Percentage of inadequate phlebograms and observer agreement in thromboprophylactic multicenter trials using standardized methodology and central assessment.

This study examines inadequacy rates for phlebography in two multicenter trials for the prevention of post-operative DVT and determines inter-and intra-observer variability in evaluating phlebograms. A total of 991 (I) and 385 (II) patients underwent bilateral phlebography in two studies of thromboprophylaxis. Phlebography was performed using a standard method designed to visualize and assess all deep veins. Each vein was scored as normal, DVT or inadequate by both local and central assessment. The study showed low inadequacy rates for phlebograms of 12.2% (121/991) and 6.5% (25/385). Inter-observer agreement (local vs. central assessment) was moderate in both studies (I: 74.8%, Kappa-value 0.41; II: 82.6%, Kappa-value 0.51). Good intra-observer agreement (within the central assessment group) was observed (I:88.8%, Kappa-value 0.75). This study demonstrates low inadequacy rates for phlebograms using a standardized methodology and superior intra-observer agreement compared to inter-observer agreement and supports the importance of central assessment of phlebograms in thromboprophylactic multicenter trials to reduce observer variability.

Arthrography in dislocation of the acromioclavicular joint.

Arthrography was performed in 10 patients with dislocation of the acromioclavicular joint. The examination was unsuccessful in one case. In the remaining 9 patients, leakage of the contrast medium was observed around the joint and in the direction of the coracoid process. The arthrographic abnormalities were compared with the findings at operation. The distribution of the medium that had leaked out provided information on the severity of the injury to the ligaments.

Circulatory disturbances after experimental fracture.

Early hemodynamic and angiographic effects after fracture with a minimum of soft tissue injury were investigated in anesthetized dogs. A close relation between hemodynamic and angiographic findings was observed. The fracture procedure did not change the regional blood flow in the soft tissues outside the bone in the injured extremity.

Fracture of the scapular notch associated with lesion of the suprascapular nerve.

In a material consisting of 18 patients with scapula fractures, the scapular notch was involved in two cases. In one of these cases injury of the suprascapular nerve function was proved. The value of X-ray examination with projections visualizing the scapular notch is pointed out. EMG examination in selected cases with the combination of reduced supraspinatus muscle function and a fracture of the scapular notch is recommended in order to diagnose injury of the suprascapular nerve.

Comparison of iohexol with metrizoate in urography. A single blind parallel investigation.

Iohexol 300 and 350 mg I/ml were compared with Na-Ca-Mg metrizoate 350 mg I/ml at the dose levels 200 and 350 mg I/kg body weight. Independent of dosage, iohexol caused a lower incidence of patient reactions during urography than metrizoate. The intensities of the patient reactions in the iohexol groups were consistently milder than those in the corresponding metrizoate groups. Both contrast media gave equally good diagnostic quality, and no unexpected changes in laboratory or physiologic components occurred. Both tolerability and patient reactions indicate that iohexol should be preferred to metrizoate in urography.

Angiography and hemodynamic measurements in extensive soft tissue trauma to the extremity.

The early circulatory changes following extensive soft tissue injury to the hind leg of the dog was examined by angiography and by measurement of blood flow by an electromagnetic flowmeter. The trauma caused a marked increase of blood flow and vasodilatation in the injured extremity with or without combination of a fracture. The later gradual increase of calculated vascular peripheral resistance was angiographically reflected by successively impaired flow in peripheral arteries. In spite of the decrease of flow, the dilatation of the larger arteries persisted for several hours.

Ultrasound in the diagnosis of popliteal cysts.

Ultrasound examination of 9 patients with suggested popliteal cyst was performed and the results are described and discussed. Ultrasonography is a diagnostic alternative which may replace arthrography.

Phlebography in crural hematoma. Differential diagnosis from recent deep vein thrombosis.

Fifteen cases of crural hematoma in which phlebography had been performed were revised. A phlebography was often normal in an early stage of hematoma. In major crural hematoma compression, displacement and occlusion of the deep venous system occurred. Non-filling of deep veins occurred in 6 cases, and venous thrombosis should therefore only be diagnosed on the basis of constant filling defects.

Radiography of the shoulder after Bristow repair.

A radiologic follow-up of 30 shoulders in 29 patients operated upon according to the Bristow procedure is presented. Four projections of the shoulder were found necessary for adequate radiographic evaluation of the surgical results, a.p., lateral, oblique lateral and modified axial views. The two latter projections are appropriate for evaluation of the bony transplant and its relation to the anterior glenoid rim. Radiographic findings relating to bony union of the transplant and to the clinical results are discussed.

Central assessment of bilateral phlebograms in a major multicentre thromboprophylactic trial. Reasons for inadequate results.

PURPOSE: To determine the cause of inadequate bilateral phlebograms at central assessment. A major antithrombotic trial was evaluated to identify and apply corrective measures for reducing inadequate results in future multicentre trials. MATERIAL AND METHODS: The inadequate results in 253 out of 1,827 patients having undergone bilateral phlebography following total hip replacement were reviewed by two central assessors using strict criteria for evaluability. The reasons for inadequate findings were assessed and ranked. RESULTS AND CONCLUSION: Insufficient contrast filling, especially of the anterior tibial, common femoral and iliac veins, was the most common reason for disqualifying examinations. Unilateral examinations and obscuring metallic devices were the second and third most common reasons, respectively. Efforts should be made to standardize the phlebography technique, to use a large volume of contrast without tourniquets, and to obtain an appropriate number of views to visualize the deep veins.

Stress views in the comparative assessment of spondylolytic spondylolisthesis.

Patients with spondylolytic spondylolisthesis were examined in six different positions to detect segmental instability. The amount of displacement was determined on lateral spot radiographs, taken in recumbent, standing, flexion, extension, axial compression, and traction positions in each patient. An error analysis was also performed. Examination in axial compression-traction was found to be a significantly better method for detection of segmental instability compared with standing-recumbent, or flexion-extension radiographs. In addition, the compression-traction method exhibited a higher sensitivity for identification of instability (73%) than standing-recumbent (33%) or flexion-extension (20%) views. The total error in the determination was small, +/- 2.5% (95% CL), providing a careful and controlled technique was used.

Thrombosis prophylaxis with low molecular weight heparin in total hip replacement.

In a randomized prospective trial, the efficacy of low molecular weight heparin (LMWH) (Fragmin) and dextran 70 (Macrodex) in preventing deep vein thrombosis (DVT) in the legs was evaluated in 98 consecutive patients undergoing elective total hip replacement. The patients were randomly allocated to receive either 2500 anti-factor Xa units LMWH twice daily for 7 days, with the first dose given 2 h before surgery; or 500 ml dextran 70 twice during the day of operation, followed by a single infusion of 500 ml on the first and again on the third postoperative day. DVT was assessed by 125I-fibrinogen test for 2 weeks postoperatively, a positive test being followed by phlebography. DVT developed in 22 (45 per cent) of 49 patients receiving dextran 70 and in 10 (20 per cent) of 49 patients in the LMWH group (P less than 0.01). LMWH was thus statistically significantly better than dextran 70 in preventing DVT in the legs. It was not firmly established whether this benefit was also valid in the high ileofemoral region. Two patients with non-fatal pulmonary embolism were found in each group. Per- and postoperative blood loss and blood transfusion requirements were significantly lower in the LMWH group.

Transurethral stone extraction with a vibrating basket catheter.

In a recent in vitro study, mechanical vibration was shown to facilitate, considerably, both the passing of a basket catheter beyond an artificial ureteral stone as well as the extraction of a calculus. Therefore, a device by which vibration can be transmitted to the basket of a modified stone extractor was developed for clinical application. The basket moves to and fro with an amplitude of 2-4 mm and a frequency of 40-60 Hz. An experimental follow-up study was performed in dogs to find out whether the vibration procedure as such induced injuries to the ureters. Modified stone extractors were passed up bilaterally into the ureters of 11 dogs. Vibration was applied in a standardized manner to one side, the other non-vibrated side served as a control. Postoperatively, 5 dogs were followed during 4-5 weeks with repeated urographies. Specimens of the ureters were examined microscopically when the dogs were sacrificed. No complications which could be ascribed to the vibration procedure as such were observed. The vibration technique was tried also in a pilot study comprising 14 patients with distal ureteral stones; in 9 patients, the stones were successfully extracted. Of the remaining 5 patients in whom the stone extraction failed, 3 passed the stone spontaneously and in 2 ureterolithotomies were performed. No complications were encountered.

Angiography of the dilator response in extremity trauma.

The dilatation of major arteries following early after extensive soft tissue trauma was demonstrated angiographically not to be affected by pharmacologic or mechanical contractile stimuli. The proximal spread of the dilatation was not abolished by the division and a reanastomosis of the vessel before the trauma. These results suggest loss or impairment of the contractile ability of the major arteries following early after the trauma.

Effects of intraarterial injection of contrast medium on regional circulation in soft tissue trauma.

The effects of repeated intraarterial injections of methylglucamine metrizoate on regional circulation were registered in soft tissue trauma to the dog hind leg. The circulatory disturbances were determined by hemodynamic measurements and by angiography. The changes of flow following injection of the contrast medium were related to the films. The informative arterial phase appeared in the time lag between injection and the flow increasing effect of the contrast medium both before and after trauma. No evidence of a cumulative effect was recorded.

Circulatory disturbances following missile wounding of soft tissue.

The early circulatory changes following high velocity missile wounding to soft tissue of an extremity were analysed by hemodynamic methods and serial angiography. The extent of the tissue injury and the functional disturbances were mapped out and the time-course of the alterations in blood flow was registered. Possible mechanisms for the observed abnormalities are discussed.

Endoprosthetic arthroplasty of the ankle joint. A clinical and radiological follow-up.

Eighteen ICLH ankle arthroplasties in 16 patients were followed up 15 to 52 months postoperatively (mean 36 months) by a review of the records, and clinical and radiological examinations. Five arthroplasties were performed for osteoarthrosis, 13 for rheumatoid arthritis. The overall clinical result was rated excellent in 2, good in 8, fair in 6, and poor in 2 joints. In osteoarthritic joints the results were somewhat poorer, no patient obtaining a rating of excellent but 2 of good, 2 of fair, and one of poor. Radiolucent zones greater than 2 millimeters were seen around the tibial component in 7 cases. Loosening defined as radiographic signs of movement between the prosthetic components and bone was present in 4 cases. The high occurrence of obvious loosening and large radiolucent zones indicates that mechanical problems will be encountered frequently in the future. From the results of this study it is concluded that ankle arthroplasty has a definite place in the treatment of severe arthritis in rheumatoid patients.

Circulatory disturbances following transient soft tissue compression trauma.

Circulatory changes following standardized compression trauma to the hind leg in dogs were evaluated using an electromagnetic flow meter and repeated angiography. A transient increase of flow to the injured limb and within the traumatized region was observed. Good agreement was found between the electromagnetic flow recordings and estimates of relative changes in flow by the angiographic method.

Phlebographic findings in venous thrombosis following total hip replacement.

The specific appearance of venous thrombosis following total hip replacement was analysed by reviewing 45 positive phlebograms from 122 patients participating in a concurrent trial against thromboembolism. Almost all thrombi were asymptomatic and non-occlusive. Forty-four per cent of the thrombi were exclusively confined to the calf. The muscular veins were the most common location, followed by the fibular and posterior tibial veins. Ipsilateral thrombi predominated over thrombi in the non-operated leg. Thirty-six per cent were located in the ipsilateral thigh and the major part was found in the proximal part of the femoral veins. Nearly all were related to valve cusps, free-floating and were of small size. In 20 per cent, thrombi were found in both the calf and the thigh. Neither contralateral thigh thrombi, nor pelvic thrombi were found. Of 25 patients with pulmonary embolism, all but 3 asymptomatic, 64 per cent had thigh thrombi. A multifocal location of thrombi was present but two major types of thrombosis were distinguished; calf vein thrombosis probably due to venous stasis and femoral thrombosis caused by the local surgical trauma.