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PubMed1998

Lower extremity arterial reconstruction in the very elderly: successful outcome preserves not only the limb but also residential status and ambulatory function.

PURPOSE: The purpose of this study was to evaluate our results with lower extremity arterial reconstruction (LEAR) in patients 80 years of age or older and to assess its impact on ambulatory function and residential status. METHODS: We performed a retrospective review of all patients 80 years of age or older undergoing LEAR at a single institution from January 1990 through December 1995. Preoperative information regarding residential status and ambulatory function was obtained from the hospital record and vascular registry. Telephone interviews with patients or next of kin were undertaken to provide information regarding postoperative residential status and ambulatory function. Residential status and level of ambulatory function were graded by a simple scoring system in which 1 indicates living independently, walking without assistance; 2 indicate living at home with family, walking with an ambulatory assistance device; 3 indicates an extended stay in a rehabilitation facility, using a wheelchair; and 4 indicates permanent nursing home, bedridden. Preoperative and postoperative scores for both residential status and ambulatory function were compared. Kaplan-Meier survival curves were generated for graft patency, limb salvage, and patient survival. RESULTS: Two hundred ninety-nine lower extremity bypass operations were performed in 262 patients 80 years of age or older (45% men, mean age 83.6 years, range 80 to 96 years). Sixty-seven percent of the patients had diabetes mellitus. Limb salvage was the indication for operation in 96%. The preoperative mean residential status and ambulatory function scores were 1.79+/-0.65 and 1.55+/-0.66, respectively. The perioperative mortality rate at 30 days was 2.3%. The median length of hospital stay decreased from 16 days in 1990 to 8 days in 1995 (range 4 to 145 days). Eighty-seven percent of grafts were performed with the autologous vein. The 5-year primary, assisted primary, and secondary graft patency rates for all grafts were 72%, 80%, and 87%, respectively. The limb salvage rate at 5 years was 92%. The patient survival rate at 5 years was 44%. The postoperative residential status and ambulatory function scores were 1.95+/-0.80 and 1.70+/-0.66, respectively. Overall scores remained the same or improved in 88% and 78% of patients, respectively. CONCLUSION: LEAR in octogenarians is safe, with graft patency and limb salvage rates comparable to those reported for younger patients. LEAR preserves the ability to ambulate and reside at home for most patients.

Activities of Daily Living↗

PubMed1981

Aortic and lower extremity arterial aneurysms.

A sonographic survey of 100 patients with suspected abdominal aortic, femoral, or popliteal arterial aneurysms was conducted over a period of 2 yr. Patients referred for suspected abdominal aortic aneurysms had a low incidence of associated lower extremity arterial aneurysms. Those patients referred for possible femoral or popliteal artery aneurysms frequently had multiple other peripheral arterial aneurysms. The authors recommend a survey scanning protocol in this subgroup with lower extremity aneurysms to rule out the presence of other aneurysms.

Adult↗

PubMed1992

Venous injuries of the lower extremities and pelvis: repair versus ligation.

Many surgeons advocate repair of venous injuries to prevent the sequelae of venous ligation. Since 1986, we have treated 74 patients with 79 venous injuries of the lower extremity or pelvis. There were 68 men and six women with a mean age of 29.2 years (range, 16-62 years). The mechanisms of injury were gunshot wounds in 61 patients, stab wounds in 11 patients, and shotgun wounds and blunt trauma in one patient each. Forty-eight injuries were treated by ligation; 31 injuries were treated by repair. Repairs included two interposition grafts, eight end-to-end repairs, 16 venorrhaphies, and five vein patches. In addition, we developed a venous injury staging system (VIS), which ranged from grade I (less than 50% laceration) to grade IV (complete interruption with soft-tissue injury). Patient age, mechanism, location of injury, associated injuries, and incidence of arterial injury were not different between the patients treated by ligation and those treated by repair. Patients treated with venous ligation had a greater VIS (mean, 3.45 vs. 2.0), a greater incidence of shock (71% vs. 39%), and higher transfusion requirements (9.23 vs. 4.82 units). Postoperative morbidity rates were identical, however. There was no increase in the need for fasciotomy in patients treated with venous ligation. Eighty-six percent of the patients treated by ligation were totally free of edema at discharge. The others had only mild edema that did not interfere with daily activities at discharge and follow-up. Ligation is a safe alternative to repair in patients with injuries to the lower extremities or pelvis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1986

[Epidemiology of diseases of the veins of the lower extremities in various climato-geographic conditions].

An epidemiological study performed in different contrast climatic and geographic zones of the country has shown higher incidence of diseases of veins in regions of Siberia as compared to regions of Middle Asia. Risk factors of diseases of lower extremity veins occur 1.5-2 times more often in Siberia than in Middle Asia. Rural population have diseases of the lower extremity veins 1.5-2 times more often that the urban population in the both regions. Such diseases are found 3-5 times more often in people with the presence of risk factors than in the population without them.

Adolescent↗

PubMed1989

Predicting lower-extremity injuries among habitual runners.

This prospective study of 583 habitual runners used baseline information to examine the relationship of several suspected risk factors to the occurrence of running-related injuries of the lower extremities that were severe enough to affect running habits, cause a visit to a health professional, or require use of medication. During the 12-month follow-up period, 252 men (52%) and 48 women (49%) reported at least one such injury. The multiple logistic regression results identified that running 64.0 km (40 miles) or more per week was the most important predictor of injury for men during the follow-up period (odds ratio = 2.9). Risk also was associated with having had a previous injury in the past year (odds ratio = 2.7) and with having been a runner for less than 3 years (odds ratio = 2.2). These results suggest that the incidence of lower-extremity injuries is high for habitual runners, and that for those new to running or those who have been previously injured, reducing weekly distance is a reasonable preventive behavior.

Adolescent↗

PubMed1998

Lower extremity deep venous thrombosis in cancer patients: correlation of presenting symptoms with venous sonographic findings.

We sought to determine how rates of sonographically detected deep venous thrombosis correlate with presenting symptoms in cancer patients. We performed venous sonography in 588 cancer patients with clinically suspected lower extremity deep venous thrombosis. Results were correlated with clinical findings. Deep venous thrombosis was diagnosed in 32% of patients with unilateral lower extremity symptoms and in 17% of patients with bilateral symptoms. Patients with unilateral symptoms of pain and swelling, swelling alone, or pain alone had significantly different rates of deep venous thrombosis (47%, 31%, and 16%, respectively). In patients with bilateral leg symptoms, deep venous thrombosis was significantly more likely when symptoms were not bilaterally symmetric.

Adult↗

PubMed1997

Split-thickness skin grafting for lower extremity ulcerations.

BACKGROUND: Leg ulcers are often refractory to conservative treatment, often mandating the use of skin grafting. OBJECTIVES: This review article discusses skin grafts, with special emphasis on split-thickness grafts for lower extremity ulcerations. METHODS: Historical background, proposed mechanisms of action, biology of skin grafts, techniques for skin grafting, and results after grafting are discussed separately. RESULTS: Skin grafting has been performed for centuries. However, how skin grafts work, whether solely as tissue replacement or, additionally, as a stimulus for healing, is still not fully known. After placement, the grafted skin proceeds through a series of phases by which nutrients are supplied and neovascularization occurs. Adherence to the ulcer bed through interactions between the graft and the ulcer bed appear critical. When meshed split-thickness skin grafts are properly performed, success rates from 50% to 75% have been reported for refractory venous ulcers. CONCLUSIONS: Better understanding of the biologic and clinical aspects of skin grafting should lead to improved patient care. LEARNING OBJECTIVES: After studying this article, participant should be able: 1. To understand the various types of skin grafts. 2. To learn the potential mechanisms of action of how skin grafts work. 3. To appreciate the benefit of skin grafts for lower extremity ulcerations.

Follow-Up Studies↗

PubMed2001

HIV/AIDS and the risk of deep vein thrombosis: a study of 45 patients with lower extremity involvement.

Many aspects of acquired immunodeficiency syndrome (AIDS) have been described in detail in the literature. However, there have been very few articles on the phenomenon of deep vein thrombosis (DVT) in the lower extremities of human immunodeficiency virus (HIV)/AIDS patients. The objective of this communication is to record the incidence of DVT in HIV/AIDS patients and the risks for development of embolic events and to emphasize the need for prevention and for the vigorous treatment of this complication. We conducted a retrospective review of HIV/AIDS-infected patients with DVT admitted to Mount Sinai School of Medicine/Cabrini Hospital in New York during the last 5 years. Analysis includes demographic data; risk factors for HIV/AIDS infection; associated medical problems; recent surgery; and laboratory findings including CD4 counts, platelet counts, prothrombin times, partial thromboplastin times, and plasma albumin levels; and image studies. From January 1995 to January 2000 4752 HIV/AIDS-infected patients were admitted. Of those admitted to the hospital 45 (0.95%) were found to have DVT. There were 36 males and nine females (mean age 43 years). Of the 45 patients 38 had infectious complications and 13 developed a malignancy. The distribution of the thromboses were the femoral vein in 23 patients, the popliteal vein in 20 patients, and the iliofemoral system in 2 patients. Twelve patients had recurrent DVT and three patients developed a pulmonary embolism. HIV/AIDS infection is a considerable risk for development of DVT in the lower extremity. Statistically DVT in HIV/AIDS is approximately 10 times greater than in the general population. Emphasis upon prevention and vigorous treatment of DVT is recommended.

AIDS-Related Opportunistic Infections↗

PubMed2005

Lower-extremity arterial disease.

Peripheral arterial disease is a common disorder in the aging United States population that is both underdiagnosed and undertreated. In this review, we outline the general approaches to the diagnosis and management of lower-extremity arterial diseases. A broad array of current treatment options, including medical, catheter-based, and open surgical interventions are available for patients with symptomatic peripheral arterial disease. A patient-oriented approach based on anatomic and physiologic principles for the treatment of peripheral arterial disease is presented. Embolic and aneurysmal diseases of the lower-extremity arteries are also briefly reviewed. All surgeons should be aware of these common conditions and their applicable management strategies.

Aneurysm↗

PubMed2000

[Post-traumatic lymphatic and venous drainage changes in persistent edema of lower extremities].

Mechanical injury of soft tissues and bones of the lower extremity is followed by chronic edema at the site of trauma and distally to it. This complication affects almost every patient with a fracture of the lower limb. The question is whether posttraumatic edema is due to lymphatic obstruction, venous thrombosis or both, or a local cytokine and growth factor hyperactivity at the fracture site. The aim of study was to assess the venous and lymph outflow in patient with chronic postraumatic edema of the lower limbs. A group of 19 patients with chronic edema lasting for more than 3 months was evaluated. Limb circumference, tissue tone measurements, skin temperature and Doppler enhanced ultrasonography were all taken down for the 19 patients in the evaluated group. Limb circumference was measured at the following level: foot, ankle, calf and thigh. Results showed an increase of circumference in comparison with the healthy extremity at each evaluated level of: 1.20 +/- 1.65 cm, 1.63 +/- 1.41 cm, 1.40 +/- 1.72 cm and 0.30 +/- 1.90 cm. Local temperature increase compared to the healthy extremity was also noted (0.93 +/- 0.81 degree C and 0.37 +/- 0.21 degree C measured at ankle and calf level). Tissue tone measurements and tone index (a quotient of tone measurement values in the extremity with edema and in the healthy extremity) were also increased by 0.86 +/- 0.57, 0.85 +/- 0.34 and 0.86 +/- 0.28, when measured with 40 g, 110 g and 180 g weights respectively. In 17 cases (89.5%) lymphoscintigraphy demonstrated an increased lymphatic outflow compared to the contralateral extremity. A marked increase in the inguinal lymph nodes was also noted. In the remaining 2 cases (10.5%) extravasation of the contrast medium into the skin indicated lymph outflow disorders. Only in 5 cases (26.3%) ultrasonography indicated deep vein thrombosis. The obtained results indicate that the pathophysiology of chronic postraumatic edema is linked with an inflammatory and restorative reaction at the fracture site. Only in a limited number of cases deep vein thrombosis and damaged lymphatic vessels are responsible for postraumatic edema.

Chronic Disease↗

PubMed1995

Dynamic contrast-enhanced subtraction MR angiography of the lower extremities: initial evaluation with a multisection two-dimensional time-of-flight sequence.

PURPOSE: To determine the clinical feasibility of a contrast material--enhanced two-dimensional (2D) magnetic resonance (MR) angiographic sequence in lower extremity arteries. MATERIALS AND METHODS: Four healthy volunteers and 12 patients underwent dynamic contrast-enhanced MR angiography; all patients also underwent conventional angiography. A 2D multisection gradient-echo sequence with image subtraction was used for all MR imaging examinations. RESULTS: Oblique-coronal contrast-enhanced MR angiography was completed in less than 4 minutes, with a 256 x 512 matrix. The arterial contrast enhancement ratio was 2.0 +/- 0.8 (standard deviation), and the pre- and post-contrast contrast-to-noise ratios were 2.1 +/- 13.8 and 46.2 +/- 18.7, respectively. The sensitivity for MR angiography was 100% and specificity was 69% for distinction of vessels with greater than 50% stenoses from normal or mildly stenotic vessels. CONCLUSION: Dynamic contrast-enhanced 2D MR angiography is capable of increasing intraarterial signal intensity and depicting small vessel anatomy of the lower extremities over a large field of view in a short imaging time.

Adult↗

PubMed2006

Ultrasonography of the lower extremity.

Ultrasonography is a useful imaging tool for various soft tissue and joint pathologies affecting the lower extremity. This article reviews the normal sonographic appearance of muscles, tendons, ligaments, nerves, bone, and cartilage. The ultrasound imaging appearance of various pathologic conditions affecting the hip, thigh, knee, lower leg, ankle,and foot are illustrated. The advantages of ultrasonography are highlighted.

Bursitis↗

PubMed2001

Isolated lower extremity chemotherapeutic infusion for treatment of osteosarcoma: experimental study and preliminary clinical report.

PURPOSE: To increase the dose of drug delivered to a tumor while maintaining tolerable systemic side effects, an interventional technique of isolated lower extremity infusion was investigated. MATERIALS AND METHODS: Experiments were performed in eight dogs. Four dogs were treated by a combination of intraarterial (IA) femoral cisplatin infusion at a dose of 2.0 mg/kg with drug removal from the ipsilateral extremity venous blood by a dialyzer. The other four dogs comprised the control group. In these animals, left femoral arterial IA cisplatin infusion was performed without dialysis. Leukocyte and platelet counts, blood urea nitrogen (BUN) levels, and serum creatinine levels were recorded before and after the treatment. Subsequently, two human patients with inoperable osteosarcoma were treated with the isolated infusion. RESULTS: In the experiments, 85%-90% of the free platinum that entered the dialyzer was removed. The peak systemic plasma cisplatin concentrations in animals undergoing dialysis were reduced by 81.25% compared to those in animals undergoing femoral IA infusion without hemodialysis. There were no significant changes in the hematologic profiles or BUN and serum creatinine levels in the experimental animals. However, in the control group, all dogs developed myelosuppression and severe renal toxicity after IA infusion of the same dose of cisplatin. Clinically, immediate relief of symptoms related to the primary tumor was achieved in both human patients after the combination of isolated IA infusion and embolotherapy. CONCLUSION: Single-pass hemodialysis removed a significant amount of cisplatin after regional IA infusion, reduced systemic toxicity, and permitted survival of the experimental animals. In two patients with osteosarcoma, percutaneous isolated lower extremity chemotherapeutic infusion therapy and embolotherapy were performed safely with partial responses.

Adolescent↗

PubMed1993

Lower-extremity amputation. Incidence, risk factors, and mortality in the Oklahoma Indian Diabetes Study.

Oklahoma Indians with NIDDM (n = 1012) underwent a baseline examination in 1972-1980. The incidence of and risk factors for first lower-extremity amputation were estimated. The mortality rates of amputees using data from 875 patients who had no previous history of amputation and who underwent follow-up examination between 1987 and 1991 are presented. The mean age of the 875 patients was 51.6 +/- 10.8 yr, and the mean duration of diabetes was 6.6 +/- 6.1 yr. After a mean follow-up time of 9.9 +/- 4.3 yr, the incidence rate of first LEA among diabetic Oklahoma Indians was 18.0/1000 person-yr. The incidence rate was two times higher in men than in women. In both sexes, significant risk factors (P < 0.05) were retinopathy and duration of diabetes. Fasting plasma glucose, use of insulin, and systolic blood pressure were significant for men only. For women, plasma cholesterol and diastolic blood pressure were additional risk factors. Compared with the mortality rate of 33.5/1000 person-yr among nonamputees, the rate among amputees was 55.5/1000 person-yr. The 5-yr survival rate after first amputation was 40.4%. For the amputees, the most common causes of death were diabetes (37.3%), cardiovascular disease (29.1%), and renal disease (7.3%). The incidence and mortality rates in diabetic Oklahoma Indians were higher than those reported in Pima Indians and other diabetic populations. To lower the incidence of lower-extremity amputation in this high-risk population, preventive action through education, foot care programs, and early detection of lesions must be intensified.

Adult↗

PubMed1952