur or shaft of the tibia to determine if delayed stabilization of lower extremity fractures increased the risk of pulmonary complications or reduced the risk of cerebral complications. Forty-six patients underwent surgical fixation of their fractures within 24 hours of injury (early fixation), 26 patients had their fractures repaired more than 24 hours after injury (late fixation), and 42 patients did not undergo surgical fracture fixation. The risk of pulmonary complications was not related to the timing of surgical fracture fixation but was strongly influenced by the severity of injuries to the head and to the chest (p less than 0.001). Furthermore, a delay in fracture fixation did not protect the injured brain; the risk of CNS events was determined by the severity of the head injury (p less than 0.0001). Early fracture fixation in patients with head injury may be appropriate because it simplifies patient care and does not seem to worsen the head injury, but it does not prevent pulmonary complications in these high-risk patients.

Adolescent↗

PubMed1999

[The influence of ozone therapy on endothelial damage markers in patients with atherosclerosis of lower extremities].

The aim of study was to evaluate the influence of the treatment with oxygen-ozone mixture on the blood plasma antigen concentration of tissue plasminogen activator (t-PA) and von Willebrand factor (vWF) in patients suffering from atherosclerotic disease of lower extremities. The study was performed in the group of 28 (M/F 22/6) patients means aged 64.1 years with atherosclerotic diseases of lower extremities, in whom 2 weeks therapy with oxygen-ozone mixture was used. The control group consisted of 30 healthy volunteers in mean age 51.0 years. In the blood plasma obtained from the patients before and after treatment with oxygen-ozone mixture and from the control group determinations of t-PA and vWF antigen using ELISA were done. Both parameters were significantly increased in the patients before the treatment in comparison to the healthy controls. The treatment with oxygen-ozone therapy caused in patients slight statistically not significant raise of t-PA and vWF antigen showing the endothelial stimulation but not the destruction of vascular endothelium.

Adult↗

PubMed2004

Determination of lower extremity anthropometric parameters using dual energy X-ray absorptiometry: the influence on net joint moments during gait.

OBJECTIVE: The purpose of this study was threefold: (1) to report on a method of determining lower extremity anthropometric data using dual energy X-ray absorptiometry, (2) to compare values obtained with this method to predictions from cadaver-based estimates, and (3) to quantify the extent to which these data affect the calculation of net joint moments during walking. BACKGROUND: Anthropometric data used in inverse dynamics equations are often estimated from older cadaveric specimens. A practical method for determining population-specific data is needed. METHODS: Using DXA scans obtained from 20 healthy adults, the mass, center of mass, and moment of inertia of each lower extremity segment were determined and compared to cadaver-based estimates. In addition, gait analysis was performed on 10 of these subjects, and net joint moments (sagittal plane) were calculated at the ankle, knee, and hip using anthropometric data obtained from (a) DXA, and (b) cadaver-based estimates. RESULTS: Statistically significant differences were identified for DXA-derived and cadaver-based anthropometric values. Overall, moment curves computed using the two data sets differed more during the swing phase than during the stance of gait. CONCLUSIONS: DXA appears to be an appropriate method for obtaining population-specific anthropometric data. Moment calculations for activities involving high accelerations and no ground reaction forces (i.e. swing phase of gait, kicking, etc.) would be most influenced by the differences between the anthropometric data sets.

Absorptiometry, Photon↗