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Functional outcome after acute compartment syndrome of the thigh.

BACKGROUND: Acute compartment syndrome of the thigh is an uncommon condition that is associated with a high rate of morbidity. Because of its rarity, limited information is available on the long-term functional outcome for patients with this condition and the factors that affect the clinical result. METHODS: Eighteen patients with acute compartment syndrome of the thigh were evaluated at an average of sixty-two months after treatment. Functional outcome was evaluated by means of physical examination, isokinetic thigh-muscle testing, and validated functional outcome scores. RESULTS: Long-term functional deficits were present in eight patients, and only five patients had full recovery of thigh-muscle strength. The persistent dysfunction was reflected in worse overall functional outcome scores. High injury severity scores, ipsilateral femoral fracture, prolonged intervals to decompression, the presence of myonecrosis at the time of fasciotomy, and an age of more than thirty years were associated with increased long-term functional deficits, persistent thigh-muscle weakness, and worse functional outcome scores. CONCLUSIONS: Acute compartment syndrome of the thigh is often associated with considerable long-term morbidity. Several factors can affect the functional outcome, and knowledge of these factors can help in the development of a more effective clinical management strategy to reduce long-term morbidity.

Acute Disease↗

Interrelationships among thigh muscle co-contraction, quadriceps muscle strength and the aerobic demand of walking in children with cerebral palsy.

The purpose of this study was to quantify interrelationships among thigh muscle co-contraction, quadriceps muscle strength, and the aerobic demand of walking in 13 children with spastic hemiplegic cerebral palsy (CP). During Session 1, subjects were familiarized with testing procedures, given five minutes of treadmill walking practice, and completed quadriceps muscle strength testing. In Session 2, subjects performed three 5-min walking bouts on the treadmill at 0.67 m x s(-1) to further accommodate to treadmill ambulation. During Session 3, resting VO2 was measured and subjects walked at 0.67, 0.89, and 1.12 m x s(-1) for five minutes while oxygen uptake (VO2) and thigh muscle co-contraction data were collected. Results demonstrated that no significant relationship existed between net VO2 and measures of thigh muscle co-contraction or quadriceps muscle strength. In addition, thigh muscle co-contraction was not shown to be associated with quadriceps muscle strength. Collectively, thigh muscle co-contraction and quadriceps muscle strength explained 13. 5%, 6.2%, and 2.2% of the variance in VO2 at 0.67, 0.89, and 1.12 m x s(-1), respectively. Viewed in concert, these results suggest that the walking energy expenditure of children with spastic hemiplegic CP is not influenced by the level of thigh muscle co-contraction or quadriceps muscle strength.

Cerebral Palsy↗

[Nonclostridial gas-producing phlegmone originating in the right thigh of a diabetic patient: report of a case with autopsy findings].

A 49-year-old male with a history of diabetes mellitus of a period of twenty years noticed pain and feverish sensation in both thighs and both inguinal regions: they were more severe in the right than in the left. There were redness and swelling of the skins of the scrotum and of the superomedial aspects of both thighs. He had no diabetic ulcer on the right foot or right leg. Examination revealed evidence of gas retention in the subcutaneous tissue of the right thigh. Incision confirmed the presence of pus, from which Escherichia coli and Bacteroides fragilis were cultured. His condition gradually deteriorated despite wide incision, debridement, irrigation, and intensive chemotherapy. He expired on the 26th hospital day. Autopsy showed phlegmone of the right loin, right buttock, right thigh, and upper half of the right leg. We presume that the skin of the superomedial aspect of the right thigh was first infected. Bacteria rapidly invaded into the subcutaneous tissue; they induced phlegmone with gas production. We conclude that phlegmone of the right thigh simultaneously spread both to the right loin and right buttock, and to the right leg.

Bacteroides Infections↗

Lean and fat component of the human thigh. The effects of immobilization in plaster and subsequent physical training.

Changes in thigh components were investigated with the one-legged inactivity- and training-model using 22 young healthy male soccer players, who for 4-5 weeks had one leg immobilized in a cast. They were investigated before and after the cast period and after 4 weeks' physical training of the inactivated leg. Immobilization induced a significant increase in the subcutaneous thickness and a significant decrease in the circumference of the thigh (p less than 0.01). The calculated lean thigh volume was reduced from 4.93 1 to 4.10 1 (p less than 0.01), whereas the calculated fat thigh volume (1.5 1) was unchanged. The changes reversed after four weeks of progressive dynamic training, but did not reach the pre-immobilized values. Body weight decreased from 73.4 kg to 70.8 kg (p less than 0.01) during the immobilization period and was regained after the training period. The fat fraction of the body was unchanged. It is concluded that the loss in total thigh volume during inactivation in a cast is due to waste of the muscle tissue, and further that this loss is partly concealed by an unchanged fat thigh volume.

Adipose Tissue↗

A case-control study of risk factors that predict femoral arterial injury in penetrating thigh trauma.

STUDY HYPOTHESIS: Femoral artery injuries can be predicted by the mechanism of injury, wound location and tract, and physical findings following penetrating thigh trauma. DESIGN: Retrospective case-control study. PARTICIPANTS: All 808 consecutive patients undergoing femoral arteriography for penetrating thigh trauma from September 1986 through December 1990 were eligible for inclusion in the study. All 50 patients in the eligible population with proven femoral artery injuries diagnosed by angiogram were the study subjects. Fifty patients with penetrating thigh trauma who had angiograms negative for injury and were systematically chosen from the eligible population served as controls. INTERVENTIONS: Data included mechanism of injury; location of wound entrance, tract, exit, and retained missile; physical findings (including ankle-brachial index); and the presence of femur fractures. Physical findings were divided into hard findings (pulse abnormality, expanding hematoma, or pulsatile bleeding) or soft findings (neurologic deficit, hypotension without another source, or bruit/thrill). RESULTS: Of the 808 eligible patients, 50 (6.2%) had a femoral arterial injury on angiography, 20 (40%) of which were clinically occult injuries. A medial thigh tract made an arterial injury 58 times more likely (odds ratio [OR], 57.5; P < .001) and was present in 100% of cases and 64% of controls. An anteromedial thigh tract made an arterial injury 12 times more likely (OR, 11.5; P < .001) and was present in 92% of cases and 50% of controls. A wound with hard physical findings was 118 times more likely to have an arterial injury (OR, 118; P < .00001) and was found in 54% of cases and none of the controls. The presence of any physical finding made an arterial injury 36 times more likely (OR, 36; P < .00001) and was found in 60% of cases and 4% of controls. The presence of a femur fracture or a gunshot mechanism was not predictive of injury. CONCLUSION: Only patients with medial thigh wounds need to undergo angiography for the detection of femoral artery injuries. This approach would have reduced the angiography rate by 36% in this series. Had angiography been performed only on patients with any physical findings, a 70% reduction in the rate of angiography would have been achieved, although five occult arterial injuries per year would have been missed. Angiography should not be performed solely because of a gunshot mechanism or the presence of a femur fracture.

Adult↗

Heterotopic ossification as a complication of the staged total thigh muscles flap in spinal cord injury patients.

Between 1980 and 1990, 24 total thigh flap procedures were performed at Rancho Los Amigos Medical Center (Downey, CA) by the Pressure Ulcer Management Service. An unexpected occurrence was identified, that is, the rapid development of heterotopic ossification (HO) occurring in the exposed muscle flap between the first and second stages. There were 15 two-stage total thigh flap procedures on 14 patients performed between 1980 and 1990. Of these 15 flap procedures, 11 in 10 patients were found to have HO evident at the second-stage debridement/closure. In comparing our findings with those in other studies (earliest evidence of HO at 19 days), the initial presentation of HO in affected tissues might be even earlier than previously detected. The risks and technical difficulties due to development of HO associated with the two-stage total thigh flap procedure point toward future modifications in preoperative planning that may prove beneficial. Therefore, if the two-stage total thigh flap procedure is necessary, the interval between initial debridement/disarticulation (stage 1) and definitive flap closure (stage 2) should be kept to an absolute minimum. Additionally, HO medicinal prophylaxis (that is, indomethacin or diphosphonates) or radiation after the first stage of the total thigh flap procedure should be considered. Our final conclusion is that the total thigh flap procedure should be done as a one-stage procedure if possible.

Adult↗

Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma.

OBJECTIVE: To compare the effectiveness of calf-thigh sequential pneumatic compression devices with the effectiveness of plantar venous intermittent pneumatic compression devices in prevention of venous thrombosis after major trauma. SUBJECTS AND METHODS: We evaluated 181 consecutive patients after major trauma without lower extremity injuries that precluded the use of pneumatic compression devices. We randomly assigned 149 patients to either calf-thigh sequential pneumatic compression or plantar venous pneumatic compression. After blinding the observers to the method of prophylaxis against deep-vein thrombosis, we performed bilateral compression ultrasonography on or before day 8 after randomization. RESULTS: Among 149 randomized patients, 62 who received calf-thigh sequential pneumatic compression and 62 who received plantar venous intermittent pneumatic compression devices completed the trial. Thirteen patients randomized to plantar venous intermittent pneumatic compression (21.0%) and 4 patients randomized to calf-thigh sequential pneumatic compression (6.5%) had deep-vein thrombosis (p = 0.009). Seven of 13 patients with deep-vein thrombosis after prophylaxis with plantar venous intermittent pneumatic compression had bilateral deep-vein thromboses, whereas all 4 patients with deep-vein thrombosis after prophylaxis with calf-thigh sequential pneumatic compression had unilateral deep-vein thrombosis. CONCLUSION: Calf-thigh sequential pneumatic compression prevents deep-vein thrombosis more effectively than plantar venous intermittent pneumatic compression after major trauma without lower extremity injuries.

Adult↗

Pharmacodynamic assessment of ertapenem (MK-0826) against Streptococcus pneumoniae in a murine neutropenic thigh infection model.

The objective of this study was to determine the susceptibility breakpoint of a new carbapenem, ertapenem (MK-0826), against Streptococcus pneumoniae strains based on bacterial density and survival studies in a murine thigh infection model. Sixteen S. pneumoniae isolates for which MICs ranged from 0.015 to 4.0 mg/liter were tested with neutropenic ICR mice. Animals were infected with bacteria at 10(5) to 10(6) CFU per thigh and were treated with ertapenem starting at 2 h postinfection for 4 days. Ertapenem was given subcutaneously at 50 mg/kg of body weight every 6 h, which simulates the human pharmacodynamic profile (in particular, the duration of time that the concentration of free drug remains above the MIC of 2 mg/liter). At 0 and 24 h postinfection, thighs were harvested for bacterial density determination. Survival was assessed during 4 days of therapy and 3 days after the therapy. A protein binding study was conducted with mice by use of the ultrafiltration method. Protein binding in mice was approximately 95%, which is comparable to that in humans. The average change in bacterial density ranged from -0.22 to -4.4 log CFU per thigh over 24 h compared to 0-h controls. The extent of microbial eradication was dependent on the MIC for the S. pneumoniae isolate. Substantial bactericidal activities (i.e., killing of approximately 2 log CFU per thigh) were consistently observed against isolates for which MICs were <or=2 mg/liter, which also resulted in nearly 100% survival during the 4 days of drug dosing and 3 days after the therapy. Less-pronounced and highly variable bactericidal activities were detected against isolates for which the MIC was 4 mg/liter. Substantial enhancement in bactericidal activity was observed for CBA/J mice and is attributed to the contribution of the host defenses in the immunocompetent species. Assessment of the effectiveness of ertapenem by bacterial-density reduction over 24 h and by survival over 4 days of therapy in the murine thigh infection model reveals that the drug maintains maximal efficacy against S. pneumoniae isolates for which the MIC of this agent is <or=2 mg/liter.

Animals↗

Should knee-length replace thigh-length graduated compression stockings in the prevention of deep-vein thrombosis?

OBJECTIVE: To compare knee-length with thigh-length graduated compression stockings for correct application and rate of compliance when they are prescribed for the prevention of deep-vein thrombosis in surgical patients. METHODOLOGY: Patients who were prescribed graduated compression stockings were prospectively studied in three surgical units at Groote Schuur Hospital from February to June 1997. Knee-length stockings were prescribed in the colorectal unit, while the thigh-length variety were prescribed in the hepatobiliary and trauma units. Patients were observed for the correct application and size of stockings, and the presence of compression bands. A total of 72 patients were studied. RESULTS: One patient in the knee-length group and 7 patients in the thigh-length group were not wearing their stockings. Twenty-one of 30 patients (70%) in the knee-length group and 15 of 42 (35.7%) in the thigh-length group had correctly applied stockings (P = 0.009). CONCLUSIONS: Knee-length are more likely to be correctly applied than thigh-length stockings. Knee-length should replace thigh-length stockings in general surgical patients.

Adolescent↗

The anterolateral thigh flap: radial forearm's "big brother" for extensive soft tissue head and neck defects.

OBJECTIVE: The anterolateral thigh flap has recently been rediscovered in Asia as a perforator flap. The objective of this study was to describe the reliability and donor morbidity of the anterolateral thigh flap for head and neck reconstruction without transmuscular perforator dissection. DESIGN: Consecutive case series by a single surgeon. SETTING: A regional tertiary-referral head, neck, and skull base surgical oncology center. PATIENTS: The first 34 consecutive patients. INTERVENTION: Microvascular reconstruction with an anterolateral thigh free flap. MAIN OUTCOME MEASURES: Primary insufficiency, partial necrosis, complete necrosis, and donor morbidity rates. RESULTS: Two flaps necrosed partially (6%). No flaps demonstrated primary insufficiency, necrosed completely, or incurred significant donor morbidity. CONCLUSIONS: The anterolateral thigh flap can be reliably harvested without transmuscular perforator dissection and without incurring serious donor morbidity. It possesses workhorse attributes (no repositioning, remote from defect, long pedicle) and is extremely versatile (one is able to independently tailor the skin and muscle), making it ideal for the heterogeneous group of extensive soft tissue head and neck defects. When a forearm flap will likely be too thin or too morbid, the anterolateral thigh flap can be considered its "big brother."

Adolescent↗

Head and neck reconstruction using lateral thigh free flap: flap design.

Eleven lateral thigh free flaps were used in head and neck reconstruction, transferred on the basis of the second perforator as well as the third perforator of the profunda femoris artery. The lateral thigh free flap was useful and reliable in head and neck reconstruction and was versatile in flap design. Due to the wide cutaneous territory of the lateral thigh flap, the skin island could be designed freely in the lateral thigh region. Careful patient selection is mandatory for good results. The pinch test and an understanding of the variety of subcutaneous thicknesses in the lateral thigh region are helpful in designing a skin island of adequate thickness. Other considerations in flap design are discussed.

Adult↗

Pharyngoesophageal reconstruction with lateral thigh free flap.

BACKGROUND: We evaluated the use of a lateral thigh free flap in pharyngoesophageal reconstruction, which is often overlooked and less widely used despite its distinct advantages. METHODS: This study reviewed the patient's medical records, including the patient's age, gender, histopathologic diagnosis, surgical defects, flap size, flap survival, donor and recipient site complications, and swallowing function and voice rehabilitation. RESULTS: Twelve lateral thigh free flaps were used to primarily reconstruct the pharyngoesophagus in 11 patients after tumor resection from July 1997 to May 1999. Eleven of the 12 flaps (91.7%) were transferred successfully. In one patient, the flap failure occurred as a result of venous thrombosis, and therefore another lateral thigh free flap from the opposite thigh was used 3 days later. The swallowing function was restored in all patients. Prosthetic voice rehabilitation was successfully achieved in all five patients, who primarily underwent tracheoesophageal punctures. No frank fistula or stricture developed. Significant donor site morbidity was not noted. CONCLUSIONS: The lateral thigh free flap is useful and reliable in selected cases of pharyngoesophageal reconstruction and versatile in flap design with favorable functional outcomes of swallowing and voice rehabilitation with minimal donor site morbidity.

Aged↗

Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction.

BACKGROUND: Although the anterolateral thigh flap has been extensively used for head and neck reconstruction in Asia, reported variations of vascular anatomy seem confusing and may have contributed to the unpopularity of this flap in the United States. The purposes of this study are to classify the vascular anatomy and to assess the suitability of this flap for head and neck reconstruction in a Western population. METHODS: Seventy-two consecutive anterolateral thigh flaps for head and neck reconstruction was retrospectively reviewed. RESULTS: The number of cutaneous perforators for the anterolateral thigh flap ranged from one to three. On the basis of their location and origin, a simple classification system is introduced to assist flap dissection. Of the 72 thighs explored, 68 flaps (94%) were raised successfully. CONCLUSIONS: The vascular anatomy of the flap follows predictable patterns. The anterolateral thigh flap is well suited for head and neck reconstruction in Westerners.

Adult↗

Slow volume changes in calf and thigh during cycle ergometer exercise.

To study the transcapillary fluid movements in the human lower limb in the upright body position and during muscle exercise, the slow changes in thigh and calf volumes were measured by mercury-in-rubber-strain gauge plethysmography. Measurements were carried out on 20 healthy volunteers while sitting, standing and doing cycle ergometer exercise at intensities of 50 and 100-W. A plethysmographic recording of slow extravascular volume changes during muscle exercise was possible because movement artefacts were eliminated by low-pass filtering. While standing and sitting the volumes of both thigh and calf increased due to enhanced transcapillary filtration. While standing the mean rate of increase was 0.13%.min-1 in the calf and 0.09%.min-1 in the thigh. During cycle ergometer exercise at 50 and 100 W, the calf volume decreased with a mean rate of -0.09.min-1. In contrast, the thigh volume did not change significantly during exercise at 50 W and increased at 100 W. Most of the increase occurred during the first half of the experimental period i.e. between min 2 and 12, amounting to +0.6%. Thus, simultaneous measurements revealed opposite changes in the thigh and calf. This demonstrates that the conflicting findings reported in the literature may have occurred because opposite changes can occur in different muscle groups of the working limb at the same time. Lowered venous pressure, increased lymph flow and increased tissue pressure in the contracting muscle are considered to have caused the reduction in calf volume during exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Arterial injury associated with acute compartment syndrome of the thigh following blunt trauma.

BACKGROUND: Acute compartment syndrome of the thigh is a rare condition, and the basic causes of high pressure within a muscle compartment have been considered to be intramuscular haematoma and soft-tissue oedema. However, the importance of arterial injury has not been well recognized. METHODS: Among 3658 blunt trauma patients admitted to our Level 1 Trauma Centre between 1994 and 2001, there were eight patients (nine thighs) who had undergone emergency fasciotomy and these were the subjects of the present study. Arteriography of the proximal lower limb had been performed after the fasciotomy in patients with prolonged hypotension and persistent bleeding from the fasciotomy wound. RESULTS: All the patients had sustained high-energy trauma, systemic hypotension and local trauma to the proximal lower limb. Among them, four (five thighs) had undergone arteriography and four (four thighs) were confirmed as having sustained arterial injuries. In those patients with definitive arterial injuries, the time from injury to the onset of the compartment syndrome was less than 5 h. CONCLUSIONS: Acute compartment syndrome of the thigh in blunt trauma patients may be the result of associated arterial injuries. It is suggested that patients with local trauma to the proximal lower limb who exhibit an acute compartment syndrome together with haemodynamic instability should undergo arteriography soon after fasciotomy.

Acute Disease↗

Preoperative assessment of anterolateral thigh flap cutaneous perforators by colour Doppler flowmetry.

An anterolateral thigh flap is very useful in head and neck reconstruction because of its long and large-caliber vascular pedicle, large skin territory and elevation simultaneous with tumour resection. However, the number and locations of cutaneous perforators vary individually, and thus, it is not widely used because flap elevation is often complicated and time-consuming owing to unexpected anatomical variations. To overcome this disadvantage, we assessed the number and locations of cutaneous perforators preoperatively by colour Doppler flowmetry. These data were compared with the intraoperative anatomical findings and their reliability evaluated. A total of 48 cutaneous perforators were found by preoperative colour Doppler flowmetry scanning of 17 anterolateral thigh flaps. All the perforators except two were found intraoperatively. Doppler scanning failed to detect four perforators. Colour Doppler flowmetry assessment therefore has a 92% true-positive rate and a 95.8% positive predictive value. All the flaps except one included multiple perforators, and sufficient blood circulation was observed in all cases. No flaps were unexpectedly changed to anteromedial thigh flaps or contralateral anterolateral thigh flaps because of inappropriate cutaneous perforators or the absence of perforators. Though this investigation is relatively time-consuming (30-40 min) and requires skill, it is very useful for preoperative flap planning and increases the reliability and safety of elevating an anterolateral thigh flap.

Adult↗

Fetal weight prediction by thigh volume measurement with three-dimensional ultrasonography.

OBJECTIVE: To evaluate the usefulness and accuracy of a simple method of predicting fetal weight by measuring fetal thigh volume with three-dimensional ultrasonography. METHODS: In 84 pregnant women, fetuses without structural or chromosomal anomalies were studied prospectively and cross-sectionally. Biparietal diameter (BPD), abdominal circumference (AC), and femur length (FL) were measured by two-dimensional ultrasound. Fetal thigh volume was measured by three-dimensional ultrasound, using three cross-sectional images of femur, from proximal, middle, and distal parts of femur diaphysis. Infants were delivered within 48 hours after ultrasound examinations. RESULTS: Modified thigh volume measurements using three cross-sectional images of femur by three-dimensional ultrasound were correlated strongly with birth weight (R(2) = 0.921, P <.001). Using linear and polynomial regression, we calculated a new best-fit formula: Birth weight (g) = 165.32 + 28.78 x modified thigh volume (mL). The mean and standard deviation of the residual were 121.8 and 110.4, respectively, in three-dimensional formulas, which were significantly smaller than those of two-dimensional formulas. CONCLUSION: Thigh volume measurement using three cross-sectional images of femur by three-dimensional ultrasound was simple, and there was better accuracy with this method than with two-dimensional ultrasound methods for predicting fetal weight during the third trimester of pregnancy.

Adult↗

How accurate are high thigh narrow cuff pressure measurements in the assessment of aorto-iliac obstructive disease?

Thigh cuff pressure measurements are commonly used as a diagnostic method in the assessment of the aorto-iliac (AI) segment of patients with arterial obstructive disease. For a reliable assessment of the AI segment the use of a narrow cuff placed high on the thigh has been advocated. Although this method is commonly used, opinions on its diagnostic value are very divergent. To investigate its diagnostic value the pressure measured with a high thigh narrow cuff was compared with the intra-arterial pressure of the common femoral artery measured at rest and during reactive hyperaemia. Furthermore, the accuracy of these thigh pressures for detecting haemodynamically significant (HDS) AI stenoses was examined. The influence of an occlusion of the superficial femoral artery (SFA) on the pressure measurements was also studied. A correlation coefficient of 0.64 (P less than 0.05) was found between the femoro-brachial index (FBI) at rest and the thigh-brachial index (TBI). Using the TBI as a criterion for detecting a HDS AI stenosis, an accuracy of 73% could be obtained. Furthermore, it appeared that an occluded SFA could influence the pressure measurements dramatically. For clinical practice a TBI less than 0.90, in the presence of a patent SFA, ensures the presence of an HDS AI stenosis. A TBI greater than 1.35 suggests that the AI tract is normal, irrespective of the condition of the SFA. All other values of TBI should be interpreted with caution and only used as a decisive diagnostic method for the assessment of the haemodynamics of the AI segment in combination with other tests.

Adult↗