Functional and muscle morphometric effects of ACL reconstruction. A prospective CT study with 1 year follow-up.

Computed tomography (CT) was used to explore if changes in muscle cross-sectional area and quality after anterior cruciate ligament (ACL) injury and reconstruction would be related to knee function. Fourteen females and 23 males (16-54 years) underwent clinical tests, subjective questionnaires, and CT 1 week before and 1 year after ACL surgery with semitendinosus-gracilis (STG) graft and rehabilitation. Postoperatively, knee laxity was decreased and functional knee measures and subjective patient scores improved. The most obvious remaining deficit was the quadriceps atrophy, which was significantly larger if the right leg was injured. Right-leg injury also tended to cause larger compensatory hypertrophy of the combined knee flexor and tibial internal rotator muscles (preoperatively). The quadriceps atrophy was significantly correlated with the scores and functional tests, the latter also being related to the remaining size of the gracilis muscle. Biceps femoris hypertrophy and, in males only, semimembranosus hypertrophy was observed following the ACL reconstruction. The lack of semimembranosus hypertrophy in the women could, via tibial internal rotation torque deficit, contribute to the less favorable functional and subjective outcome recorded for the women. The results indicate that the quadriceps, the combined knee flexor/tibial internal rotator muscles, side of ACL injury, and sex are important to consider in rehabilitation after STG graft.

Carotid endarterectomy in octogenerians.

PURPOSE: The purpose of this study was to determine the safety and efficacy of carotid endarterectomy (CEA) in octogenerians. METHODS: The records of 59 CEA performed in 57 patients who were 80yr or older between April 1993 and September 1998 were reviewed. There were 33 males and 24 females with a mean age of 82. Forty-nine procedures (83%) were performed for symptomatic carotid stenosis. The perioperative mortality and morbidity including neurological events were recorded. Long term follow-up data was also obtained. RESULTS: There were three perioperative deaths (5.1%) and three perioperative neurological events, including one stroke (1.7%) and two transient ischemic attacks (3.4%). The combined mortality and stroke rate was 6.8%. With a mean follow-up of 25+/-21months, Kaplan-Meier estimates of the 4-yr survival rate, freedom from stroke, and stroke free survival were 78, 94 and 75% respectively. For comparison, during the same time period, the same group of surgeons performed 597 CEA in patients less than 80yr of age. The perioperative mortality and stroke rate was 0.3 and 2.5% respectively, with a combined mortality and stroke rate of 2.7%. Perioperative mortality was significantly higher in patients over 80yr of age (P<0.01). CONCLUSIONS: CEA in octogenerians is associated with a higher mortality rate than in younger patients. However, good long term survival and freedom from stroke make CEA beneficial in octogenerians. With careful patient selection and perioperative management, CEA in octogenerians is worthwhile and should be advised in selected patients.

Predictors of death in nonruptured and ruptured abdominal aortic aneurysms.

PURPOSE: This study evaluated perioperative variables to predict death in nonruptured and ruptured abdominal aortic aneurysm (AAA) surgery. METHODS: A consecutive review of all patients who underwent AAA surgery from January 1984 to December 1993 was carried out. Perioperative variables were analyzed with univariate and multivariate statistical models to predict mortality rates. RESULTS: Four hundred seventy-eight patients with nonruptured AAAs and 157 patients with ruptured AAAs were studied. In patients with nonruptured AAAs, the mortality rate was 3.8%. Using stepwise logistic regression analysis, independent predictors of death were perioperative myocardial infarction (odds ratio [OR], 5.0; p < 0.01), prolonged postoperative ventilation (OR, 4.0; p < 0.01), history of peripheral vascular disease (OR, 2.9; p < 0.01), preoperative renal dysfunction (OR, 2.7; p < 0.01), and history of congestive heart failure (OR, 2.6; p < 0.03). In patients with ruptured AAAs, the mortality rate was 46%. Analysis of preoperative variables using multivariate stepwise logistic regression found predictors of death to be preoperative unconsciousness (OR, 3.1; p < 0.01), advanced age (OR, 1.9; p < 0.01), and cardiac arrest (OR, 1.8; p < 0.05). In patients who survived the initial surgery for ruptured AAA, a second stepwise logistic regression model found independent predictors for subsequent postoperative death to be coagulation disorder (OR, 7.9; p < 0.01), ischemic colitis (OR, 6.4; p < 0.01), inotropic support beyond 48 hours (OR, 4.8; p < 0.01), delayed transport to operating room (OR, 4.6; p < 0.01), advanced age (OR, 4.4; p < 0.01), perioperative myocardial infarction (OR, 4.0; p < 0.05) and postoperative renal dysfunction (OR, 3.7; p < 0.01). CONCLUSION: Prolonged ventilation, perioperative myocardial infarction, a history of peripheral vascular disease, preoperative renal dysfunction, and a history of congestive heart failure are independent predictors of perioperative death in patients with nonruptured AAAs. For patients with ruptured AAAs, mortality rates can be estimated before surgery using age, level of consciousness, and cardiac arrest. For patients who survive the initial surgery for ruptured AAA, subsequent mortality rates can also be predicted.

Determination of plasma amitriptyline by electron-capture gas chromatography after oxidation to anthraquinone.

A selective procedure is described for the determination of amitriptyline in plasma. The method involves extraction, separation of amitriptyline from its metabolites and subsequent oxidation by ceric sulphate in 5.4 M sulphuric acid. The oxidation product, anthraquinone, is determined by means of electron-capture gas chromatography. The metabolites were separated by a column chromatographic extraction technique. The choice of oxidation reagent, optimum conditions for the oxidation, and the electron-capture properties of anthraquinone are discussed. The method can be used to determine down to 2 ng of amitriptyline in a plasma sample; the relative standard deviation at the 50-ng level was 4.0% (n = 8). The levels of amitriptyline found in a series of plasma samples are compared with those obtained by gas chromatography with use of nitrogen-specific detection; the two techniques gave coincident results.