Biomedical subjects
Publications and source records attributed to P Ohlin.
The pressure between the ulnar nerve and the arcade bridging the two heads of the flexor carpi ulnaris muscle was recorded peroperatively in ten patients with electrophysiologically confirmed ulnar neuropathy at the elbow. At rest, with the elbow extended, pressures ranged from 0 to 19 mm Hg but increased in flexion and during isometric contraction of the flexor carpi ulnaris muscle to maximal values above 200 mm Hg.
Twenty-eight consecutive cases of acute superficial thrombophlebitis of the long saphenous vein above the knee were reviewed concerning presence of asymptomatic deep venous thrombosis and pulmonary embolism and early clinical results after surgical treatment. Contrast phlebography of the ipsilateral leg revealed asymptomatic involvement of major deep veins of the thigh or calf in 4 of 21 examined patients. Perfusion lung scanning and chest radiography demonstrated typical segmental perfusion defects consistent with pulmonary embolism in two of ten examined patients. High ligation and stripping of the phlebitic veins gave prompt cure in 19 patients, though in two who were simultaneously treated with anticoagulants there was troublesome bleeding. Simple high ligation was performed in nine patients without complications, but four of them had protracted phlebitic pain. The results indicated that preoperative phlebography and lung scanning are helpful in detecting associated asymptomatic disorders and for planning therapy in patients with clinically isolated, superficial thrombophlebitis of the long saphenous vein. The treatment of choice is acute high ligation with removal of all phlebitic veins. If anticoagulation is indicated because of concomitant deep venous thrombosis or pulmonary embolism, the initial procedure should preferably be limited to high ligation.
The results of iliac vein reconstruction performed early after secondary iliofemoral venous thrombosis were retrospectively evaluated. The review comprised seven patients who underwent acute thrombectomy combined with cross-femoral (4 cases) or iliocaval (3 cases) bypass procedures using polytetrafluoroethylene (PTFE) grafts. The clinical course, graft patency and venous physiology were studied. Five patients had a satisfactory clinical course, but one patient died of postoperative complications and another underwent leg amputation after 20 months. Contrast and radionuclide phlebograms showed that only two grafts were still patent after two years, but only one of these was still patent five years postoperatively. Clinical symptoms and physiologic parameters correlated poorly with graft patency, demonstrating the necessity of phlebography in evaluating patency rates after venous surgery. Our study indicates that early venous reconstruction using PTFE grafts does not result in satisfactory long-term patency rates. Further development of graft materials suitable for the venous system is required.
The treatment of choice in acute iliofemoral venous thrombosis is still controversial. This prospective randomized study compares the results of conventional anticoagulation of 32 patients with the results obtained in 31 patients undergoing acute thrombectomy combined with a temporary arteriovenous fistula and anticoagulation. Early complications were few in both treatment groups, and significant pulmonary embolism developed in only one conservatively treated patient. At 6-month follow-up in all surviving patients, leg swelling, varicose veins, and venous claudication were more frequent after conservative treatment. Only 7% (2 of 27) of these patients were completely free from postthrombotic symptoms compared with 42% (10 of 24) of the operated patients (p less than 0.005). Contrast phlebography demonstrated an excellent venous outflow through the iliofemoral segment in 35% (9 of 26) of the conservatively treated and in 76% (16 of 21) of the operated patients (p less than 0.025). Open femoropopliteal veins with competent valves were recorded in 26% (7 of 27) in the conservative group and in 52% (12 of 23) in the thrombectomy group (p less than 0.05). Thus thrombectomy combined with arteriovenous fistula decreases early symptoms and preserves venous outflow and valvular function better than conservative treatment. This procedure is therefore recommended for young patients with acute iliofemoral thrombosis to avoid development of incapacitating postthrombotic sequelae.
The effects of fetal heart arrhythmias were examined serially in two pregnancies by three non-invasive methods: fetal ECG, fetal phonocardiography and ultrasonic measurement of fetal blood flow. In a case of supraventricular arrhythmia, there was evidence suggesting that the stroke volume varied with ventricular filling according to the Frank-Starling law. In a case of total atrioventricular block the mean blood flow in the fetal descending aorta and in the umbilical vein was within the normal range. Blood flow velocity in the inferior vena cava of the fetus reflected atrial contractions. In the phonocardiogram, a phenomenon similar to 'bruit de canon' was found. Both pregnancies had good outcomes and subsequent development of the infants was normal except for the persisting dysrhythmias. The two cases exemplify how fetal heart function can be assessed in utero.
In 20 patients with suspect deep venous thrombosis (DVT), scintillation detector measurements were performed over each leg during the first 60 min after intravenous injection of 99Tcm-porcine plasmin. Thereafter, 99Tcm-labelled autologous erythrocytes were injected i.v. and repeat measurements were performed. Finally, scintillation camera images of both legs were obtained. Phlebography was used as a reference method. A close relationship (P less than 0.01) was found between the scintillation detector measurements, both in patients with DVT (n = 11) and in patients without DVT (n = 9). Thus, 99Tcm-plasmin is not specifically bound to the thrombus. Rather the clinical utility of the test depends mainly on circulatory changes secondary to the thrombus. Scintillation camera images of 99Tcm-erythrocytes in the legs were not useful for diagnosis of DVT in the calves but showed a high specificity for DVT in the popliteal and femoral veins.
In 22 patients with femoral neck fractures 99mTc-MDP scintimetry was performed before operation and again shortly after operation; in 17 of these patients the investigation was repeated after four months. Six patients with increased uptake in the femoral head before operation and eight with decreased uptake had similar results at the first postoperative investigation. Of eight patients with an intermediate uptake before operation, two showed increased and six decreased femoral head uptake after operation. It is concluded that for the patients in the group with intermediate femoral head uptake before operation, the operative procedure probably influenced the postoperative blood supply of the femoral head.
In four patients ectopic bone formed after total hip replacement was replaced with free fat transplants. One year later the patients were free from pain, and hip flexion had increased by 60 degrees on average. Ectopic bone was completely absent in one patient, and markedly reduced in the remaining three patients. Bone scintigraphy was found to be a sensitive technique to reveal early ectopic bone formation. Fat transplantation seems to be a satisfactory complement in the treatment of ectopic bone.
Nine patients with chronic iliac vein obstruction and venous claudication were investigated. Intramuscular pressure was measured in the anterior tibial and the deep posterior compartments in both legs at rest and during exercise. The pressures were significantly higher in the leg with iliac vein obstruction (39 +/- 10 mm Hg) than in the contralateral leg (26 +/- 12 mm Hg) at rest as well as during exercise (60 +/- 16 mm Hg and 41 +/- 15 mm Hg, respectively) in the deep posterior compartment. Similar changes were observed in the anterior tibial compartment. Muscle water content was higher (P less than 0.01) in the obstructed leg and contributes to the explanation for the high intramuscular pressure in this leg. Muscle blood flow, adenosine triphosphate, phosphocreatine, and lactate were determined in the gastrocnemius muscles at rest and at exercise. Muscle blood flow, measured with the 133xenon clearance technique, was lower in the obstructed leg (17.5 ml/min, 100 gm) than in the control leg (28.1 ml/min, 100 gm) during exercise. Lactate increased more (P less than 0.05) in the obstructed leg. It is suggested that pain in venous claudication is caused by the high intramuscular pressure, and therefore fasciotomy may be useful in the treatment of this disorder.
Swelling is known to occur after peripheral revascularization. In this study of 14 patients undergoing revascularization of the popliteal artery for severe ischaemia, leg swelling and intramuscular pressure were recorded before and after operation. Calf circumference increased with a maximum swelling of 3.9 +/- 1.1 cm on postoperative day 6. There was a gradual increase in intramuscular pressure from 9 +/- 2 mmHg on the day before operation in the anterior tibial compartment to a maximum pressure on postoperative days 6-7 of 26 +/- 4 mmHg. Similar intramuscular pressure changes were seen in the superficial posterior compartment. These high intramuscular pressures may lead to a compartment syndrome and perhaps graft failure, which was actually observed in one case. Deep-vein thrombosis in the postoperative course may contribute to the high intramuscular pressures. Phlebography revealed a deep-vein thrombosis in 2 patients. In conclusion popliteal revascularization causes leg swelling and increased intramuscular pressure which may lead to a compartment syndrome and graft failure. Therefore follow-up of intramuscular pressure in patients with marked swelling after distal revascularization procedures and early fasciotomy may be considered on wide indications.
The influence of deep vein thrombosis on intramuscular pressure was evaluated in 22 patients by means of the wick technique. Intramuscular pressure was measured in the anterior tibial and the deep posterior compartments in both legs before and during treatment. The intramuscular pressure was significantly (p less than 0.001) higher in the thrombosed leg than in the contralateral leg (0-16 mmHg). The increase in intramuscular pressure was related to the extension of the thrombus. Iliofemoral thrombosis caused a significantly (p less than 0.001) higher pressure (17-28 mmHg) than calf thrombosis (16-23 mmHg). A compartment syndrome was found to be a part of the entity phlegmasia cerulea dolens (rest pressure 47-56 mmHg). In the treatment of phlegmasia cerulea dolens, fasciotomy is suggested additional to other therapeutic procedures.
Ten patients with congenital vein valve aplasia verified at contrast phlebography were evaluated clinically and by physiologic examinations. All had orthostatic edema and varicose veins, but leg ulcers and other "postphlebitic" sequelae were infrequent. Foot volumetry and measurement of ambulatory foot vein pressures revealed a severe deep venous incompetence with a defective muscle pump function and considerable reflux. Eight limbs were operated on with conventional varicose vein surgery and physiologically re-examined six to 26 weeks after the operation. All had an improved ambulatory pressure reduction (p less than 0.001). Foot volumetry revealed better muscle pump function (p less than 0.01), while the reflux flow was unchanged. Surgery of the incompetent superficial venous system is therefore recommended in cases with deep venous insufficiency due to congenital vein valve aplasia.
In 16 patients, where the diagnosis carpal tunnel syndrome was electrophysiologically confirmed, the pressure between the median nerve and the carpal ligament was measured peroperatively. At rest the pressure was 18-64 mmHg, mean 31 mmHg. Passive volar and dorsal wrist flexion increased the pressure about three times. Isometric or isotonic maximal contractions of wrist and finger muscles, elicited by tetanic nerve stimulation increased the pressure to three to six times the resting value. These high pressures may be one of the causes of the nerve lesion in the carpal tunnel syndrome.
One hundred eight patients with lower leg pain of unknown cause underwent intramuscular pressure measurements by the wick technique. Fifteen patients (14%) were found to have a chronic anterior tibial compartment syndrome. In these patients the intramuscular pressure was significantly increased at rest and during and after exercise as compared with normal subjects. The pressure increase after exercise was long-lasting (40 minutes). Biopsies of the anterior tibial muscles showed increased water content, which may explain the elevated pressures. Muscle blood flow during exercise as measured by the xenon-133 clearance technique was decreased, and muscle lactate concentration was increased in the anterior tibial muscles. Fasciotomy relieved pain and normalized intramuscular pressure, muscle blood flow, and skeletal muscle metabolism.
Intramuscular pressure, muscle blood flow and venous emptying was studied in seven patients with unilateral lymphedema of the leg. Intramuscular pressure was measured with the wick technique. Muscle blood flow was assessed by means of the 133Xenon clearance technique. Venous emptying was studied with strain gauge technique. Intramuscular pressure in the anterior tibial compartment of the edematous leg was 30 +/- 14 mmHg at rest, rising to 49 +/- 16 mmHg during exercise (p less than 0.05). In the healthy leg the pressure rose from 16 +/- 8 mmHg at rest to 28 +/- 6 mmHg during exercise (p less than 0.05). In the deep posterior compartment similar pressure values were obtained. Muscle blood flow during exercise was significantly higher (p less than 0.05) in the healthy leg, 32.4 +/- 6.8 ml X min-1 X (100 g)-1 than in the edematous leg, 29.9 +/- 4.8 ml X min-1 X (100 g)-1. Venous emptying was significantly lower (p less than 0.05) in the diseased leg, 44.7 +/- 18.7 ml X min-1 X (100 g)-1 than in the healthy leg, 61.4 +/- 18,9 ml X min-1 X (100 g)-1. Thus, lymphatic obstruction of the leg causes edema which leads to an increased intramuscular pressure and a decreased muscle blood flow and venous emptying.
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To investigate whether effort-related dorsal forearm pain could be due to an increase of the intracompartmental pressure (ICP) in the dorsal forearm compartment, the normal range of the ICP at rest and during exercise was first determined in 11 volunteers using a wick catheter. The ICP at rest was 6 mm Hg (range, 2-11 mm Hg), and during exercise the pressure rose to about six times the resting level. Fourteen patients with pain in the dorsal forearm during exercise were similarly examined. In six patients the pressure at rest and/or during exercise was more than twice that of the normal persons or that of the healthy forearm. After fasciotomy four of these six patients were relieved of pain within three weeks, which might suggest a relation between ICP and pain.
One hundred and thirty-four patients admitted to the medical emergency ward due to suspect deep venous thrombosis (DVT) were examined. The uptake of intravenously injected porcine 99Tcm-plasmin was estimated in both legs. Thereafter, phlebography was performed using a high osmolar contrast medium. All phlebographies were evaluated independently. All patients with negative phlebography were examined clinically after 3-5 days. The plasmin test and phlebography were repeated when called for. The sensitivity of the plasmin test was 100% and the specificity 51% when compared to phlebography. The extension of the DVT as demonstrated by the plasmin test was similar to that determined by phlebography. Post-phlebographic thrombosis was very rare. It is concluded that 99Tcm- plasmin test is a rapid method, convenient to the patient and well suitable as a screening test. The results indicate that a negative plasmin test excludes DVT while a positive test necessitates additional examination by phlebography.