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Pseudoaneurysms of the dorsalis pedis artery are rare complications following arthroscopic surgery. This manuscript reports a case of an intra-articular pseudoaneurysm presenting nearly 5 months following an arthroscopic Broström procedure. The rarity of this complication and the patient's unusual clinical presentation prompted the use of imaging to diagnose the problem and guide management. Although imaging artifacts are often a nuisance, recognition of clinically relevant artifacts can help make a diagnosis. This case illustrates such a situation.

Purpose: Open reduction and internal fixation (ORIF) using an extended lateral approach combined with plate osteosynthesis represents the current gold standard in calcaneal fracture treatment, but it is associated with a wound complication rate of up to 30%. Literature suggests that micro-circulation is one of the key factors for sufficient wound healing. The aim of this study was to evaluate soft tissue micro-circulation of the hindfoot in healthy volunteers to determine influencing factors and to identify hypoxic or hypoperfused areas in non-trauma situations, with special attention to surgical approaches., Methods: Micro-circulation of the lateral hindfoot of 125 participants was non-invasively measured at 2 and 8 mm depths, utilizing a Micro-Lightguide O2C® spectrophotometer. Blood flow (BF [AU]) and oxygen saturation (SO2 [%]) of ten measurement points (MPs) were documented. Demographic factors (age, gender, body mass index [BMI], systolic/diastolic blood pressure, smoking, and pack-years) and regional differences with special regard to surgical approaches (extended lateral approach, Palmer approach, Ollier approach, and a self-modified extended lateral approach) were analyzed., Results: The SO2 assessments at 2- and 8-mm depths revealed higher values in males (p = 0.043; p = 0.025). There was a correlation between higher age and lower 2 mm BF (p = 0.044). Smoking history and number of pack-years did not predict micro-circulation. BF at the 2 mm depth was highest in the regions of Palmer and Ollier approach (p < 0.001). The MP at the distal calcaneal tuberosity showed significantly higher values regarding all parameters (SO2 (2 mm), p < 0.001; SO2 (8 mm), p = 0.001; BF (2 mm), p < 0.001; BF (8 mm), p < 0.001), compared to the surrounding area., Conclusions: In non-trauma situations, young males were associated with better micro-circulatory supply of the lateral hindfoot. There was a trend for higher blood flow in regions of the Palmer and Ollier approach. The distal calcaneal tuberosity was clearly superior in all micro-circulatory parameters when compared to the surrounding area.

Purpose: Low-intensity pulsed ultrasound (LIPUS) has been shown to accelerate bone healing and is considered to increase blood flow. The aim of this study was to assess changes in micro-circulation of the foots' soft tissue in response to LIPUS intervention. We hypothesised improved micro-circulation in response to LIPUS., Methods: Micro-circulation was assessed in 2 mm and 8 mm-deep skin of 50 healthy volunteers using non-invasive laser-doppler spectrophotometry (O2C-device). Measurements were performed before LIPUS-intervention (pre), directly after intervention (post) and 20, 40 and 60 minutes after LIPUS., Results: All parameter of micro-circulation increased directly after LIPUS intervention at 8 mm depth. Participants with a low pre-intervention flow showed the largest changes (p < 0.001) with an increased post-flow of 38%. SO 2 levels increased significantly after intervention (p = 0.045) and decreased after 60 minutes in comparison to pre-intervention status. rHb levels after 60 min were significantly higher in comparison to pre-intervention levels., Conclusion: In healthy volunteers, low-intensity pulsed ultrasound led to significant short-term changes in microcirculation of the foot. Younger subjects with a low pre-flow level and smokers showed a higher potential to increase blood flow after LIPUS.

Purpose: To report on the first clinical experience with perfusion angiography (PA) of the foot in patients with chronic critical limb ischemia., Materials and Methods: PA is a post-processing software algorithm and no extra digital subtraction angiography (DSA) has to be performed for this analysis. The data used to test the feasibility of PA were obtained from a consecutive group of 89 patients with CLI who were treated with standard below the knee angioplasty and 12 separate patients who were not suitable for endovascular revascularization., Results: Motion artifacts in the dataset of the DSA made post-procedural analysis impossible in 10 % intervention. In the majority of patients (59/68) PA showed an increase in volume flow in the foot after successful angioplasty of the crural vessels. However, in 9/68 patients no increase was seen after successful angioplasty. With the use of a local administered competitive α-adrenergic receptor antagonist, it is also possible to test and quantify the capillary resistance index which is a parameter for the remaining functionality of the microcirculation in CLI patients., Conclusion: PA might be used as a new endpoint for lower limb revascularization and can also be used to test the functionality the microcirculation to identify sub-types of patients with CLI. Clinical evaluation and standardization of PA is mandatory before introduction in daily practice.

Objective: To study the feasibility of 2D perfusion imaging in critical limb ischemia (CLI)., Methods/results: Perfusion angiography is a new technology which was tested in 18 patients with CLI of the foot. A standardized protocol was used with a catheter placed at the mid-part of the popliteal artery, and a total of 9 cc of non-ionic iodinated contrast material was injected at a rate of 3 cc/sec. The technology is based on early cardiology research where iodinated contrast agents were used for imaging of cardiac perfusion. During the first pass of the contrast, there is a significant diffusion of the contrast agents into the interstitial space, particularly for non-ionic and low-molecular-weight compounds., Discussion: The original angiography data can be used to make a time-density curve, which represents the actual perfusion of the foot in time. Angiographic perfusion imaging is a post-processing modality for which no extra contrast or radiation is needed. With this technique, it is possible to get more information about the perfusion status and microcirculation of the foot. This is a step toward functional imaging in CLI patients.

We aimed to determine reference values of perfusion index (PI) in healthy newborns during the early neonatal period. Preductal (right hand) and postductal (foot) PI values were assessed during the first 5 days of life by using a new generation pulse oximetry. A total of 241 newborn infants (196 [81.3 %] term and 45 [18.7 %] preterm) were enrolled to the study. On the first day, in term infants, the median (interquartile range [IQR]) preductal and postductal PI were 1.35 (1.02-1.91) and 0.88 (0.62-1.22), respectively (p = 0.001). These values were 0.88 (0.60-1.26) and 0.61 (0.35-0.92) in preterm infants, with the same respect (p = 0.001). From the first to third days, preductal PI remained significantly higher than the postductal PI (p < 0.001, for all comparisons). Both preductal and postductal PI of term newborns were significantly higher than those of preterm infants (p < 0.001, for both comparisons). These differences in PI disappeared on the fifth day of life. Conclusion PI values which reflect peripheral perfusion seem to reach to a steady state on the fifth day of life following physiological maturation.

Charcot neuroarthropathy is a low-incidence complication of diabetic foot and is associated with ankle and hind foot deformity. Patients who have not developed deep ulcers are managed with offloading and supportive bracing or orthopedic arthrodesis. In patients who have developed ulcers and severe ankle instability and deformity, below-the-knee amputation is often indicated, especially when deformity and cutaneous involvement result in osteomyelitis. Ischemic association has not been described but can be present as a part of peripheral arterial disease in the diabetic population. In this extreme and advanced stage of combined neuroischemic diabetic foot disease, revascularization strategies can support surgical and orthopedic therapy, thus preventing osteomyelitis and leading to limb and foot salvage.

Purpose: To evaluate the additional value of three-dimensional rotational angiography (3DRA) of the foot compared with digital subtraction angiography (DSA) in patients with critical limb ischemia (CLI)., Technique: For 3DRA, the C-arm was placed in the propeller position with the foot in an isocentric position. The patient's unaffected foot was positioned in a footrest outside the field of view. For correct timing of 3DRA, the delay from contrast injection in the popliteal artery at the level of knee joint to complete pedal arterial enhancement was assessed using DSA. With this delay, 3DRA was started after injection of 15 ml contrast. Imaging of the 3DRA could directly be reconstructed and visualized., Materials and Methods: Patients undergoing 3DRA of the foot were prospectively registered. DSA and 3DRA images were scored separately for arterial patency and presence of collaterals. Treatment strategies were proposed based on DSA with and without the availability of 3DRA., Results: Eleven patients underwent 3DRA of the foot. One 3DRA was not included because the acquisition was focused on the heel instead of the entire foot. Diagnostic quality of 3DRA was good in all ten patients. 3DRA compared with DSA showed additional patent arteries in six patients, patent plantar arch in three patients, and collaterals between the pedal arteries in five patients. Additional information from 3DRA resulted in a change of treatment strategy in six patients., Conclusion: 3DRA of the foot contains valuable additional real-time information to better guide peripheral vascular interventions in patients with CLI and nonhealing tissue lesions.

Pseudoaneurysms in the foot are more often reported in the lateral plantar artery than the medial plantar artery, most likely because of its more superficial location. There are no reports of pseudoaneurysm of the medial plantar artery after trauma. We present two cases of pseudoaneurysm of the medial plantar artery after blunt foot trauma and foot laceration. This pseudoaneurysm compressed a posterior tibial nerve, resulting in tarsal tunnel syndrome. The patients were treated successfully using transcatheter embolization without the need for surgical intervention. The tarsal tunnel syndrome also subsided. Here, the authors report these cases and provide a review of literature.

The definitive aim of a minor amputation is limited resection with retention of feet and legs resulting in a completely loadable extremity, in contrast to the lower leg stump. A shift in the amputation level in the sense of a shortening is inevitably accompanied by a reduction in the stand area, an increase in axial pressure and a disruption of muscle equilibrium in the extent of movement of the rest of the foot. This knowledge forms the central issue for further treatment of minor amputations in addition to the subtle treatment of the skin of the sole for coverage of a tension-free tip of the stump. Advantageous are longitudinal partial amputations of the forefoot and midfoot.

Aims/hypothesis: The aim of the study was to stratify the risk of diabetic patients with leg ulcer or gangrene undergoing infrainguinal revascularisation for critical limb ischaemia., Methods: The study cohort included 732 revascularisation procedures performed in 597 diabetic patients with ulcer or gangrene. Logistic regression and CART analysis were used for identification of predictors of 1-year outcome., Results: Logistic regression showed that chronic kidney disease (CKD) class (OR 1.38, 95% CI 1.16, 1.65) was an independent predictor of 1-year leg salvage (area under the receiver operating characteristic [ROC] curve 0.60, 95% CI 0.54, 0.65). The terminal nodes of the CART for 1-year leg salvage were CKD classes 4-5, the level (infrapopliteal vs femoropopliteal revascularisation), type of revascularisation (bypass surgery vs percutaneous transluminal angioplasty) and gangrene (area under the ROC curve 0.62, 95% CI 0.57, 0.68). Logistic regression showed that pulmonary disease (OR 1.76, 95% CI 1.11, 2.78), CKD class (OR 1.43, 95% CI 1.24, 1.65), foot gangrene (OR 1.76, 95% CI 1.21, 2.60) and patient age (OR 1.02, 95% CI 1.01, 1.04) were independent predictors of 1-year amputation-free survival (area under the ROC curve 0.65, 95% CI 0.60, 0.69). The terminal nodes of the CART for 1-year amputation-free survival were CKD classes 3-5, patient's age of ≥ 75 years and foot gangrene (area under the ROC curve 0.64, 95% CI 0.60, 0.68)., Conclusions/interpretation: CKD is a formidable risk factor for poor intermediate outcome after infrainguinal revascularisation in diabetic patients with foot ulcer or gangrene. CART analysis indicates that foot gangrene is also a significant risk factor for adverse outcome.

Diabetic foot syndrome is a major complication for patients with diabetes mellitus. About 25% of the 6 million patients with diabetes in Germany will suffer from diabetic foot syndrome at some point during the course of disease. Diabetic neuropathy and peripheral vascular disease are the main causative factors in the pathogenesis of diabetic foot ulcers. The mortality rate of these patients is more than twice as high as that of the average population. 25% of costs incurred by patients with diabetes are spent on diabetic foot ulcers, and 50% of hospital days are attributed to the treatment of the diabetic foot syndrome. This syndrome is also the most common cause of non-traumatic amputations. Both the risk of amputation and mortality are much increased in case of peripheral vascular disease. Hence, the aim is to lower the still high number of amputations in Germany by appropriate preventive measures as well as by multidisciplinary diagnostics and therapy.

Deep-vein thrombosis (DVT) and pulmonary embolism (PE) represent life-threatening postoperative complications frequently responsible for in-hospital mortality following total knee arthroplasty (TKA). Mechanical prophylaxis in the form of a foot pump offers an alternative to pharmacological and physical therapy. The aim of this prospective and randomised study was to examine the clinical efficacy of the A-V Impulse (AVI) system in reduction of soft-tissue swelling of the lower limb following a TKA. A total of 80 patients undergoing cemented TKA between September 2005 and December 2006 were randomised into two groups of 40 patients (n¹ = 40, n² = 40) during the 16-month study period. All patients received a subcutaneous dose of low molecular weight heparin (LMWH) (Enoxaparin/Clexane® 40 mg) once daily beginning 24 hours prior to the operation. The mean age for the groups n¹ and n² were 68.93 and 68.15 years, respectively. The reduction of soft-tissue swelling in the n¹ group was significantly higher (p < 0.05) compared with n². Evaluation of body mass index (BMI) with regard to the average reduction of soft-tissue swelling showed no significant influence (p < 0.05). The better function of the operated knee in group AVI was a significant predictor for improved agility and mobility (p < 0.01). No complications were reported for the application of the AVI. No ultrasonographic evidence of DVT or PE was found in any of the 80 patients during the investigative time period of eight days. After three months, there was no evidence of a symptomatic DVT.

Standing on a foam surface is believed to exaggerate balance deficits by decreasing the reliability of somatosensory information from cutaneous mechanoreceptors on the plantar soles (i.e. base of feet) and by altering the effectiveness of ankle torque. The aim was to further document the nature of foam posturography testing by comparing between standing on foam and standing with decreased Rapidly Adapting Mechanoreceptive Sensation (RAMS). Sixteen healthy adults (mean age 20.8 years) were tested with posturography, standing with eyes open and closed on a solid surface and on foam, with and without decreased plantar RAMS. Standing balance was measured as torque variance and further analyzed by being divided into three spectral categories. Plantar cutaneous hypothermic anesthesia by ice-cooling was used to decrease RAMS. Plantar mechanoreceptive sensation was precisely determined with tactile sensitivity and vibration perception tests. Vibration perception was significantly decreased by hypothermic anesthesia, but tactile sensitivity was not. The anterior-posterior torque variance was significantly larger for frequencies less than 0.1 Hz under eyes closed conditions when standing on a solid surface with decreased RAMS compared to normal sensation. No effect of decreased RAMS was seen with eyes open on a solid surface, nor on foam with eyes open or closed. Decreased RAMS produced body sway responses on a solid surface that were different in spectral composition, amplitude, direction and that responded differently to vision compared with standing on foam. Hence, this study showed that RAMS contributes to postural control but reduction in RAMS does not produce a similar challenge as standing on foam.

Vasculitis consists of a group of diseases characterized by an inflammatory process of the vessel wall. There is a wide variation in symptoms and almost any organ or tissue can be affected. Thromboangiitis obliterans (TAO; also known as Buerger's disease) is a special form of vasculitis with recurring inflammation and thrombosis of small and medium size arteries and veins of the hands and feet. To date the etiology still remains unclear but there is a strong association with the use of tobacco products. Ulcerations and gangrene of the extremities are common complications often resulting in the need for amputation of the extremity involved. Treatment of TAO includes both surgical and non-surgical methods but there is still no agreement concerning the optimal treatment strategy. In this contribution the advantages and disadvantages of different treatment options will be addressed and representative cases will be discussed.

In the last 20 years the prevalence of diabetes in Germany has increased by approximately 50%. Associated with this is a distinct rise of diabetes-induced comorbidities and long-term consequences. One of the most frequent consequences is the diabetic foot or the diabetic foot syndrome. This is an ulceration of neuropathic and angiopathic origin, which often reaches a chronic stadium due to a poor healing tendency. Despite the disease management program for diabetes in Germany which mainly concentrates on the prophylaxis and multidisciplinary treatment of chronic diseases, there are approximately 250,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years. To achieve a reduction of the amputation rate identification of the main reasons is necessary. In addition a professional therapy of the vascular disorders and a stage-adjusted wound therapy have to take place in an interdisciplinary collaboration in a centre for wound care. Last but not least this aim can only be achieved by a preventive education of diabetics.

There are more than 6 million diabetes patients in Germany. Due to long-term neuropathic and angiopathic sequelae, the number of patients with "diabetic foot syndrome" has increased dramatically in recent years. Diabetic foot ulcers have become one of the most common pathologies in interdisciplinary wound care centers. Because of its complex pathogenesis, diabetic foot syndrome needs a multidisciplinary therapeutic approach. More than 150,000 diabetics per year develop foot ulcers that often heal slowly and progress into chronic wounds. Despite all efforts at prevention, early diagnosis, and adequate therapy, more than 20,000 diabetics suffer major limb amputation in Germany every year. Applying stringent standards of care in interdisciplinary wound care centers, the amputation rate in patients with diabetic foot syndrome can be reduced to less than 50%. This article describes the complexity of diabetic foot syndrome with respect to pathogenesis, diagnostics, and therapy from a vascular surgeon's point of view. The importance of an interdisciplinary approach is emphasized.

The purpose of this article is to report complications from a coronary drug-eluting stent lost in the peripheral circulation. We report the case of successful retrieval of a sirolimus coronary stent from a pedal artery in a young patient who underwent coronary angiography for previous anterior myocardial infarction. Recognition of stent embolization requires adequate removal of the device to avoid unwelcome clinical sequelae.

Plantar vein thrombosis is a rare condition, with only a handful of cases reported in the literature. The cause is unknown; however, the disease has been attributed to prior surgery, trauma, and paraneoplastic conditions. We present a case of a 32-year-old female runner with plantar vein thrombosis diagnosed on contrast-enhanced MRI and confirmed on ultrasound. The symptoms resolved with conservative treatment and evaluation revealed the presence of a prothrombin gene mutation and use of oral contraceptive pills. To our knowledge, this is the first case of plantar vein thrombosis diagnosed initially by MRI. Moreover, this case suggests that plantar vein thrombosis should be considered in patients with hypercoagulable states and plantar foot pain.

We report a 30-year-old patient suffering a plantar dislocation fracture after he dropped a heavy weight on his foot. The patient was treated immediately after diagnosis was secured by CT scan. Median approach and dermatofasciotomy of the foot were followed by anatomic reduction of the fractures and the Lisfranc dislocation and fixed by internal osteosynthesis. After 3 months the patient was able to ambulate pain free without walking aids. Plantar dislocation is a very rare direction of comminuted Lisfranc dislocation fractures. The outcome may be favorable with early reduction and stable internal fixation of the fractures. One always has to be aware of the major soft tissue trauma associated with complex Lisfranc dislocation fractures.

The present study aimed to report the technical feasibility of percutaneous transluminal angioplasty (PTA) of obstructed or insufficient collateral branches (anterior and posterior perforating branches) from distal peroneal to foot arteries in diabetic patients with chronic critical limb ischemia (CLI) and chronic noncrossable occlusion of the anterior and posterior tibial arteries. Twenty-four diabetic CLI patients (age, 67 +/- 8 years; 87% males) undergoing collateral PTA were included. Baseline clinical angiographic and follow-up data were retrospectively reviewed. Collateral PTA was associated with a concomitant PTA of other sites in 21 (83%) cases. In 15 cases the treated collateral linked the peroneal with the plantaris communis; in 9 cases, the peroneal with the dorsalis pedis. Angiographic results of collateral PTA were good in 13 cases (<30% residual stenosis), whereas the result was considered moderate (30%-49% residual stenosis) in the remaining cases. Neither perforation nor acute occlusion of the treated collaterals or other relevant complications were observed. Mean follow-up was 32 +/- 17 months. Major amputation was necessary for two (8.3%) patients. Cumulative limb salvage rates at 2 and 4 years were 96% and 87%, respectively. In conclusion, this initial experience shows that PTA of the collateral branches from distal peroneal to foot arteries is a feasible technique. Future studies are required to define the clinical role of this novel approach.

Report on therapeutic procedures in patients with second and third degree congelations (frostbite) on the feet. Two mechanisms of tissue damage caused by exposure to cold temperature will be discussed pathophysiologically: direct freezing injuries and cell death through intra and extracellular ice crystal formation as well as transient and finally irreversible tissue damage due to decreased perfusion. The condition of decreased perfusion results from persistent vaso-constriction induced by cold temperature, increased blood viscosity, sludge phenomenon and occlusion by platelet thrombi in the microvasculature. Frostbite beyond the erythematous stage should be treated primarily with a parenteral therapy in order to improve the hemorrheologic parameters, in particular within the micro-vascular compartment. Colloidal plasma volume expander such as 10% dextran solution is used to increase the intravascular volume. This solution (with its coating effect) and pentoxifyllin lowers the aggregation of erythrocytes and platelets. The latter will also be favourably influenced by the use of iloprost or acetylsalicylic acid. Iloprost as a stable metabolite of prostacyclin is a powerful vasodilator which attenuates the peripheral vascular resistance and activates fribrinolysis. Pentoxifyllin is considered to lower pathologically increased levels of fibrinogen. Both drugs may protect against damage of the vascular endothelium. Based on their pharmacological effects the above-mentioned drugs may improve tissue perfusion and therefore tissue damage caused by frostbite can be limited. However, an important factor is to strictly avoid bacterial infections in the cold-damaged tissue.

Percutaneous cardiopulmonary support (PCPS) is a powerful resuscitation tool for patients in cardiogenic shock. The femoral artery is generally used for arterial access; however, vascular complications, particularly in atherosclerotic arteries, can occur. Although such complications occur infrequently, they can be fatal. We describe the case of a 75-year-old woman who required extended PCPS for cardiogenic shock secondary to coronary spasm after on-pump beating coronary artery bypass grafting. Limb ischemia occurred because of an occlusive cannula, and distal perfusion with a 20G elastic intravenous catheter inserted into the dorsalis pedis artery resolved the ischemia. The catheter was connected to the side port of an oxygenator and provided distal limb perfusion during PCPS. This technique appears to be useful in treating limb ischemia and may have application in patients with arterial occlusive disease who are dependent on mechanical support.

The management of the chronically ischemic leg with ulcer formation that is not suitable for either surgical or interventional treatment is still a matter of controversy. We describe three cases of ischemic ulcer treated with basic fibroblast growth factor spray. Ulcer healing was accelerated and complete epithelialization was achieved in all cases. Basic fibroblast growth factor spray is useful in the treatment of the ischemic ulcer in patients with arteriosclerosis obliterans, especially in high-risk surgical patients.

Allogenic venous transplantation represents an alternative procedure for preventing leg amputation. This study reviewed the question of whether immunologic monitoring and immunosuppressive therapy provide results close to those of autologous reconstructions. Twenty-eight patients received 31 homologous venous transplants. The average age in this group of 15 women and 13 men was 64.5 years. Limbs in danger of amputation could be kept longer in two thirds of them. These promising results show the superiority of this method over the use of alloplastic material in regions with cruropedal vessels. Therefore, it can be recommended in acute leg ischemia with lack of autologous vascularity. Improving guidelines for indication will be an interesting research field, and more contributions are needed.

Aims/hypothesis: The aim of this study was to investigate the influence of peripheral polyneuropathy (PNP) on skin microcirculation and foot swelling rate in the feet of patients with Type II (non-insulin-dependent) diabetes mellitus., Methods: 38 Type II diabetic patients, 24 with PNP (PNP+), 14 without PNP (PNP-), and 16 healthy control subjects were studied, first supine and subsequently sitting with the foot dependent for 50 mn., Results: In patients with PNP, foot skin temperature was higher, (p<0.04) and capillary blood cell velocity (CBV, nailfold capillary microscopy), was lower compared to patients without PNP (222 vs 313 micro m/s respectively, p<0.03). Compared to the control subjects, the percentage reduction in skin blood flux, (LDF, laser-Doppler fluxmetry), after 10 min was higher in the PNP- and PNP+ patients (3% vs 18% and 26% respectively, p<0.02). These disturbances were most pronounced in PNP+ patients with a history of a foot ulcer. Foot swelling rate (mercury strain gauge plethysmography) in the first 10 min of dependency, was lower in patients with PNP+ compared to the control subjects (0.00165 vs 0.00286 ml.100 ml(-1)s respectively, p<0.01). In addition, we found a negative correlation (r=-0.41; p<0.01) between Valk-score (severity of PNP) and FSR., Conclusion/interpretation: Type II diabetes PNP is associated with multiple abnormalities in the (skin) microcirculation of the foot, characterised by reduced capillary blood flow, an enhanced reduction in skin blood flux and impaired fluid filtration after sitting up. The most severe abnormalities were observed in patients with a history of foot ulceration.

Melorheostosis is an unusual sclerotic dysplasia of bone. The case of a 51-year-old female patient with melorheostosis and occlusion of the dorsalis pedis artery is described. Although numerous vascular anomalies have been noted in patients with melorheostosis, occlusion of the dorsalis pedis artery has not been reported previously.

Aims/hypothesis: We studied 76 patients with Type II (non-insulin-dependent) diabetes mellitus and 16 age-matched non-diabetic subjects (control group) to clarify qualitative and quantitative abnormalities of waveform and flow volume of the popliteal artery., Methods: The 76 diabetic patients comprised 16 patients with occlusive arterial disease in the lower extremities [arteriosclerosis obliterans (ASO) group] and 60 patients free from this disease (non-ASO group). We flow analysed the popliteal artery and measured the phosphocreatine to inorganic phosphate ratio of resting plantar muscles to identify risk factors for foot lesions using gated magnetic resonance two-dimensional cine-mode phase-contrast imaging and 31P spectroscopy., Results: The control and non-ASO groups had a triphasic waveform with systolic, early and late diastolic components. All ASO patients had an abnormal monophasic waveform and a lower ankle brachial index than that of the control and non-ASO groups. To clarify the mechanism of reduced flow volume of lower extremities, we assigned the 60 patients of the non-ASO group to the three subgroups based on their levels of total flow volume of the popliteal artery. The lowest group showed an abnormal triphasic waveform with lower amplitudes of systolic and late diastolic components and flow velocities in foot arteries than those of the highest group although ABI was similar. From stepwise multiple regression analysis, late diastolic flow volume was identified as an independent determinant for the phosphocreatine to inorganic phosphate ratio (r2 = 0.484, p < 0.001)., Conclusion/interpretation: Waveform analysis of popliteal artery provides a powerful tool for identifying impaired peripheral circulation caused by either occlusive arterial disease or increased arterial resistance in diabetic patients.

The Stewart-Bluefarb syndrome is defined as an unilateral angiodermatitis due to multiple arterio-venous fistules accompanied by acroangiodermatitis resembling Kaposi sarcoma (pseudo-kaposi sarcoma). The acroangiodermatitis is most common on the lower limb. It leads to ulcerated nodules with a high risk of bleeding and infection, as well as edema, pain and seldom limb hypertrophy. Curative therapy requires elimination of the arteriovenous shunts. Surgical destruction of the multiple small fistulae is a limitating factor. A better alternative is embolisation, but this approach carries the risk of ischemia and necrosis. A 32 year old female patient with Stewart-Bluefarb syndrome is presented; she has been successfully treated with embolisation on eight occasions.

Two years after the diagnosis of Sézary syndrome, a 50-year old female patient experienced attacks of painful ischemia of both hands and feet, leading to acral necrosis. Another 59-year old patient presented with severe pain in his feet, secondary to ischemia. This was the first symptom of a T-cell-chronic lymphocytic leukemia. Similar cases have only occasionally been described. The relationship between acral ischemia and T-cell-lymphoma is not clear but is discussed in this article.

An 8.5-month-old male infant with Kawasaki disease (KD) received high-dose intravenous immunoglobulin (IVIG) therapy on the fifth day after fever onset. However, multiple peripheral limb ischemias occurred 2 days later. Accordingly, heparin followed by dipyridamole was administered. Aside from a small amputation at the tip of the right middle finger, all other digital ischemias resolved. This presentation demonstrates that early recognition and management of peripheral gangrene in KD may keep its sequela to a minimum.

Skin capillary circulation is impaired during postocclusive reactive hyperaemia (PRH) in toes of diabetic patients independent of diabetes duration and macrocirculation. The aim of this study was to examine its relation to metabolic control. The skin microcirculation was investigated in 20 patients with insulin-dependent diabetes mellitus: 10 patients with bad [HbA1c > 7.5 (8.7 +/- 0.8) %], and 10 patients with good metabolic control [HbA1c < 7.5 (6.3 +/- 1.0) %]. The diabetes duration was similar in both groups (16 +/- 9 and 16 +/- 6 years, respectively). None had macroangiopathy. Thirteen healthy subjects served as controls. The capillary blood cell velocity (CBV) in the nailfold of the great toe was investigated by videophotometric capillaroscopy, and the total skin microcirculation by laser Doppler fluxmetry (LDF). CBV and LDF were studied during rest and after 1-min arterial occlusion. The vibration perception thresholds (VPT) of the feet were higher (p < 0.05) in the patients with bad (34 +/- 12 V), as compared to patients with good metabolic control (18 +/- 10 V) and to healthy subjects (13 +/- 3 V). Peak CBV during PRH was reduced in both patient groups (p < 0.01), and lowest in the patients with bad metabolic control (p < 0.05). Time to peak CBV was prolonged (p < 0.01) in the patients with bad, while normal in the patients with good metabolic control. LDF was similar in all groups. An inverse correlation was found between HbA1c and peak CBV during PRH (r = 0.60; p = 0.008), while positive correlations were found to time to peak CBV (r = 0.62; p = 0.004) and VPT (r = 0.60; p = 0.01). No associations were seen between VPT and the microcirculatory variables. The results indicate that the metabolic control is of importance for the nutritive capillary circulation and the peripheral nerve function in the diabetic foot.

Purpose: To present the initial results of a new percutaneously implantable catheter port system (PIPS) used for long-term intraarterial infusion therapy in patients with severe ischemic limb disease., Methods: Ten patients with deep, extended ischemic ulcerations (all 10) and osteomyelitis (6/10) of the foot received intraarterial infusions of prostaglandine E1 and antibiotics, if indicated, via a new port catheter system with the port placed subcutaneously above the groin after percutaneous introduction and the catheter tip placed into the superficial or deep femoral artery., Results: Port implantation and repeated port access were uncomplicated. During the follow-up period (mean 11 months, range 1 week-50 months), port migration, leakage, or infection was not observed. Three catheters thrombosed and were opened by fibrinolysis with recombinant tissue plasminogen activator instilled via the port. Treatment success was achieved in 8 patients: relief from rest pain (8 patients), reduction of ulcer size (4/8), and complete healing (4/8). Limb savage rate was 80%. In 2 patients amputation could not be avoided., Conclusion: Selective long-term arterial infusion therapy presents a valuable therapeutic regimen for limb salvage. With the new catheter port system, repeated local intraarterial infusion is safe and simple.

Reflex sympathetic dystrophy (RSD) is a pain syndrome characterized by somatosensory and motor disturbances, as well as by autonomic and trophic changes. The term is used in a descriptive sense and does not imply specific mechanisms of pathogenesis. We report on a patient who fulfilled the clinical criteria of RSD and who also displayed increasing impairment of peripheral blood supply. Angiography revealed a circumscribed stenosis of the abdominal aorta adjacent to the bifurcation. Disturbances in peripheral circulation as a potential cause of RSD are discussed.

A stent-graft was custom made to close a high-flow traumatic arteriovenous fistula of the left superficial femoral artery, present for 30 years, in a 60-year-old man with congestive heart failure and ischemic ulceration in the left foot. A balloon expandable Palmaz stent (P394; 2.5 mm X 3.9 cm) was covered with a polytetrafluoroethylene (PTFE) graft and was inserted percutaneously through an 11 Fr vascular sheath. Follow-up Doppler ultrasound at 6 months demonstrated occlusion of the arteriovenous fistula, patency of the artery, and luminal integrity of the artery and vein.

Due to the high risk of amputation they involve, diabetic neuropathic plantar ulcers (DNPU) must be regarded as a late manifestation/complication of diabetes mellitus. The suspected cause of these ulcers--disturbed cutaneous microcirculation--was studied by simultaneously measuring laser-Doppler flux (LDF) and cutaneous oxygen tension (pCUO2) in 14 patients with DNPU at three differently affected sites (dorsal forefoot, ulcer edge, lower leg). Dynamic tests (arterial occlusion, local hyperthermia) as a measure of vascular reactivity showed significantly reduced pCUO2 parameters coinciding with elevated LDF values. This reflects a shift of blood flow from the nutritive capillaries towards deeper vessels. Abolition of normal vasoconstriction in the arteriovenous shunt vessels by diabetic polyneuropathy is the assumed cause of increased AV perfusion, with a consequent rise in LDF values. In a subgroup of the above patients (n = 7) undergoing daily intravenous retrograde perfusion therapy (RVP) over 10 days several basic and dynamic microcirculatory functions were studied before and after this treatment. This subgroup showed on the forefoot and the lower leg a remarkable improvement of the microcirculatory parameters investigated, suggesting a better oxygen supply to the tissues after RVP therapy.

46 patients with deep vein thrombosis have been investigated by strain gauge plethysmography and by foot-volumetry in the acute state, after 4 weeks, and after every year up to 5 years. The primary therapy consisted in anticoagulation, compression-bandages and walking exercises. Venous drainage measured by venous occlusion plethysmography showed in average a normalisation after one year, while expelled volume as a parameter for the venous pumping function (assessed by foot-volumetry) remained in the pathological range. Since the clinical outcome--ulceration in 6.5%, lipodermatosclerosis in 15% and no major signs in 78%--does not correspond to these functional findings it is concluded that venous refluxes which are the main cause for the impeded pumping function lead to skin changes only in specially predisposed cases.

At the Maribor Teaching Hospital two elderly with progressive atherosclerotic disease below the knee were treated between 1986-1992 for open fracture of ankle joint and pedal arterial trauma. The only patent atherosclerotic vessel (dorsal artery of the foot) that was disrupted was reconstructed in both cases by interposition of a part of the great and small saphenous vein in one case each. A termino-terminal anastomosis with a long, triangular patch was used, fixed with interrupted sutures. The fractures were stabilized with external fixators. Both extremities were saved.

Regional drug-induced sympathectomy is a modification of Bier's block technique. By applying this method skin perfusion in patients with occlusions of lower leg arteries or functional disturbance of peripheral circulation can be improved. Under optimal technical conditions effects of regional and surgical sympathectomy are comparable. Fluorescence angiography can be applied to assess the effectiveness of drug-induced as well as surgical sympathectomy.

In 12 patients with trophic foot-lesions (diabetic feet) retrograde intravenous pressure infusions (150 ml) containing radioactive tracers (99m Tc, 99m Tc labelled human serum albumin) were carried out. With the veins emptied time-activity curves over the legs reflect tissue concentrations after release of the occlusion. Tissue-concentration is about 3 times higher than after intraarterial and 7 times higher than after intravenous injection of the same dose. The high count-rates which can be measured in the wound-secretion demonstrate the "rinsing effect" of the injected fluid. Hemodynamic investigations have been performed in a double blind study. 8 patients received buflomedil and 9 got placebo 3 times per week by retrograde intravenous pressure infusions. After 3 weeks there was an increase of the peak-flow on the lower leg (venous occlusion plethysmography), an increase of transcutaneous oxygen pressure and a fall of peak flow-time and of plasma-viscosity, both for buflomedil and for placebo (without statistical significance). Preliminary investigations after an arterial occlusion for 1 hour showed an increase of flow-values measured by venous occlusion plethysmography which reached a maximum after 4 to 5 days.

23 patients with diabetic gangrene and complete occlusion of all 3 tibial arteries were treated by 26 popliteopedal vein bypass grafts. All 6 early graft failures resulted in major amputations. The cumulative graft patency rate was 76% after 6 years. One patient needed lower-leg amputation despite a functioning graft. All other limbs were saved (mean follow-up period: 24.8 months). It is concluded that despite a palpable popliteal pulse an angiographic examination should be performed, when the infectious lesion cannot be controlled by local treatment and pedal pulses are absent.

Following severe indirect and/or direct trauma to the foot, compartment syndrome can easily develop in this foot. Untreated, the compartment syndrome results in a complex post-traumatic deformity--the "short foot syndrome." This may manifest itself as a contracted pes equinovarus foot with clawing of the toes. Isolated compartment syndrome of the foot due to local injury may result in the formation of hammer toes. During childhood and adolescence, severe soft tissue injuries to the lower leg or foot, with subsequent compartment syndrome of the foot or a neurovascular injury to the lower limb, may result in an alteration in growth of the affected region or may involve the foot. Radiological assessment of this contracted "short foot" using sonography or MRI demonstrates scarred, necrotic musculature mainly involving the muscles of the posterior tibia, the flexor hallucis and the flexor digitum. Muscular imbalance due to long-standing muscle palsies, or chronic post-traumatic osteitis of the tibia contribute to the development of rigid equinus foot and ankle. Treatment of the contracted foot includes complex soft tissue release, muscle and tendon transfer, tendon-lengthening procedures, and intrinsic releases to correct the toe deformities. In the adult with a severe post-traumatic pes equino-varus deformity, triple arthrodesis is recommended.

From 1982 to 1988 a total of 29 patients with compartment syndrome of the foot were treated by fasciotomy. The most common causes were fracture dislocations of the Lisfranc (n = 14) and Chopart joints (n = 4). Since these injuries lead to a severe damage to soft tissue structures--joint capsules, ligaments, fasciae--the muscular compartments often communicate and decompression can be achieved by a longitudinal dorsal incision of the skin and fasciotomy of the fascia dorsalis pedis and the retinacula extensorum superior and inferior. Subsequent measurement of intracompartmental pressure dictates whether blunt dissection of the interosseous muscles and separate fasciotomy of the medial, lateral and plantar compartments have to be performed. Follow-up was possible in 18 patients: half had good results, while 9 patients had limited motion of their toes and/or paresthesia. It is impossible to know whether these negative findings are caused by the compartment syndrome itself or by the severe soft tissue damage resulting from the initial trauma.

The objective of this study was to investigate the clinical applicability of pulse oximetry to measure haemoglobin oxygen saturation and heart rate in the first 20 min of life and to analyse the effect of pre- or post-ductal (hand, respectively, foot) fixation of sensors on oxygen saturation. Measurements were carried out on 53 newborn infants selected at random after delivery by caesarean section. Signal detection occurred significantly faster from the hand (50% after 1.3 min, 90% after 4 min) than from the foot (50% after 3.1 min, 90% after 9 min). Both fixation sites showed equally great sensitivity to motion. The heart rates from pulse oximetry recordings were up to 30% lower than those from ECG recordings. Saturation values from the hand were nearly always higher than those from the foot (median difference in the 5th min was 10%; between the 5th and 10th min it was 7%; no significant difference occurred after the 17th min). We conclude that pulse oximetry can be used for documenting oxygenation and right-to-left shunting in newborn infants during the first minutes of life in spite of limitations due to incomplete pulse wave detection and artifacts.

Doppler sonographic examination of 51 diabetic subjects showed that the macrovascular hyperemic response of the pedal blood flow was negatively correlated to the duration of the disease (p less than 0.01). In comparison with non-diabetic controls (n = 20), the response was increased by more than 210% in newly detected diabetics, but decreased by more than 20% in long-term diabetics. Vascular response was correlated also not only to the duration of the diabetes, but to peripheral neuropathy (p less than 0.001). The hyperemic response was reduced in patients with reduced nerve conduction time, or somatic neuropathy (142 + 152%, p less than 0.005), and in patients with reduced arterial pulsation, or autonomic neuropathy (152 + 88, p less than 0.005), both in comparison with non-diabetic controls (293 +/- 108%). The frequency of decreased macrovascular hyperemic response was in agreement with somatic neuropathy in 69.7% and with autonomic neuropathy in 75.8% of all patients. The results demonstrate that the macrovascular hyperemic response of blood flow in diabetic feet is already reduced at an early stage of peripheral neuropathy without peripheral vascular occlusive disease. The functional reduction of pedal blood flow may be important for the development of diabetic foot gangrene.

Venous occlusion plethysmography has been used to measure sympathetic vasoconstrictor responses in the feet and hands to a deep breath and body cooling and to assess blood flow variability. Measurements were made in 14 non-diabetic control subjects and 52 diabetic patients, 30 of whom had evidence of peripheral neuropathy. All the measurements were significantly reduced in the feet of patients with neuropathy. Vasoconstrictor responses were not significantly impaired in the hands of these patients. Cardiovascular autonomic function was assessed in the same subjects by standard tests of reflex heart rate responses and compared to sympathetic vasoconstrictor function as determined by the response to a deep breath. Eighteen of the 30 diabetic patients with peripheral neuropathy had impairment of both cardiovascular and sympathetic vasoconstrictor function. Five had normal vasoconstrictor but impaired cardiovascular responses and two had normal cardiovascular but impaired vasoconstrictor function. It may therefore be important to assess both systems in diabetic patients.

The retrograde intravenous pressure infusion into an arterially occluded segment of an extremity (Bier's technique) is the most effective method to achieve maximal tissue concentrations of a drug. This was proven by nuclear medical examinations. By application of contrast-medium it was shown that the injected fluid penetrates in a retrograde direction into the foot inspite of primarily intact valves. A second important mechanism of action is the haemodynamic consequence of an arterial occlusion which is characterized not only by an immediate reactive hyperaemic response but also by a delayed increase of blood flow after several days. Favourable clinical results were obtained with antibiotics in infected gangrene of the feet or in necrotizing erysipelas and with urokinase in resistant leg ulcers.

In major knee trauma fractures and/or dislocations can be associated with arterial lesions. Two case reports demonstrate the difficulties in the diagnosis of intimal lesions in the popliteal artery. The presence of a pedal pulse present at the time of admission can be a false sign of security. The importance of prompt diagnosis and treatment is emphasized. The use of arteriography is discussed.

The efficiency of prophylactic antibiotic therapy in amputation surgery was studied in a prospective, randomized trial of a first-generation cephalosporin (cephalothin) compared with a narrow-spectrum beta-lactam stable penicillin (methicillin). Eighty-eight patients received cephalothin 2 g X 4 on the day of operation, while 86 patients received methicillin 1 g X 4. The patients were followed up for 21 days. Infected wounds occurred in 14.8% of the patients in the cephalothin group, compared with 14% in the methicillin group. The frequency of deep infections was 10.2% versus 4.7% (P = 0.1611). The reamputation frequency was 18.2% in the cephalothin group compared with 12.8% in the methicillin group; the frequency of below-knee reamputation was 18.4% versus 7.7% (P = 0.1469). No clostridial infections were found. The study did not demonstrate any significant difference between cephalothin and methicillin in the prophylaxis for lower-extremity amputations, although the latter drug tended to be the best choice.