The authors observed good clinical courses in patients with lower limb ulcers and extensive skin inflammation who showed early venous enhancement at contrast-enhanced lower extremity computed ...tomographic angiography. The author hypothesized that these early venous enhancements tend to occur in conditions of healthier vascular status. A total of 145 patients who met the inclusion criteria were classified based on the degree of arterial occlusion and early venous enhancement according to lower extremity angiography. Early venous enhancement correlated with age over 65 (t-score = 0.001), absence of ulcer history (t-score = 0.003), absence of amputation history (t-score = 0.004), and low ankle-brachial index (P value = .001). We confirmed that the factors related with early venous enhancement differ from the factor inducing arterial occlusion. Prior to this study, early enhancement of veins in the lower limb was thought to be an artifact. However, in this study, veins that show early enhancement are suspected of being healthier and more responsive to inflammation than those that do not show early enhancement. These findings may help to predict the clinical course and to determine therapeutic planning without additional studies. Also, it can be easily reproduced in other facilities.
Fibroadipose vascular anomaly (FAVA) is a recently-defined vascular malformation often involving the extremities and presenting in childhood. Patients may present to orthopaedic surgeons with pain, ...swelling, joint contractures, and leg length discrepancy. There is no established therapy or treatment paradigm. We report on outcomes following surgical excision for patients with this condition.
Between 2007 and 2016, all 35 patients that underwent excision of lower-extremity FAVA were retrospectively reviewed using a combination of medical records, radiologic findings, and telemedicine reviews.
Mean age at initial presentation was 12.3±6.8 years. Mean follow-up from time of definitive diagnosis at our institution was 66 months (range: 12 to 161 mo). Mean follow-up after surgery was 35 months (range: 6 to 138 mo). Females were affected more than males (71% vs. 29%). The most common location of FAVA was in the calf (49%), followed by the thigh (40%). The most commonly involved muscle was gastrocnemius (29%), followed by the quadriceps (26%). At latest follow-up after surgery, there was an improvement in the proportion of patients with pain at rest (63% vs. 29%), pain with activity (100% vs. 60%), as well as analgesia use (94% vs. 37%). Fourteen patients (40%) had symptomatic residual disease or recurrence of FAVA requiring further treatment. Six patients (17%) required further surgery and 6 (17%) required further interventional radiologic procedures. Three patients (9%) required eventual amputation for intractable pain and loss of function. Lesions with direct nerve involvement were associated with persistent neuropathic symptoms at latest follow-up (P=0.002) as well as symptomatic residual disease and/or recurrence requiring further treatment (P=0.01). Seventeen patients (49%) had 19 preoperative joint contractures. Eighteen of the 19 contractures (95%) had sustained improvement at latest follow-up.
In carefully selected patients, surgical excision of FAVA results in improvement of symptoms. However, symptomatic residual disease and/or recurrence are not uncommon. Direct nerve involvement is associated with a worse outcome.
Level IV-case series.
Aims/hypothesis
Diabetes progression and complication risk are different in Asian people compared with those of European ancestry. In this study, we sought to understand the epidemiology of ...diabetes-related lower extremity complications (DRLECs: symptomatic peripheral arterial disease, ulceration, infection, gangrene) and amputations in a multi-ethnic Asian population.
Methods
This was a retrospective observational study using data obtained from one of three integrated public healthcare clusters in Singapore. The population consisted of individuals with incident type 2 diabetes who were of Chinese, Malay, Indian or Other ethnicity. We examined incidence, time to event and risk factors of DRLECs and amputation.
Results
Between 2007 and 2017, of the 156,593 individuals with incident type 2 diabetes, 20,744 developed a DRLEC, of whom 1208 underwent amputation. Age- and sex-standardised incidence of first DRLEC and first amputation was 28.29/1000 person-years of diabetes and 8.18/1000 person-years of DRLEC, respectively. Incidence of both was highest in individuals of Malay ethnicity (DRLEC, 36.09/1000 person-years of diabetes; amputation, 12.96/1000 person-years of DRLEC). Median time from diabetes diagnosis in the public healthcare system to first DRLEC was 30.5 months for those without subsequent amputation and 10.9 months for those with subsequent amputation. Median time from DRLEC to first amputation was 2.3 months. Older age (
p
< 0.001), male sex (
p
< 0.001), Malay ethnicity (
p
< 0.001), Indian ethnicity (
p
= 0.014), chronic comorbidities (nephropathy
p
< 0.001, heart disease
p
< 0.001, stroke
p
< 0.001, retinopathy
p
< 0.001, neuropathy
p
< 0.001), poorer or missing HbA
1c
(
p
< 0.001), lower (
p
< 0.001) or missing (
p
= 0.002) eGFR, greater or missing BMI (
p
< 0.001), missing LDL-cholesterol (
p
< 0.001) at diagnosis, and ever-smoking (
p
< 0.001) were associated with higher hazard of DRLEC. Retinopathy (
p
< 0.001), peripheral vascular disease (
p
< 0.001), poorer HbA
1c
(
p
< 0.001), higher (
p
= 0.009) or missing (
p
< 0.001) LDL-cholesterol and missing BMI (
p
= 0.008) were associated with higher hazard of amputation in those with DRLEC. Indian ethnicity (
p
= 0.007) was associated with significantly lower hazard of amputation.
Conclusions/interpretation
This study has revealed important ethnic differences in risk of diabetes-related lower limb complications, with Malays most likely to progress to DRLEC. Greater research efforts are needed to understand the aetiopathological and sociocultural processes that contribute to the higher risk of lower extremity complications among these ethnic groups.
Graphical abstract
Supervised high-intensity walking exercise that induces ischemic leg symptoms is the first-line therapy for people with lower-extremity peripheral artery disease (PAD), but adherence is poor.
To ...determine whether low-intensity home-based walking exercise at a comfortable pace significantly improves walking ability in people with PAD vs high-intensity home-based walking exercise that induces ischemic leg symptoms and vs a nonexercise control.
Multicenter randomized clinical trial conducted at 4 US centers and including 305 participants. Enrollment occurred between September 25, 2015, and December 11, 2019; final follow-up was October 7, 2020.
Participants with PAD were randomized to low-intensity walking exercise (n = 116), high-intensity walking exercise (n = 124), or nonexercise control (n = 65) for 12 months. Both exercise groups were asked to walk for exercise in an unsupervised setting 5 times per week for up to 50 minutes per session wearing an accelerometer to document exercise intensity and time. The low-intensity group walked at a pace without ischemic leg symptoms. The high-intensity group walked at a pace eliciting moderate to severe ischemic leg symptoms. Accelerometer data were viewable to a coach who telephoned participants weekly for 12 months and helped them adhere to their prescribed exercise. The nonexercise control group received weekly educational telephone calls for 12 months.
The primary outcome was mean change in 6-minute walk distance at 12 months (minimum clinically important difference, 8-20 m).
Among 305 randomized patients (mean age, 69.3 SD, 9.5 years, 146 47.9% women, 181 59.3% Black patients), 250 (82%) completed 12-month follow-up. The 6-minute walk distance changed from 332.1 m at baseline to 327.5 m at 12-month follow-up in the low-intensity exercise group (within-group mean change, -6.4 m 95% CI, -21.5 to 8.8 m; P = .34) and from 338.1 m to 371.2 m in the high-intensity exercise group (within-group mean change, 34.5 m 95% CI, 20.1 to 48.9 m; P < .001) and the mean change for the between-group comparison was -40.9 m (97.5% CI, -61.7 to -20.0 m; P < .001). The 6-minute walk distance changed from 328.1 m at baseline to 317.5 m at 12-month follow-up in the nonexercise control group (within-group mean change, -15.1 m 95% CI, -35.8 to 5.7 m; P = .10), which was not significantly different from the change in the low-intensity exercise group (between-group mean change, 8.7 m 97.5% CI, -17.0 to 34.4 m; P = .44). Of 184 serious adverse events, the event rate per participant was 0.64 in the low-intensity group, 0.65 in the high-intensity group, and 0.46 in the nonexercise control group. One serious adverse event in each exercise group was related to study participation.
Among patients with PAD, low-intensity home-based exercise was significantly less effective than high-intensity home-based exercise and was not significantly different from the nonexercise control for improving 6-minute walk distance. These results do not support the use of low-intensity home-based walking exercise for improving objectively measured walking performance in patients with PAD.
ClinicalTrials.gov Identifier: NCT02538900.
Background and purpose: Mortality after major lower extremity amputations is high and may depend on amputation level. We aimed to examine the mortality risk in the first year after major lower ...extremity amputation divided into transtibial and transfemoral amputations.Methods: This observational cohort study used data from the Danish Nationwide Health registers. 11,205 first-time major lower extremity amputations were included from January 1, 2010, to December 31, 2021, comprising 3,921 transtibial amputations and 7,284 transfemoral amputations.Results: The 30-day mortality after transtibial amputation was overall 11%, 95% confidence interval (CI) 10–12 (440/3,921) during the study period, but declined from 10%, CI 7–13 (37/381) in 2010 to 7%, CI 4–11 (15/220) in 2021. The 1-year mortality was 29% overall, CI 28–30 (1,140 /3,921), with a decline from 31%, CI 21–36 (117/381) to 20%, CI 15–26 (45/220) during the study period. For initial transfemoral amputation, the 30-day mortality was overall 23%, CI 22–23 (1,673/7,284) and declined from 27%, CI 23–31 (138/509) to 22%, CI 19–25 (148/683) during the study period. The 1-year mortality was 48% overall, CI 46–49 (3,466/7,284) and declined from 55%, CI 50–59 (279/509) to 46%, CI 42–50 (315/638).Conclusion: The mortality after major lower extremity amputation declined in the 12-year study period; however, the 1-year mortality remained high after both transtibial and transfemoral amputations (20% and 46% in 2021). Hence, major lower extremity amputation patients constitute one of the most fragile orthopedic patient groups, emphasizing an increased need for attention in the pre-, peri-, and postoperative setting.
Background:
Biomechanical studies have shown that synthetic turf surfaces do not release cleats as readily as natural turf, and it has been hypothesized that concomitant increased loading on the foot ...contributes to the incidence of lower body injuries.
This study evaluates this hypothesis from an epidemiologic perspective, examining whether the lower extremity injury rate in National Football League (NFL) games is greater on contemporary synthetic turfs as compared with natural surfaces.
Hypothesis:
Incidence of lower body injury is higher on synthetic turf than on natural turf among elite NFL athletes playing on modern-generation surfaces.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Lower extremity injuries reported during 2012-2016 regular season games were included, with all 32 NFL teams reporting injuries under mandated, consistent data collection guidelines. Poisson models were used to construct crude and adjusted incidence rate ratios (IRRs) to estimate the influence of surface type on lower body injury groupings (all lower extremity, knee, ankle/foot) for any injury reported as causing a player to miss football participation as well as injuries resulting in ≥8 days missed. A secondary analysis was performed on noncontact/surface contact injuries.
Results:
Play on synthetic turf resulted in a 16% increase in lower extremity injuries per play than that on natural turf (IRR, 1.16; 95% CI, 1.10-1.23). This association between synthetic turf and injury remained when injuries were restricted to those that resulted in ≥8 days missed, as well as when categorizations were narrowed to focus on distal injuries anatomically closer to the playing surface (knee, ankle/foot). The higher rate of injury on synthetic turf was notably stronger when injuries were restricted to noncontact/surface contact injuries (IRRs, 1.20-2.03; all statistically significant).
Conclusion:
These results support the biomechanical mechanism hypothesized and add confidence to the conclusion that synthetic turf surfaces have a causal impact on lower extremity injury.
Background and objective:
Consensus on management of pelvic sentinel lymph nodes (PSLNs) has not been reached and thus the extent of sentinel lymph node biopsy (SLNB) of the groin in melanoma ...patients varies among centers and surgeons. Lymphatic drainage to PSLNs is often identified in, but the diagnostic and clinical relevance of PSLNs has been debated. Our aim was to determine if the presence of PSLNs affected recurrence or survival rates in patients with melanoma in the lower extremities.
Methods:
This retrospective study consisted of 702 patients with cutaneous melanoma operated between 2005 and 2018. Of these, 134 patients with melanoma in the lower extremities were included in the study. Images of lymphoscintigraphy and SPECT-CT studies were thoroughly observed together with surgery reports to define the status of SLNs.
Results:
Overall, 85 of 134 patients went through SLNB and 28 of them had PSLN identified. Two had their PSLN removed, which led 26 patients with PSLN to be compared to the 57 who did not have PSLN identified. We did not find statistically significant differences in overall recurrence (26.9% versus 28.0%, p = 1.00), regional nodal recurrence (11.5% versus 15.8%, p = 0.67), local or in-transit recurrence (19.2% versus 8.8%, p = 0.17), or distant recurrence rates (15.4% versus 19.3%, p = 0.66). Disease-free survival did not differ between the groups (median 23.0 (IQR 15.0–39.0) versus 19.0 (IQR 10.3–61.8) months, p = 0.82). Likewise, there was no statistically significant difference in melanoma-specific 5-year survival (78.6% versus 87.2%, p = 0.42).
Conclusions:
We did not find more frequent recurrence, shorter disease-free survival, or poorer melanoma-specific survival in patients with drainage to PSLN. Our findings strengthen the evidence that PSLNs should not be routinely biopsied if they are not the first-tier nodes.
Prospective cohort.
To determine if Star Excursion Balance Test (SEBT) reach distance was associated with risk of lower extremity injury among high school basketball players.
Although balance has ...been proposed as a risk factor for sports-related injury, few researchers have used a dynamic balance test to examine this relationship.
Prior to the 2004 basketball season, the anterior, posteromedial, and posterolateral SEBT reach distances and limb lengths of 235 high school basketball players were measured bilaterally. The Athletic Health Care System Daily Injury Report was used to document time loss injuries. After normalizing for lower limb length, each reach distance, right/left reach distance difference, and composite reach distance were examined using odds ratio and logistic regression analyses.
The reliability of the SEBT components ranged from 0.82 to 0.87 (ICC3,1) and was 0.99 for the measurement of limb length. Logistic regression models indicated that players with an anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain a lower extremity injury (P<.05). Girls with a composite reach distance less than 94.0% of their limb length were 6.5 times more likely to have a lower extremity injury (P<.05).
We found components of the SEBT to be reliable and predictive measures of lower extremity injury in high school basketball players. Our results suggest that the SEBT can be incorporated into preparticipation physical examinations to identify basketball players who are at increased risk for injury.
Purpose of Review
Diabetic peripheral neuropathy eventually affects nearly 50% of adults with diabetes during their lifetime and is associated with substantial morbidity including pain, foot ulcers, ...and lower limb amputation. This review summarizes the epidemiology, risk factors, and management of diabetic peripheral neuropathy and related lower extremity complications.
Recent Findings
The prevalence of peripheral neuropathy is estimated to be between 6 and 51% among adults with diabetes depending on age, duration of diabetes, glucose control, and type 1 versus type 2 diabetes. The clinical manifestations are variable, ranging from asymptomatic to painful neuropathic symptoms. Because of the risk of foot ulcer (25%) and amputation associated with diabetic peripheral neuropathy, aggressive screening and treatment in the form of glycemic control, regular foot exams, and pain management are important. There is an emerging focus on lifestyle interventions including weight loss and physical activity as well.
Summary
The American Diabetes Association has issued multiple recommendation statements pertaining to diabetic neuropathies and the care of the diabetic foot. Given that approximately 50% of adults with diabetes will be affected by peripheral neuropathy in their lifetime, more diligent screening and management are important to reduce the complications and health care burden associated with the disease.
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