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The lower extremity tourniquet failure rate remains significantly higher in combat than in preclinical testing, so we hypothesized that tourniquet placement accuracy, speed, and effectiveness would improve during training and decline during simulated combat. Navy Hospital Corpsman (N = 89), enrolled in a Tactical Combat Casualty Care training course in preparation for deployment, applied Combat Application Tourniquet (CAT) and the Special Operations Forces Tactical Tourniquet (SOFT-T) on day 1 and day 4 of classroom training, then under simulated combat, wherein participants ran an obstacle course to apply a tourniquet while wearing full body armor and avoiding simulated small arms fire (paint balls). Application time and pulse elimination effectiveness improved day 1 to day 4 (p < 0.005). Under simulated combat, application time slowed significantly (p < 0.001), whereas accuracy and effectiveness declined slightly. Pulse elimination was poor for CAT (25% failure) and SOFT-T (60% failure) even in classroom conditions following training. CAT was more quickly applied (p < 0.005) and more effective (p < 0.002) than SOFT-T. Training fostered fast and effective application of leg tourniquets while performance declined under simulated combat. The inherent efficacy of tourniquet products contributes to high failure rates under combat conditions, pointing to the need for superior tourniquets and for rigorous deployment preparation training in simulated combat scenarios., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Background: Previous studies have suggested that the presence of the vascular component of hand-arm vibration syndrome (HAVS) in the hands increases the risk of cold-induced vasospasm in the feet., Aims: To determine if objectively measured cold-induced vasospasm in the hands is a risk factor for objectively measured cold-induced vasospasm in the feet in workers being assessed for HAVS., Methods: The subjects were 191 male construction workers who had a standardized assessment for HAVS including cold provocation digital photocell plethysmography of the hands and feet to measure cold-induced vasospasm. Bivariate analysis and multinomial logistic regression were used to examine the association between plethysmographic findings in the feet and predictor variables including years worked in construction, occupation, current smoking, cold intolerance in the feet, the Stockholm vascular stage and plethysmographic findings in the hands., Results: Sixty-one (32%) subjects had non-severe vasospasm and 59 (31%) had severe vasospasm in the right foot with the corresponding values being 57(30%) and 62 (32%) in the left foot. Multinomial logistic regression indicated that the only statistically significant predictor of severe vasospasm in the feet was the presence of severe vasospasm in the hands (OR: 4.11, 95% CI: 1.60-10.6, P < 0.01 on the right side and OR: 4.97, 95% CI: 1.82-13.53, P < 0.01 on the left side). Multinomial logistic regression analysis did not indicate any statistically significant predictors of non-severe vasospasm in the feet., Conclusions: Workers assessed for HAVS frequently have cold-induced vasospasm of their feet. The main predictor of severe vasospastic foot abnormalities is severe cold-induced vasospasm in the hands.

We report an unusual case of a true atherosclerotic dorsalis pedis aneurysm in a relatively young (53-year-old), ex-semi-professional soccer player patient. This lesion is a rare entity and due to its location may require surgical intervention and removal. The presentation, the diagnostic evaluation, and the surgical treatment of the aneurysm are discussed. Pathological analysis did confirm atherosclerotic findings despite the rapid clinical onset of the lesion and the possible traumatic origin.

Larval therapy (LT) is known to be a gentle and effective method for removing necrotic tissue and bacteria and reducing the accompanying unpleasant odour. Ischaemia has been considered a relative contraindication for LT. We report a patient with ischaemia treated with LT. Inguinal revascularization was performed on a 69-year-old man with critical limb ischaemia, diabetes mellitus, heart failure and end-stage renal disease. Areas of dry black malodorous gangrene remained on the distal areas of the feet after surgery and the patient's poor health did not allow any additional surgery. The patient was referred to the dermatology department for LT. Although patients are usually given this treatment as inpatients, the patient requested treatment at home. After the first LT, there was a marked reduction in odour. The gangrene needed repeated applications of larvae to remove the dead tissue. After eight treatments, the result was more positive than we had expected, with total lack of odour and initiation of healing. Larvae cannot penetrate eschar, thus free-range larvae were used because they can move beneath the hard necrotic tissue and dissolve it.

Background: Although digital ulcerations frequently occur in patients with systemic sclerosis (SSc), there have been few reports on the macrovascular involvement., Objectives: To evaluate the macrovascular involvement in patients with SSc exhibiting digital ulceration or gangrene., Methods: Transfemoral catheter arteriography of the upper and/or lower extremities was performed in eight patients (one man and seven women, age range 42-71 years) with SSc exhibiting digital ulceration or gangrene. The background of the patients, such as autoantibody profiles and vascular risk factors including smoking habits, was also investigated., Results: Macrovascular involvement was detected in seven of eight patients. In three of seven patients who underwent arteriography of the upper extremity, occlusion was limited to the digital arteries. Obliteration of the ulnar artery and superficial palmar arch was detected in three of seven patients, and the radial artery in one patient. Only one of five patients who underwent arteriography of the lower extremity showed the occlusion limited to digital arteries of the foot. Occlusion of the posterior tibial artery, dorsalis pedis artery and arcuate artery was detected, each in one patient. Two patients showed occlusion of the plantar arch. Overall, the occlusion of arteries proximal to the digits was demonstrated in four of eight patients. Three of the four patients were positive for antitopoisomerase-1 antibody and had diffuse cutaneous SSc (dcSSc) with multiple skin ulcers or gangrene., Conclusions: Macrovascular involvement as detected with arteriography is not rare in SSc patients with digital ulceration or gangrene. Moreover, the vascular occlusion proximal to the digits seemed to be frequent in antitopoisomerase-1 antibody-positive dcSSc patients with multiple skin ulcers or gangrene.

Study Objectives: In healthy subjects, sleep propensity increases when the distal skin temperature increases relative to the proximal skin temperature. This increase results from increased blood flow in the skin of the extremities and is, among other factors, controlled by the hypothalamic circadian clock, as is sleep. Because narcolepsy is characterized by hypothalamic alterations, we studied skin temperature in narcoleptic patients in relation to their characteristically increased sleep propensity during the day., Design: Distal and proximal skin temperature and their gradient (DPG) were measured during a Multiple Sleep Latency Test. This allowed temperature to be studied during wakefulness, at sleep onset and during sleep., Setting: Tertiary narcolepsy referral center in a university hospital., Patients: Fifteen unmedicated narcolepsy patients with cataplexy and 15 controls., Interventions: None., Measurements and Results: In subjects in the waking state, DPG was higher in narcoleptics than in controls throughout the day (time by group interaction, p < .0001), due to increased distal skin temperature and decreased proximal skin temperature. The increase in DPG was related to a shorter subsequent sleep-onset latency (p = .02). Once asleep, narcoleptics maintained their elevated distal skin temperature and DPG (p < .0001), whereas proximal skin temperature increased to reach normal levels., Conclusions: This is the first demonstration of a dramatic alteration of daytime skin temperature control in narcolepsy. Even awake narcoleptic patients showed a DPG higher than that which healthy controls achieve when asleep. This observation suggests that hypocretin deficiency in narcolepsy affects skin-temperature regulation and invites further examination. Skin-temperature control might ultimately even have therapeutic implications for the alleviation of narcoleptic symptoms.

Introduction: The unreliability of the pulse examination of the foot has primarily been due to variability of technique between examiners. Whereas the groove between the medial malleolus and the Achilles tendon more readily defines the location of the posterior tibial pulse, the location of the dorsalis pedis pulse remains vague. In this paper a novel method of locating the dorsalis pedis pulse by physical examination is described., Methods: Forty one consecutive patients admitted to a general surgery service of a tertiary medical centre within a two month period were examined. Using the dorsal most prominence of the navicular bone as a landmark, the distance to the dorsalis pedis pulse in bilateral lower extremities was measured by palpation and compared to Doppler ultrasound. Measurements were confirmed by two separate examiners blinded to each others' results., Results: The dorsalis pedis artery was palpable in 78% of extremities and present by Doppler ultrasound in 95%. The location of the left dorsalis pedis artery was a mean (SD) 9.8 (1.4) mm by palpation and 11.1 (2.1) mm by Doppler ultrasound from the dorsal most prominence of the navicular bone. The right dorsalis pedis artery was 10.4 (3.4) mm by palpation and 11.5 (0.7) mm from the dorsal most prominence of the navicular bone. No significant differences in location of the dorsalis pedis artery were observed bilaterally between Doppler ultrasound and palpation; No significant differences were observed comparing contralateral dorsalis pedis arteries nor any differences between the examiners' results., Conclusion: The dorsal most prominence of the navicular bone provides a bony landmark to readily locate the dorsalis pedis artery. Reliability of the examination may be increased as to the patency of the dorsalis pedis artery by using this dependable anatomic landmark.

Background: Measurement of foot venous pressure (FVP) is useful for evaluating chronic venous insufficiency (CVI) functionally, because CVI always causes venous hypertension. In the present study, the various FVP parameters were analysed according to the new classification of venous disorders based on clinical, aetiological, anatomical and pathophysiological data (the CEAP classification)., Methods: During the past 7 years, a total of 257 legs in 196 consecutive patients with CVI have been studied. The following FVP parameters were assessed: the percentage decrease in pressure from rest with manual calf compression, the rate of increase of pressure during 4 s after compression (4SR) and the time to 50 per cent recovery of pressure (RT50) after release of compression., Results: The incidence of skin changes due to venous stasis increased as the percentage pressure drop and RT50 fell. In addition, a pressure drop of less than 72 per cent and an RT50 of less than 20 s could detect legs with skin changes with a sensitivity of 76 per cent and a specificity of 62 per cent. In legs with primary varicose veins, pressure drop, 4SR and RT50 values deteriorated in proportion to the severity of the associated deep venous reflux., Conclusion: FVP parameters correlate well with the severity of clinical manifestations and venous reflux, and could be used quantitatively to evaluate the severity of CVI.

Background: The aim of this study was to investigate possible differences in capillary density of the skin of the foot between normal subjects and patients with peripheral vascular disease., Methods: Using in vivo video microscopy, a method was developed to measure the average capillary density (ACD) of the skin of the foot and toes. In a cross-sectional observational study, 21 patients with intermittent claudication and 23 patients with rest pain or ischaemic ulceration were compared with 19 age- and sex-matched controls., Results: Mean(s.e.m). values of ACD of the foot were 33.7(1.9) and 34.4(1.7) per mm2 in the right and left sides respectively for controls, 31.2(1.8) per mm2 (P not significant) and 31.9(2.6) per mm2 (P not significant) in the symptomatic and contralateral sides respectively for patients with claudication, and 22.0(1.8) per mm2 (P < 0.001) and 24.3(1.7) per mm2 (P < 0.001) in the symptomatic and contralateral sides respectively for patients with rest pain or ulceration., Conclusion: Capillary density of the skin of the foot is significantly reduced in patients with arterial ulceration compared with that in patients with claudication and healthy subjects.

Background: The past decade has seen an increase in the use of distal arterial bypass grafts for treating critical lower limb ischaemia. However, this surgical policy is associated with variable results. The aims of this study were to identify factors that affect outcome and to calculate the cost of such surgical interventions., Methods: A prospective analysis of femorocrural and femoropedal bypass grafts and primary amputations was performed between June 1991 and January 1995. A consecutive series of 109 limbs with critical lower limb ischaemia underwent a bypass graft to a single crural or pedal vessel shown on either preoperative intra-arterial digital subtraction angiography or at surgical exploration. Complete data were available for all patients during follow-up which ranged from 0 to 42 (median 12) months. The factors assessed were age, sex, diabetes, pedal arch, graft material, outflow vessel, number of calf vessels, number of vessels crossing the ankle, inflow state, previous revascularization procedures and foot gangrene and tissue necrosis. Chief outcome measures were survival, knee and limb salvage, patency rates and hospital cost. The Kaplan-Meier method was used to construct life tables and the log rank test for comparison of factors. Cost was measured according to National Health Service criteria, and comparisons were made by the Mann-Whitney U test., Results: At 36 months primary patency was 27 per cent, primary assisted patency 31 per cent and secondary patency 45 per cent; limb salvage was 54 per cent, knee salvage 73 per cent and survival 58 per cent. Significant factors in predicting outcome were graft material (P = 0.004), inflow state (P = 0.0001), number of calf vessels (P = 0.039), number of vessels crossing the ankle (P < 0.0001) and the condition of pedal vessels (P < 0.0001). Cost analysis showed that the median price for a successful bypass was 4320 pounds, that of a failed bypass leading to amputation 17,066 pounds and that of primary amputation in patients with non-reconstructable distal disease 12,730 pounds., Conclusion: The patency rate of femorotibial and peroneal bypass depends on the inflow state, the availability of a venous conduit, the number of calf vessels, the presence of straight flow to the foot and the presence of patent pedal vessels. These factors can help in the selection of patients for femorodistal reconstruction and may explain the wide variation in published results. The low cost of revascularization compared with amputation justifies attempted reconstruction. However, repeated attempts to reconstruct patients with severe distal disease who may benefit more from primary amputation will significantly increase the cost.

We report two patients treated with interferon-alpha who developed Raynaud's phenomenon followed by multiple digital necrosis. Arteriography of the legs revealed diffuse distal narrowing. Histological examination of the resected tissue showed ischaemic necrosis within the dermis and subcutaneous tissue without vasculitis. Resolution of the symptoms was observed when interferon-alpha was withdrawn. Since other causes of Raynaud's phenomenon and digital necrosis were ruled out, a drug cause is likely. Raynaud's phenomenon should be looked for in patients treated with interferon-alpha. If present, immediate withdrawal of the drug is required.

The effects of nilvadipine on the peripheral circulation in the lower extremities using a duplex system of two-dimensional colour and pulse Doppler ultrasonography were studied in 32 patients with type 2 diabetes mellitus and mild essential hypertension. The patients (19 men and 13 women) were randomly divided into treatment and control groups. The anatomical cross-sectional area and blood flow index of the dorsal pedis artery were determined by colour and pulse Doppler ultrasonography before and 60 min after administration of 4 mg nilvadipine or placebo. Pulse rate and blood pressure were measured simultaneously. There were no significant changes in pulse rate or blood pressure after administration of either drug. Both cross-sectional areas (from 4.3 +/- 0.4 to 5.2 +/- 0.5 mm2, p < 0.05) and blood flow index (from 40.3 +/- 4.3 to 58.8 +/- 9.0, p < 0.05) were significantly increased in the treatment group, whereas there were no significant changes in either measurement in the control group. The findings showed that a single administration of nilvadipine increases blood flow in the dorsal pedis arteries of diabetic patients.

The severity of post-thrombotic symptoms in 111 limbs (107 patients) with previous phlebographically proven deep vein thrombosis (DVT) was correlated with superficial and deep venous function as determined by foot volumetry (n = 90) and duplex ultrasonography (n = 62). The median delay between DVT and assessment was 8 (range 1-34) years. Symptoms were mild (group 1) in 31 limbs (28 per cent), moderate (group 2) in 41 (37 per cent) and severe (group 3) in 39 (35 per cent). There was no significant relationship between the site of DVT, or the time since DVT, and the severity of symptoms. Without tourniquet occlusion of superficial veins, limbs in group 3 had a significantly shorter half-refilling time than those in groups 1 and 2 (P = 0.01). Although a similar trend was observed after tourniquet occlusion of superficial veins, this was not statistically significant. There was no significant difference in the expelled volumes between the three clinical groups. On duplex scanning, deep and superficial venous reflux was detected in just over half of the limbs in each group. Eight patients had entirely normal scans and none of them had severe symptoms (P = 0.04). This study identifies a strong association between severe postphlebitic syndrome and venous reflux, such that it may be considered that venous reflux is necessary for the development of severe post-thrombotic symptoms. However, many patients with severe reflux have only mild symptoms and additional factors must therefore contribute to the development of severe postphlebitic syndrome.

The feasibility of vein bypass surgery to the arteries of the foot was studied in a diabetic population with critical ischaemia; whether or not such reconstruction leads to an independent lifestyle was assessed 1 year later. Thirty-three reconstructions were performed on 32 limbs in 31 patients. The mortality and reoperation rates within 1 month were both 6 per cent. Primary and secondary patency, limb salvage and survival rates at 1 year were 76, 89, 89 and 82 per cent respectively. Good results in the form of combined survival, patency, limb salvage, walking ability, relief of pain and residence at home were achieved in 64 per cent of patients after 1 year. Reconstructive vascular surgery to the foot in diabetics is feasible and affords two-thirds of patients an independent lifestyle 1 year after surgery.

Medical therapy of PAOD is only indicated in patients unsuitable for vascular reconstruction or angioplasty. The approach includes early detection of subjects at risk, avoidance of known risk factors, and appropriate management of diseases such as diabetes and hypertension. Vasodilators are of little use orally, though some drugs may have a part to play for short-term management and iloprost should be considered for patients unsuitable for revascularization. The ankle systolic or toe pressure should be used as a measure of disease and, if reduced, arteriography should be performed. This should not be limited to those thought fit for major surgery, as angioplasty or thrombolytic therapy may be appropriate, and aortoiliac disease may be treated by extra-anatomic bypass if not suitable for major surgery. Arterial reconstruction is associated with a reduction in both mortality and amputation, and should be attempted if a greater than 25% chance of limb salvage could be expected.

Graduated compression stockings are frequently used in the prevention of deep venous thrombosis and the treatment of venous insufficiency. Two patients are discussed who sustained ischaemic complications after application of graduated compression stockings. Review of the literature demonstrates that low cutaneous pressures significantly decrease local blood flow and that the amount of pressure exerted by graduated compression stockings increases significantly with increases in leg girth. Ischaemic complications associated with the use of these stockings also appears to be more common than previously thought and any policy of routine prescription to patients should be questioned.

The A-V Impulse System reduces the incidence of deep vein thrombosis by pneumatically compressing the venae comitantes of the lateral plantar artery, causing an increase in the velocity of blood in the proximal axial veins. Using a duplex scanner the effects of altering the pressure, pulse duration and frequency of foot compression on the velocity and volume of blood flow in the superficial femoral and popliteal veins were quantified. In 20 legs, foot compression of 50, 125 and 200 mmHg significantly increased the maximum venous blood flow by 9.0, 13.4 and 15.1 ml/s respectively (P < 0.001). Conversely, reducing the frequency of compression from 6 to 3 cycles per min significantly increased the rise in peak flow from 10.1 to 14.8 ml/s (P < 0.001). Changing the duration of compression from 1 to 3 s had no significant effect on peak flow. Increased blood flow is best achieved with high-pressure low-frequency foot compression. Increasing the duration of compression beyond 1 s has no effect on augmentation of flow in the deep veins.

Cyanosis of the hands and feet in Buerger's disease is known as 'Buerger's colour'. This characteristic skin colour is produced by the subpapillary venous plexus. The reactions of the subpapillary venous plexus in patients with Buerger's disease were observed by analysing the fractional blood volume of tissue using a visible light reflective spectrophotometer. Capillary morphology was investigated using an intravital video-microscopic system. Twenty-seven subjects, comprising 13 normals and 14 patients with Buerger's disease, were studied. In the nailbeds of patients with Buerger's disease, an increase in the number of loops, cyanotic colour change and dilatation were observed. In this condition there was incompetence of venular tonus and regurgitation at venular valves. Buerger's colour is probably due to excessive congestion of venous blood in the subpapillary venous plexus which is produced by these mechanisms.

This case report documents the treatment of a spinal cord injured patient with acrocyanosis of both feet. The 37-year-old white male patient sustained a traumatic spinal cord injury at the age of 16 years, which resulted in an incomplete vertebral fracture of the C5-C6 level. He was treated with computerized neuro-muscular electrical stimulation (NMES) of the quadriceps femoris muscle with weights applied to the ankles an average of two times per week for six weeks. Improvements in the color of the patient's skin and toe ulcers, stronger pedal pulses bilaterally, decreased swelling bilaterally, and subjective reports of less discomfort were noted. The empirical findings of this case report suggest that computerized NMES may be effective for improving circulation in the spinal cord injured individual with acrocyanosis. Further study, however, is needed to determine whether a relationship may exist between blood flow and computerized NMES.

Age-related changes in the feet include alterations in the skin, which becomes dry, inelastic, and cool and often exhibits hyperkeratoses. Thickened and brittle toenails complicate pedicure. The contour of the foot widens with age and may have increased forefoot height in the presence of toe deformities. Sensory acuity diminishes, as does joint mobility, muscle-force production, and ability to withstand stress. The elderly person's gait is slower and less forceful, with shorter strides. Visual loss affects footwear donning and toenail trimming. Older individuals on a limited income are less likely to have appropriate shoes and hose. Preventive care begins with good hygiene and continues with selection of suitable hosiery and shoes. Conservative management of the podiatric conditions most often seen in geriatric patients (eg, metatarsalgia and hallux valgus) should be based on relating the pathomechanics of the disorder to the options available in shoe selection, modification, and insert design.

Four hundred and seventeen consecutive patients referred with significant chronic venous disorders of the lower limb have been studied. Two hundred and ninety-nine were considered to have uncomplicated primary varicose veins, with saphenous incompetence. The remaining 118 presented with past or current skin ulceration, prominent pain and swelling, or both. Ascending and descending venography and further Doppler studies revealed only 18 patients (17 with ulceration) with an incompetent long saphenous system and ankle perforators as the only identifiable abnormalities. In 12 of these, patients' dorsal foot vein pressures were measured at rest and the maximum fall demonstrable after exercise expressed as a percentage of this (12.9 per cent +/- 6.0). This test was repeated with a narrow tourniquet inflated to 160 mmHg, applied to the mid-thigh (35.6 per cent +/- 7.4) (P less than 0.05), and again after accurate groin ligation and stripping of the long saphenous vein to the knee (31.9 per cent +/- 10.7) (P less than 0.05). These results seem to validate the use of the foot pressure/tourniquet test in assessing the relevance of saphenofemoral incompetence, and suggest in a proportion of venous ulcers this is a princical factor.

A series of 112 consecutive femorotibial bypasses was reviewed in which glutaraldehyde-stabilized human umbilical vein was used for the bypass. The duration of follow-up was between 6 months and 2 1/2 years. Cumulative patency at 2 years for the entire group was 9 per cent. The state of the pedal arteries, site of the distal anastomosis and age of the patient influenced the results. The difference in the patency rates at 1 year between patients with 3 patent pedal arteries and those with only 1 is significant (P less than 0.001) as is that between those with 3 and those with 2 (P = 0.024). Of 49 patients with pre-gangrene, in whom the bypass worked for a period in excess of 2 months, only 7 eventually required amputation in contrast to 32 of a group of 39 similar patients in whom the bypass failed early.

The changes in foot vein pressure during exercise have been measured in 30 normal legs and 109 legs with varicose veins or postphlebitic changes and correlated with the number of capillaries visible in a histological section of skin from the ulcer-bearing area. There was a significant correlation between the inability of the calf pump to reduce foot vein pressure during exercise and the number of capillaries in the skin. It is suggested that the increased number of capillaries secondary to venous hypertension during exercise may be the prime cause of the nutritional abnormalities that eventually cause a venous ulcer.

Temperature assessment has proven valuable in detecting areas of inflammation in the insensitive limb. Monitoring the inflammatory response to the stresses of footwear and walking has worked as a "pain substitute." In conjunction with other evaluation methods, the results of temperature assessment can be used to reduce the incidence of injury and ulceration in the insensitive foot. A review of principles and methods, a presentation of a case study, and a discussion will elaborate upon the concepts of temperature assessment.

The ankle and foot complex at times must be mobile and at other times must be quite stable. The bony, ligamentous, and muscular structures of the ankle and foot are presented with respect to their mobility and stability functions. Innervation and vascular supply are discussed. Normal anatomy provides a basis and a reference point for discussion of dysfunction of the ankle and foot.

An attempt has been made to determine the effect on vasomotor tone and sweating of peripheral neuropathy in the feet of diabetics with vascular disease. There was a loss of vasomotor tone in 48 per cent of patients with peripheral neuropathy and in 12 per cent of those without neuropathy (P less than 0.01). Complete loss of sudomotor activity was rare in both groups.

The objective of this investigation was to study the pathogenesis of intermittent claudication in the foot and to determine whether it could be used as a diagnostic manifestation of Buerger's disease. In 30 limbs with foot claudication and 20 limbs without foot claudication, systolic pressures at various levels of the leg were measured by a photoelectric technique, and the significance of collateral circulation in the foot on the development of claudication was studied. Although there was a significant difference between blood pressures at the foot and toe, considerable overlapping was seen between the two groups. This finding might indicate that muscle circulatory insufficiency in limbs with foot claudication results from occlusion of the nutrient arteries supplying the plantar muscles as well as poor collateral circulation in the foot. Hospital records of 48 patients with foot claudication were reviewed and the question of whether these patients could be diagnosed as having Buerger's disease was discussed. On the basis of clinical findings and arteriographic appearances, the diagnosis of Buerger's disease was made in all patients except one with hypercholesteraemia. From the results obtained here, foot claudication could be considered to be almost specific to Buerger's disease and a useful guide in the clinical diagnosis of this disease.

Blood flow was measured in the feet and toes of 23 diabetics, 7 controls and 6 non-diabetic neuropathic controls, using venous occlusion plethysmography. All of the diabetics showed a characteristic flow abnormality with mild hyperperfusion of the foot at rest but impaired peak flow following arterial occlusion. When the diabetics were subdivided into those with 'small vessel disease', those with neuropathic ulceration and those with neuropathy but no ulceration, the groups had remarkably comparable blood flows, except that peak great toe blood flow was rather lower in small vessel disease. In small vessel disease, the combination of high resting blood flow and elevated foot venous oxygen saturation suggests that the hyperperfusion is due to arteriovenous shunting. It seems likely that the toe lesions ascribed to small vessel disease were in fact manifestations of severe diabetic neuropathy. The term small vessel disease should be avoided in the context of diabetic foot lesions.

Studies are underway on the effect on insensitive feet of repeated, "normal," nonischemic pressure, such as that caused by walking. Although such stress does not harm normal tissues, it can lead to soft-tissue damage in the insensitive foot. This research is trying to determine such information as the amount of energy input required to damage soft tissue, microscopic and macroscopic changes that occur during early soft-tissue damage, importance of time sequence of energy input, and amount of energy input that causes hypertrophy rather than ulceration. The progress of these studies is reported.

Systolic blood pressures were measured at the ankle by Doppler ultrasound sphygmomanometry in a series of elderly patients. Twenty-four limbs were affected by severe occlusive arterial disease and in 15 limbs there was no good evidence of significant peripheral vascular insufficiency. The pressures were measured in the supine position and again with the subject sitting upright or standing. In both series there was, as anticipated, a marked increase in the pressure, so that the sitting/erect range of pressures in the ischaemic limbs overlapped considerably with the supine pressure range in the healthy limbs and were then higher than the values usually associated with rest pain and non-healing skin lesions. This postural effect almost certainly does not reflect a corresponding rise in blood flow in the normal extremity, but in the ischaemic foot it may offer a simple means of improving perfusion.

A post-stress imaging study utilizing single intravenous doses of thallium-201 was performed on feet with trophic skin lesions. Forty-two ischaemic ulcers were classified into four basic types according to the presence and degree of the inherent inflammatory response of the ulcer in both the initial and delayed distributions. Both the relationship between ulcer type and prognosis and the effects of therapy within ulcer type were assessed. The results suggest that ulcers of Type I or Type II heal in response to conservative treatment, while ulcers of Type III, although undergoing healing, require surgical treatment to prevent a protracted hospitalization. In Type IV ulcers, healing is not to be expected at all with conservative therapy; therefore an early decision of amputation may be necessary if surgical measures are not indicated. The technique reported may be helpful not only in the prediction of spontaneous ulcer healing but also in the selection of appropriate treatment.

The importance of physically intact hands and feet is taken for granted and consequently not appreciated until they are functionally impaired by vascular or neural injury of disease. The pathogenesis and clinical manifestations of cutaneous lesions complicating hypersensitive and insensitive limbs are described. The current therapeutic approaches and measures for these conditions are presented. Protection and prophylaxis trauma for neurologically impaired parts are emphasized.

A method to revascularize the critically ischaemic lower limb by arterialization of the dorsal venous arch of the foot via the long saphenous vein is described. Satisfactory procedures were achieved in 5 of 6 patients for whom standard arterial reconstructions were not possible and who would otherwise have required amputation. Of these, 2 failed in the early postoperative period and amputation was performed. Two others failed after 1 year and 18 months respectively but amputation was not required. One patient died 8 months after operation with a functioning arterialized vein and pain-free limb. In the 5 patients with successfully revascularized limbs rest pain was relieved, and incisions, ischaemic ulcers and gangrene healed, showing that effective nutrition of the lower limb was achieved by delivering arterial blood through the venous system. Complications were minor and easily controlled. Although as a result of the procedure amputation was avoided in 3 out of 6 patients, the place of the method in the treatment of critical ischaemia of the lower limb remains dubious. Further investigation and modification of the method are planned.