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At least 973 records · Page 54Linked to original sources
PubMed1994

Lower-extremity motor neuropathy associated with surgery performed on patients in a lithotomy position.

BACKGROUND: Motor neuropathy of a lower extremity is well-recognized as a potential complication of procedures performed on patients in a lithotomy position. Most of this awareness is based on anecdotal reports, however, and the incidence and risk factors for this complication have not been reported. METHODS: We retrospectively reviewed the perioperative courses of 198,461 consecutive patients who underwent 1 of 56 surgical procedures historically performed on patients in a lithotomy position at the Mayo Clinic, Rochester, Minnesota, from 1957 to 1991 inclusive. The medical diagnoses of patients who had procedures in a lithotomy position were scanned for 26 diagnoses associated with neuropathy. Persistent neuropathy of the lower extremity was defined as a motor deficit of at least 3 months' duration. Risk factors anecdotally associated with persistent neuropathy were analyzed by comparing identified cases of neuropathy to controls in a 1:3 case-control study. RESULTS: Persistent neuropathies after procedures performed on patients in a lithotomy position were identified in 55 cases for a rate of 1 per 3,608. Multivariate risk factors for development of a persistent neuropathy of a lower extremity included duration in lithotomy of 4 h or longer, a body mass index (kilograms per squared meter) of 20 or less, and a history of smoking within 30 days of the procedure. Regional anesthetic techniques were not found to be associated with an increased risk of neuropathy. Of the 53 patients who lived at least 1 yr after their procedure, 24 (45%) required either prosthetic or ambulatory support for persistent foot drop or leg weakness. CONCLUSIONS: These data suggest that prolonged duration in lithotomy and patient risk factors, including very thin body habitus and smoking in the preoperative period, are associated with the development of a lower-extremity neuropathy after procedures performed on patients in a lithotomy position. A reduction of time in the lithotomy position may be particularly worthwhile for patients with these risk factors.

Adolescent↗
PubMed1992

Isolated limb perfusion for recurrent melanoma of the extremity.

Recent reports in the literature suggest that hyperthermic isolated limb perfusion (HILP) may be effective in preventing local recurrence in patients with deeply invasive melanoma or in patients with recurrent disease confined to the extremity. It has been used in the past as an adjuvant treatment after resection of the primary melanoma or recurrence, or as a therapeutic measure if all the disease on the extremity cannot be resected. A prospective, nonrandomized trial of 16 patients with melanoma with recurrent disease confined to the extremity underwent HILP. The protocol involved the wide local excision of all recurrent disease when possible, elective or therapeutic node dissection when indicated, and HILP using cisplatin. In 11 patients in whom all recurrent disease could be resected and the HILP was considered prophylactic, only 1 patient's disease has recurred in the perfusion circuit. Before the perfusion, the 11 patients had a total of 19 local or intransit recurrences. Of the 5 patients in whom all recurrent disease could not be resected, disease persisted in 4 patients. When compared with a concurrent control population of patients with extremity melanoma who had a local recurrence and were not perfused, the patients with melanoma who underwent HILP had a significant prolongation of disease-free survival (p less than 0.05), but a similar actuarial survival. In this study, we demonstrate that HILP can prevent local regional recurrences in patients with metastatic melanoma who are at high risk for further recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Arm↗
PubMed1993

The extended deep inferior epigastric pedicle flap for lower extremity reconstruction.

Large soft-tissue defects of the lower extremity can present a challenging reconstructive problem. The extended deep inferior epigastric pedicle flap is a versatile and reliable flap that can be used for the coverage of complex lower extremity soft-tissue defects as far distal as the knee. We reviewed our 5-year experience with 20 consecutive extended deep inferior epigastric pedicle flaps used to cover lower extremity defects. All wounds, including 4 soft-tissue defects of the knee, were successfully covered. Two minor complications occurred. Flap anatomy, surgical approach, and new refinements in flap design are presented. The indications for the flap and its role in ablative tumor surgery are discussed. This flap has proved to be versatile, easy to raise, and extremely hardy. The ample skin island with its large arc of rotation is well vascularized, healing well even in irradiated wounds, and the flap tolerates both postoperative pressure and radiation.

Adult↗
PubMed1997

Adjuvant therapy: the effects on microvascular lower extremity reconstruction.

Adjuvant therapy and microsurgery have allowed advances in surgical extirpation of lower extremity neoplasms. This retrospective study was designed to evaluate the microvascular transfer for lower extremity reconstruction in patients receiving pre- or post-operative irradiation and chemotherapy alone and in combination. Over a 5-year period, 24 free tissue transfers were performed in 22 patients undergoing surgical resection with adjuvant therapy for lower extremity neoplasms. There were 13 male and 9 female patients with an average age of 51 years. The latissimus dorsi muscle was most commonly transferred (N = 15). Eighteen tumors received pre- and three received postoperative radiotherapy. Two tumors received a combination of radiotherapy and brachytherapy. Pre- and/or postoperative chemotherapy was used in 14 patients. Twelve of these patients had both chemo- and radiation therapy. A total of six complications occurred, with no flap loss. Complications were evenly distributed among adjuvant regimens. All patients who underwent attempted limb salvage were able to ambulate postoperatively, except for 1 patients who had local recurrence. In conclusion, adjuvant therapy did not increase the complication rate for free tissue transfer in the lower extremity. Adjuvant therapy did not require alterations in the free tissue transfer and, similarly, free tissue transfer did not alter adjuvant therapy. We believe that free tissue transfer in complicated wounds allows for better wound healing with adjuvant therapy rather than local or primary wound closure alone.

Adult↗
PubMed1998

Venous gangrene of the upper extremity.

Venous gangrene of the upper extremity is a rare entity and is the result of massive occlusion of all venous outflow of the extremity. The syndrome is strongly associated with hypercoagulable states including malignancy, low cardiac output states, and hereditary or acquired hematological abnormalities. Diagnosis can be straightforward but must be made early in the course of the process for treatment to be effective. Treatment has historically produced only modest results, and patients continue to suffer a high morbidity and mortality. We present a series of 6 patients with venous gangrene or impending venous gangrene of the upper extremities--a relatively large series. Two patients suffered from malignancy, 3 patients suffered from low-flow cardiac states, and 1 patient suffered from an overdose of calcium channel blockers. Hematological abnormalities included heparin-induced thrombocytopenia and thrombosis in 3 patients, activated protein C resistance in 1 patient, and lupus anticoagulant in 1 patient. Three patients experienced other major venous thrombotic complications, two of whom died (renal and cerebral venous infarction). Venous gangrene of the upper extremity remains a rare occurrence but one in which early identification and intervention may lead to improved outcomes.

Aged↗
PubMed2002

Reliability of primary vein grafts in lower extremity free tissue transfers.

Free flaps transferred to the lower extremity have a higher risk of failure, which may be expected to increase further with the use of vein grafts. The results of 103 consecutive free flaps to the lower extremities of 98 patients who were operated from March 1994 to December 1999 were evaluated to assess the reliability of vein grafts in lower extremity reconstruction. Five flaps were lost and the overall success rate was 95.1%. Eighty-four free tissue transfers in 79 patients were performed for the reconstruction of traumatic cases, and 81 of these flaps were performed in a delayed manner, between 1 week and 4 months after the injury. Interpositional vein grafts were used primarily in 22 flaps--all in traumatic cases--and 21 of them survived completely (95.4%). Primary vein grafts were used both for arteries and veins in 15 flaps and for arteries only in 7 flaps. The most common cause of tissue loss in these patients was a crush injury in earthquake survivors, followed by electrical injuries, gunshot injuries, motor vehicle accidents, and chronic infections. Free muscle flaps in 13 patients, skin flaps in 4 patients, osseous flaps in 2 patients, and temporal fascial flaps in 2 patients were the flaps of choice in vein graft reconstructions. Although a higher incidence of flap loss has been reported with the use of interpositional vein grafts than with regular transfers, and the technical and pathophysiological problems in flap transfers are also high in the lower extremity, the success rate in vein-grafted free flaps did not differ from that of the simple free flap transfers in the current series. This appears to be the result of meticulous preoperative planning and proper selection of recipient vessels during optimal operative conditions.

Adolescent↗
PubMed1975

Comparison of long-term results of 364 femoropopliteal or femorotibial bypasses for revascularization of severely ischemic lower extremities.

Successful revascularization of the severely ischemic lower extremity can be achieved by femorotibial as well as femoropopliteal bypass. The incidence of delayed graft occlusion after salvage of the severely ischemic lower extremity is low in patients with femorotibial or femoropopliteal bypass. Femorotibial bypass was performed in over one-third of patients undergoing bypass. Tibial bypasses resulted in effective prolonged revascularization of the severely ischemic lower extremity. An aggressive diagnostic and therapeutic approach to revascularization of the severely ischemic lower extremity can result in prolonged limb salvage by tibial or popliteal bypasses in lieu of primary amputation.

Arteries↗
PubMed1996

Intrapreneurial nursing: the Comprehensive Lower Extremity Assessment Form.

The Comprehensive Lower Extremity Assessment Form was developed in response to the need for a screening tool in a nurse-managed foot care clinic. It differs from other such tools because it includes clinical measures that identify the potential for foot pathology. The Comprehensive Lower Extremity Assessment Form also serves as an assessment teaching guide in a foot care course and is included as part of a home-study program. The authors demonstrate how the Comprehensive Lower Extremity Assessment Form has generated revenue as part of an intrapreneurial outgrowth of their foot clinic and provides a comprehensive approach to lower extremity assessment. The form can be tailored to meet the needs of the advanced practice nurse, the clinical setting, or patient population.

Entrepreneurship↗
PubMed1975

Thromboembolic complications of cast immobilization for injuries of the lower extremities.

Six cases of thromboembolic complications in patients being treated with plaster cast immobilization for a variety of injuries to the lower extremity were encountered over a four month period on an Air Force orthopaedic service. These injuries, consisting of three ruptures of the tendo achillis, two fractures of the tibia, and a sub-talar dislocation of the foot, resulted in one death from pulmonary emboli and three other serious complications of pulmonary emboli. The literature on thromboembolic complications following lower extremity injuries (including information of pathogenesis, clinical characteristics and epidemiology of venous thromboembolism and the hazards of lowere extremity cast immobilization in an individual susceptible to his complication) suggests that prophylaxis against thrombosis should be instituted in high risk individuals who must undergo case immobilization for injuries to the lower extremity.

Achilles Tendon↗
PubMed1987

Extremity dose: its definition, standards and regulatory limits, radiobiological significance, measurement and practical considerations.

This paper reviews several inter-related aspects of partial-body exposures to ionizing radiation, with particular emphasis on hands. The topics featured in this review are: the definition of extremity, the radiobiological significance of extremity dose and its influence on dose standards, current and future dose standards and regulatory limits, monitoring requirements along with the availability and selection of suitable dosimeters, the question of dose averaging and dosimeter placement and practical considerations for the implementation of an extremity dosimetry program. The review is purposely kept general in nature and readers with a specific interest in a particular aspect are encouraged to read the original papers. This review is written from the perspective of a practicing health physicist who may wish to read the available literature on this topic and incorporate some of the information into an existing or planned extremity dosimetry program.

Arm↗
PubMedDate not supplied

Pulse oximetry for vascular monitoring in burned upper extremities.

The reliability and accuracy of pulse oximetry as a monitoring device in deep superficial and full-thickness circumferential burns of the upper extremity were evaluated clinically. Pulse oximetry was correlated with the laser Doppler flowmeter experimentally in healthy volunteers. By continuously monitoring oxygen saturation levels, the pulse oximeter detected extremity hypoxia before it resulted in an adverse outcome. Extremities exhibiting oxygen saturation above 95% were treated with early excision and skin grafting without escharotomy. Extremities with O2 saturations of less than 95% underwent immediate escharotomy with return to normal saturation levels. The pulse oximeter is easy to use by nursing personnel; is noninvasive and accurate; and displays the oxygen saturation level within seconds.

Arm↗
PubMedDate not supplied

Outpatient skin grafting of extremity burn wounds with the use of Unna Boot compression dressings.

Thirty-one patients underwent split-thickness skin grafting for burn injuries of an extremity, after which Unna Boot compression dressings were applied for fixation of the graft. Three patients required hospitalization of 2 to 4 days, and 28 patients were treated strictly on an outpatient basis. The lower extremity was involved in 25 patients, and the upper extremity was involved in six. Average wound size was 284 cm2. Eighteen patients were treated with sheet grafts, and 13 received meshed grafts. Nine wounds extended across a joint. Patients were allowed immediate ambulation after surgery. All grafts resulted in 95% to 100% wound coverage, and no regrafting was required. Application of Unna boot compression dressings to extremity skin grafts provides excellent protection of both meshed and nonmeshed grafts and allows immediate ambulation and range of motion. Many patients with burn injuries may be treated on an outpatient basis with the use of this technique.

Adult↗
PubMed1998

Extremely high levels of alkaline phosphatase in hospitalized patients.

We determined the diseases associated with extremely high levels of alkaline phosphatase in hospitalized patients. Computerized laboratory records of the Hospital of Saint Raphael identified all inpatients who had elevations of alkaline phosphatase above 1,000 U/l from April 1994 to September 1995. Thirty-seven inpatients with alkaline phosphatase levels above 1,000 U/l were identified. Six had bone involvement from malignancy or Paget's disease and were eliminated from further analysis, and 31 patients were included in the study. Levels of alkaline phosphatase ranged from 1,014 to 3,360 U/l. Ten patients had sepsis as the cause of the elevated alkaline phosphatase. These included gram-negative organisms, gram-positive organisms, and two patients with fungal sepsis. Seven of 10 patients with sepsis had an extremely high alkaline phosphatase level and a normal bilirubin, 3 of 10 patients with sepsis also had acquired immunodeficiency syndrome (AIDS). Eight patients had biliary obstruction, 7 with malignant obstruction and 1 with a common bile duct stone. Nine patients had AIDS. The cause of the elevated alkaline phosphatase in these included three with sepsis, three with mycobacterium avium intracellulare (MAI) infection, two with cytomegalovirus infection, and one with Dilantin toxicity. Three patients had diffuse liver metastases. Finally, four patients had benign intrahepatic disease, including one patient with liver hemangiomas, one patient with sarcoid hepatitis, one patient with lead toxicity, and one patient with drug-induced cholestasis. Extremely high elevations of alkaline phosphatase are most frequently seen in patients with sepsis, malignant obstruction, and AIDS. Patients with sepsis can have an extremely high alkaline phosphatase level and a normal bilirubin. A variety of other causes were also noted.

Adult↗
PubMed2006

High-pressure injection injuries to the upper extremity: a review of the literature.

OBJECTIVES: The purpose of this review was to identify the relative impact of injected material, location of injury, time to debridement, injection pressure, infection, and the use of adjuvant steroid medication upon the need for amputation after high-pressure injection injuries to the upper extremity. DATA SOURCES AND STUDY SELECTION: A Medline literature search extending from 1966 to December 2003 was performed, referencing the key words "high-pressure injection injury," "grease gun injury," "paint gun injury," "pressure gun injury," and "high-pressure injection." The results were limited to the English language and to reports involving human subjects. Each abstract was reviewed to confirm that the described injury had occurred in the upper extremity and that it had truly been a high-pressure injection. The reference pages from each of the papers were reviewed to identify additional reports of high-pressure injection injury. Manuscripts describing injuries resulting from hand held syringes or other low-pressure mechanisms were excluded. DATA EXTRACTION: All of the manuscripts were analyzed to identify the clinical outcome, age, hand dominance, site of injection, substance injected, injection pressure, elapsed time to wide debridement, use of steroids, and incidence of infection. These variables were subjected to a Pearson chi test to determine their impact upon the need for amputation. RESULTS: Four hundred thirty-five cases of high-pressure injection injury to the upper extremity were identified. The amputation rate after these injuries was 30%. The location of the injury and the material injected contributed significantly to the need for amputation. For injections of paint, paint thinner, gasoline, oil, or jet fuel (organic solvents), the amputation risk was lower if wide surgical debridement occurred within 6 hours of injury. Steroids did not impact the amputation rate or incidence of infection. The presence of infection did not affect the incidence of amputation. CONCLUSIONS: The risk of amputation after high-pressure injection injury to the upper extremity is highest with organic solvent injection into the fingers. Injections into the thumb or palm result in a much lower frequency of tissue loss. Emergent surgical debridement reduces the amputation risk after injections of organic solvents. From the available data, no conclusions could be reached regarding functional outcomes, other than amputation, after high-pressure injection injury.

Forearm Injuries↗
PubMed2002

Increased parenteral amino acid administration to extremely low-birth-weight infants during early postnatal life.

BACKGROUND: Early administration of parenteral amino acids to infants with extremely low birth weight (birth weight < or = 1,000 g) has been encouraged to foster growth. However, excessive intravenous intake of amino acids may cause metabolic acidosis and uremia in extremely low birth weight infants. The hypothesis for this study was that extremely low birth weight infants would tolerate slightly increased early postnatal parenteral amino acid administration and benefit. METHODS: The peak daily parenteral amino acid dosage was increased from 3 g/kg (standard group) to 4 g/kg (modified group). The corrected parenteral amino acid dosage was computed to account for enteral protein intake and keep the combined daily intravenous amino acid and enteral protein intake at or below 3 g . kg -1 . d -1 in the standard group and 4 g . kg -1 . d -1 in the modified group. The primary outcome measure was plasma bicarbonate concentration as an indicator of acid-base status. Data were collected for patient demographics, nutritional intake, serum bicarbonate and serum urea nitrogen concentrations, and outcome. RESULTS: The corrected parenteral amino acid intake of the modified group was 16% greater at postnatal week 1 (3.30 +/- 0.83 g . kg -1 . d -1; mean, +/-1 SD) and 18% greater (3.86 +/- 0.94 g . kg -1 . d -1 ) at postnatal week 2 than the parenteral amino acid intake of the standard group. In the modified group, the mean serum bicarbonate concentration was 19.1 +/- 1.8 mEq/dL at week 1 and 23.9 +/- 2.9 mEq/dL at week 2, with no difference between the groups. At week 1, serum urea nitrogen concentrations were the same in both groups. The mean serum urea nitrogen concentration of the modified group at postnatal week 2 (18.2 +/- 8.8 mg/dL) was unchanged from postnatal week 1, but was greater than that of the standard group at postnatal week 2. Weight gain was the same in both groups. Corrected parenteral amino acid intake at postnatal week 1 correlated directly with weight gain from birth to postnatal week 2 ( P < 0.03) in both groups. CONCLUSIONS: Infants with extremely low birth weight tolerated parenteral amino acid intake of approximately 4 g . kg -1 . d -1. Mild increases of mean serum urea nitrogen concentration and mean weight gain were associated with increased parenteral amino acid administration without significant acidosis.

Acid-Base Equilibrium↗
PubMed1995

Lower extremity injuries in drivers of airbag-equipped automobiles: clinical and crash reconstruction correlations.

OBJECTIVE AND DESIGN: To determine the relationship between airbags and lower extremity injuries, 10 drivers admitted to a level-I trauma center with substantial lower extremity trauma incurred in crashes involving airbag-equipped vehicles were studied in depth with regard to their injuries, the circumstances of the crashes, and the medical charges for the acute management of those injuries. MATERIALS AND METHODS: During the clinical investigation portion of this study, we photographed lower extremity injuries, both soft tissue and radiographs, and performed a detailed surgical exploration during the debridement of open wounds or fracture fixation to treat them appropriately and to define the mechanism of injury, the fracture pattern, the pattern of soft-tissue insult, and the extent of periosteal stripping. We recorded the hospital and professional charges associated with the acute management not only of these injuries, but of the other injuries as well. The analysis performed for each case included a detailed crash reconstruction, including force, contact point, and vehicle intrusion data. Particular attention was paid to the dashboard and toe pan areas to determine deformation and intrusion and their association with thigh, leg, and foot injuries. Pertinent deformation and trajectory information was entered into the Calspan Reconstruction of Accident Speeds on the Highway (CRASH) computer program to generate a delta V or change in velocity measurement used as a measure of collision severity. When field data were incompatible with the limitations of the CRASH program, manual calculations such as "slide to stop" and conservation of momentum formulas were used. RESULTS: The seven male and three female drivers had a mean age of 39.4 years. Only four used seatbelt restraints. The mean delta V was 28.3 mph and the mean maximum crush was 32.4 inches. The mean Injury Severity Score of 13.2. Musculoskeletal injuries included 11 foot/ankle fractures, 6 tibial fractures, 2 patellar fractures, 6 femoral fractures, and two acetabular/pelvic fractures. Other trauma included abdominal, thoracic, head and upper torso injuries, it seems that these safety devices do not prevent injuries to the lower extremity.

Accidents, Traffic↗
PubMed1998

Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up.

PURPOSE: To establish by long-term follow-up the safety and efficacy of nonoperative management of clinically occult arterial injuries and the use of physical examination (PE) alone in determining treatment of penetrating extremity trauma (PET). METHODS: Two groups of patients were studied: (1) all patients with PET, arterial abnormalities on arteriograms, and no hard signs of vascular injury treated nonoperatively from 1986 to 1989; and (2) all patients with PET to the extremities managed by PE alone from 1989 to 1991. Telephone contact, PE, and duplex ultrasonography (US) were attempted in all group 1 patients, and telephone interviews were attempted in all group 2 patients. RESULTS: Group 1 had 43 patients with 44 clinically occult penetrating injuries to extremity arteries. Arteriography identified 21 intimal flaps/irregularities, 19 narrowings, 2 pseudoaneurysms, and 1 arteriovenous fistula. Four patients (9%) had clinical deterioration within 1 month and required surgery, with good results. Twenty-three of the other 39 patients (58%) were able to be contacted, and 17 (43%) with 18 injuries underwent PE and US. All were asymptomatic and had normal PE, and one had mild residual narrowing on US. The other 6 patients (four in prison, two out of state) reported no symptoms of vascular insufficiency and never sought medical attention for vascular problems. Mean follow-up was 9.1 years (range, 8.6-11.1 years). Group 2 had 287 patients (309 injuries) with PET treated by observation based on PE alone. Four patients (1.3%) required delayed surgery within the first week, and 78 with 90 injuries (29%) were able to be contacted. No patient reported any vascular symptoms or ever saw a physician for vascular problems. Mean follow-up was 5.4 years (range, 2.2-6.0 years). CONCLUSION: This is the first long-term follow-up of nonoperative management of clinically occult arterial injuries of the extremities and the use of PE alone in the initial management of PET. The results show these approaches to be safe, effective, and now a proven standard of care.

Adult↗
PubMed2001

Validity of lower extremity strength and power utilizing a new closed chain dynamometer.

PURPOSE: The purpose of this study was to compare selected variables measured on a traditional isokinetic dynamometer (Cybex II) with a new lower extremity, closed chain dynamometer (Omnikinetic, OmK). METHODS: Twelve subjects (6 male, 6 female, age = 28+/-5 yr, mean +/- SD) performed Cybex II knee flexion and extension at 1.05, 3.14, and 5.23 rad x s(-1). A maximal effort of 10 repetitions of lower extremity concentric extension and eccentric flexion at 36% of subject's 1-RM was performed on the OmK. Crank power and joint (ankle, knee, and hip) kinetics were recorded as a mean of 10 repetitions. RESULTS: t-Tests revealed right versus left leg differences (P < 0.05) for Cybex II peak torque flexion at 5.23 rad x s(-1), and OmK knee and hip peak power and hip root mean square power (RMS) power. Cybex peak knee torques were related (Pearson r values 0.78-0.92, P < 0.01) to OmK peak knee torques. Cybex average power was related to OmK knee power (Pearson r values 0.71-0.96, P < 0.01) and OmK crank power (r = 0.62-0.94, P < .01). Correlations tended to be stronger comparing the OmK with the fastest (5.23 rad x s(-1)) Cybex II speed. CONCLUSIONS: These results suggest that the OmK knee and crank kinetic data are comparable to Cybex It isokinetic dynamometry. The ability to evaluate lower extremity joint exercise at a subject's maximal movement speed, in addition to the use of a closed-chain, multi-joint motion, may allow for the OmK to provide a more global evaluation of lower extremity kinetics during seated concentric-extension, eccentric-flexion exercise.

Adult↗