Increased blood pressure variability in menopause.

Blood pressure variability represents an independent risk factor for cardiovascular diseases. To detect possible blood pressure variability changes from fertile to menopausal status, we enrolled consecutively 219 women: 104 fertile women (46.6 +/- 3.4 years) and 115 menopausal women (53.9 +/- 3.98 years). We evaluated for each patient the body mass index (BMI), 24 h, daytime, night-time systolic and diastolic mean blood pressure values and blood pressure variability data by means of an Ambulatory Blood Pressure Monitoring device. We found a significant higher mean age, body mass index, systolic and diastolic 24 h, day and night-time blood pressure variability in menopausal women when compared to fertile women. Age and BMI were significantly correlated to most blood pressure variability data with the Spearman Rank test. The multivariate logistic regression with dichotomic variables showed that the menopausal status is independently correlated to 24 h systolic (p < 0.0005) and diastolic (p < 0.05) variability, systolic (p < 0.05) and diastolic (p < 0.05) daytime pressure variability and systolic night-time pressure variability (p < 0.05). Furthermore, we found independent correlations between age 24 h systolic (p < 0.05) and night-time diastolic blood pressure variability (p < 0.05), while the BMI was indepententely correlated to BMI 24h diastolic (p < 0.01), daytime systolic (p < 0.01) and diastolic (p < 0.05) blood pressure variability. These data show a significant increase of blood pressure variability in menopausal women when compared to fertile women, even after exclusion of confounding factors, such as aging and BMI. Menopausal status, aging and BMI increase may all, independently, contribute to the enhanced blood pressure variability we found in menopausal women.

Combination therapy with beta-adrenergic blockade and amlodipine as second line treatment in essential hypertension.

In hypertension both beta-blockers and calcium antagonists are drugs with proved efficacy. Because only half the patients respond to a single drug, even at full dosage, a second hypotensive agent is frequently required to obtain adequate blood pressure control. The combination of a dihydropyridine calcium antagonist and a beta-blocker can be justified by their different mechanisms of action. A randomised double blind parallel group study versus placebo was performed, in order to assess the efficacy of atenolol combined with amlodipine in the treatment of stage I-II essential hypertension not controlled by atenolol alone. Twenty-four-hour arterial blood pressure monitoring showed that amlodipine added to atenolol produced a statistically significant reduction of blood pressure values compared with placebo in patients whose blood pressure was not controlled by atenolol alone. Blood pressure circadian rhythm was unchanged. The reduction of side-effects, obtained by adding a dihydropyridine derivate to a beta-blocker, confirms the effectiveness of this combination.

A technical report reviewing the use of the 11-mm Gamma nail: interoperative femur fracture incidence.

Two years after the first large series on the Gamma nail, the authors analyze 119 surgical procedures for proximal femur fractures performed using the 11 mm Gamma nail. The study was performed by 24 surgeons (from six orthopedics departments) at different levels of learning, as in the previous study. The small-sized nail allows an easier surgical procedure and a manual introduction of the nail even in small femurs, as suggested by the previous experience. A careful operative technique and a 2 mm overreaming, which was almost always adopted, explains the decrease in interoperative and postoperative complications (evaluated in 88 cases), compared to the last case report published in 1991. No interoperative shaft fractures occurred in 119 nailings.

Intramedullary osteosynthesis with Grosse-Kempf nailing for the treatment of distal fractures of the femur.

The authors report the results they obtained in a homogeneous series of fractures of the distal third of the femur treated by Grosse-Kempf nailing. Of the 67 fractures (58 closed, 9 exposed) treated with closed surgery (except for 1 case treated by nailing 35 days after trauma) non-union was never observed. The two cases of delay in consolidation (one related to an infection) did not require a change in method. Bone grafting was never necessary. Only in 3 cases (2 with multiple trauma, 1 treated by open reduction) was moderate reduction in range of movement of the knee observed.

The results of a multicenter Italian study on the use of the Gamma nail for the treatment of pertrochanteric and subtrochanteric fractures: a review of 1181 cases.

A total of 1147 pertrochanteric and subtrochanteric fractures, 10 delays in consolidation and non-union, 24 pathologic fractures and osteolysis with the risk of fracture, treated with a gamma nail in 17 Italian departments of traumatology, were collected. In 70% of the patients weight-bearing was allowed during the first week postsurgery; 77% of the patients followed-up recovered the same ability to walk that had preceded trauma. Complications included intraoperative (1.8%) and postoperative (1.1%) diaphyseal fractures, cephalic screw cut out (2.2%), and breakage of the nail (0.4%). There were two cases of infection (0.3%). Most of the complications were related to errors in technique. The safest procedure is constituted by the choice of a nail with a thinner caliber, 2 mm diaphyseal over-reaming, insertion of the nail without the use of a hammer, and distal locking; the cephalic screw must always be inserted in the lower portion of the femoral head.

The role of magnetic resonance in necrosis of the femoral epiphysis as the sequelae of acetabular fracture (preliminary results).

Eleven patients surgically treated for fracture of the acetabulum were examined postoperatively by MRI in order to reveal any signs of necrosis of the femoral head at an early stage. The means of osteosynthesis used underwent preliminary testing in order to exclude magnetic or thermal phenomena. The study confirmed the usefulness of this test in the early diagnosis of this serious complication. In 3 cases the presence of the means of osteosynthesis obstructed a correct interpretation of the images.

The role of magnetic resonance imaging in lumbar disc disease.

The authors analyze 30 cases of herniated lumbar disc, comparing the clinical features with the magnetic resonance images and the intraoperative findings. In 10 cases it was possible to compare MRI with computerized tomography as well. This paper confirms, in agreement with the international literature, the great diagnostic value of this new imaging study. While MRI is non-invasive and does not expose the patient to ionizing radiation, it provides an amount of information that could previously be obtained only by combining CT with myelography and discography.

Results of the multicentric Italian experience on the Gamma nail: a report on 648 cases.

In a multicentric study, the data of 628 trochanteric fractures, two non-unions, and 18 pathologic or impending fractures treated by Gamma nail in 13 Italian traumatology services were collected and analyzed. In 70% of the patients weight bearing was allowed in the first postoperative week and 78% of the controlled patients returned to their pretrauma walking ability. Complications included intraoperative (1.4%) and postoperative (1.2%) shaft fractures, "cut out" of the lag screw (2.6%), and nail failure (0.5%). There were no cases of infection. An analysis of complications showed that most of them were due to technical mistakes. The safest procedure is 2 mm diaphyseal overreaming, introduction of the nail without hammering, and distal locking; the lag screw should be placed in the lower part of the head of the femur.

Grosse-Kempf nailing in fractures of the tibia.

A series of 136 tibial fractures treated with locked Grosse-Kempf nailing is reviewed, evaluating the results according to rapidity of healing, functional recovery, and complications. Locked nailing proved so reliable that immediate mobilization was possible. There was only a 6% incidence of delayed union, including infections (3 cases, 2%) and nail breakage (2 cases, 1.5%). Several details of the operative technique that were decisive in the final result are discussed.

The letournel lateral approach for treatment of acetabular fractures.

The authors report 9 cases of acetabular fracture, 6 recent complex and 3 inveterate, treated surgically through the lateral incision of Letournel. This approach provides excellent exposure of the acetabulum, the iliac wing, the posterior column, and the anterior column up to the iliopectineal eminence. Nevertheless, the high incidence of often serious complications makes the combined anterior-posterior approach preferable for severe inveterate fractures of the acetabulum.

Problems related to blocked nailing in fractures of the proximal femur.

The modern treatment of fractures of the proximal femur in the adult usually involves surgery. Open plating has proved to be reliable, but often involves a high percentage of complications: axial deformity, delayed union, breakage of the plate and/or screws (the risk of which increases in relation to the degree of comminution). At this site, in fact, the plate is submitted to strong flexion stress. It therefore becomes essential to associate cancellous grafts (as proposed by the AO School) (Muller et al., 1981) or a homoplastic cortical craft (as in our experience) (Zinghi and Masetti, 1982). Furthermore, open osteosynthesis is time consuming and this means considerable blood loss and a risk of infection. There are thus many reasons for preferring closed surgery, but effective stabilisation can only be obtained with blocked nailing; in fact, only metadiaphyseal screwing is capable of neutralising the rotation or axial stresses which cause deviation, instability or telescoping of the fracture (Kempf et al., 1978; Tigani et al., 1986; Zinghi et al., 1984). Osteosynthesis with Grosse-Kempf nailing is thus an effective alternative to open nailing, particularly in those fractures which would require additional bone grafting with this method. The purpose of our study was to verify the effectiveness of intramedullary osteosynthesis with Grosse-Kempf blocked nailing, in particular analysing the problems encountered in the use of this method.

A comparison between delayed and immediate intramedullary nailing in the treatment of comminuted and open fractures (grade 1) of the tibia.

The authors studied a group of 215 comminuted or open (Grade 1) fractures of the tibial diaphysis in order to compare two methods successively adopted at the 1st Clinic and 3rd Division of the Rizzoli Orthopaedic Institute. We at first chose to delay nailing in these two types of fracture for 4 weeks (131 cases) and obtained good results in terms of consolidation, but only fair results in terms of functional recovery of ankle and subtalar movement and axial alignment of the tibia. Successively, we used immediate osteosynthesis with a screwed nail (84 cases), the results of which were better for all the parameters considered. The criteria for delaying intramedullary osteosynthesis in grade 1 open fractures are still valid, particularly when there are problems which necessarily delay operative treatment within 8 hours of injury. However, immediate treatment is essential in these fractures when they are associated with vascular lesions or in patients with multiple injuries. Finally, the authors express their preference for intramedullary nailing as compared with external fixation for the treatment of these open fractures with limited exposure.

Lumbar disc herniation: diagnosis, surgical treatment, recurrence. A review of 872 operated cases.

This review is based on 972 cases treated surgically for lumbar disc herniation between 1974 and 1984. The authors discuss several problems related to this condition. The importance of the history and clinical assessment are emphasized, as well as the role of instrumental tests such as radiculography and CT scan. The authors report what they believe to be the treatment of choice to avoid recurrence, based on an analysis of two groups of patients. The first group consisted of patients in whom lumbar and radicular pain persisted after operation. The second group consisted of patients in whom these symptoms recurred after an interval of complete relief. This analysis leads to the following conclusions: 1) clinical examination is pre-eminent; CT scan and radiculography are complementary to an accurate neurological examination; 2) hemilaminectomy is the operation of choice because it is sufficient to ensure accurate exploration of both root and disc; 3) most recurrences are due to errors in diagnosis or surgical technique.

The treatment of fractures of the acetabulum involving both anterior and posterior columns.

Over a period of 20 years, 35 cases of fracture of the acetabulum involving both columns were treated by operation in our unit. These were followed up after a minimum of 8 to a maximum of 20 years. The Iselin approach, even when extended forwards by partial disinsertion of the gluteal muscles, allowed good reduction only when there was little or no displacement of the ilio-pubic column. In the other cases, it was necessary to use a combined anterior and posterior approach, or the Letournel approach, but the latter was reserved for cases with very severe displacement or comminution of the fragments when it is essential to have access and control of the iliac and acetabular complex in its entirety. The clinical and radiographic results of fractures involving both columns are not unlike those observed in other complex fractures of the pelvis: good reduction and osteosynthesis is synonymous with good function even in the long term.

The surgical treatment of inveterate fractures of the acetabulum.

Any fracture of the acetabulum which is not adequately treated within 3 weeks poses a considerable surgical problem. Reduction is difficult, callus has already begun to form between the displaced fragments, and the risks of complications are therefore increased. Our material consists of 35 cases, subdivided into 18 fractures submitted for treatment between 3 and 12 weeks after injury, and 17 fractures submitted for treatment beyond the 12 week limit. In the first group the incidence of complications (ischaemic necrosis, arthrosis, infection) was high; satisfactory results were obtained only when the fracture was of the simplest type. In the second group, malunion had to be accepted, and treatment was concerned solely with improving function by correcting malposition and relieving or eliminating pain. The surgical methods adopted depended on the circumstances: corrective osteotomy, arthrodesis or total prosthetic replacement.