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PubMed1990

High energy (42-66 MeV reactions) fast neutron dose optimization studies in the head and neck, thorax, upper abdomen, pelvis and extremities.

Five hundred and fifty patients were entered into a set of dose-searching studies designed to determine normal tissue tolerance to high energy (42-66 MeV reactions) fast neutrons delivered in 12 equal fractions over 4 weeks. Participating institutions included: The Fermilab (66 MeV p+----Be), The University of Washington (50 MeVp+----Be), U.C.L.A. (45 MeVH-----Be), M.D. Anderson Hospital (42 MeVH-----Be), and The Cleveland Clinic (42 MeVp+----Be). Patients were stratified by treatment facility and then randomized to receive 16, 18 or 20 Gy for tumors located in the upper abdomen or pelvis, and 18, 20 or 22 Gy for tumors located in the head and neck, thorax or extremities. Following completion of the randomized protocols, additional patients were studied at the 20.4 Gy level in the head and neck, thorax and pelvis. Normal tissue effect scoring was accomplished using the RTOG-EORTC acute and late normal tissue effect scales. Acute Grade 3 + toxicity rates in the head and neck were 19% for 20/20.4 Gy and 20% for 22 Gy. Time adjusted late toxicity rates in the head and neck at 12 months were 15% for 20/20.4 Gy and 0% for 22 Gy. The 18 Gy treatment arm of the head and neck protocol was dropped early in the study after only two patients were accrued. For cases treated in the thorax, acute Grade 3 + toxicity rates were 6% for 18 Gy, 15% for 20/20.4 Gy and 7% for 22 Gy. Late toxicity rates at 12 months were 0% for 18 Gy, 11% for 20/20.4 Gy and 18% for 22 Gy. Acute Grade 3+ toxicity rates in the upper abdomen were 0% for 16 Gy, 8% for 18 Gy and 12% for 20 Gy. There were no Grade 3 + late toxicities in the upper abdomen. In the pelvis, acute Grade 3 + toxicity rates were 0% for 16 Gy, 3% for 18 Gy and 3% for 20/20.4 Gy. Late Grade 3 + toxicities at 24 months were 20% for 16 Gy, 5% for 18 Gy and 24% for 20/20.4 Gy. In extremities, acute Grade 3 + toxicity rates were 7% for 20 Gy and 21% for 22 Gy while at 12 months, late Grade 3 + toxicity rates were 14 and 35%, respectively. The 18 Gy treatment arm of the extremities protocol was dropped early in the study after only two patients were accrued. Factors associated with normal tissue effects in addition to treatment dose are discussed.

Abdominal Neoplasms↗
PubMed1996

Fatty acids in extremity tissues of Finnish beavers (Castor canadensis and Castor fiber) and muskrats (Ondatra zibethicus).

Site-specific differences in fatty acid composition of adipose tissues from Finnish beavers (Castor canadensis and Castor fiber) and muskrats (Ondatra zibethicus) were studied by gas liquid chromatography. In the total lipids of heterothermic extremities the proportions of potentially endogenous (delta 9-desaturated) monoenoic fatty acids were 1.5-fold and those of the saturated fatty acids 0.5-fold the proportions of subcutaneous or inner depots. Thus the role of delta 9-desaturation in the biochemical adaptation of the extremity tissues is discussed. Dietary polyunsaturated fatty acids, with the exception of 18:3 omega 3 in the beavers, did not accumulate selectively in the extremity tissues. The liver of the muskrat (which also eats fish and mussels) contained high proportions of 22:6 omega 3, which was a minor component in the beaver (exclusively a herbivore).

Adipose Tissue↗
PubMed1982

Radiation therapy technique in soft tissue sarcomas of the extremity--policies of treatment at the National Cancer Institute.

We have formulated certain treatment techniques for soft sarcomas of the extremities in adults, based on the experience of treating 75 patients at the National Cancer Institute. Attaining a high likelihood of tumor control is heavily dependent on a variety of factors. These factors include a knowledge of the biological characteristics of the tumor, of the normal tissue anatomy and its relationship to the tumor and of the surgical techniques available and the details of the surgery already performed. Obtaining good long term function in the irradiated extremity is dependent on sparing a strip of soft tissue and using sophisticated radiation therapy techniques. These techniques include casting of the extremity for immobilization, using a variety of gantry and collimator angulations, using treatment planning for determining the necessity for wedges or compensating filters in the radiation field and utilizing secondary collimation. With this highly individualized approach to treatment of patients with soft tissue sarcomas, optimal results can be obtained.

Extremities↗
PubMed1991

Role of brachytherapy in recurrent extremity sarcoma in patients treated with prior surgery and irradiation.

The treatment options for recurrent extremity sarcoma following conservative surgery and irradiation are limited. Amputation is the treatment of choice offered for the majority of these patients. In a selected group of patients with recurrent sarcoma, we have investigated the role of brachytherapy along with function-preserving resection. From 1979 to 1988, 40 patients underwent resection and brachytherapy for recurrent extremity sarcoma. There were 23 males and 17 females. All of the patients received function-preserving resection and an afterloading temporary tumor bed implant. A median dose of 4500 cGy was delivered with a range from 3000 to 4800 cGy. The median follow-up was 36 months with a range of 12 to 120 months. The actuarial local control at 5 years is 68%. Five patients (12.5%) developed complications such as wound ulceration (4) and femoral fracture (1) requiring surgery. Five patients developed local failure and an additional two patients had both local and distant failure. All of the failures occurred in patients with more than two prior recurrences. This review suggests that brachytherapy can be used as an effective treatment option in selected patients with recurrent extremity sarcoma following prior surgery and irradiation with satisfactory limb preservation. The data also suggest that higher local control rates can be achieved with early brachytherapeutic intervention.

Adult↗
PubMed1992

Immobilization and treatment of patients receiving radiation therapy for extremity soft-tissue sarcoma.

The treatment of extremity soft-tissue sarcoma has evolved considerably over the years. Previously, the preferred treatment was radical resection or amputation. Recently, radiation therapy combined with conservative resection has been shown to provide adequate tumor control while preserving a functional limb. Often, a large volume of tissue is irradiated in a manner that requires the patient to be in a reproducible position. Minimizing patient movement is imperative to ensure that the prescribed dose is delivered to the designated target volume. At our institution, Alpha Cradles have been routinely used for eight years to aid in positioning extremity sarcoma patients. The positioning of the patient for tumors at different locations in the extremity and the Alpha Cradle fabrication is described. The positioning device is comfortable for the patient and the accuracy is verified by comparison of simulation films with weekly port films.

Extremities↗
PubMed1994

Limb-sparing therapy of extremity soft tissue sarcomas: treatment outcome and long-term functional results.

The purpose of this study is to assess the long-term success rate and functional results of limb-sparing therapy in a group of 156 patients with soft tissue sarcomas of the extremities in the Netherlands Cancer Institute, treated according to a standard protocol of surgery and radiotherapy, if indicated. The patients (79 females and 77 males) were treated between 1977 and 1983 by an intended wide local excision with a margin of at least 2 cm. Postoperative radiotherapy was applied in 117 patients; 26 patients had surgery only, including 13 patients who had to be treated by amputation. The total dose was 60 Gy, with 40 Gy to a large volume and a boost of 20 Gy to the tumour bed at 2 Gy per fraction, five fractions per week. Most sarcomas were located in the proximal part of the lower extremity (51%). The group comprised 50 liposarcomas, 47 malignant fibrous hystiocystoma (MFH) and 59 other histologies; 69 (44%) had high-grade tumours. Three treatment groups with limb-sparing treatment were defined: group I (n = 26) patients who had a complete excision receiving no further treatment, group II (n = 64) with narrow surgical margins and radiotherapy and group III (n = 53) with incomplete resection and radiotherapy. The 10-year actuarial overall survival and local control rate for all patients was 63 and 81%, respectively. Multivariate analysis showed that histological grade (P < 0.0001), age (P = 0.0005) and location deep to the fascia (P = 0.0008) were independent prognostic factors for survival, while local control was predicted by grade (P = 0.0014) and treatment group (p = 0.028). Patients with surgery only (group I) had 81% 5-year local control as compared to 92% with radiotherapy after narrow surgery (group II) and 74% with incomplete surgery and radiotherapy (group III). Limb preservation when attempted was achieved in 90% of the patients. After limb-sparing treatment, 7% had severe impairment of mobility, 3% had lymph oedema and 16% marked fibrosis. Fractures in the irradiated bone occurred in 6% of the patients. The combination of limited surgery followed by radiotherapy resulted in a high local control rate with good functional results. Ultimately limb sparing treatment was successful in 83% of all patients with extremity sarcomas.

Adolescent↗
PubMed2006

Patient follow-up after negative lower extremity bedside ultrasound for deep venous thrombosis in the ED.

OBJECTIVES: To evaluate the rate of patient compliance with follow-up ultrasound (US) examinations 5 to 7 days after emergency physician EP performed US exams to rule out lower extremity deep venous thrombosis (DVT) in the ED. METHODS: This was a prospective observational study at a level I ED with a residency program, US training program, and an annual census of 75000. Hospital-based emergency US credentialing is available and derived from American College of Emergency Physicians guidelines. Five US-credentialed emergency physicians participated in the study. All patients who received negative lower extremity DVT US exams were eligible. All higher risk patients were given verbal and written instructions and provided with prescriptions to have a follow-up US examination 5 to 7 days after their examination in the ED. Those classified as "low risk" based on Wells criteria were excluded. After 3 months, patients were contacted via telephone and asked questions regarding their follow-up US examinations, reasons for not following up, continued symptoms, and thromboembolic events. Statistical methods included descriptive statistics. RESULTS: One hundred fifty-nine patients were eligible for enrollment during the 10-month study period. Eighty-five patients (54%) fell into the higher risk category of these; 54 (64%) were contacted successfully. Fifteen (28%) of the patients contacted had obtained a follow-up US exam. Of the 39 who did not follow-up, 29% were told by their physician that a follow-up US was unnecessary, 21% forgot to follow-up, 8% did not follow-up for financial reasons, 16% felt better, 5% could not arrange a study, 21% were unsure. One patient died from sepsis before a follow-up scan. Two patients were diagnosed with DVT, one at 7 days follow-up and the other 9 months later (this particular patient had their 7-day scan cancelled by their primary care physician). CONCLUSION: Patients who were instructed to obtain follow-up lower extremity US examinations to rule out propagation of unseen, distal DVTs did so at a very low rate in our study. One of the largest impediments in our study population was a patients' primary care physician who may not understand the need for a follow-up US examination.

Emergency Service, Hospital↗
PubMed2004

Measuring activity limitations in climbing stairs: development of a hierarchical scale for patients with lower-extremity disorders living at home.

OBJECTIVE: To develop a hierarchical scale that measures activity limitations in climbing stairs in patients with lower-extremity disorders living at home. DESIGN: Cross-sectional study with Mokken scale analysis of 15 dichotomous items. SETTING: Outpatient clinics of secondary and tertiary care centers. PARTICIPANTS: Patients (N=759; mean age +/- standard deviation, 59.8+/-15.0y; 48% men) living at home, with different lower-extremity disorders: stroke, poliomyelitis, osteoarthritis, amputation, complex regional pain syndrome type I, and diabetic foot problems. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: (1) Fit of the monotone homogeneity model, indicating whether items can be used for measuring patients; (2) fit of the double monotonicity model, indicating invariant (hierarchical) item ordering; (3) intratest reliability, indicating repeatability of the sum score; and (4) differential item functioning, addressing the validity of comparisons between subgroups of patients. RESULTS: There was (1) good fit of the monotone homogeneity model (coefficient H=.50) for all items for all patients, and for subgroups defined by age, gender, and diagnosis; (2) good fit of the double monotonicity model (coefficient H(T)=.58); (3) good intratest reliability (coefficient rho=.90); and (4) no differential item functioning with respect to age and gender, but differential item functioning for 4 items in amputees compared with nonamputees. CONCLUSIONS: A hierarchical scale, with excellent scaling characteristics, has been developed for measuring activity limitations in climbing stairs in patients with lower-extremity disorders who live at home. However, measurements should be interpreted with caution when comparisons are made between patients with and without amputation.

Activities of Daily Living↗
PubMed2005

Choice-based evaluation for the improvement of upper-extremity function compared with other impairments in tetraplegia.

OBJECTIVES: To assess preference of reconstructive treatment of upper extremities in subjects with tetraplegia compared with preference of treatment of 3 other impairments and to determine the effect of subjects' characteristics on preference of upper-extremity reconstruction. DESIGN: Survey. SETTING: Two specialized spinal cord injury centers in the Netherlands. PARTICIPANTS: A consecutive sample of 47 patients with tetraplegia in stable condition. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The quality weight of 5 tetraplegic health states determined with the time trade-off technique and expressed as a single value (the "utility") on a scale between 0 (worst possible situation) and 1 (best possible situation). RESULTS: The response rate was 92%. The utility of tetraplegia +/- standard deviation was .57+/-.30. The utilities of tetraplegia without impairment in one of the following functions were .69+/-.33 for sexuality, .69+/-.33 for standing/walking, .63+/-.31 for bladder and bowel function, and .65+/-.32 for upper-extremity function. The differences between these utilities and the utility of tetraplegia were significant (P<.05). No significant differences were found between the utilities of the impairments. Improvement of a specific impairment contributed between 14% and 28% to the potential overall gain in the tetraplegic health state utility. CONCLUSIONS: The combination of impairments determines the low utility of the tetraplegic health state. No priority for improvement of any of the investigated impairments was found. This emphasizes the need for the meticulous selection of patients for treatment of specific conditions. Further research should try to determine the crucial factors in the decision-making process of patients for specific interventions.

Adult↗
PubMed2005

Measuring activity limitations in walking: development of a hierarchical scale for patients with lower-extremity disorders who live at home.

OBJECTIVE: To develop a hierarchical scale that measures activity limitations in walking in patients with lower-extremity disorders who live at home. DESIGN: Cross-sectional study. SETTING: Orthopedic workshops and outpatient clinics of secondary and tertiary care centers. PARTICIPANTS: Patients (N=981; mean age +/- standard deviation, 58.6+/-15.4 y; 46% men) living at home, with different lower-extremity disorders: stroke, poliomyelitis, osteoarthritis, amputation, complex regional pain syndrome type I, and diabetic and degenerative foot disorders. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: (1) Fit of the monotone homogeneity model, indicating whether items can be used for measuring patients; (2) fit of the double monotonicity model, indicating invariant (hierarchical) item ordering; (3) intratest reliability, indicating repeatability of the sum score; (4) robustness, addressing the clinimetric properties within subgroups of patients; and (5) differential item functioning, addressing the validity of comparisons between subgroups of patients. RESULTS: Thirty-five of 41 dichotomous items had (1) good fit of the monotone homogeneity model (coefficient H=.50), (2) good fit of the double monotonicity model (coefficient H(T)=.33), (3) good intratest reliability (coefficient rho=.95), (4) satisfactory robustness (within subgroups of patients defined by age, sex, and diagnosis), and (5) some differential item functioning (6 items in amputees compared with nonamputees). CONCLUSIONS: A hierarchical scale, with excellent scaling characteristics, was developed to measure activity limitations in walking in patients with lower-extremity disorders who live at home. The measurements should be interpreted cautiously when making comparisons between amputees and nonamputees.

Cross-Sectional Studies↗
PubMed2006

Salvage of the lower extremity free flap using cross-leg venous repair.

This retrospective study was designed to evaluate a salvage technique for free flaps suffering venous congestion by using a cross-leg vein repair in patients with venous-impaired lower extremities. Four free flap reconstructions were performed using the latissimus dorsi muscle to reconstruct soft tissue defects in the lower extremity. The recipient artery was confined to the ipsilateral leg and the venous anastomosis was performed with a long saphenous vein from the contralateral side. The legs were immobilised together by means of an external fixator. All patients were males with a mean age of 31 years. The mean time of pedicle division was 8.8 days (7-10). The mean size of the free flap was 186.5 cm(2). All flaps survived after pedicle division without venous congestion. There were no complications such as joint stiffness or donor site morbidity except for a linear scar. The cross-leg venous repair is a refinement of a salvage procedure for compromised free flaps used in the reconstruction of severe soft tissue defects in vascularly compromised lower extremities.

Accidents, Traffic↗
PubMed2004

Lower extremity joint coupling during running: a current update.

BACKGROUND: The relationship between lower extremity mechanics and injury is not well understood. However, joint coupling studies are beginning to emerge, which may lend further insight into running biomechanics. PURPOSE: To provide a current review of the research examining lower extremity joint coupling in running. SUMMARY: There are various techniques utilized to measure joint coupling, including joint timing, rearfoot eversion/tibial internal rotation ratios, continuous relative phase calculations, and vector coding. The study of joint coupling is of particular interest as it may pertain to running injuries. There is some evidence that joint coupling may be altered with orthotics and/or with footwear. Most studies have included a relatively small sample size and larger scale studies are needed to quantify normal ranges for many of the coupling measures. In addition, prospective studies are needed to clarify the relationship to injury. RELEVANCE: It is hoped that this update will serve as a review of the current state of thought regarding lower extremity joint coupling during running. As greater insight into the role of joint coupling in injuries is gained, more optimal intervention and prevention strategies can be developed to minimize injury risk.

Ankle Joint↗
PubMed2005

Lower extremity biomechanics during the landing of a stop-jump task.

BACKGROUND: Literature shows that landing with great impact forces may be a risk factor for knee injuries. The purpose of this study was to examine the relationships among selected lower extremity kinematics and kinetics during the landing of a stop-jump task. METHODS: Landmark coordinates and ground reaction forces during a stop-jump task were collected. Lower extremity joint angles and resultants were reduced. Pearson correlation coefficients among selected lower extremity kinematics and kinetics were determined. FINDINGS: The hip flexion angular velocity at the initial foot contact had significant correlation with peak posterior and vertical ground reaction forces (r = -0.63, P < 0.001, r = -0.48, P < 0.001) during the landing of the stop-jump task. The knee flexion angular velocity at the initial foot contact also had significant correlation with peak posterior and vertical ground reaction force (r = -0.49, P < 0.001, r = -0.06, P < 0.001) during the landing of the stop-jump task. Peak proximal tibia anterior shear force and peak knee extension moment during landing of the stop-jump task had significantly correlation with the corresponding posterior and vertical ground reaction forces (r > 0.51, P < 0.001). INTERPRETATION: A large hip and knee flexion angles at the initial foot contact with the ground do not necessarily reduce the impact forces during the landing of the stop-jump task, but active hip and knee flexion motions do. Hip joint motion at the initial foot contact with the ground appears to be an important technical factor that affects anterior cruciate ligament loading during the landing of the stop-jump task.

Adolescent↗
PubMed2006

Influence of a custom foot orthotic intervention on lower extremity dynamics in healthy runners.

OBJECTIVE: To investigate the influence of a custom foot orthotic intervention on the lower extremity dynamics in healthy runners. DESIGN: Three-dimensional kinematics and kinetics were collected on 15 female runners (>15 miles per week) while each performed the over-ground running trials in either a shoe only or a shoe+custom foot orthotic condition. Kinematic and kinetic variables were analyzed using Paired Sample t-tests. BACKGROUND: Custom foot orthotics are frequently prescribed treatment modality for the management of overuse running injuries. Although it is generally accepted that a custom foot orthotic intervention produces positive clinical outcomes, it remains unclear what influence this therapeutic modality has on the dynamics of the lower extremity. METHODS: Each subject performed five acceptable over-ground running trials (3.6 m s(-1) +/-5%) with and without the custom foot orthotic intervention in a running shoe. Selected maximum ankle and knee joint angles and moments were measured during the stance phase. RESULTS: While wearing the custom foot orthotic, subjects exhibited significantly decreased maximum values in rearfoot eversion angle, rearfoot eversion velocity and internal ankle inversion moment. CONCLUSIONS: In this sample of healthy female runners, the custom foot orthotic intervention led to significant decreases in maximum values for ankle dynamics in the frontal plane and in the sagittal plane of the knee joint. Relevance It remains unclear how a custom foot orthotic intervention influences lower extremity dynamics to produce positive clinical outcomes. Furthering our understanding of the dynamic influence will not only inform improved prescription and manufacturing practices but may provide insight into the mechanisms that cause overuse injuries.

Adult↗
PubMed2006

Upper extremity stress fractures.

Although less common than lower-extremity stress fractures, upper-extremity stress fractures are becoming recognized much more frequently. A majority of these fractures are caused by overuse and fatigue of the surrounding musculature and, as a result, may be prevented by appropriate training and conditioning. Diagnosis is made by history and physical examination with the aid of plain radiographs, bone scans, and MRI. Most of these fractures heal with a period of relative rest followed by a structured rehabilitation program. A small percentage of these fractures, however, may require surgical fixation. The present article reviews the different types of upper extremity and torso stress fractures seen in athletes, starting with the sternum and extending outward to the fingers. The presentation, diagnosis, mechanism of injury, treatment, prevention, and prognosis for each of these injuries will be discussed.

Adolescent↗
PubMed2004

Long-term outcome following thrombembolectomy in the upper extremity.

OBJECTIVES: To evaluate short- and long-term mortality and morbidity in patients that were treated for acute upper extremity ischemia. DESIGN: Single center retrospective study. PATIENTS: A consecutive series of 148 patients who were admitted with a diagnosis of acute ischemia of the upper extremity during an 11-year period. METHODS: All charts were reviewed retrospectively and 96% of all survivors participated in clinical follow-up. RESULTS: The median age was 78 years and 64% of patients were females. The 30-day mortality was 8% and the overall 5-year survival 37%. The observed mortality during the follow-up period was significantly higher than expected. Survival was not significantly different in patients who received anticoagulant drugs following discharge from the hospital. The duration of ischemia did not significantly influence long-term arm-function. CONCLUSIONS: Acute embolic episodes in the upper extremity primarily occur in elderly and the peri-operative mortality is high. Mortality following discharge from the hospital remains significantly higher than that of the background population.

Acute Disease↗
PubMed2006

Nontraumatic compartment syndrome of the extremities in children.

Acute compartment syndrome of an extremity poses a threat to both life and limb. The usual cause in children is trauma, especially fractures and burns. Two recent cases of nontraumatic compartment syndrome of the extremities in children are presented, both owing to infection followed by myositis or fasciitis. Both cases required urgent decompression by fasciotomy, resulting in limb salvage and full recovery of neuromuscular function of the extremity. The value of prompt recognition and treatment of this condition is emphasized.

Anti-Bacterial Agents↗
PubMed2005

The distinct and secondary harmful effect of pelvic and extremity injury on the outcome of laparotomy for trauma.

HYPOTHESIS: Extra-abdominal injury negatively affects the outcome of abdominal injury following trauma laparotomy. DESIGN: Retrospective review of 920 consecutive patients receiving laparotomy for trauma who survived more than 24 h between January 1989 and May 1998 at a Level 1 trauma center. Major abdominal complications (MAC) were defined as: abdominal compartment syndrome (ACS), abscess/peritonitis, enterocutaneous fistula, necrotizing fasciitis, and necrotizing pancreatitis. METHODS: Univariant and multivariant logistic regression were used to identify predictors of MAC. RESULTS: Sixty-nine patients (7.5%) developed one or more MAC. Patients who developed MAC had higher injury severity scores (ISS), abdominal trauma indices (ATI), and blood transfusions in the first 24 h (PRCs) than patients who did not develop MAC. Patients with MAC were more likely to have suffered a thoracic or pelvic injury with an abbreviated injury scale (AIS) > or =3 and were more likely to have received an extremity injury (AIS > or =3) operation than patients without MAC. Independent predictors of MAC in multivariant analysis included colon injury (AIS > or =3) [odds ratio (OR) = 3.1, 95% confidence interval (CI) 1.5- 6.3)], pelvic injury (AIS > or =3) or operation for extremity injury (AIS > or =3) [OR 2.9, 95% CI 1.5-5.3], and ATI (OR = 1.03 for each 10 unit increase in ATI, 95% CI 1.02-1.05). PRCs did not independently predict MAC. CONCLUSION: The outcome of laparotomy for trauma (both blunt and penetrating) is negatively affected by a severe pelvic injury or a severe extremity injury operation independent of initial hemorrhage and abdominal injury severity.

Abdominal Injuries↗