[The results of surgery by means of metal synthesis in one extremity and conservative treatment in the other extremity of the same patient in fractures of long bones[].
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Increased arterial inflow in extremities with chronic venous insufficiency: an important and unappreciated hemodynamic parameter.
BACKGROUND: The purpose of this study was to evaluate and analyze arterial inflow (AI) in lower extremities of patients with symptoms of chronic venous insufficiency (CVI) and of members of a healthy control group. METHODS: Foot mercury-in-silicon strain-gauge plethysmography was used to measure AI, venous reflux, and muscle pump efficiency in 388 extremities of 194 patients with symptoms of CVI. Severe stage III symptoms (Society for Vascular Surgery/International Society for Cardiovascular Surgery classification) were present in 84 extremities, moderate stage II symptoms were present in 81 extremities, and mild stage I symptoms were present in 158 extremities. No symptoms, stage 0, were found in 65 contralateral extremities of patients with unilateral symptoms. Identical parameters were measured in 70 extremities of 35 healthy subjects in a control group. AI in each staged group was compared with that of the control group and with that of the other groups with symptoms with the use of Kruskall-Wallis analysis of multiple variances. RESULTS: The mean AI (+/-SD) in milliliters per 100 ml of foot tissue per minute in the extremities in the control group was 0.82 +/- 0.48. In the extremities without symptoms, contralateral to those with symptoms in patients with unilateral disease, the AI was 1.24 +/- 0.88. In extremities with mild symptoms the AI was 1.54 +/- 1.20, in extremities with moderate symptoms it was 2.88 +/- 1.70, and in extremities with severe symptoms it was 6.25 +/- 4.91. The AI was significantly increased in all extremities of patients with CVI (stages 0 to III) when compared with that of patients in the control group. Extremities with stage II and III disease had significantly higher AI than did extremities with stage 0 and stage I disease. The difference in AI between extremities with stage 0 and I disease was not statistically significant, and no significant difference in AI was seen between extremities with stage II and III disease. CONCLUSIONS: When plethysmographic methods are used to evaluate extremities with CVI, high AI, if not considered, can overrepresent the true magnitude of reflux. High AI may indicate presence of primary anatomic arterioventricular fistulas, or it may be the consequence of inflammatory changes and secondary functional arterioventricular shunting. Increased AI in contralateral extremities with no symptoms may point to the role of high flow in the pathogenesis of CVI. Clarification of this question requires further investigation.
Adult↗
Effects of velocity on upper to lower extremity muscular work and power output ratios of intercollegiate athletes.
OBJECTIVES: Peak torque expresses a point output which may, but does not always, correlate well with full range output measures such as work or power, particularly in a rehabilitating muscle. This study evaluates isokinetic performance variables, particularly (a) flexor to extensor work and power output ratios of upper and lower extremities and (b) overall upper to lower extremity work and power ratios, in intercollegiate athletes. The purpose was to ascertain how speeds of 30 and 180 degrees/s influence agonist to antagonist ratios for torque, work, and power and to determine the effects of these speeds on upper to lower limb flexor (F), extensor (E), and combined (F + E) ratios, as a guide to rehabilitation protocols and outcomes after injury. METHODS: Twenty seven athletic men without upper or lower extremity clinical histories were tested isokinetically at slow and moderately fast speeds likely to be encountered in early stages of rehabilitation after injury. Seated knee extensor and flexor outputs, particularly work and power, were investigated, as were full range elbow extensor and flexor outputs. The subjects were morphologically similar in linearity and muscularity (coefficient of variation 4.17%) so that standardisation of isokinetic outputs to body mass effectively normalised for strength differences due to body size. Peak torque (N.m/kg), total work (J/kg), and average power (W/kg) for elbow and knee flexions and extensions were measured on a Cybex 6000 isokinetic dynamometer. With respect to the raw data, the four test conditions (F at 30 degrees/s; E at 30 degrees/s; F at 180 degrees/s; E at 180 degrees/s) were analysed by one way analysis of variance. Reciprocal (agonist to antagonist) F to E ratios of the upper and lower extremities were calculated, as were upper to lower extremity flexor, extensor, and combined (F + E) ratios. Speed related differences between the derived ratios were analysed by Student's t tests (related samples). RESULTS: At the speeds tested all torque responses exhibited velocity related decrements at rates that kept flexor to extensor ratios and upper to lower extremity ratios constant (p > 0.05) for work and power. All upper extremity relative torque, work, and power flexion responses were equal to extension responses (p > 0.05) regardless of speed. Conversely, all lower extremity relative measures of torque, work, and power of flexors were significantly lower than extensor responses. In the case of both upper and lower extremities, work and power F to E ratios were unaffected by speed. Moreover, increasing speed from 30 to 180 degrees/s had no effect on upper to lower extremity work and power ratios, whether for flexion, extension, or flexion and extension combined. CONCLUSIONS: Peak torque responses may not adequately reflect tension development through an extensive range of motion. Total work produced and mean power generated, on the other hand, are highly relevant measures of performance, and these, expressed as F to E ratios, are unaffected by speeds of 30 and 180 degrees/s, whether for upper or lower extremities or for upper to lower extremities. In this sample, regardless of speed, the upper extremity produced 55% of the work and 39% of the power of the lower extremity, when flexor and extensor outputs were combined. Injured athletes are, in the early stages of function restoration, often not able to exert tension at fast speeds. An understanding of upper to lower extremity muscular work and power ratios has important implications for muscle strengthening after injury. Knowledge of normal upper to lower extremity work and power output ratios at slow to moderately fast isokinetic speeds is particularly useful in cases of bilateral upper (or lower) extremity rehabilitation, when the performance of a contralateral limb cannot be used as a yardstick.
Adult↗
Risk factors for deep venous thrombosis of the upper extremities.
BACKGROUND: Hypercoagulable states and triggering factors (surgery, trauma, immobilization, pregnancy, and use of oral contraceptives) are associated with an increased risk for deep venous thrombosis of the lower extremities. In contrast, risk factors for deep venous thrombosis of the upper extremities have not been identified. OBJECTIVE: To evaluate the prevalence of hypercoagulable states and triggering factors in patients with primary deep venous thrombosis of the upper extremities. DESIGN: Frequency-matched case-control study. SETTING: Hemophilia and thrombosis center at a university hospital. PATIENTS: 36 patients who had primary deep venous thrombosis of the upper extremities, 121 patients who had primary deep venous thrombosis of the lower extremities, and 108 healthy controls. Patients who had deep venous thrombosis of the lower extremities and study controls were frequency-matched by age, sex, geographic origin, and social status with patients who had deep venous thrombosis of the upper extremities. MEASUREMENTS: Resistance to activated protein C was evaluated by a clotting method based on the activated partial thromboplastin time. If test results were abnormal or borderline, DNA analysis for substitution in coagulation factor V gene was done. Antithrombin, protein C, protein S, antiphospholipid antibodies, and total plasma homocysteine levels were also measured. RESULTS: Prevalences of abnormalities of the natural anticoagulant system (9%) and hyperhomocysteinemia (6%) in patients who had deep venous thrombosis of the upper extremities were similar to prevalences of both factors in controls (6% and 7%, respectively) but lower than in patients who had deep venous thrombosis of the lower extremities (31% and 14%, respectively). Antiphospholipid antibodies were found only in patients who had venous thrombosis of the lower extremities (7%). The overall prevalence of hypercoagulable states in patients who had thrombosis of the upper extremities (15%) was similar to that in controls (12%) but was significantly lower than that in patients who had thrombosis of the lower extremities (56%). A recent history of strenuous exercise of muscles in the affected extremity was the most frequent triggering factor for patients who had deep venous thrombosis in the upper extremities (33%). CONCLUSIONS: This preliminary study indicates that the prevalence of hypercoagulable states is low in patients who have primary deep venous thrombosis of the upper extremities.
Adult↗
Similar motor recovery of upper and lower extremities after stroke.
BACKGROUND AND PURPOSE: This study examined the validity of the clinical tenet that poststroke recovery of the upper extremity is less rapid and complete than poststroke recovery of the lower extremity. Previous studies comparing upper and lower extremity recovery have evaluated disability rather than motor impairment. Individuals with lower extremity impairments may be more functional and appear less disabled than individuals with upper extremity impairments. Function of the upper extremity requires finer motor control, for which the patient can less readily compensate. Therefore, impairments and disability would predictably be more highly correlated in this area. We tested the hypothesis that upper and lower extremity motor recovery are similar. METHODS: The 95 patients selected for this study were enrolled in the Durham County Stroke Study and had been diagnosed with anterior circulation ischemic stroke. Each subject received Fugl-Meyer assessments within 24 hours of admission and then 5, 30, 90, and 180 days after stroke. We used these assessments to compare the time course and patterns of motor function of the upper and lower extremities. RESULTS: Repeated-measures ANOVA revealed that percent maximal motor recovery was significantly (P < .001) affected by time after stroke but not by extremity (upper extremity versus lower extremity) (P = .32). When stroke severity level is controlled, the upper and lower extremities continue to show no difference in percent motor recovery (P = .19). CONCLUSIONS: In patients with anterior circulation ischemic stroke, the severity of motor impairment and the patterns of motor recovery are similar for the upper and lower extremities. The most rapid recovery for both extremities occurs within 30 days.
Aged↗
The influence of anatomic location on outcome in patients with soft tissue sarcoma of the extremity.
BACKGROUND: The anatomic location of an extremity soft tissue sarcoma may influence the patient's presentation, management, and local and systemic recurrence rates. The objective of this study was to compare the presentation, management, and outcome of patients with soft tissue sarcomas of the upper extremity and the lower extremity. METHODS: Prospectively collected data from patients who underwent limb-sparing surgery for extremity soft tissue sarcoma between January, 1986 and April, 1997 were analyzed. Local recurrence free rates and metastasis free rates were calculated using the method of Kaplan and Meier. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and the Cox proportional hazards model. RESULTS: Of 480 eligible patients, 48 patients (10.0%) had a local recurrence, and 131 patients (27.3%) developed distant metastasis. The median follow-up of survivors was 4.8 years (range, 0.1-12.9 years). Patients with upper extremity tumors had smaller lesions (6.0 cm vs. 9.3 cm; P < 0.001), more often underwent unplanned excision before referral (89 patients [64.0%] vs. 160 patients [46.9%]; P < 0.001), and less often received radiotherapy (98 patients [70.5%] vs. 289 patients [84.8%]; P < 0.001). The 5-year local recurrence free rate was 82% for patients with sarcomas of the upper extremity and 93% for patients with sarcomas of the lower extremity (P = 0.002). The 5-year metastasis free rate was 82% for patients with sarcomas of the upper extremity and 69% for patients with sarcomas of the lower extremity (P = 0.013). CONCLUSIONS: Local recurrence was more frequent in patients who had sarcomas of the upper extremity compared with patients who had sarcomas of the lower extremity. Factors that contributed to this difference included histologic type, the use of radiotherapy, and local anatomy. Metastasis was more frequent among patients with sarcomas of the lower extremity, because those tumors tended to be large and deeper compared with upper extremity tumors.
Adolescent↗
Prospective evaluation of combined upper and lower extremity DVT.
The clinical importance of upper extremity deep venous thrombosis (UEDVT) has been increasingly demonstrated in recent literature. Not only has the risk of pulmonary embolism from isolated upper extremity DVT been demonstrated, but a significant associated mortality has been encountered. Examination of this group of patients has demonstrated the existence of combined upper and lower extremity deep venous thrombosis (DVT) in some patients who exhibit an even higher associated mortality. As a result of this information, it has become the standard practice at this institution to search for lower extremity DVTs in patients found to have acute thrombosis of upper extremity veins. Since January 1999, there have been a total of 227 patients diagnosed with acute UEDVT. Within this group, 211 (93%) patients had lower extremity studies; 45 of these 211 (21%) had acute lower extremity DVTs by duplex examination in addition to the upper extremity DVTs. Overall, there were 145 women, 66 men, and the average age was 70 +/-1.2 (SEM); 22 of these patients had bilateral lower extremity thrombosis (LEDVT), and 8 patients were found to have chronic thrombosis of lower extremity veins. Of the patients with bilateral upper extremity DVTs, there were 3 with bilateral LE acute DVTs. Finally, 8 of the remaining 166 patients (5%) with originally negative lower extremity studies were found to develop a thrombosis at a later date. These data serve to confirm previous studies, on a larger scale, that there should be a high index of suspicion in patients with UEDVT of a coexistent LEDVT.
Aged↗
[Prevalence of disabilities of the upper and lower extremities among community-dwelling middle-aged and elderly women].
OBJECTIVE: In order to obtain baseline data for designing programs aimed at promoting physical function among elderly people in Japan, we determined the prevalence of disabilities affecting upper and lower extremities and their impact on function in community-dwelling middle-aged and elderly Japanese women. METHODS: Subjects were 580 women aged 40 years and over, living in Oshima town, Nagasaki, Japan. Information on disabilities affecting all four extremities was collected by questionnaire. Subjects were asked about the extent of disability in each extremity (no disability, some, moderate, cannot or very difficult to use extremity) and the reason for the disability. The functional level was defined using a disability score, calculated by summing the disabilities for upper or lower extremities (no disability, 0; some, 1; moderate, 2; cannot or very difficult to use, 3). Women who scored 0 were classified as 'good', women who scored 1-2 'fair', and who scored 3-6 as 'poor'. RESULTS: Prevalence of disability affecting the upper extremities increased significantly with age (11.9% with some or greater, and 4.3% with moderate or worse). Disabilities of the lower extremities also increased significantly with age (27.2% with some or greater, and 12.9% with moderate or worse), affecting a larger proportion of individuals. With regard to the upper extremities, the women classified a 'fair' and 'poor' increased significantly with age (9.5% with 'fair', and 2.4% with 'poor'), and function decreased (p = 0.003). The same was the case for the lower extremities (19.0% with 'fair', and 8.3% with 'poor') (P < 0.001). The most frequently cited cause of disability was arthritis, both in the upper (20%) and lower (40%) extremities, followed by stroke (10%), fracture (10%) and trauma not associated with fracture (10%). CONCLUSIONS: In middle aged and elderly women, disabilities of the upper and lower extremities become more prevalent and are associated with further functional impairment with aging. Such disabilities are more common in the lower extremities, and arthritis seems to be the most frequent cause.
Adult↗
Upper extremity deep venous thrombosis.
PURPOSE: To determine the prevalence of symptomatic upper extremity deep venous thrombosis (DVT) and its association with symptomatic acute pulmonary embolism (PE) in a community teaching hospital. METHODS: The prevalence of symptomatic upper extremity DVT was evaluated retrospectively at a community teaching hospital during the 2-year period between July 1, 1998, and June 30, 2000. Patients were identified by International Classification of Disease, ninth revision, clinical modification, discharge codes and a review of the records of all compression Doppler ultrasonograms, venograms of the upper extremities, and magnetic resonance angiograms of the upper extremities. RESULTS: Symptomatic upper extremity DVT was diagnosed in 65 of 44,136 patients of all ages (0.15%) [or 64 of 34,567 adult patients >or= 20 years of age; 0.19%]. In seven patients, the upper extremity DVT was shown by venography to extend proximally to the brachiocephalic vein. Among these, the DVT extended to the superior vena cava in two. All of the patients received anticoagulant therapy for upper extremity DVT. No patients developed symptomatic PE. Central lines at the site of the upper extremity DVT were inserted in 39 of 65 patients (60%). Cancer was diagnosed in 30 of 65 patients (46%), 23 cancer patients also had central lines, and 19 patients (29%) had upper extremity DVT with no apparent cause. All patients had swelling of the upper extremities. Erythema over the affected site was present in four patients (6%). Pain was present in 26 patients (40%), although some discomfort due to swelling was present in all patients. CONCLUSION: Symptomatic upper extremity DVT is not uncommon in hospitalized patients. Symptomatic PE resulting from upper extremity DVT was not observed in these patients, all of whom were treated with anticoagulants.
Acute Disease↗
Comparison of changes in upper and lower extremity impairments and disabilities after stroke.
The aims of this study were to determine if the changes in impairment and disability measures for the upper and lower extremities were equivalent during the post-stroke rehabilitation period and whether the rates of change were maintained 6 months after discharge from rehabilitation. A prospective cohort study design was used. One-hundred-and-thirty-two people who had sustained a stroke and who were enrolled in an intensive functional rehabilitation programme were recruited. Upper and lower extremity impairments and disabilities were evaluated at admission, at discharge from rehabilitation and 6 months later. During active rehabilitation, the changes in both extremities were smaller for the impairment measures (standardized response mean (SRM), 0.37-0.63) than the disability measures (SRM, 0.76-1.05). While the changes in upper and lower extremities were equivalent for impairment measures, they were larger in the lower extremity for disability measures, indicating that the rate of functional improvement was faster in the lower extremity during active rehabilitation. After discharge, however, while the rate of motor recovery in the lower extremity dropped (SRM, 0.54-0.18), it was maintained in the upper extremity (SRM, 0.45 and 0.42). Present findings indicate that functional (disability) measures improve faster than impairment measures in both extremities during the active rehabilitation period and suggest that motor recovery occurs at a different rate in the upper and lower extremities, with that of the upper extremity occurring later and extending into the period after discharge from active rehabilitation.
Aged↗
Higher and lower extremity vein color duplex sonography in highly qualified football players and wrestlers.
It is recognized that due to muscle exercises cardio-vascular system undergoes various morphologic and functional changes among highly qualified sportsmen. Healthy vascular system is needed to meet successfully great physical load. Aim of the search was to study higher and lower extremity venous system functional condition during physical exercise and rest among highly qualified football players and wrestlers. Highly qualified 30 wrestlers and 25 football players of age 18-25 years were studied. Olympic, World and Europe champions were included among wrestlers. Apparatus Acuson 128 X P/10 performed color duplex sonography examinations, transducers 7.5 MHz lineal. Higher and lower extremity venous screening in B regime was simultaneously performed by blood stream color cartogram and blood stream spectral analysis. Study revealed no pathology and documented about even rates among football players and wrestlers for higher and lower extremities by color duplex sonography. B-regime revealed same echonegativity of lower extremity veins among wrestlers and football players. Target veins were distinguished by echopositive vessel wall lineal structure. In color duplex regime venous lumen were evenly filled with color. Sportsmen post--physical exercise color duplex sonography examination revealed higher extremity venous lumen diameter and blood stream parameters twice exceeded among wrestlers than football players. However, time needed for the venous lumen diameter and blood stream changes was equal for both groups of sportsmen. The study revealed that football player lower extremity medial and wide calibre venous diameter 2.5-3 fold increased during post-exercise examination; lower extremity venous diameter and blood stream restores to primary parameters 30 min earlier in soccer players than in wrestlers. Thus, higher and lower extremity veins react in different ways among sportsmen of different kinds. For example lower extremity vein diameter and blood stream increases in football players more than in wrestlers, while, higher extremity veins reach higher rates in wrestlers to compare to soccer players. These evidences conclude different adaptation resources among sportsmen of different physical trainings. That is why during physical load blood circulation in down to up direction is facilitated because of lower extremity muscle contraction support in football players.
Adolescent↗
Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? A randomized, controlled intervention trial of 146 military conscripts.
BACKGROUND: Shock-absorbing and biomechanic shoe orthoses are frequently used in the prevention and treatment of back and lower extremity problems. One review concludes that the former is clinically effective in relation to prevention, whereas the latter has been tested in only 1 randomized clinical trial, concluding that stress fractures could be prevented. OBJECTIVES: To investigate if biomechanic shoe orthoses can prevent problems in the back and lower extremities and if reducing the number of days off-duty because of back or lower extremity problems is possible. DESIGN: Prospective, randomized, controlled intervention trial. STUDY SUBJECTS: One female and 145 male military conscripts (aged 18 to 24 years), representing 25% of all new conscripts in a Danish regiment. METHOD: Health data were collected by questionnaires at initiation of the study and 3 months later. Custom-made biomechanic shoe orthoses to be worn in military boots were provided to all in the study group during the 3-month intervention period. No intervention was provided for the control group. Differences between the 2 groups were tested with the chi-square test, and statistical significance was accepted at P <.05. Risk ratio (RR), risk difference (ARR), numbers needed to prevent (NNP), and cost per successfully prevented case were calculated. OUTCOME VARIABLES: Outcome variables included self-reported back and/or lower extremity problems; specific problems in the back or knees or shin splints, Achilles tendonitis, sprained ankle, or other problems in the lower extremity; number of subjects with at least 1 day off-duty because of back or lower extremity problems and total number of days off-duty within the first 3 months of military service because of back or lower extremity problems. RESULTS: Results were significantly better in an actual-use analysis in the intervention group for total number of subjects with back or lower extremity problems (RR 0.7, ARR 19%, NNP 5, cost 98 US dollars); number of subjects with shin splints (RR 0.2, ARR 19%, NNP 5, cost 101 US dollars); number of off-duty days because of back or lower extremity problems (RR 0.6, ARR < 1%, NNP 200, cost 3750 US dollars). In an intention-to-treat analysis, a significant difference was found for only number of subjects with shin splints (RR 0.3, ARR 18%, NNP 6 cost 105 US dollars), whereas a worst-case analysis revealed no significant differences between the study groups. CONCLUSIONS: This study shows that it may be possible to prevent certain musculoskeletal problems in the back or lower extremities among military conscripts by using custom-made biomechanic shoe orthoses. However, because care-seeking for lower extremity problems is rare, using this method of prevention in military conscripts would be too costly. We also noted that the choice of statistical approach determined the outcome.
Adolescent↗
[Anatomic and hemodynamic changes in the venous vascular bed in the lower extremities with chronic venous insufficiency].
The authors paid attention to revealing as precisely as possible anatomical and haemodynamic conditions in venous vascular bed in the course of ultrasonographic examination of 309 lower extremities with clinical manifestations of chronic venous insufficiency (CVI). A combined reflux in the superficial and deep venous system (53.7%) or isolated reflux in superficial veins (25.9%) proved to be the most frequent pathogenic bases of CVI. Pathophysiology of varices was mostly based on the venous reflux and the primary idiopathic CVI was mostly present (98.1%). The post-thrombotic partial obstruction of the deep venous system (post-thrombotic venous changes on the walls) was demonstrated exceptionally (1.9%). A high coincidence of reflux in the deep and superficial venous system points out to s.c. secondary reflux in the deep veins originating on the basis of primary reflux in the large or small saphena. An attempt was made to clarify, whether the development and frequency of incompetent perforators is directly connected with the presence and seriousness of reflux in the large and small saphena. The presence and severity of large saphena insufficiency does not univocally indicate the presence of dilated or insufficient perforators on the medical side of the crus, where these anastomoses are present most frequently. The large saphena is a long vein typically suffering from segmental insufficiency, i.e. reflux affecting a certain portion, whereas other parts of the vein may be fully competent. Anatomical venous variability and abnormalities on lower extremities were demonstrated in every fifth extremity (62 extremities, 20.1%). Most of them concerned large saphena (39 extremities, 62.8%), small saphena being second (15 extremities, 25.2%). Other anatomical deviations occurred sporadically as solitary findings. In the large saphena, duplication was present most frequently (54.8%). Insufficient variable superficial veins and anatomical venous anomalies were mostly not the only pathogenic basis of CVI, but were predominantly associated with insufficiently in the area of deep veins and perforators (84%). In our cohort there were altogether 55 extremities (17.8%) after the operation on superficial venous system, where relapses of varices were found. The causes of post-operation relapse of varices may be divided into three groups: 1. insufficiency of the large saphena, 2. insufficiency of the small saphena and 3. insufficiency of the deep veins. A combined simultaneous insufficiency in several venous systems was found most frequently (27 extremities, 49.1%). Even though the reflux in the deep veins was demonstrated in 50.9% of these extremities, a combination with the reflux in superficial veins and perforators (49.1%) was present with the exception of one case of isolated insufficiency. The insufficiency of the large and small saphena was clearly the leading single causes (15 extremities, 27.3%) of varix relapses. The patients should never be operated on the venous system of lower extremities without previous detailed ultrasonographic examination. It is the only way to increase probability of the operation success and to decrease the risk of relapses of CVI manifestations.
Chronic Disease↗
The contribution of non-insulin-dependent diabetes to lower-extremity amputation in the community.
BACKGROUND: Despite the significant public health burden of lower-extremity amputations in diabetes mellitus, few data are available on the epidemiology of lower-extremity amputations in diabetes mellitus in the community setting. METHODS: A retrospective incidence cohort study based in Rochester, Minn, was conducted. RESULTS: Among the 2015 diabetic individuals free of lower-extremity amputation at the diagnosis of diabetes mellitus, 57 individuals underwent 79 lower-extremity amputations (incidence, 375 per 100,000 person-years; 95% confidence interval, 297 to 467). Among the 1826 patients with non-insulin-dependent diabetes mellitus, 52 underwent 73 lower-extremity amputations, and the subsequent incidence of lower-extremity amputation among these residents was 388 per 100,000 person-years (95% confidence interval, 304 to 487). Of the 137 insulin-dependent diabetic patients, four subsequently underwent five lower-extremity amputations (incidence, 283 per 100,000 person-years; 95% confidence interval, 92 to 659). Twenty-five years after the diagnosis of diabetes mellitus, the cumulative risk of one lower-extremity amputation was 11.2% in insulin-dependent diabetes mellitus and 11.0% in non-insulin-dependent diabetes mellitus. When compared with lower-extremity amputation rates for Rochester residents without diabetes, patients with non-insulin-dependent diabetes mellitus were nearly 400 times more likely to undergo an initial transphalangeal amputation (rate ratio, 378.8) and had almost a 12-fold increased risk of a below-knee amputation (rate ratio, 11.8). In this community, more than 60% of lower-extremity amputations were attributable to non-insulin-dependent diabetes mellitus. CONCLUSIONS: These population-based data document the magnitude of the elevated risk of lower-extremity amputation among diabetic individuals. Efforts should be made to identify more precisely risk factors for amputation in diabetes and to intervene in the processes leading to amputation.
Amputation, Surgical↗
Altered perceptions after upper and lower extremity blocks: an initial investigation.
BACKGROUND AND OBJECTIVES: Nerve blocks frequently produce unusual altered perceptions in the extremities. We examined perceptual changes experienced after peripheral blocks. METHODS: Fifty consecutive patients having an upper or lower extremity block for surgery participated in this prospective study. Patients were divided into 2 groups: upper extremity (n = 20) and lower extremity (n = 30). Each group was asked a list of questions about perceptions of limb sensation, length, weight, and location and given a detailed 2-point discrimination test over the V(1)-V(3) divisions of the trigeminal nerve prior to block and sedation. While the extremity was still blocked, the exam was repeated before postanesthesia care unit discharge. RESULTS: In both groups, 98% of patients described altered limb perception. The perceptions in the upper extremity were: heaviness, 60%; numbness, 50%; warmth, 40%; pain, 30%; full or fat, 20%; floating, 5%; shorter, 0%; or thinner, 10%. The perceptions in the lower extremity were: numbness, 75%; heaviness, 46%; warmth, 33%; pain, 32%; full or fat, 36%; floating, 25%; shorter, 18%, or thinner, 7%. Upper extremity block patients were more likely to describe the limb as lighter (P <.0001); the lower extremity group was more likely to describe the limb as numb (P =.01) or floating (P =.0002). There was no difference in the ability to correctly identify the location of the limb between the groups. There was no difference in 2-point discrimination between each assessment for either group. CONCLUSION: The results of this study confirm and quantify the perceptions experienced by patients undergoing upper and lower extremity blocks. These perceptions are prevalent. This knowledge is helpful in providing patients with accurate preoperative preparation. Further investigation is warranted to determine the neurologic etiology of these observations.
Adult↗
Cost analysis of functional restoration surgery for extremity soft-tissue sarcoma.
BACKGROUND: Limb-sparing surgery, consisting of wide-margin tumor resection and preoperative or postoperative radiotherapy/chemotherapy, has become the surgical treatment of choice for extremity sarcomas. However, adequate tumor resection can sometimes compromise crucial limb function, necessitating functional restoration surgery. The purpose of this study was to determine the cost impact and functional outcomes of such procedures. METHODS: Patients receiving either functional restoration surgery or soft-tissue-only reconstruction following extremity soft-tissue sarcoma excision were identified. Patients were then compared along several dimensions: overall length of stay and its subdivisions, surgical time, and total charges and its subdivisions. Patients' functional outcomes were assessed with the Toronto Extremity Salvage Score. RESULTS: Sixty-seven patients who underwent 69 limb-sparing procedures were identified. Fifteen of these procedures (eight upper extremity, seven lower extremity) required functional restoration surgery; 54 of these procedures (13 upper extremity, 41 lower extremity) required only soft-tissue coverage. In the upper extremity, there was a statistically significant increase in overall length of stay (2.8 days) and its subdivisions, surgical time (3.7 hours), and total charges (12,484 dollars) and its subdivisions associated with performing functional restoration surgery. In lower extremity cases, statistically significant increases were determined in only the total charges (9190 dollars) and medical supply charges (13,204 dollars) following functional restoration. Patients who underwent functional restoration surgery had better postoperative function (mean Toronto Extremity Salvage Score, 82 versus 80), but this difference was not statistically significant. CONCLUSION: Although functional restoration surgery is more costly than soft-tissue reconstruction alone, the authors believe that the associated better functional outcome justifies its performance.
Adolescent↗
Extremity pain and refusal to walk in children with invasive meningococcal disease.
OBJECTIVE: Early recognition of invasive meningococcal disease in children may be difficult. Extremity pain and refusal to walk (extremity symptoms) are uncommonly mentioned as clinical findings in children who present with this disease. We sought to determine 1) the frequency of extremity symptoms as part of the clinical presentation in children with invasive meningococcal disease and 2) whether these symptoms help identify children with otherwise unsuspected meningococcal disease. METHODS: We reviewed the medical records of patients who were younger than 20 years and had invasive meningococcal disease from 1985 to 1996 at 3 pediatric referral centers. Children with extremity symptoms were identified and described. We compared clinical and laboratory findings and frequency of adverse outcomes between these children and those with invasive meningococcal disease without extremity symptoms. RESULTS: We identified 274 children with invasive meningococcal disease, 45 (16%) of whom had either history or physical examination evidence of extremity pain (31) or refusal to walk (14) as part of their clinical presentations. Five of the 45 patients had arthritis at the time of presentation. Patients with extremity symptoms at presentation were significantly older (77.9 +/- 62.2 vs 44.0 +/- 56.9 months), had lower temperatures (38.8 +/- 1.2 degrees C vs 39.2 +/- 1.2 degrees C), and had higher band counts (28.2 +/- 15.2% vs 18.1 +/- 12.4%) than did patients without extremity symptoms. There were no significant differences, however, between groups with regard to rash, white blood cell counts, coagulation parameters, prevalence of meningitis, or adverse outcomes. Seventy-three (27%) of the 274 patients had unsuspected disease, and 5 (7%) of these had extremity symptoms at the time of diagnosis. CONCLUSIONS: Sixteen percent of children with invasive meningococcal disease have extremity symptoms at the time of diagnosis. These symptoms may help to identify some patients with otherwise unsuspected invasive meningococcal disease.
Child↗
Transitions to mobility difficulty associated with lower extremity osteoarthritis in high functioning older women: longitudinal data from the Women's Health and Aging Study II.
OBJECTIVE: To assess the impact of lower extremity osteoarthritis (OA) on transitions to mobility difficulty, and to assess the influence of pain, excess weight, and quadriceps strength on these transitions. METHODS: We analyzed longitudinal data acquired from 199 participants in the Women's Health and Aging Study II (ages 70-79 years) who initially reported no lower extremity limitation (e.g., difficulty walking one-quarter mile) or difficulty in activities of daily living (ADL; e.g., transferring). Prevalent lower extremity OA was determined from validated algorithms encompassing multiple data sources. Markov transition models were created to analyze the first transition from no difficulty at baseline to lower extremity limitations, ADL difficulty, or both 18, 36, and 72 months later. RESULTS: Compared with women without OA (n = 140), a higher proportion of women with lower extremity OA (n = 59) initially reported pain on most days and more severe pain while walking (P < 0.05). Women with OA were also heavier, with a higher proportion being obese or overweight (P < 0.001). Lower extremity OA, higher body mass index, and lower knee extensor strength independently increased the risk of transition to combined lower extremity and ADL difficulty first over 72 months. CONCLUSION: Lower extremity OA increased the likelihood of developing difficulty in both lower extremity tasks and ADL over 72 months in a cohort of initially high functioning older women. Two modifiable factors, higher relative weight and lower knee extensor strength, substantially impacted these transitions, and therefore warrant increased attention in the management of lower extremity OA.
Activities of Daily Living↗