Controlled trial of low-dose heparin and sulfinpyrazone to prevent venous thromboembolism after operation on the hip.

A randomized, double-blind controlled trial of low-dose heparin combined with sulfinpyrazone to prevent deep-vein thrombosis after operation on the hip was carried out. In a group of seventy-three patients after arthroplasty, postoperative thrombosis of the veins of the lower limbs occurred in 51 per cent of the control patients and in 36 per cent of the treated patients. In a fracture group of thirty patients, thrombosis occurred in 75 per cent of the control patients and in 36 per cent of the treated patients. These differences are of borderline statistical significance in the fracture group and are of no statistical significance in the arthroplasty group. However, a 36 per cent incidence of venous thrombosis in the drug-treated patients is too high to justify recommendation of the regimen tested without careful monitoring of patients by tests designed to detect thrombosis. Then, appropriate anticoagulant therapy can be instituted if necessary.     

The posterior stocking seam approach to radical subfascial clipping of perforating veins

Retrospective analysis of 150 consecutive patients undergoing splenectomy for various reasons from January 1970 to June 1975 revealed seven instances of documented thromboembolic complications (4.6 per cent). When the patients are placed into subgroups by their diagnosis, it appears that splenectomy for lymphoma staging produced the highest incidence. Two of sixteen splenectomy patients (13 per cent) evaluated prospectively with ¹²⁵I-fibrinogen scans developed deep vein thrombosis (DVT). This incidence was greater than in both the retrospective group and a control group of sixteen general surgical patients scanned (with ¹²⁵I-fibrinogen), but the numbers of patients are too small for comparison. Platelet count data for the retrospective and prospective splenectomy patients showed that elevation of platelet count does not necessarily mean a greater incidence of DVT. However, when DVT occurs after splenectomy, platelet counts are elevated. Although thrombocytosis occurs after splenectomy, the incidence of DVT (6 to 13 per cent) is no greater than in other surgical patients not undergoing splenectomy. But when all other risk factors for DVT—diagnosis, obesity, prolonged bed rest, age, and associated illness —are considered, then aggressive prophylactic measures to prevent DVT in selected patients after splenectomy seems indicated.     

Thromboembolic prophylaxis in hip fracture

The effect of either heparin-dihydergot or heparin-acenocoumarin on the incidence of deep-vein thrombosis in the legs was studied in 181 women undergoing Ender nailing for intertrochanteric fracture of the femur. All the patients were screened with the 125-I-fibrinogen uptake test, confirmed by a bilateral ascending venogram. Deep-vein thrombosis developed in 40 per cent of the heparin-dihydergot group and in 61 per cent of the heparin-acenocoumarin group (p less than 0.015).     

Fatal road accidents in Birmingham: Times to death and their causes

The intervals between injury and death in the 254 fatalities after road traffic accidents in Birmingham during 1969 and 1970 were analysed and correlated with other data. Sixty-three per cent were pedestrians and 23 per cent were passengers and drivers of vehicles. In round figures, about a third of the series died within half an hour, a half by 2 hours, two-thirds by 24 hours, and three-quarters by 2–4 days. The patterns of survival-time could be divided into three phases. There was an early steep decline, with 36 per cent dying during the first half-hour and 44 per cent within 1 hour of the accidents. This was followed by a longer stage during which the rate of dying decreased progressively in logarithmic fashion. The cumulative tolls were 51 per cent by 2 hours, 58 per cent by 4 hours, 68 per cent by 24 hours, and 83 per cent by 7 days. The curve then flattened into a prolonged tail. Between 7 and 28 days another 10 per cent died, making 93 per cent by 28 days. The remaining 7 per cent succumbed during the subsequent weeks and months, 3 patients surviving longer than a year.

Fifty-six per cent of vehicle occupants and 40 per cent of pedestrians died within an hour of injury, and the excess of rapid deaths among vehicle occupants was mainly due to a higher proportion of rupture of the aorta. All the ruptured aortae in vehicle occupants occurred after accidents at night or the early hours of the morning. Many of the affected drivers and passengers had consumed alcohol and their injuries were more rapidly lethal than after accidents at other times. Serious cerebral trauma dominated all groups of road users and multiple injuries were common. Included among the fatality tail was a group of subjects, mainly pedestrians, with relatively modest injuries who might have survived had they not developed pulmonary embolism, respiratory infection, or other complications.     

Compression ultrasonography for the detection of deep venous thrombosis in patients who have a fracture of the hip. A prospective study

The effectiveness of compression ultrasonography in the detection of femoral and popliteal venous thrombosis was determined in a prospective trial over a period of seven months. Forty-two patients who had an isolated intertrochanteric or femoral neck fracture participated, and forty of these patients completed the study. The average age of the patients was 81.6 years. Venography was the standard with which all ultrasonic studies were compared. A total of 112 ultrasonic studies were performed. The incidence of major venous thrombosis, as detected by venography, was 12.5 per cent. All patients were clinically asymptomatic. The compression ultrasonic technique had an accuracy of 97 per cent, a sensitivity of 100 per cent, and a specificity of 97 per cent. Compression ultrasonography appears to be a very effective technique for diagnosing venous thrombosis in patients who have a fracture of the hip. It is safe, well accepted by both patients and staff, and simply and quickly performed, and it carries no inherent risks. It also can be readily repeated, making it ideal for monitoring high-risk patients.     

The use of graduated compression stockings in the prevention of postoperative deep vein thrombosis

The efficacy of graduated compression stockings in the prevention of postoperative deep vein thrombosis was studied in a randomized, prospective, controlled trial of 200 patients, aged 40 years and over, undergoing abdominal surgery (100 for benign disease, 100 for malignant conditions). Deep vein thrombosis was diagnosed by the 125I-fibrinogen test. The incidence of deep vein thrombosis was 35.9 per cent in the control group (103 patients) and 15.5 per cent in the stockinged group (97 patients) (P less than 0.025). In the patients with benign disease, deep vein thrombosis developed in 24.5 per cent of the control limbs and 6.1 per cent of stockinged limbs (P less than 0.005); in patients with malignant disease the similar figures were 27.9 and 11.5 per cent (P less than 0.05). Increasing age did not alter the efficacy of the stockings. It is concluded that graduated compression stockings provide a safe and effective method of prophylaxis against deep vein thrombosis.     

The time course of 99Tcm-Sn-polyphosphate scintimetry of normally healing tibial fractures in man

In 38 fractures of the human tibia showing radiological consolidation within 6 months, the amount of callus formed was assessed monthly by scintimetry following intravenous administration of ⁹⁹Tc^m-Sn-poIyphosphate. The results of the scintimetry were expressed as a ratio (as radioactivity over the fracture divided by that over the contralateral area of the normal leg). The error of the scintimetric ratio within the period of measurements (20–60 minutes after the injection of isotope) was ± 5 per cent.More isotope accumulated around the fracture in all patients. The scintimetric time course of transverse as well as longitudinal fractures showed a peak value (scintimetric ratio 3.6 ± 0.6 s.d.) in the fourth to fifth week, whatever the primary treatment, and was of the same magnitude in the two types of fracture. A secondary increase of the scintimetric ratio was found in 70 per cent of the fractures following the start of weight bearing.Infection of a fracture induced a higher scintimetric ratio than that of an uninfected fracture. Re-fractures showed exceptionally high scintimetric ratios in the second to fourth week (twice the values of primary fractures), but the ratios decreased rapidly.Scintimetry is a non-invasive, quantitative method of estimating the formation of callus. In this study the scintimetric time course of healing fractures of the tibia was determined. The results are to serve as a basic study of the method's suitability in early diagnosis of pathological healing.     

A survey of fractures of the proximal femur

A series of 1494 fractures of the proximal femur, admitted over a 68-month period to the North East Area Accident Unit, is presented.The mortality for the series was 18 per cent, with operative mortality varying according to the fracture site and the method of treatment, being 18.1 per cent for extracapsular fractures, 14 per cent for Smith-Petersen nailing of intracapsular fractures, and 31 per cent for primary prosthetic replacement.In general terms, morbidity and mortality were proportional to age and to pre-existing general medical conditions. The results are presented in full, and are compared with other published series.     

Tetrazolium reductase as an index of viability of stored skin

The take or failure of 264 split-skin grafts on burned patients has been investigated; the single most important reason for failure was non-viability of the graft at its time of application, as measured by the relative tetrazolium reductase (TR) activity. There was a high correlation between relative TR activity of less than 50 per cent and graft failure, and between TR activity of greater than 50 per cent graft take.The longest period for which a graft could be stored at ?10°C and remain viable was 12 days; a few were non-viable before 10 days. Repeated freezing and thawing of stored skin grafts reduced the length of viability by 40 per cent compared with grafts which had been frozen and thawed only once.The tetrazolium reductase activity provides a quick reliable prognostic indication of whether or not a graft should be applied with the anticipation of a take.     

Effects of fracture stabilization by internal fixation: I. A haemodynamic and blood gas evaluation of the systemic and regional changes

The effect of internal stabilization of a fracture of the femur on arterial blood oxygen levels, limb blood flow and oxygen consumption was measured in 24 dogs. Those with stabilized fractures bore weight on their limbs and were much more active. Without fracture stabilization the arterial oxygen tension fell by 10 per cent. With internal fixation this hypoxia did not develop. In fact, there was a 10 per cent increase beginning in the third week. Stabilization of the fracture gave a persistent increase in limb blood flow, but without stabilization this increase was transient and followed by a significant decrease. Over the 7-week observation period, the total oxygen consumption of the uninjured limbs in the stabilized group was twice that in the unstabilized group, an indication of their functional activity. Also with stabilization, the oxygen consumption of the injured limb was not significantly different from the opposite limb, whereas without stabilization the consumption was 32 per cent greater, an indication of the energy cost of countering instability.     

Unstable fractures of the distal end of the radius (Transfixion pins and a cast)

Forty-five unstable fractures of the distal end of the radius were treated with transfixion pins and plaster cast. Thirty-seven patients were personally reviewed and an analysis of the results are presented in this paper. Scheck's point system was used to grade functional results; 81.1 per cent were classified as satisfactory (excellent and good) and 18.9 per cent unsatisfactory (poor) group.     

Extent of leg vein thrombosis determined by impedance and 125I fibrinogen

Modification of impedance plethysmography to include a thigh cuff improves sensitivity. Twenty-seven of thirty-two subjects (85 per cent) were correctly classified by comparison with phlebograms. Combined surveillance of patients at risk with cuff impedance plethysmography and ¹²⁵I fibrinogen, carried out in fifty subjects after total hip replacement, demonstrated that silent venous thrombosis can be detected. Moreover, an estimate of thrombus size can be made, at least to the extent that clinically significant thrombi can be distinguished from minute thrombi.     

Trauma and the cystic meniscus: Review of 500 cases

A review is presented of 500 cases of cystic menisci diagnosed clinically. The distribution by age, sex, side, and site is analysed as is the mode of presentation, history, and type of trauma, as well as locking.

Operative findings in 299 patients are discussed, undamaged menisci being found in 50 per cent.

With a history of trauma (37 per cent) the meniscus was found to be damaged in 59 per cent, without it the incidence was 45 per cent.     

Upper limb ischemia resulting from arterial thromboembolism.

Acute ischemia of the upper limb is commonly caused by trauma and embolic arterial occlusion. However, primary atherosclerotic thrombosis is found infrequently and concern regarding its incidence, recognition, and treatment prompted a review of our clinical experience. Of 36 patients with acute ischemia of the upper limb, 17 (47.2 per cent) had embolic occlusion, 9 (25 per cent) iatrogenic thrombosis in the brachial artery, and 10 (27.8 per cent) primary arterial thrombosis. Of the total group, noncardiac arterial emboli (two patients) and primary atherosclerotic thrombosis (six patients) accounted for 8 of 36 (22.2 per cent) ischemic limbs. Including 2 additional patients who had atherosclerotic thrombosis associated with trauma, the total number represented 10 of 36 (27.8 per cent). An aggressive approach to the undiagnosed patient with acute ischemia of the upper limb is warranted, including the use of arteriography in most cases. In patients with iatrogenic thrombosis in the brachial artery, we believe that the routine use of intraoperative arteriograms may improve the operative results.     

Dihydroergotamine/heparin in the prevention of deep-vein thrombosis after total hip replacement. A controlled, prospective, randomized multicenter trial

In a randomized, double-blind, placebo-controlled multicenter trial, the efficacy and safety of dihydroergotamine mesylate/heparin sodium as a prophylactic agent for deep-vein thrombosis were evaluated in 148 patients who were forty years old or more and who underwent total hip replacement. The incidence of venographically proved postoperative deep-vein thrombosis was 52 per cent in the placebo group and 25 per cent in the dihydroergotamine mesylate/heparin sodium group (p = 0.002). Proximal thrombi developed in only 5 per cent and extensive thrombi, in only 10 per cent of the patients who received dihydroergotamine mesylate/heparin sodium. In contrast, proximal thrombi and extensive thrombi developed in 19 and 25 per cent, respectively, of the patients in the placebo group (p less than 0.05). Adverse reactions in the two groups did not differ significantly: in the treatment group they consisted primarily of hematoma at the site of injection (9 per cent), hematoma at the wound (5 per cent), and excessive postoperative bleeding, and in the placebo group there was hematoma at the site of injection (3 per cent). It was concluded that the combination agent dihydroergotamine mesylate/heparin sodium was effective and safe prophylaxis against deep-vein thrombosis for the patients who underwent total hip replacement in this study.     

Immediate radial nerve palsy complicating fracture of the shaft of the humerus: when is early exploration justified?

A series of 59 patients with immediate complete radial nerve palsy complicating a fracture of the shaft of the humerus was analysed. In 27 patients the radial nerve was explored and the fracture was fixed within 3 weeks of the accident. In 12 other patients exploration was performed after an average of 17 weeks. The remaining 20 patients showed signs of spontaneous recovery within 4 months and were managed conservatively. The mean follow-up time was 3 years.At exploration, laceration, interposition between the fragments or entrapment of the radial nerve in callus was found significantly (P < 0.01) more often with longitudinal fractures of the distal third (46 per cent) than with transverse fractures of the middle third, in which 85 per cent of the explored cases showed the nerve to be no more than slightly bruised. Useful recovery was seen in 46 patients (78 per cent of the whole series).     

The incidence of deep vein thrombosis in prostatectomised patients following the administration of the fibrinolytic inhibitor,aminocaproic acid (EACA)

Summary Forty patients undergoing prostatectomy for benign prostatic hypertrophy were included in a double blind trial of epsilon aminocaproic acid, and the incidence of postoperative deep vein thrombosis determined, using the ¹²⁵I-fibrinogen technique. There was no significant difference between the groups, the overall incidence of abnormal scans being 50 per cent, but of the patients undergoing enucleative prostatectomy 68 per cent developed significant scan findings compared with 33 per cent following transurethral surgery.     

Low-molecular-weight heparinoid compared with warfarin for prophylaxis of deep-vein thrombosis in patients who are operated on for fracture of the hip. A prospective, randomized trial.

In a randomized, prospective trial, a low-molecular-weight heparinoid (Org 10172 [Lomoparan]) was compared with warfarin for efficacy and safety in preventing deep-vein thrombosis in 263 patients who had an operatively treated fracture of the hip. One group of patients received Org 10172 in a dose of 750 units subcutaneously every twelve hours until the ninth postoperative day; on the seventh postoperative day, warfarin was added to the regimen. The other group received only warfarin. Both drugs were begun preoperatively, immediately after the admission evaluation. In the patients who received warfarin, the desired prothrombin time was one and one-half times the control level. Deep-vein thrombosis was detected by 125I-fibrinogen scanning and impedance plethysmography and was confirmed by phlebography and compression ultrasonography. Deep-vein thrombosis was found in nine (7 per cent) of the 132 patients who received Org 10172 and in twenty-eight (21 per cent) of the 131 patients who received warfarin (p less than 0.001). Adverse reactions were not significantly different in the two groups. Major bleeding complications occurred in eight patients in the Org-10172 group, only four of whom were receiving the drug at the time of bleeding, and in five patients who were receiving warfarin (not significant). There was no difference in intraoperative loss of blood or in requirements for transfusion. We concluded that the low-molecular-weight heparinoid Org 10172 is a safe, convenient, effective antithrombotic agent for the prevention of venous thrombosis after an operation for fracture of the hip.     

Management of dialysis fistula thrombosis

The results of 74 operations for fistula thrombosis were analyzed by life table methods to identify aspects of operative management that were important in restoring long-term patency. Fistula patency was restored by simple thrombectomy in 14 of 15 (93 per cent) arteriovenous fistulas between the radial artery and cephalic vein and in 20 of 26 (77 per cent) bovine heterograft fistulas. However, early reocclusion was common after thrombectomy, resulting in cumulative 6 month patency rates of only 22 per cent for radiocephalic fistulas and 41 per cent for bovine heterograft fistulas.A protocol including routine intraoperative angiography and revision of identified fistula defects was employed in 33 operations (12 radiocephalic fistulas and 21 bovine heterograft fistulas). Significant defects were detected in 21 (64 per cent) and were revised concurrent with thrombectomy. Eleven lesions (52 per cent) were unsuspected and would have been undetected without routine angiographic assessment. Revision or demonstration of normal post-thrombectomy angiograms resulted in cumulative 6 month patency rates of 70 per cent for radiocephalic fistulas and 72 per cent for bovine heterograft fistulas, which are significantly better (p <0.05) than the results of thrombectomy alone. Revised defects included stenotic venous outflow intimal fibroplasia (14 instances), pseudoaneurysms (3), and anastomotic technical imperfections (4).A variety of remediable vascular lesions may contribute to recurrent dialysis fistula thrombosis. Correction of these defects is rewarded by improved maintenance of vascular access patency.     

Pulmonary embolism associated with surgically proved deep venous thrombosis

In a prospective study, thrombosis of the femoral or popliteal veins was discovered at operation in nine of eighty-one patients requiring amputation of a lower extremity for arterial insufficiency. One week postoperatively, all nine patients had evidence of pulmonary embolism on the lung scan. Embolization was documented by arteriography in two patients and at autopsy in a third patient. In none of these patients was there clinical evidence of venous thrombosis prior to operation.Two of the subjects with proved thrombosis died during study, a mortality of 22 per cent, whereas the mortality for the entire group was 10 per cent.It is concluded that the deep venous system of patients requiring amputation for ischemia should be examined carefully at operation. These patients have a high incidence of deep venous thrombosis and the discovery of thrombus at the time of operation places them in a particularly high risk group.