Clinical and functional outcomes of acute lower extremity compartment syndrome at a Major Trauma Hospital

Background: Acute lower extremity compartment syndrome (CS) is a condition that untreated causes irreversible nerve and muscle ischemia. Treatment by decompression fasciotomy without delay prevents permanent disability. The use of intracompartmental pressure (iCP) measurement in uncertain situations aids in diagnosis of severe leg pain. As an infrequent complication of lower extremity trauma, consequences of CS include chronic pain, nerve injury, and contractures. The purpose of this study was to observe the clinical and functional outcomes for patients with lower extremity CS after fasciotomy. Methods: Retrospective chart analysis for patients with a discharge diagnosis of CS was performed. Physical demographics, employment status, activity at time of injury, injury severity score, fracture types, pain scores, hours to fasciotomy, iCP, serum creatine kinase levels, wound treatment regimen, length of hospital stay, and discharge facility were collected. Lower extremity neurologic examination, pain scores, orthopedic complications, and employment status at 30 days and 12 months after discharge were noted. Results: One hundred twenty‑four patients were enrolled in this study. One hundred and eight patients were assessed at 12 months. Eighty‑one percent were male. Motorized vehicles caused 51% of injuries in males. Forty‑one percent of injuries were tibia fractures. Acute kidney injury occurred in 2.4%. Mean peak serum creatine kinase levels were 58,600 units/ml. Gauze dressing was used in 78.9% of nonfracture patients and negative pressure wound vacuum therapy in 78.2% of fracture patients. About 21.6% of patients with CS had prior surgery. Nearly 12.9% of patients required leg amputation. Around 81.8% of amputees were male. Sixty‑seven percent of amputees had associated vascular injuries. Foot numbness occurred in 20.5% of patients and drop foot palsy in 18.2%. Osteomyelitis developed in 10.2% of patients and fracture nonunion in 6.8%. About 14.7% of patients underwent further orthopedic surgery. At long‑term follow‑up, 10.2% of patients reported moderate lower extremity pain and 69.2% had returned to work. Conclusion: Escalation in leg pain and changes in sensation are the cardinal signs for CS rather than reliance on assessing for firm compartments and pressures. The severity of nerve injury worsens with the delay in performing fasciotomy. Standardized diagnostic protocols and wound treatment strategies will result in improved outcomes from this complication.

Deep Venous Thrombosis (DVT) in Lower Extremity Amputation as Cause of Pulmonary Embolism

The authors describe the case of a 43-year-old man with a right-leg knee amputation performed 14 years prior. He presented to hospital with dyspnea. A pulmonary embolism was detected. A Doppler ultrasound test showed deep vein thrombosis (DVT), which affected the stump of the amputated limb. When a pulmonary embolism is detected in a patient with an amputated lower limb, an exploration of the stump should be performed to rule out this uncommon complication.

What are the key conditions associated with lower limb amputations in a major Australian teaching hospital?

Background Lower extremity amputation results in significant global morbidity and mortality. Australia appears to have a paucity of studies investigating lower extremity amputation. The primary aim of this retrospective study was to investigate key conditions associated with lower extremity amputations in an Australian population. Secondary objectives were to determine the influence of age and sex on lower extremity amputations, and the reliability of hospital coded amputations. Methods: Lower extremity amputation cases performed at the Princess Alexandra Hospital (Brisbane, Australia) between July 2006 and June 2007 were identified through the relevant hospital discharge dataset (n = 197). All eligible clinical records were interrogated for age, sex, key condition associated with amputation, amputation site, first ever amputation status and the accuracy of the original hospital coding. Exclusion criteria included records unavailable for audit and cases where the key condition was unable to be determined. Chi-squared, t-tests, ANOVA and post hoc tests were used to determine differences between groups. Kappa statistics were used to measure reliability between coded and audited amputations. A minimum significance level of p < 0.05 was used throughout. Results: One hundred and eighty-six cases were eligible and audited. Overall 69% were male, 56% were first amputations, 54% were major amputations, and mean age was 62 ± 16 years. Key conditions associated included type 2 diabetes (53%), peripheral arterial disease (non-diabetes) (18%), trauma (8%), type 1 diabetes (7%) and malignant tumours (5%). Differences in ages at amputation were associated with trauma 36 ± 10 years, type 1 diabetes 52 ± 12 years and type 2 diabetes 67 ± 10 years (p < 0.01). Reliability of original hospital coding was high with Kappa values over 0.8 for all variables. Conclusions: This study, the first in over 20 years to report on all levels of lower extremity amputations in Australia, found that people undergoing amputation are more likely to be older, male and have diabetes. It is recommended that large prospective studies are implemented and national lower extremity amputation rates are established to address the large preventable burden of lower extremity amputation in Australia.

Design of a traumatic injury simulator for assessing lower limb response to high loading rates

Current military conflicts are characterized by the use of the improvised explosive device. Improvements in personal protection, medical care, and evacuation logistics have resulted in increasing numbers of casualties surviving with complex musculoskeletal injuries, often leading to lifelong disability. Thus, there exists an urgent requirement to investigate the mechanism of extremity injury caused by these devices in order to develop mitigation strategies. In addition, the wounds of war are no longer restricted to the battlefield; similar injuries can be witnessed in civilian centers following a terrorist attack. Key to understanding such mechanisms of injury is the ability to deconstruct the complexities of an explosive event into a controlled, laboratory-based environment. In this article, a traumatic injury simulator, designed to recreate in the laboratory the impulse that is transferred to the lower extremity from an anti-vehicle explosion, is presented and characterized experimentally and numerically. Tests with instrumented cadaveric limbs were then conducted to assess the simulator’s ability to interact with the human in two mounting conditions, simulating typical seated and standing vehicle passengers. This experimental device will now allow us to (a) gain comprehensive understanding of the load-transfer mechanisms through the lower limb, (b) characterize the dissipating capacity of mitigation technologies, and (c) assess the bio-fidelity of surrogates.

Microvascular reconstruction in extremity soft tissue sarcoma surgery

Soft tissue sarcomas (STS) are rare tumors of soft tissue occurring most frequently in the extremities. Modern treatment of extremity STS is based on limb-sparing surgery combined with radiotherapy. To prevent local recurrence, a healthy tissue margin of 2.5 cm around the resected tumor is required. This results in large defects of soft tissue and bone, necessitating the use of reconstructive surgery to achieve wound closure. When local or pedicled soft tissue flaps are unavailable, reconstruction with free flaps is used. Free flaps are elevated at a distant site, and have their blood flow restored at the recipient site through microvascular anastomosis. When limb-sparing surgery is made impossible, amputation is the only option. Proximal amputation such as forequarter amputation (FQA) causes considerable morbidity, but is nevertheless warranted for carefully selected patients for cure or palliation. 116 patients treated in 1985 - 2006 were included in the study. Of these, 93 patients treated with limb-sparing surgery and microvascular reconstructive surgery after resection of extremity STS. 25 patients who underwent FQA were also included. Patients were identified and their medical records retrospectively reviewed. In all, 105 free flap procedures were performed for 103 patients. A total of 95 curatively treated STS patients were included in survival analysis. The latissimus dorsi, used in 56% of cases, was the most frequently used free flap. Free flap success rate was 96%. There were 9% microvascular anastomosis complications and 15% wound complications. For curatively treated STS patients, local recurrence-free survival at 5 years was 73.1%, metastasis-free survival 58.3%, and overall disease-specific survival 68.9%. Functional results were good, with 75% of patients regaining normal or near-normal function after lower extremity, and 55% after upper extremity STS resection. Among curatively treated forequarter amputees, 5-year disease-free survival was 44%. In the palliatively treated group median time until disease death was 14 months. Microvascular reconstruction after extremity soft tissue sarcoma resection is safe and reliable, and produces well-healing wounds allowing early oncological treatment. Oncological outcome after these procedures is comparable to that of other extremity sarcoma patients. Functional results are generally good. Forequarter amputation is a useful treatment option for soft tissue tumors of the shoulder girdle and proximal upper extremity. When free flap coverage of extended forequarter amputation is required, the preferable flap is a fillet flap from the amputated extremity. Acceptable oncological outcome is achieved for curatively treated FQA patients. In the palliatively treated patient considerable periods of increased quality of life can be achieved.

The relationship between lower body strength and obstructed gait in community-dwelling older adults

OBJECTIVES: To determine the relationship between lower body strength of community-dwelling older adults and the time to negotiate obstructed gait tasks.

DESIGN: A correlational study.

SETTING: The Biomechanics Laboratory, Deakin University, Australia.

PARTICIPANTS: Twenty-nine women and 16 men aged 62 to 88 were recruited using advertisements placed in local newspapers. The participants were independent community dwellers, healthy and functionally mobile.

MEASUREMENTS: Maximal isometric strength of the knee extensors and dynamic strength of the hip extensors, hip flexors, hip adductors, hip abductors, knee extensors, knee flexors, and ankle plantar flexors were assessed. The times to negotiate four obstructed gait tasks at three progressively challenging levels on an obstacle course and to complete the course were recorded. The relationship between strength and the crossing times was explored using linear regression models.

RESULTS: Significant associations between the seven strength measures and the times to negotiate each gait task and to walk the entire course at each level were obtained (r = -0.38 to -0.55; P < .05). In addition, the percentage of the variance explained by strength (R2), consistently increased as a function of the progressively challenging level. This increase was particularly marked for the stepping over task (R2 = 19.3%,25.0%, and 27.2%, for levels 1, 2, and 3, respectively) and the raised surface condition (R2 = 17.1%,21.1%, and 30.8%, for levels 1,2, and 3, respectively) .

CONCLUSION: The findings of the study showed that strength is a critical requirement for obstructed locomotion. That the magnitude of the association increased as a function of the challenging levels suggests that intervention programs aimed at improving strength would potentially be effective in helping community-dwelling older adults negotiate environmental gait challenges.

Electromyographic validation of the double pulley equipment during movements of the lower limbs

The double pulley equipment was tested on ten male volunteers during contraction of the semitendinosus and biceps femoris (caput longum) muscles in the following movements of the lower limbs: 1) hip extension with extended knee and erect trunk, 2) hip extension with flexed knee and erect trunk, 3) hip extension with flexed knee and erect trunk, 3) hip extension with extended knee and inclined trunk, 5) hip abduction along the midline, 7) hip abduction with extension beyond the midline, 8) adduction with hip flexion beyond the midline, 8) adduction with hip flexion beyond the midline, and 9) adduction with hip extension beyond the midline. The myoelectric signals were taken up by Lec Tec surface electrodes connected to a 6-channel Lynx electromyographic signal amplifier coupled with a computer equipped with a model CAD 10/26 analogue digital conversion board and with a specific software for signal recording and analysis. The semitendinosus and biceps femoris muscles presented the highest potentials in movements 1; 2; 7, 8 and 9, whereas the potentials in the remaining movements were negligible. The pattern of activity of the semitendinosus and the biceps femoris was similar in exercises 1, 2, 3, 4 and 8. The potentials of the semitendinosus prevailed in movements 5, 6 and 7, and the strongest potentials observed in movement 9 were those of the biceps femoris.

Influence of a preventive training program on lower limb kinematics and vertical jump height of male volleyball athletes

Objective: To examine the influence of a preventative training program (PTP) on sagittal plane kinematics during different landing tasks and vertical jump height (VJH) in males. Design: Six weeks prospective exercise intervention. Participants: Fifteen male volleyball athletes (13 ± 0.7 years, 1.70 ± 0.12 m, 60 ± 12 kg). Interventions: PTP consisting of plyometric, balance and core stability exercises three times per week for six weeks. Bilateral vertical jumps with double leg (DL) and single leg (SL) landings were performed to measure the effects of training. Main outcome measurements: Kinematics of the knee and hip before and after training and VJH attained during both tasks after training. The hypothesis was that the PTP would produce improvements in VJH, but would not generate great changes in biomechanical behavior. Results: The only change identified for the SL was the longest duration of landing, which represents the time spent from initial ground contact to maximum knee flexion, after training, while increased angular displacement of the knee was observed during DL. The training did not significantly alter the VJH in either the SL (difference: 2.7 cm) or the DL conditions (difference: 3.5 cm). Conclusions: Despite the PTP's effectiveness in inducing some changes in kinematics, the changes were specific for each task, which highlights the importance of the specificity and individuality in selecting prevention injury exercises. Despite the absence of significant increases in the VJH, the absolute differences after training showed increases corroborating with the findings of statistically powerful studies that compared the results with control groups. The results suggest that short-term PTPs in low risk young male volleyball athletes may enhance performance and induce changes in some kinematic parameters. © 2012 Elsevier Ltd.

Effect of Functional Stabilization Training on Lower Limb Biomechanics in Women

BALDON, R. D. M., D. F. M. LOBATO, L. P. CARVALHO, P. Y. L. WUN, P. R. P. SANTIAGO, and F. V. SERRAO. Effect of Functional Stabilization Training on Lower Limb Biomechanics in Women. Med. Sci. Sports Exerc., Vol. 44, No. 1, pp. 135-145, 2012. Purpose: This study aimed to verify the effects of functional stabilization training on lower limb kinematics, functional performance, and eccentric hip and knee torques. Methods: Twenty-eight women were divided into a training group (TG; n = 14), which carried out the functional stabilization training during 8 wk, and a control group (CG; n = 14), which carried out no physical training. The kinematic assessment of the lower limb was performed during a single-leg squat, and the functional performance was evaluated by way of the single-leg triple hop and the timed 6-m single-leg hop tests. The eccentric hip abductor, adductor, lateral rotator, medial rotator, and the knee flexor and extensor torques were measured using an isokinetic dynamometer. Results: After 8 wk, the TG significantly reduced the values for knee abduction (from -6.86 degrees to 1.49 degrees), pelvis depression (from -10.21 degrees to -7.86 degrees) and femur adduction (from 7.08 degrees to 5.19 degrees) as well as increasing the excursion of femur lateral rotation (from -0.55 degrees to -3.67 degrees). Similarly, the TG significantly increased the values of single-leg triple hop (from 3.52 to 3.92 m) and significantly decreased the values of timed 6-m single-leg hop tests (from 2.43 to 2.14 s). Finally, the TG significantly increased the eccentric hip abductor (from 1.31 to 1.45 N center dot m center dot kg(-1)), hip lateral rotator (from 0.75 to 0.91 N center dot m center dot kg(-1)), hip medial rotator (from 1.45 to 1.66 N center dot m center dot kg(-1)), knee flexor (from 1.43 to 1.55 N center dot m center dot kg(-1)), and knee extensor (from 3.46 to 4.40 N center dot m center dot kg(-1)) torques. Conclusions: Strengthening of the hip abductor and lateral rotator muscles associated with functional training improves dynamic lower limb alignment and increases the strength and functional performance.

Compression stockings have a synergistic effect with walking in the late afternoon to reduce edema of the lower limbs

Aim. The aim of this study was to evaluate whether an association of elastic stockings and walking for a short period in the late afternoon reduces leg edema. Methods. Volume changes of the legs of sixteen patients (32 limbs), who walked on a treadmill for 30 minutes using elastic compression stockings, were analyzed in a quantitative, cross-over randomized (in order of arrival at the clinic) study. They were submitted to volumetry using the water displacement technique and subsequently required to put on 20/30 made-to-measure compression stockings (Sigvaris). The patients walked on a treadmill for 30 minutes and after removing the stockings volumetry of the legs was again performed. Legs were assessed using the CEAP classification and divided into groups. Analysis of variance was used for statistical analysis with an alpha error of 5% being considered acceptable. Results. When participants walked wearing compression stockings, there was a reduction in leg volume. When the CEAP classification was evaluated, it was noted that there was a statistically significant difference for the CEAP C0, C1 and C2 categories of legs using stockings compared to those that did not use. Conclusion. Compression stockings have a synergistic effect with walking in the late afternoon thus reducing edema of the lower limbs. [Int Angiol 2012;31:490-3]

Renal insufficiency is independently associated with a distal distribution pattern of symptomatic lower-limb atherosclerosis

Objectives The purpose of this study was to assess the impact of renal insufficiency (RI) on the distribution pattern of peripheral arterial disease (PAD). We hypothesised that RI is associated with a distally accentuated involvement of the peripheral arterial tree. Design This is a retrospective analysis. Materials and Methods Analysis was based on a consecutive series of 2709 patients with chronic PAD of atherosclerotic origin undergoing primary endovascular treatment of lower-extremity arteries. Atherosclerotic pattern was grouped into femoropopliteal (n = 2085) and infragenicular (n = 892) disease according to target lesions treated while using iliac disease (n = 1133) as reference. Univariable and multivariable multinomial regression analyses were performed to assess relation with RI. Results are shown as relative risk ratio (RRRs) with 95% confidence intervals (95% CIs). A p < 0.05 was considered statistically significant. RI was defined as glomerular filtration rate (GFR) < 60 ml min−1 1.73 m−2. Results Presence of RI was an independent risk factor for a centrifugal lesion pattern (RRR 1.48, 95% CI: 1.17–1.86, p = 0.001). Moreover, a decrease in GFR by 10 ml min−1 1.73 m−2 was associated with an RRR of 1.08 for below-the-knee arterial disease (95% CI: 1.03–1.13, p = 0.003). Conclusion Presence and severity of RI are independent predictors of a distal obstructive pattern in patients with symptomatic PAD.

The Lower Limb Functional Index: development and clinimetric properties

Background Existing lower-limb, region-specific, patient-reported outcome measures have clinimetric limitations, including limitations in psychometric characteristics (eg, lack of internal consistency, lack of responsiveness, measurement error) and the lack of reported practical and general characteristics. A new patient-reported outcome measure, the Lower Limb Functional Index (LLFI), was developed to address these limitations. Objective The purpose of this study was to overcome recognized deficiencies in existing lower-limb, region-specific, patient-reported outcome measures through: (1) development of a new lower-extremity outcome scale (ie, the LLFI) and (2) evaluation of the clinimetric properties of the LLFI using the Lower Extremity Functional Scale (LEFS) as a criterion measure. Design This was a prospective observational study. Methods The LLFI was developed in a 3-stage process of: (1) item generation, (2) item reduction with an expert panel, and (3) pilot field testing (n=18) for reliability, responsiveness, and sample size requirements for a larger study. The main study used a convenience sample (n=127) from 10 physical therapy clinics. Participants completed the LLFI and LEFS every 2 weeks for 6 weeks and then every 4 weeks until discharge. Data were used to assess the psychometric, practical, and general characteristics of the LLFI and the LEFS. The characteristics also were evaluated for overall performance using the Measurement of Outcome Measures and Bot clinimetric assessment scales. Results The LLFI and LEFS demonstrated a single-factor structure, comparable reliability (intraclass correlation coefficient [2,1]=.97), scale width, and high criterion validity (Pearson r=.88, with 95% confidence interval [CI]). Clinimetric performance was higher for the LLFI compared with the LEFS on the Measurement of Outcome Measures scale (96% and 95%, respectively) and the Bot scale (100% and 83%, respectively). The LLFI, compared with the LEFS, had improved responsiveness (standardized response mean=1.75 and 1.64, respectively), minimal detectable change with 90% CI (6.6% and 8.1%, respectively), and internal consistency (α=.91 and .95, respectively), as well as readability with reduced user error and completion and scoring times. Limitations Limitations of the study were that only participants recruited from outpatient physical therapy clinics were included and that no specific conditions or diagnostic subgroups were investigated. Conclusion The LLFI demonstrated sound clinimetric properties. There was lower response error, efficient completion and scoring, and improved responsiveness and overall performance compared with the LEFS. The LLFI is suitable for assessment of lower-limb function.

Association of cardiovascular risk factors with pattern of lower limb atherosclerosis in 2659 patients undergoing angioplasty

OBJECTIVES: Aim of this study is to correlate distribution pattern of lower limb atherosclerosis with cardiovascular risk factor profile of patients with peripheral arterial occlusive disease (PAD). PATIENTS AND METHODS: Analysis is based on a consecutive series of 2659 patients (1583 men, 1076 women, 70+/-11 years) with chronic PAD of atherosclerotic origin undergoing primary endovascular treatment of lower extremity arteries. Pattern of atherosclerosis was grouped into iliac (n=1166), femoropopliteal (n=2151) and infrageniculate (n=888) disease defined according to target lesions treated. A multivariable multinomial logistic regression analysis was performed to assess relation with age, gender and classical cardiovascular risk factors (diabetes mellitus, arterial hypertension, hypercholesterolemia, cigarette smoking) using femoropopliteal disease as reference. RESULTS: Iliac disease was associated with younger age (RRR 0.95 per year of age, 95%-CI 0.94-0.96, p<0.001), male gender (RRR 1.32, 95%-CI 1.09-1.59, p=0.004) and cigarette smoking (RRR 2.02, 95%-CI 1.68-2.42, p<0.001). Infrageniculate disease was associated with higher age (RRR 1.02, 95%-CI 1.01-1.02, p<0.001), male gender (RRR 1.23, 95%-CI 1.06-1.41, p=0.005) and diabetes mellitus (RRR 1.68, 95%-CI 1.47-1.92, p<0.001). Hypercholesterolemia was less prevalent in patients with lesions below the knee (RRR 0.82, 95%-CI 0.71-0.94, p=0.006), whereas no distinct pattern was apparent related to arterial hypertension. CONCLUSION: Clinical phenotype of peripheral atherosclerosis varies with prevalence of cardiovascular risk factors suggesting differences in mechanisms involved in iliac as compared with infrageniculate lesions. Identification of molecular mechanism might have influence on future therapeutic strategies in PAD patients.

On analysing and interpreting variability in motor output

A recent article in the Journal of Science and Medicine in Sport by Chapman et al.1 reported data from an empirical investigation comparing lower extremity joint motions, joint coordination and muscle recruitment in expert and novice cyclists. 3D kinematic and intramuscular electromyographic (EMG) analyses revealed no differences between expert and novice cyclists for normalised joint angles and velocities of the pelvis, hip, knee and ankle. However, significant differences in the strength of sagittal plane kinematics for hip–ankle and knee–ankle joint couplings were reported, with expert cyclists displaying tighter coupling relationships than novice cyclists. Furthermore, significant differences between expert and novice cyclists for all muscle recruitment parameters, except timing of peak EMG amplitude, were also reported.

Effects of pediatric obesity on joint kinematics and kinetics during 2 walking cadences

Objective: To determine whether differences existed in lower-extremity joint biomechanics during self-selected walking cadence (SW) and fast walking cadence (FW) in overweight- and normal-weight children.---------- Design: Survey.---------- Setting: Institutional gait study center.---------- Participants: Participants (N=20; mean age ± SD, 10.4±1.6y) from referred and volunteer samples were classified based on body mass index percentiles and stratified by age and sex. Exclusion criteria were a history of diabetes, neuromuscular disorder, or recent lower-extremity injury.---------- Main Outcome Measures: Sagittal, frontal, and transverse plane angular displacements (degrees) and peak moments (newton meters) at the hip, knee, and ankle joints.---------- Results: The level of significance was set at P less than .008. Compared with normal-weight children, overweight children had greater absolute peak joint moments at the hip (flexor, extensor, abductor, external rotator), the knee (flexor, extensor, abductor, adductor, internal rotator), and the ankle (plantarflexor, inverter, external/internal rotators). After including body weight as a covariate, overweight children had greater peak ankle dorsiflexor moments than normal-weight children. No kinematic differences existed between groups. Greater peak hip extensor moments and less peak ankle inverter moments occurred during FW than SW. There was greater angular displacement during hip flexion as well as less angular displacement at the hip (extension, abduction), knee (flexion, extension), and ankle (plantarflexion, inversion) during FW than SW.---------- Conclusions: Overweight children experienced increased joint moments, which can have long-term orthopedic implications and suggest a need for more nonweight-bearing activities within exercise prescription. The percent of increase in joint moments from SW to FW was not different for overweight and normal-weight children. These findings can be used in developing an exercise prescription that must involve weight-bearing activity.