Pro-inflammatory interleukins in patients operated on for proximal femur fracture.

OBJECTIVES: The aims of this study were to measure plasma IL 6 and IL 8 in patients with proximal femoral fracture (PFF) during the early phases of trauma and operation and to find out if there was any correlation between these ILs and the post-operative lower limb oedema. MATERIAL AND METHODS: Thirty patients with a median age of 81 years were grouped into pertrochanteric fracture (PTF) (n = 16) and femoral cervical fracture (FCF) (n = 14). Plasma interleukin levels were determined on blood samples obtained from the common femoral vein, immediately after hospital admission, 1 h before operation, and post-operatively at 1, 6, 12, 24, 48 h and on the 7th day. Thigh oedema was calculated by the frustum method. RESULTS: In the patients with PTF, maximum mean plasma IL-6 and IL-8 values were found, respectively at 24 h (45.12 pg/mL) and 6 hours (21.7 pg/mL) postoperatively. Whereas, in the patients with FCF, it was respectively, at 12 h (33.1 pg/mL) and 6 h (17.0 pg/mL), for IL-6 and IL-8 post operatively. The patients with PTF and FCF had respectively, 34.1% and 27.4% more thigh oedema in the operated limb on the 7th post-operative day as compared to the preoperative oedema volume (p<0.001). No significant correlation could be found between the plasma IL-6 and IL-8 levels and oedema in the operated limb. CONCLUSION: Increased levels of IL 6 and IL 8 suggest ongoing inflammation.

[Laparoscopic aortic surgery]. / Laparoskopisk aortakirurgi.

BACKGROUND: Laparoscopic aortic surgery (LAS), performed since 1993, has undergone a number of technical improvements during recent years. The published results are comparable with those for open surgery. The aim of this article is to present the method with a focus on technical details, and at the same time present our experience with this technique. MATERIAL AND METHODS: Eight patients with debilitating intermittent claudication were operated with a total laparoscopic aortofemoral bypass. Operations were performed through a transperitoneal retrorenal approach. Median age of the patients was 61 years (range 51-76). All patients had an aortoiliac occlusive disease of type D according to the Transatlantic Inter Society Consensus (TASC). Prior to the procedures an operation team followed a structured training programme that comprised using a training model and operating on pigs, and visited an international referral centre. RESULTS AND INTERPRETATION: All operations were successfully performed. No patient developed per- or post-operative complications. Median post-operative hospital stay was four days. LAS is a technically demanding procedure and it can be established through well targeted and carefully planned training.

Edema in the lower limb of patients operated on for proximal femoral fractures.

BACKGROUND: Patients with proximal femoral fracture (PFF) often develop postoperative edema in the operated limb. This may lead to reduced mobilization, increasing the length of hospitalization. It is therefore relevant to gain information about the extent and pathogenesis of this edema formation. METHODS: Forty-one patients with PFF (30 women and 11 men) were studied pre- and postoperatively. Patients were grouped into pertrochanteric fractures and femoral cervical fractures, according to the AO/ASIF classification of PFF. Thigh and calf volumes were calculated in both fractured and contralateral limbs preoperatively and on postoperative days 3, 5, 7, and 30. RESULTS: All patients with PFF developed edema in the operated limb. The greatest volume increase occurred on postoperative day 7 (p < 0.0005). The magnitude of edema in the thigh and the leg of patients with pertrochanteric fractures as compared with the nonoperative side was approximately twice as great as in those with femoral cervical fractures (p < 0.0001). There was a statistically significant daily increase in the volume of the operative limb as compared with the nonoperative side. Age and sex were not correlated with the extent of edema formation. Functionally significant deep venous thrombosis and local infection could be excluded as causative factors. CONCLUSIONS: Postoperative edema in the thigh and leg of the operated limb was considerable. The magnitude of edema formation was related to the severity of primary trauma and the type of osteosynthesis. Therefore, the operation performed for PFF should be minimally traumatic.

Blood pressure response to isometric exercise in patients with peripheral atherosclerotic disease.

BACKGROUND: The purpose of this study was to compare the circulatory responses to isometric exercise in patients with peripheral atherosclerotic disease (PAD) with healthy controls. METHODS: Eleven patients with diagnosed PAD, a control group of eleven healthy young adults, and a control group of eleven healthy age-matched adults participated. Blood pressure, heart rate, stroke volume, cardiac output, blood velocity in the brachial artery, acral skin perfusion was continuously recorded and total peripheral resistance calculated before, during and after 2 min of 40% maximum voluntary contraction of the forearm. RESULTS: At rest we found a consistently higher level of mean arterial pressure (MAP) and systolic pressure (SP) in the elderly, both PAD patients and elderly controls, compared with the young controls. We found no significant difference in diastolic blood pressure. Two minutes isometric handgrip exercise induced a similar increase in MAP in all three groups (patients 32.6 (17.9) mm Hg [mean (SD)], young control group 25.3 (8.9) mm Hg, age-matched control group 36.1 (10.6) mm Hg). No significant differences were found in the other measured cardiovascular variables during isometric handgrip. Increased TPR is the main factor contributing to the increase in blood pressure in all three groups. CONCLUSION: Our study indicates that the pressor response continues to be well regulated with age, also when the cardiovascular system is altered by marked atherosclerosis. The consequence is that both PAD patients and elderly controls reach higher SP values during isometric exercise due to higher SP baseline values.

[A construction worker with acute knee pain]. / En anleggsarbeider med akutte knesmerter.

BACKGROUND: Out of all peripheral arterial aneurysms, 70% are located in the popliteal artery; less than 4% of these rupture. Ruptured popliteal aneurysms may be mistaken for deep venous thrombosis. MATERIAL AND METHODS: From March until June 2001 three patients were primarily admitted with a diagnosis of venous thrombosis. This delayed the appropriate treatment of a ruptured popliteal aneurysm considerably. Two patients were first anticoagulated with warfarin before being transferred to the surgical ward. All the patients were operated on with the exclusion of the popliteal aneurysm and a femoropopliteal bypass conduit. RESULTS: The haematoma from a ruptured popliteal aneurysm presenting with pain and venous swelling is easily mistaken for a deep venous thrombosis. In these three patients the correct diagnosis was made respectively 18, 2 and 20 days after the onset of swelling and pain. INTERPRETATION: Ruptured popliteal aneurysms can be mistaken for a venous thrombosis or a Baker cyst. A Duplex scan will most often lead to a correct diagnosis. Surgery is mandatory. Delayed diagnosis and treatment increases morbidity and may lead to loss of limb.

Prothrombotic activity is associated with the anatomical as well as the functional severity of peripheral arterial occlusive disease.

The importance of prothrombotic activity in cardiovascular disease has been well established. However, limited data exist on the relationship between prothrombotic activity and the severity of peripheral arterial occlusive disease (PAD). The objective of the present study was to investigate the relationship between markers of haemostasis and the diagnostic measures of PAD: ankle-brachial-index (ABI), maximum treadmill walking distance and angiographic score. In a cross-sectional study of 127 patients (mean age 66 years; 64% males) with angiographically verified PAD, fasting blood samples were drawn, and citrated plasma was obtained for determination of selected haemostatic variables: von Willebrand factor (vWF), thrombomodulin (sTM), thrombin-antithrombin complex (TAT), soluble tissue factor (sTF), tPA antigen (tPAag) and D-dimer were all significantly correlated with the angiographic score (p < 0.05 for all). D-dimer, tPAag and fibrinogen were inversely correlated with the maximum treadmill walking distance, (p < 0.0001, p < 0.04 and p < 0.05, respectively), whereas fibrinogen was the only variable correlating to ABI (r = -0.223, p < 0.05). After adjustment for relevant covariates, D-dimer and TAT remained statistically significantly associated with the angiographic score (p < 0.001), and fibrinogen was, independent of other risk factors, inversely related with both the maximum treadmill walking distance and the ABI (p < 0.01 for both). This rather large study in patients with PAD showed that plasma levels of D-dimer, TAT and fibrinogen significantly predicted the extent of atherosclerosis, evaluated by angiographic score, maximum treadmill walking distance and ABI, respectively. These findings demonstrate a prothrombotic state in PAD patients, which might be of importance in future diagnosis and treatment of the disease.