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PubMed1990

Restless legs syndrome and periodic movements of sleep.

Two entities of special interest in sleep disorders medicine are restless legs syndrome and periodic movements of sleep. Most patients with restless legs syndrome have periodic movements of sleep, but most patients with the nocturnal disorder do not have restless legs when awake. In both conditions, the underlying cause is obscure, and the frequency of occurrence increases with advancing age. In most patients with restless legs syndrome, the results of complete blood cell counts and iron, ferritin, folate, and vitamin B12 levels are normal. No hematologic or chemical abnormalities have been reported in patients with periodic movements of sleep who do not also have restless legs syndrome. Various pharmacologic agents, including benzodiazepines, opiates, and levodopa, have been proposed for the treatment of both disorders. Although some patients respond to a single drug for long periods, in many patients tolerance develops and the efficacy diminishes. In such circumstances, a reasonable approach is to alternate chemically unrelated agents on a weekly or biweekly schedule. Transcutaneous electric nerve stimulation may be beneficial.

Humans↗

PubMed1998

Factors affecting the results of surgery for chronic critical leg ischemia--a nationwide survey. Finnvasc Study Group.

PURPOSE: To assess the factors affecting immediate outcome of surgery for chronic critical leg ischemia, especially the influence of surgeon's caseload and hospital volume. METHODS: The data of Finnvasc registry were retrospectively analyzed. A total of 11,747 surgical vascular reconstructions included 1,761 operations for chronic critical leg ischemia during 1991 to 1994. RESULTS: The 30-day postoperative leg amputation rate was 7.5% and the mortality rate 4.7%. Diabetes, previous vascular surgery or amputation, preoperative ulcer or gangrene, a surgeon's annual caseload fewer than 10 operations, and hospital volume fewer than 20 operations for chronic critical leg ischemia adversely affected amputation rates. The presence of coronary artery disease and renal dysfunction increased postoperative mortality rates. Both amputation rates and postoperative mortality rates were affected by the type of procedure. CONCLUSIONS: A surgeon's caseload and hospital volume affect amputation rate, but not mortality rate, in patients operated for chronic critical leg ischemia.

Aged↗

PubMedDate not supplied

Deep venous valve reconstruction for non-healing leg ulcers: techniques and results.

BACKGROUND: The purpose of the present paper was to report clinical and imaging results of a 5 year experience of deep venous valve surgery with evaluation of end-points at 2 year follow up for the management of non-healing venous leg ulcers in 137 patients. METHODS: Between October 1994 and November 1999, 137 patients (169 limbs) underwent deep vein reconstructions for non-healing venous leg ulcers of clinical, etiological, anatomical, pathological classification (CEAP) C6 class, as a 'last resort' treatment. End-points of the study were post-valve reconstruction, freedom from leg ulceration, vein valve patency and competency at 2 years. Primary refluxive disease was present in 96 patients (118 limbs). External valvuloplasty was performed in 12 limbs (19 valves) and internal valvuloplasty was performed in 90 limbs (144 valves). External supports were used in 16 limbs (16 valves). Multilevel (2-3) reconstructions were performed in 37 limbs. Forty-one patients had secondary valvular defects involving 51 limbs. Axillary-femoral vein or saphenofemoral vein valve transplant was performed for 29 patients (35 limbs) and three patients (three limbs), respectively, saphenofemoral venous transposition was performed in three patients (four limbs), and femoral/popliteal vein ligation was carried out in six patients (nine limbs). RESULTS: Two year results of external valvuloplasty showed ulcer healing in 50% of limbs with maintenance of competency at only 31% of valve stations. Internal valvuloplasty was the most durable valve repair procedure with 2 year leg ulcer healing rates of 67% and valve station competency of 79%. For secondary incompetence, valve transplants had a significant deterioration in valve patency and competence at 2 years: 58% and 47%, respectively, with 55.3% leg ulcer healing. It was also noted that single-level repairs or single valve transplants had lower ulcer healing rates than multilevel repairs or valve transplants with multiple valve stations. CONCLUSION: In a 2 year follow up, valvular reconstruction for refluxive disease is effective in healing venous ulcers that defy conservative management and superficial/perforator venous surgery. Furthermore, these procedures appear more promising for primary than for secondary incompetence. Multilevel or multivalve reconstructions yield superior results to single-level repairs in medium-term follow up.

Adolescent↗

PubMedDate not supplied

[Intraoperative assessment of leg length in alloplastic hip joint replacement].

A new measuring device has been developed at the Orthopedic Clinic of the University of Tübingen. Its task is to ensure that the right length of leg is selected intraoperatively. The method of measurement can be used in all approaches for alloplastic hip replacement when the patient is in the supine position. Measurement is quick, non-invasive, and can be carried out in a direct comparison to the contralateral leg, using measuring points at the iliac crest and the upper edge of the patella. In a prospective randomized study we were able to demonstrate on 53 patients that the use of this newly-developed measuring device improves the accuracy of the length of the operated leg as compared to the contralateral leg, so that the difference is only +/- 0.5 cm (post-operative difference in length of leg without use of the measuring device 1.1 cm on average, with the measuring device 0.5 cm; p < 0.05).

Anthropometry↗

PubMed1990

Validity of derived measurements of leg-length differences obtained by use of a tape measure.

Determining the difference in the length of an individual's legs is often an important component of a musculoskeletal examination. Although measurements are easily obtained with a tape measure, the validity of these measurements is not known. The purpose of this study was to examine the validity of determinations of leg-length differences (LLDs) obtained by use of a specified tape measure method (TMM). Leg-length differences using the TMM and a radiographic technique were determined for 10 subjects who were candidates for clinical leg-length measurements and for 9 healthy control subjects. Validity of the TMM measurements was determined by assessing the degree of agreement between TMM-obtained LLDs and those obtained by the radiographic method. Validity estimates as determined by intraclass correlation coefficients (ICCs) were .770 for patients, .359 for healthy subjects, and .683 for all subjects. When the means of the two values obtained by use of the TMM were compared with the radiographic measurements, the ICCs were .852 for the patient group, .637 for the healthy subjects, and .793 for all subjects. This study suggests that TMM-derived LLD measurements are valid indicators of leg-length inequality and that the estimates of validity are improved by using the average of two determinations rather than a single determination.

Adult↗

PubMed1995

A familial awake movement disorder mimicking restless legs in a sleep apnea patient.

We report on a patient with sleep apnea and an unusual familial movement disorder. The movements were present only during wakefulness and nocturnal arousals caused by disordered breathing. A 27-year-old obese man was referred with sleep onset insomnia, symptoms suggesting restless legs syndrome, daytime sleepiness, loud snoring and awakening with choking sensations. He was proven to have obstructive sleep apnea (apnea hypopnea index = 60.6). He also had a daytime movement disorder that was characterized by almost continuous stereotypic tapping of one or both legs. The movements were suppressible and not associated with any unpleasant or abnormal leg sensation. Virtually identical movements were present in three generations of his family. The severity of the movements did not worsen late in the day or with supine posturing. The nocturnal movements, consisting of a visible shaking of one or both legs, occurred only during arousals secondary to the apnea, had a mean duration of 5.7 +/- 3.0 (standard deviation) seconds and could not be defined as periodic limb movements in sleep (PLMS). Successful treatment of apnea by nasal continuous positive airway pressure dramatically reduced the movements during sleep (from 88.2 to 1.9 per hour). The clinical significance and the mechanism of this movement disorder is unknown. We discuss the features inconsistent with restless legs syndrome and consider other possible phenomenology, including akathisia. We conclude that this patient may have a previously unreported familial movement disorder and in addition developed the sleep apnea syndrome related to obesity.

Adult↗

PubMed2001

Use of distally based saphenous neurofasciocutaneous and musculofasciocutaneous cross-leg flaps in limb salvage.

Neurocutaneous island flaps have been very popular in soft-tissue coverage of the lower extremities. These flaps are based on the arterial network around the superficial sensory nerves. The advantages of these flaps are easy and quick dissection (hence a time-saving operation), acceptable donor site morbidity, and preservation of major arteries of the leg. The authors used five neurofasciocutaneous and three musculofasciocutaneous flaps successfully as cross-leg flaps for the coverage of relatively large defects of the lower two thirds of the leg and foot in 8 patients. They conclude that reverse saphenous neurofasciocutaneous and musculofasciocutaneous flaps as a cross-leg flap in patients who cannot be reconstructed with other flap alternatives have many advantages over traditional cross-leg procedures, such as short vascularization time, minimal patient discomfort, wide arc of rotation and great versatility, and a safe vascular pattern.

Adult↗

PubMed1998

Evaluation of the long-pulse dye laser for the treatment of leg telangiectasias.

BACKGROUND: Leg telangiectasias are common visible ecstatic dermal capillaries, arterioles, or veins. Multiple methods of treatment have been reported for this entity. A long-pulse (1500 microsecond) dye laser has been developed to treat leg veins ranging in size from 0.1 to 1.0 mm in diameter. OBJECTIVE: To determine the effectiveness of this novel device on treating leg veins with varying wavelengths and fluences. METHODS: Eight patients with more than 250 sites of leg telangiectasis were treated with the long-pulse dye laser. RESULTS: Clearance of 100% was achieved after one or two treatments by vessels with diameters up to 0.5 mm. Vessels with diameters between 0.5 and 1.0 mm faded in about 80% of treatments. Transient adverse affects were observed in a low incidence. CONCLUSIONS: The long-pulse dye laser is a safe and effective tool in the treatment of leg telangiectasias.

Adult↗

PubMed2002

Nerve entrapments of the lower leg, ankle and foot in sport.

Exercise-related leg pain is a common and yet difficult management problem in sports medicine. There are many common causes of such symptoms including stress fractures and muscle compartment syndromes. There are also a number of less common but important conditions including popliteal artery entrapment and nerve entrapment syndromes. Even for an astute clinician, distinction between the different medical causes may be difficult given that many of their presenting features overlap. This review highlights the common clinical presentations and raises a regional approach to the diagnosis of the neurogenic symptoms. In part, this overlapping presentation of different pathological conditions may be due to a common aetiological basis of many of these conditions namely, fascial dysfunction. The same fascial restriction that predisposes to muscle compartment syndromes may also envelop the neurovascular structures within the leg resulting in either ischaemic or neurogenic symptoms. For many athletes with chronic exercise-related leg pain, combinations of such problems often coexist suggesting a more widespread fascial pathology. In our clinical experience, we often label such patients as 'fasciopaths'; however, the precise pathophysiological basis of this fascial problem remains to be elucidated. This review discusses the various nerve entrapment syndromes in the lower limb that may result in exercise-related leg pain in the sporting context. The anatomy, clinical presentation, investigation, medical management and surgical treatment are discussed at length for each of the syndromes. It is clear from clinical experience that the outcome of surgical management of such syndromes fares much better where a clear dermatomal pain distribution is present or where focal weakness and/or sensory symptoms appropriate for the nerve are present. In many situations, however, nonspecific leg pain or vague nonlocalising sensory symptoms are present and in such situations, alternative diagnoses must be considered and investigated appropriately. As mentioned above, many different pathologies may coexist in the lower limb and may be a source of confusion for the clinician or alternatively may be the reason for poor treatment outcomes.

Athletic Injuries↗

PubMed1999

[Leg perforating veins].

Our knowledge of the so-called incompetent leg perforating veins remains questionable. Anatomic and hemodynamic studies show that perforators in a healthy subject do not always convey inward flowing blood. Are incompetent perforating veins more frequent with increasing severity of chronic venous disease? Answering this question is difficult as no consensus has been established on how to assess incompetent leg perforating veins and we have no gold standard to refer to. The number of incompetent leg perforating veins is generally greater in severe chronic venous disease although their frequency in clinical stage 4 to 6 (CEAP classification) is not statistically different. This means that incompetent leg perforating veins are not markers of severity of chronic venous insufficiency. When analyzing published series which take into account etiology (primary or secondary venous diseases) the frequency of incompetent perforating veins is variable. Is surgical management required when incompetent leg perforating veins are present? Angiologists and surgeons have not come to an agreement on this point. What can be recommended today? It is generally accepted that the more severe the disease the more worthwhile surgical treatment. Technically speaking, subfascial endoscopic ligature is a promising new method although long-term results are still lacking. We must watch carefully the prospective and randomized studies which have been started in different countries. A lot of questions, only a few reliable answers.

Catheterization↗

PubMed2000

[Anatomical study and clinical application of a leg flap pedicle-included with cutaneous nerve and its concomitant vessels].

OBJECTIVE: To investigate the blood supply patterns and the clinical liability of a leg flap pedicle-included with cutaneous nerve and its concomitant vessels. METHODS: Fresh cadaver legs with thirty-two in infants and two in adults were anatomically examined after the intravenous injection of the red Chlorinated Poly Vingl Choride (CPVC). Five patients with the soft tissue defects were selected for the treatment with the flap pedicle-included with the cutaneous nerve and its concomitant vessels. RESULTS: Four main cutaneous nerves were found in the leg after they perforated the deep fascia out. They were companioned with their concomitant vessels with different blood-supply pateeerns, which the upper part of the leg was in an axial pattern and the lower part was in a "chain-type anastomosing" pattern. Following the above-mentioned findings, five cases were successfully treated with this led flap. CONCLUSIONS: The leg flap should be designed along the cutaneous nerve and its concomitant vessels. When the flap is applied in the area of blood supply with "chain-type anastomosing" pattern, the deep fascia should also be included in the flap.

Adult↗

PubMed1991

Leg symptoms in outpatient veterans.

In a survey of outpatients at the Denver Veterans Affairs Medical Center for common leg symptoms--515 questionnaires returned in a 3-week period--56% reported nocturnal leg cramps, 29% reported the restless leg syndrome, and 49% reported symptoms of peripheral neuropathy. Only 33% of patients had no symptoms relating to their legs. Patients often did not report these symptoms to their physician but were more likely to do so if the symptoms were frequent. Conditions especially related to leg symptoms were hypertension, peripheral vascular disease, coronary artery disease, cerebrovascular disease, kidney disease, and hypokalemia. Most patients did not receive effective therapy for these symptoms.

Adult↗

PubMedDate not supplied

Viscoelastic behavior of tissue in leg lengthening by distraction.

The leg lengthening distraction procedure was analyzed with objectives of understanding complications which arise due to overstretching, establishing guidelines to the optimum distraction rates and the frequency of distraction, and, determining the final amount of leg lengthening. An electronic recording system was devised to provide continuous monitoring of the tractive load resulting from distraction of the leg during the elongation procedure. The mechanical behavior patterns of the involved stretched tissues domonstrate time-dependent viscoelastic effects during distraction. During a leg lenthening procedure it is desirable to establish, if possible, a regular pattern of distraction early in the process. If it is necessary in the course of treatment to reduce the distraction rate for clinical reasons, then it is preferable to keep the same number of distraction events but reduce the distraction amount. Distract at equally spaced time intervals to obtain repetitive load cycles and thereby reduce peak values of load and maintain similar stress relaxation patterns for each instantaneous load increase. The total amount of lengthening depends on the characteristics of each individual leg length discrepancy and the physical properties of each distracted tissue.

Adolescent↗

PubMed1994

Optoelectric measurement of changes in leg length inequality resulting from isolation tests.

OBJECTIVE: a) Establish a precise, standardized method to assess prone leg alignment changes (functional "leg length inequality"), which have, until now, been reported clinically to occur as a result putative chiropractic subluxation isolation tests [neck flexion (C5) and extension (C1)]; and b) describe differences in leg alignment changes in a group of healthy subjects and patients with chronic spinal complaints. DESIGN: Two group, two isolation tests, descriptive, repeated measure analysis of variance. SETTING: Exercise and Sport Research Institute, Arizona State University. PARTICIPANTS: Eight healthy controls, eight patients with a history of chronic spinal complaints and observable leg alignment reactivity. INTERVENTIONS: Active cervical flexion/extension maneuvers. OUTCOME MEASURES: Optoelectric markers affixed to heels and occiput, as subjects lay prone. Marker locations sampled at 100 Hz for 10 sec during: a) three no movement trials, b) three cervical extension and c) three flexion trials. Data transformed to local reference frame approximately each subject's longitudinal axis prior to analysis. RESULTS: Heel position movement occurred during trials and were highly individualistic. Patients exhibited more asymmetrical movements than the controls during the head-up trials. No differences existed between controls and patients for range of heel displacement or net displacement. CONCLUSIONS: The results of this study allow the following to be concluded: 1) small leg displacements (< 1 mm) were recorded by the optoelectric measurement system; 2) heel position changes during isolation tests were identifiable; 3) as a result of head-up maneuvers, patients exhibited more asymmetrical heel movement than controls (t = 8.743, p < .01); 4) The heel range of motion was not different between the groups; and 5) The net change in heel position was not different between the groups. Patients exhibited more asymmetrical heel motion during head-up isolation tests, suggesting that some phenomena may separate these two groups, warranting future study.

Adult↗

PubMed1999

Risk factors associated with the failure of a venous leg ulcer to heal.

BACKGROUND: Venous leg ulcers afflict a significant portion of the population. The most popular form of therapy for venous leg ulcers is a compression bandage (eg, Unna boot), a therapy that is frequently unsuccessful. OBJECTIVE: To describe risk factors associated with the failure of a wound to heal when treated with a limb-compression bandage for 24 weeks. DESIGN: A retrospective cohort study. SETTING: Single-center outpatient specialty clinic at an academic medical center. PARTICIPANTS: Two hundred sixty consecutive patients with chronic venous leg ulcers. MAIN OUTCOME MEASURE: The magnitude of the effect of a given risk factor on the probability that a wound will heal within 24 weeks of care. RESULTS: Based on an assessment of leg wounds during initial office visits, we observed that the failure of a wound to heal within 24 weeks was significantly associated with larger wound area, measured in square centimeters (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.11-1.27), duration of the wound in months (OR, 1.09; 95% CI, 1.04-1.16), history of venous ligation or venous stripping (OR, 4.58; 95% CI, 1.84-11.36), history of hip or knee replacement surgery (OR, 3.52; 95% CI, 1.12-11.08), ankle brachial index of less than 0.80 (OR, 3.52; 95% CI, 1.12-11.08), and the presence of fibrin on more than 50% of the wound surface (OR, 3.42; 95% CI, 1.38-8.45). CONCLUSIONS: Several risk factors are associated with the failure of a patient's venous leg ulcer to heal while using limb-compression therapy. It is prudent to consider these factors when referring a patient to a wound care subspecialists or for alternative therapies.

Aged↗

PubMed2004

Ultrasound-guided injection of polidocanol microfoam in the management of venous leg ulcers.

BACKGROUND: Venous leg ulceration is a frequent and severe complication of lower limb venous insufficiency. Compression therapy is associated with a protracted course of healing and multiple recurrences. Minimally invasive surgery (subfascial endoscopic perforating surgery) is only possible in a subset of patients with leg ulcers. Low-cost and noninvasive therapeutic procedures are needed as alternative treatments. OBJECTIVE: To evaluate the efficacy and safety of sclerosant in microfoam in treating venous leg ulceration. DESIGN: A retrospective study of medical records, pretreatment and posttreatment color photographs, and echo Doppler in patients with venous leg ulceration. All patients were evaluated at 6 months after therapy, 70% were also evaluated at 2 years, 25% at 3 years, and 14% at 4 or more years after treatment. They were assessed for complete (100%) ulcer healing, time to wound closure, and recurrence. SETTING: Private vascular surgery clinic in Granada and dermatology department at a hospital in Pamplona, Spain. PATIENTS: Over 115 months, 116 consecutive patients (mean age [range], 57 [25-85] years) treated with ultrasound-guided injection of polidocanol microfoam (UIPM). INTERVENTIONS: To reduce venous hypertension, UIPM was used to selectively and progressively sclerose sources of incompetence. The number of sessions per patient varied between 1 and 17 (mean, 3.6). MAIN OUTCOME MEASURES: Complete ulcer healing, defined as full reepithelialization of the wound with absence of drainage. Recurrence was defined as epithelial breakdown in the healed limb. RESULTS: At 6-months' follow-up, treatment with UIPM achieved complete healing in 83% of patients (96/116), with median time to healing of 2.7 months; 7 patients were never cured, and 1 patient was lost to follow-up. There were recurrences in 10 patients. CONCLUSIONS: The use of UIPM to selectively and progressively sclerose incompetent veins produced by venous hypertension is highly effective to achieve a stable ulcer healing with minimal invasion, even in elderly patients. Recurrences are easily treatable with this approach. This technique may become a first-line treatment in the management of leg venous ulcers.

Adult↗

PubMedDate not supplied

Bilateral leg edema, obesity, pulmonary hypertension, and obstructive sleep apnea.

BACKGROUND: Pulmonary hypertension is usually due to an underlying cardiac or pulmonary condition. An association between unexplained pulmonary hypertension and bilateral leg edema in primary care patients was found previously. We undertook this study to identify the frequency of obstructive sleep apnea (OSA) in ambulatory, adult patients with pulmonary hypertension who initially presented with bilateral leg edema. METHODS: Twenty ambulatory adults with bilateral leg edema, echocardiocardiographic evidence of pulmonary hypertension (estimated pulmonary artery systolic pressure >30 mm Hg) without left ventricular dysfunction, and no clinically apparent pulmonary disease [corrected] were enrolled from a suburban family practice and an inner-city family practice during a 3-year period. Spirometric assessment, pulse oximetry, rheumatologic evaluation, polysomnography, and questionnaire information regarding risk factors for pulmonary hypertension were obtained for each subject. RESULTS: Fifteen patients (75%) completed the study. Almost all of the subjects were obese. Nine (60%) of the 15 had OSA. None of the subjects demonstrated an obstructive pattern on spirometric evaluation results, but 9 (60%) had a restrictive spirometry pattern, consistent with their obesity. None of the subjects had daytime hypoxemia. Systemic hypertension was present in two-thirds of the subjects with OSA, and was absent in all of the subjects who lacked OSA. CONCLUSIONS: Bilateral leg edema in obese primary care patients is associated with both OSA and modest pulmonary hypertension. If these findings are generalizable, then bilateral leg edema may be an important clinical marker for underlying OSA.

Adult↗

PubMed2004

Sex and the risk of restless legs syndrome in the general population.

BACKGROUND: Restless legs syndrome (RLS) is characterized by the desire to move the limbs associated with paresthesias of the legs, a motor restlessness, an intensification of symptoms at rest with relief by activity, and a worsening of symptoms in the evening or at night. Population-based studies are rare, and risk factors in the general population are not known. METHODS: Cross-sectional survey with face-to-face interviews and physical examination among 4310 participants in the Study of Health in Pomerania in northeastern Germany. Participants were aged 20 to 79 years and were randomly selected from population registers. Restless legs syndrome was assessed with standardized, validated questions addressing the 4 minimal criteria for RLS as defined by the International Restless Legs Syndrome Study Group. RESULTS: The overall prevalence of RLS was 10.6%, increasing with age, and women were twice as often affected as men. While nulliparous women had prevalences similar to those among men up to age 64 years, the risk of RLS increased gradually for women with 1 child (odds ratio, 1.98; 95% confidence interval, 1.25-3.13), 2 children (odds ratio, 3.04; 95% confidence interval, 2.11-4.40), and 3 or more children (odds ratio, 3.57; 95% confidence interval, 2.30-5.55). Subjects with RLS had significantly lower quality-of-life scores than those without the syndrome. CONCLUSIONS: Restless legs syndrome is a common disease in the general population, affecting women more often than men. It is associated with reduced quality of life in cross-sectional analysis. Parity is a major factor in explaining the sex difference and may guide further clarification of the etiology of the disease.

Adult↗