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PubMed1992

Quantification of skeletal muscle necrosis in the lower extremities using 99Tcm pyrophosphate with single photon emission computed tomography.

No non-invasive quantitative method is currently available for measuring the amount of regional skeletal muscle necrosis in humans. A threshold method using 99Tcm pyrophosphate (PPi) with single photon emission computed tomography (SPECT) has been reported to quantify muscle necrosis successfully in a canine model. This method has been modified to measure muscle necrosis in the lower extremities of human patients. Modifications include adding background subtraction and using the contralateral unaffected lower extremity as background region. A region of interest was also manually drawn around the affected lower extremity muscle to exclude the tibia. In order to identify the group of patients with no significant necrosis and with diffuse hyperaemia, nine control subjects were studied. The variance of the counts within the pixels of the lower extremities was 132 (S.D. = 27). A variance of greater than 159 was considered as being significant for necrosis. Thirteen patients were studied. Six patients had significant muscle necrosis (462 ml, S.D. = 280 ml). All except one patient (who had a small amount of muscle necrosis) developed foot drop. Seven patients had no significant necrosis. All patients had normal ankle dorsiflexion. It is possible to quantify regional muscle necrosis using PPi with SPECT. Volume of necrosis determined by this method can also predict clinical outcome.

Aged↗
PubMedDate not supplied

Transfer techniques of the lower extremity with an external fixator.

This article describes the uses of external fixation for lower extremity problems and addresses some issues related to the correct way to lift an extremity with an external fixator. The differences in opinions between nurses and among physicians is discussed, followed by suggestions for solving this confusion within the settings in which people work. The article then pictorially demonstrates how to lift an extremity with an external fixator. It proceeds through a series of photographs depicting how to transfer a patient into a chair by supporting the extremity, and again by supporting the external fixator itself.

Beds↗
PubMedDate not supplied

Broken bones: common pediatric lower extremity fractures--Part III.

Lower extremity injuries and fractures occur frequently in young children and adolescents. Nurses are often one of the first healthcare providers to assess a child with an injury or fracture. Although basic fracture care and principles can be applied, nurses caring for these young patients must have a good understanding of normal bone growth and development as well as common mechanisms of injury and fracture patterns seen in children. Similar to many of the injuries in the upper extremity, fractures in the lower extremity in children often can be treated nonoperatively with closed reduction and casting. However, this article will also review several lower extremity fractures that frequently require surgical intervention to obtain a precise anatomical reduction. Common mechanisms of injury, fracture patterns, and current management techniques will be discussed. Teaching strategies and guidelines that will enable nurses and nurse practitioners to confidently educate parents, families, and other providers caring for these young patients will be reviewed.

Adolescent↗
PubMed1988

Soft-tissue expansion in the lower extremities.

Soft-tissue expansion enjoys ever-wider use, but to date an experience using this technique in the lower extremity has never been presented. We reviewed our first 16 patients to describe the indications and contraindications for the use of tissue expansion in the lower extremity. Guidelines evolved from study of the data. Soft-tissue expansion merits consideration for coverage of problem wounds, in preparation for removal of large benign lesions, and for the repair of contour defects. The operator should know that an open wound below the knee predicts a complication if soft-tissue expansion is attempted in that location. In the thigh, incisions can be confidently placed at the edge of the defect. In every location, large expanders should be chosen so that they are as long as or longer than the adjacent defect. The increase in circumference of the limb should be followed. Simple designs for advancement flaps usually work well. As our experience has grown, reconstruction using soft-tissue expansion in the lower extremity has become safer and the results more predictable through better patient selection and diligent monitoring of intraluminal pressures, even if only by ensuring that the patient is always comfortable. Soft-tissue expansion has a role in reconstruction of the lower extremity.

Adolescent↗
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↗
PubMed2000

Management of hand and upper-extremity infections in heart transplant recipients.

Hand and upper-extremity infections are routinely managed by antibiotics, immobilization, and limited incision and drainage. However, in immunocompromised patients, these infections may be more aggressive and they may require more emergent treatment. The authors performed a retrospective review of the Stanford University Medical Center experience with hand and upper-extremity infections in 911 cardiac transplant recipients over the past 30 years. Thirteen heart transplant recipients were treated for infections of the hand and upper extremity on an inpatient basis. Ten patients (77 percent) required operative debridement, and three (23 percent) required more than one operative procedure. Nine patients (69 percent) had bacterial infections, six (46 percent) had fungal infections [four of these patients (31 percent) had both bacterial and fungal infections], one (7.7 percent) had a mycobacterial infection, and one (7.7 percent) was not cultured. Hand and upper-extremity infections in transplant recipients frequently resulted in deep-space infections, tenosynovitis, and osteomyelitis. The authors believe such infections represent a surgical emergency, requiring immediate evaluation by hand surgeons and early, aggressive treatment.

Adult↗
PubMed2001

The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone.

Lower-extremity wounds with exposed tendon, bone, or orthopedic hardware present a difficult treatment challenge. In this series of patients, subatmospheric pressure therapy was applied to such lower-extremity wounds. Seventy-five patients with lower-extremity wounds, most of which were the result of trauma, were selected for this study. Dressings made of sterile open-cell foam with embedded fenestrated tubing were contoured to the wound size and placed into the wound. The site was covered with an adhesive plastic sheet. The sheet was placed beneath any external fixation devices, or the fixation device was enclosed within the sheet. The tubing was connected to the vacuum-assisted closure pump. Continuous subatmospheric suction pressure (125 mmHg) was applied to the wound site. The wounds were inspected and the dressings were changed every 48 hours.Vacuum-assisted closure therapy greatly reduced the amount of tissue edema, diminishing the circumference of the extremity and thus decreasing the surface area of the wound. Profuse granulation tissue formed rapidly, covering bone and hardware. The wounds were closed primarily and covered with split-thickness skin grafts, or a regional flap was rotated into the granulating bed to fill the defect. Successful coverage was obtained without complication in 71 of 75 patients. Wounds have been stable from 6 months up to 6 years.

Bandages↗
PubMed1993

Physiologic amputation prevents myoglobinuria from lower extremity myonecrosis.

Myoglobinuria secondary to myonecrosis is a proven cause of renal failure, especially in critically ill patients. Physiologic amputation or cryoamputation has been used at our institution for the past two decades as a safe and effective treatment for lower extremity infection, intractable rest pain, and irreversible myonecrosis. We retrospectively studied five critically ill patients with myonecrosis of lower extremities associated with myoglobinuria. The etiology of myonecrosis included preexisting peripheral vascular disease or crush injury to the lower extremities. It was determined that all five patients were too ill to undergo emergency amputation. Myoglobinuria was documented in all five patients and cleared within 24 hours of physiologic amputation in four patients. All five patients had elevated creatine phosphokinase levels (mean 20,270 mU/mL, range 12,090 to 43,164 mU/mL) that significantly decreased within 48 hours of physiologic amputation (mean 6,488 mU/mL, range 2,250 to 13,580 mU/mL). Mechanical ventilation and cardiovascular support were required in four patients. All patients had transient episodes of renal insufficiency with two progressing to anuric renal failure and requiring dialysis. One patient's renal failure resolved after 56 days, but the other patient died of a cerebrovascular accident 22 days after initiation of physiologic amputation. The mean duration of physiologic amputation was 15.6 days (range 5 to 32 days) with no significant complication due to physiologic amputation. All five patients had surgical amputation successfully. Three patients survived. The two deaths in the study were due to a cerebrovascular accident in one patient and a cardiopulmonary arrest in another. Physiologic amputation is a treatment option that halts myonecrosis, prevents myoglobinuria, and lessens the risk of associated acute renal failure. Physiologic amputation may be appropriately used in patients with myoglobinuria due to extremity myonecrosis who are deemed too critically ill to survive emergency amputation.

Acute Kidney Injury↗
PubMed2006

The extremes of spinal motion: a kinematic study of a contortionist in an open-configuration magnetic resonance scanner: case report.

STUDY DESIGN: Observational case study on a female contortionist. OBJECTIVE: To investigate how the human spine of a young athlete aligns during extreme body contortions. SUMMARY OF BACKGROUND DATA: To our knowledge, there are no data available in the literature on the spinal kinematics under extreme body contortions. METHODS: Conventional and kinematic magnetic resonance imaging was used to study a 22-year-old female Chinese contortionist. The images were analyzed with regard to abnormal segmental motion and degenerative alterations. RESULTS: No abnormal segmental motion was observed. The patient had a normal spine beside a mild anterior displacement of L1 relative to L2, with mild disc degeneration and small anterior spondylosis. In addition, a mild disc degeneration was observed at T4/5. No other abnormal findings were diagnosed. CONCLUSIONS: The kinematic magnetic resonance investigation of the presented case did not reveal any evidence for abnormal segmental motion or subluxation in extreme body contortions and indicates that this excessive motion results from extreme spinal flexibility.

Adult↗
PubMed2004

Tumescent and dry liposuction of lower extremities: differences in lymph vessel injury.

Lipectomy is a standard procedure in plastic surgery. Until now, however, there was no definite information about the influence of different liposuction techniques (tumescent versus dry liposuction) on the integrity of lymph collectors during this procedure. To study the effect of these liposuction techniques on the incidence of lymph vessel injury, postmortem lymphatic preparations were done in nine human cadavers (18 lower extremities). Conventional liposuction with a blunt 4-mm cannula in the dry technique (n = 29 regions) was compared with the tumescent technique (n = 26). Liposuction was performed in parallel to the superficial lymph vessels (longitudinal suction) or transversally in an 80-degree to 90-degree angle to the extremity (vertical suction). Careful surgical preparation of different regions followed. A specific macroscopic lymph vessel injury score was applied to differentiate three degrees of lymph vessel lesions according to the extravasation of patent blue. In all lower extremities, postmortem lymph flow occurred as indicated by patent blue staining of the lymph vessels. Injection of fluid that is obligatory during tumescent suction did not result in grade 2 injury. On the contrary, tumescent suction overall produced significantly fewer lymph vessel lesions when compared with the dry technique (p < 0.05). Longitudinal liposuction produced significantly less injury when compared with vertical suction (p < 0.05). Tumescent suction and dry suction were equally effective in removing adipose aspirates, as verified by circumference measurements. In addition, tumescent liposuction is unlikely to cause major lesions of epifascial lymph vessels during suction procedures vertical to the extremity axis. Therefore, in this respect, this technique is superior to dry suction.

Aged↗
PubMed2005

Use of the extended-pedicle vastus lateralis free flap for lower extremity reconstruction.

BACKGROUND: Soft-tissue coverage in the lower extremity usually requires a flap with a long pedicle, low donor-site morbidity, and versatility in terms of shape and volume. The extended-pedicle free vastus lateralis muscle flap has previously been described for head and neck cancer, and it fulfills these requirements. METHODS: Twelve patients with lower extremity defects underwent reconstruction with an ipsilateral free vastus lateralis muscle flap. The flap included a segment of the distalmost part of the muscle, distal to the entry point of the motor nerve to the vastus lateralis, based on the descending branch of the lateral femoral circumflex vessels. Up to 20 cm of vascular pedicle with a large caliber was obtained. In three cases, a combined distal vastus lateralis and anterolateral thigh flap was used as a chimeric flap. RESULTS: All flaps were successful. Infection developed in two cases and required flap reelevation and new wound debridement. There was no substantial subjective donor-site morbidity. CONCLUSIONS: Elevation of the flap can be performed with the patient in the supine position and is extremely fast and straightforward, without the added difficulty of anatomical variation or extensive intramuscular vascular dissection. The pedicle is long and of large caliber. Although the series is short, the authors conclude that this is a useful free flap for lower extremity reconstruction.

Adult↗
PubMed2004

Large and giant congenital pigmented nevi of the upper extremity: an algorithm to surgical management.

The timing and choice of treatment of congenital giant pigmented nevi continues to evolve under the influence of changing opinions regarding the risk of malignant degeneration and the impact of excision and reconstruction on the affected child. Many studies exist to support a notable enough risk of malignancy to warrant excision, yet other series and pigmented lesion clinics suggest that the risk of malignancy does not warrant the potential scarring and deformity that has followed the surgery necessary to remove these giant lesions. To satisfy both sides in this controversy, we have been challenged to modify our surgical techniques in a manner that minimizes the risk of malignant degeneration and at the same time provides optimal functional and aesthetic outcomes for these complex reconstructions. Thirty consecutive patients with large and giant nevi of the upper extremity were treated over a 23-year period (1979-2002) by the senior author. These patients represent a subset of 259 children (12%) with large or giant congenital pigmented nevi treated and followed during this period of time. In proximal upper extremity lesions, expanded transposition flaps from the upper back and shoulder have effectively eliminated contour defects or circumferential constriction in the upper arm and axilla. An expanded free transverse rectus abdominis musculocutaneous flap has offered a possible avenue for larger lesions (shoulder and upper extremity to below the elbow), and pedicle flaps from the flank (both expanded and nonexpanded) have offered ways of improving the long-term contour in the forearm. Expanded and nonexpanded full-thickness skin grafts were chosen for reconstruction of the hand and the fingers. The authors describe in detail the surgical strategies and the techniques for reconstruction of each region of the upper extremity and then bring these ideas together in an algorithm for assessment and treatment of these challenging lesions.

Algorithms↗
PubMed2003

The LEGS score: a proposed grading system to direct treatment of chronic lower extremity ischemia.

OBJECTIVE: To prospectively compare the Lower Extremity Grading System (LEGS)-derived "recommended treatment" to the actual treatment performed and to analyze LEGS intergrader scoring consistency by comparing blinded scoring results between physician graders. SUMMARY BACKGROUND DATA: Due to technical advances and the increased medical complexity of the aging population, the most appropriate treatment for chronic lower extremity ischemia-open surgery versus endovascular-is again in flux. In an attempt to standardize management, the LEGS score, based on the best available outcomes data, was devised by the physicians of an established vascular service. METHODS: From March to June 2002, all chronically ischemic lower extremities that met standard indications for revascularization were prospectively enrolled and independently graded with the LEGS score by an "endovascular surgeon" and an "open surgeon" for comparative analysis. The results were then blindly evaluated to determine whether the LEGS-derived "recommended treatment" agreed with the actual treatment rendered and to assess for intergrader consistency. Agreement was assessed using kappa statistical analysis. RESULTS: Of the 137 presenting limbs (mean patient age 66.4 yo; 43% claudication, 57% limb-threatening ischemia), 107 were treated (65% endovascular, 30% open surgery, 5% amputation), 16 were pending treatment, and 14 were not treated because of patient refusal (n = 13) or death (n = 1). The LEGS score predicted the actual or offered clinical treatment in 90% of cases. The LEGS score comparison between physician graders resulted in identical "recommended treatment" in 116 of 128 cases for a 90.6% agreement. CONCLUSIONS: A reproducible scoring system to guide the treatment of patients with chronic lower extremity ischemia is possible. While systems like the LEGS score may have potential clinical application, their use as a treatment standardization tool for future prospective outcomes comparisons between open and endovascular surgery will be essential.

Adult↗
PubMed2004

Restraint use and lower extremity fractures in frontal motor vehicle collisions.

BACKGROUND: Seat belts and air bags have been shown to significantly reduce morbidity and mortality following MVCs. Research suggests that restraint use does not protect against lower extremity fracture; however, no population-based studies of this association exist. The purpose of this study is to compare the effectiveness of combined seat belt and airbag restraint systems with airbag alone, seat belt alone, and no restraints with respect to incidence and location of lower extremity fractures. METHODS: A retrospective analysis of front seat occupants involved in police-reported, tow-away frontal MVCs was conducted using data from the 1995 through 2000 National Automotive Sampling System (NASS). Incidence and relative risk (RR) of fracture to specific bony regions were measured according to seat belt use and airbag deployment. RESULTS: Compared with unrestrained occupants, occupants restrained with airbag only had significantly higher risk for all types of lower extremity fractures whereas those occupants restrained with either seat belt only or seat belt and airbag had lower risk of fracture. The greatest difference was seen with tibia/fibula fractures in airbag only (RR, 2.14) but this trend continued to be significant with femur and pelvic fractures (RR, 1.13 and 1.23, respectively). CONCLUSION: While airbags may reduce the risk of death when used alone or in combination with seat belts, the results of this study demonstrate that air bags increase the risk of lower extremity fractures when used as the sole method of passenger protection. Also, they may do so differentially according to skeletal region. This data strongly support the consideration of developing accessory knee bolster airbags to prevent the "submarining" or sliding under the airbag that may be responsible for this finding.

Accident Prevention↗
PubMed2005

Comparison of hemorrhage control agents applied to lethal extremity arterial hemorrhages in swine.

BACKGROUND: QuikClot powder (QC), chitosan dressing (CD), and fibrin sealant dressing (FSD) are new hemostatic products touted to be more effective in controlling severe extremity bleeding than the current standard gauze dressing. All have been utilized in the global war on terrorism. Our objective was to evaluate the hemostatic efficacy of these three products in a model of severe extremity arterial hemorrhage that could not be stopped by standard gauze treatment. METHODS: A model of severe extremity arterial hemorrhage was developed in swine that was 100% fatal with standard gauze application and manual compression. The Army Field Bandage (AFB) was the standard gauze control. Anesthetized animals (n = 60, 15/group, 37.7 +/- 2.5 kg) were splenectomized and instrumented. A reproducible femoral artery injury was created using a 6 mm aortic punch, and free bleeding was allowed for 45 seconds. Each hemostatic agent was applied twice with three-minute compressions. All products were applied on actively bleeding wounds through a pool of blood. Fluid resuscitation was started with the first compression and titrated to a mean pressure of 65 mm Hg. Animals were observed for 180 minutes or until death. Endpoints were percent survival, survival time, blood loss, resuscitation volume, wound temperatures and tissue histology. Data are expressed as mean +/- SD and analyzed by Fisher's exact, logrank, and nonparametric ANOVA tests. RESULTS: Baseline physiologic parameters were similar among groups. AFB did not produce hemostasis. QC also showed no hemostatic benefit, and QC treatment markedly increased maximum wound temperatures to an average of 70.8 +/- 4.2 degrees C (p < 0.001). CD stopped bleeding temporarily in only one animal. There were no survivors in the AFB, QC, or CD groups. CD numerically prolonged survival time (58.9 +/- 21.1 minute) compared with the control (38.4 +/- 24.7 minutes, p = 0.045) but the difference was not significant. FSD reduced bleeding (p < 0.05) and prevented exsanguination in 10/15 (2/3) animals, and resulted in a significantly longer average survival time (p < 0.0001). CONCLUSION: FSD was superior to other currently utilized hemostatic products in controlling lethal arterial hemorrhage in this model of a fatal extremity wound. CD showed some hemostatic benefit. The exothermic reaction of QC was significant and resulted in gross and histologic tissue changes of unknown clinical significance. Controlled human studies with the promising products are required.

Animals↗
PubMed2007

The anterolateral thigh flap is highly effective for reconstruction of complex lower extremity trauma.

BACKGROUND: Trauma patients with high-energy injuries often present with severe tissue damage that extends beyond the immediate zone of injury and requires recruitment of vascularized tissues from distant sites. The objective of this study was to evaluate the utility of the anterolateral thigh (ALT) flap for reconstruction of the traumatically injured lower extremity. METHODS: Prospective data were collected on all patients who underwent lower extremity reconstruction with an ALT flap during a 3.5-year period at a primary adult resource center (PARC). Demographics captured included age, gender, Injury Severity Score, mechanism of injury, and size of defect and complications. RESULTS: Fifty-six patients underwent a total of 59 ALT flap harvests during the study period. The majority of patients were male (75%) and sustained blunt injury (95%). The mean age was 37 +/- 14 years with a mean Injury Severity Score of 17.9 +/- 8. The mean flap size was 20.7 x 8.4 cm, with 64% harvested from the injured limb. Total flap success rate was 91.5%, with four total (6.7%) and one partial flap failure (1.7%). CONCLUSION: The ALT flap is a useful tool for trauma reconstruction in lower extremity salvage. We have shown that the ALT flap can be performed successfully in the traumatically injured patient even when harvested from the ipsilateral lower extremity.

Adult↗
PubMed1979

The cell as an extreme environment.

Living cells and their intracellular parasites show many of the characteristics ascribed to extreme environments and their dominant species. The diversity of species colonizing intracellular habitats is low, and successful inhabitants exhibit special fitness traits that often render them obligately dependent on residence within a host cell. However, the diversity-limiting factor in the extreme environment of the host cell interior is not abiotic, as it is in conventional extreme environments. It is biotic: the living cell itself and its many activities. Host cells bar the entrance to most would-be parasites, they destroy most of those that do manage to get inside, and they deny parasites free access to many components of their soluble metabolite pools. Successful intracellular parasites have evolved fitness traits that give them the capacity to survive in the face of diversity-limiting factors or to modify the intracellular habitat so that those factors no longer operate. Looking on the cell as an extreme habitat emphasizes its simultaneous roles as environment, antagonist, and competitor.

Animals↗
PubMed2004

Fluctuating fronts as correlated extreme value problems: An example of Gaussian statistics.

In this paper, we view fluctuating fronts made of particles on a one-dimensional lattice as an extreme value problem. The idea is to denote the configuration for a single front realization at time t by the set of co-ordinates [k(i) (t)] identical with [ k(1) (t) , k(2) (t) ,..., k(N (t) ) (t) ] of the constituent particles, where N (t) is the total number of particles in that realization at time t . When [k(i) (t)] are arranged in the ascending order of magnitudes, the instantaneous front position can be denoted by the location of the rightmost particle, i.e., by the extremal value k(f) (t) =max [ k(1) (t) , k(2) (t) ,..., k(N (t) ) (t) ] . Due to interparticle interactions, [k(i) (t)] at two different times for a single front realization are naturally not independent of each other, and thus the probability distribution P (k(f) ) (t) (based on an ensemble of such front realizations) describes extreme value statistics for a set of correlated random variables. In view of the fact that exact results for correlated extreme value statistics are rather rare, here we show that for a Fermionic front model in a reaction-diffusion system, P (k(f) ) (t) is Gaussian. In a Bosonic front model, however, we observe small deviations from the Gaussian.

Journal Article↗