Biomedical subjects
Publications and source records attributed to H Fredin.
Two women in their seventies sustained a perforation of the femoral shaft during a total hip replacement without trochanteric osteotomy. They both had late fractures from minor trauma 7 and 12 months postoperatively. Immediate revision followed by 3-6 months of external support should be considered in patients with peroperative femoral perforation with cement leakage.
In order to study the plasma levels of factor XaI and IIaI activity an enzymatically depolymerized low molecular weight heparin (LMW-heparin; Logiparin) was given s.c. in a dose of 35 XaI mu/kg b.w. once daily for 7 days to 10 patients undergoing total hip replacement (THR) in a pilot study. The XaI activity was less than or equal to 0.24 XaI units/ml and the IIaI activity less than or equal to 0.043 IIaI mu/ml. No accumulation of the activities were seen. No phlebographically verified thrombi or any bleeding complications were registered. From this study it was concluded that the given dose of Logiparin was safe with regard to bleeding complications. Based on these data, an open, randomized controlled trial was started. In this main study the thromboprophylactic effect of the LMW-heparin (Logiparin) in a dose of 35 XaI mu/kg b.w. once daily was compared with that of dextran 70 in patients undergoing THR. 100 patients were randomized. The over-all thrombosis rate was 28% in patients treated with LMW-heparin and 39% in those given dextran, a non-significant difference. No bleeding complications, deaths or pulmonary embolism were recorded in either group. Peroperative blood loss and transfusion requirements were similar in the two groups. In conclusion, the investigated LMW-heparin (Logiparin) is safe and effective in preventing postoperative thromboembolism in patients undergoing total hip replacement, but the dosage can probably be optimized.
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Sixty patients who were scheduled for total hip replacement were randomly allocated to receive either epidural blockade or neurolept anaesthesia. All patients received dextran 70. The blood loss during surgery and the mean arterial blood pressure were lower following epidural anaesthesia. However, the frequency of deep venous thrombosis and pulmonary embolism, as diagnosed by ascending phlebography and pulmonary scintigraphy, was the same in the two groups. It is concluded that, although epidural anaesthesia may be considered for other reasons, there is no reduction in thromboembolic complications with this anaesthetic technique in patients who receive dextran.
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The efficacy of dextran 70 with or without dihydroergotamine as prophylaxis against deep venous thrombosis (DVT) was tested prospectively in a randomized series of 65 patients with fracture of the hip. Diagnostic evaluation was made with bilateral ascending phlebography on postoperative day 7. In the dextran 70 group, 5 of the 27 phlebographically studied patients had DVT, an incidence not significantly different from the 10 DVT among 28 patients given dextran 70 + dihydroergotamine. Bleeding complications showed no intergroup difference. The study did not confirm a beneficial effect of dextran 70 in combination with dihydroergotamine as compared with dextran alone in regard to thrombotic complications after surgery for hip fracture.
A prospective study was performed in 120 patients undergoing total hip arthroplasty. The patients were randomly allocated to four groups. The first two groups had nitroprusside-induced hypotensive anesthesia with either a fixed combination of sodium heparin and dihydroergotamine mesylate (HDHE) or dextran 70. The other two groups had normotensive halothane anesthesia with either HDHE or preoperative hemodilution with dextran 70. Hypotensive anesthesia reduced surgical bleeding. Blood loss was increased in patients undergoing preoperative hemodilution as compared to thromboprophylaxis with HDHE, whereas no difference was found between conventional administration of dextran and HDHE. Deep vein thrombosis, diagnosed with ascending phlebography of the operated leg, was registered in 48% of the patients. There was no difference between the techniques of anesthesia and thromboprophylaxis. Pulmonary embolism, studied with perfusion-ventilation scintigraphy, was diagnosed in 19% of the patients. No significant difference was found between hypotensive and normotensive anesthesia, or between thromboprophylaxis with conventional dextran and HDHE. There was a lower incidence of pulmonary embolism in patients with HDHE and normotensive anesthesia. Major wound hematomas were noted postoperatively in 12% of the patients receiving HDHE, whereas no major hematomas developed following dextran prophylaxis. No anaphylactic reaction was noted from dextran 70, using hapten-dextran prophylaxis.
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A prospective study of antithrombin III, determined by electroimmunochemical assay or an amidolytical method, was carried out with special reference to thromboembolism after total hip replacement. Two hundred and seven patients were randomly allocated to thromboembolic prophylaxis with dextran 70 or low dose heparin combined with dihydroergotamine. Deep vein thrombosis determined by phlebography of the operated leg or pulmonary embolism diagnosed with perfusion/ventilation scintigraphy developed in 51% of the total material and did not differ significantly between the two groups of prophylaxis or between patients with a preoperative At III below normal and those with a normal value. The correlation between the two assay methods for At III was 0.61. An initial, postoperative decrease in At III was noted with a parallel fall in hematocrit and fibrinogen, later followed by an increase of the plasma proteins. It is concluded that the immediate postoperative decrease of At III is mostly due to hemodilution.
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One hundred patients with sprained ankles were randomly allocated to treatment with Ibuprofen 800 mg X 3 daily and placebo and to treatment with two qualities of compression bandaging. Neither Ibuprofen nor high quality bandaging had a significant effect on the swelling, pain or tenderness.
During the years 1978 and 1979, the results in 257 patients with a primary anterior dislocation of the shoulder were prospectively studied. The patients were less than forty years old and had been treated at twenty-seven Swedish hospitals. Thirty-two patients had a fracture of the greater tuberosity, but none of them reported having any further dislocations within two years after treatment, while 32 per cent of the patients without this fracture had a redislocation during the same period. The incidence of fractures of the greater tuberosity varied with the age of the patient; the highest rates were in the age groups of twelve to thirteen years and thirty-four to forty years (43 and 30 per cent, respectively), while in the age group of twenty to twenty-two years this injury was found in only 3 per cent of the patients. Chip fractures of the glenoid rim were found in 8 per cent of the patients, most of whom were in the older age groups. Impression fractures in the posterior part of the humeral head were demonstrated in 55 per cent of the patients and were not associated with a significantly higher rate of recurrence of dislocation. One hundred and twelve patients used an immobilization device for three to four weeks, while 104 patients began to use the shoulder as early and as freely as possible. At the two-year follow-up the groups showed an equal rate of recurrence of dislocation. In the age group of twenty-two years or younger nearly 50 per cent of the patients had one or more recurrences, regardless of treatment. In the two older age groups (twenty-three to twenty-nine and thirty to forty years old), the incidence of recurrence was 25 per cent or less.
A new 99mTc-microaerosol was used for ventilation scintigraphy in combination with perfusion scintigraphy for studying the incidence of pulmonary embolism (PE) from 189 consecutive investigations in patients undergoing total hip replacement. Diagnostic criteria are presented. Perfusion defects of triangular shape were significantly more frequent in combination with ventilation mismatch (PE) than with ventilation match (not PE) (P less than 0.001). Reevaluation of the scintigrams more than 2 months later gave identical results in more than 90% of patients and as regards the diagnosis of PE, in 93%. Attacks of sudden chest pain were more frequent in patients with pulmonary embolism (P less than 0.01), but measurement of arterial blood gases did not discriminate between patients with and without PE. The 99mTc-microaerosol provides a high resolution and images that are directly comparable to perfusion studies using the same, easily available isotope. In many aspects this new microaerosol seems to be superior to previously described radioaerosols and to 133Xe for ventilation studies.
Blood loss during total hip arthroplasty and the relation of different anesthetic techniques to surgical bleeding was explored in a consecutive, prospective study involving 157 patients with no previous history of hip surgery. Intraoperative blood loss was significantly reduced in patients operated under sodium nitroprusside induced hypotensive anesthesia as compared to halothane, NLA or epidural block. It might be suspected that postoperative blood loss is increased when the lowered blood pressure is raised towards normotension, but this was not the case. However, regression analysis between mean arterial pressure and intraoperative blood loss in patients anesthetized with hypotensive as well as "normotensive" techniques showed a poor correlation. Blood loss was greater with NLA and halothane anesthesia than with epidural block. The authors consider controlled hypotension a useful adjuvant in anesthesia for total hip arthroplasty in selected patients. Epidural block, on the other hand, is a suitable anesthetic technique for most patients and has the additional advantage of reduced surgical bleeding as compared to general anesthesia.
A postoperative follow-up of one and one-half to ten years was obtained in 114 of 121 patients who underwent either a Bankart or a modified Putti-Platt procedure. In the forty-six patients who had a Bankart operation, there was one recurrence (2 per cent) compared with thirteen recurrences (19 per cent) in the sixty-eight patients who had a modified Putti-Platt procedure. Twelve (36 per cent) of the latter recurrences occurred in patients who were twenty-five years old or younger at the time of the operation and only one occurred in the patients who were more than twenty-five years old. The restriction of outward rotation after shortening of the subscapular tendon averaged 6 degrees as compared with 16 degrees after a Bankart operation. A modified Putti-Platt procedure (shortening of the subscapular tendon) is recommended only for patients who are more than thirty years old. It does offer certain advantages for them because of the simplicity of the procedure and the short duration of the operation.
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