Complication Rates for the Anterior Approach to Total Hip Arthroplasty.

Total hip arthroplasty (THA) is one of the most successful orthopedic surgeries performed in the United States. Orthopedic surgeons have looked to minimally invasive approaches for THA to reduce peri- and postoperative complications, and to improve patients' quality of life; the anterior approach THA has been advocated as such a minimally invasive surgery. This study involved a retrospective chart review of 2647 consecutive unilateral THAs using the anterior approach. The following parameters and complications were examined: patient demographics, surgery duration (open to close), postoperative length of stay, intraoperative fractures requiring internal fixation, femoral or sciatic nerve injuries with or without motor loss, deep infections managed with operative irrigation and debridement, deep venous thromboses (DVTs), and dislocations. Mean patient age and body mass index were 65 years and 29.78 kg/m2, respectively. Mean length of surgery was 69.1 minutes, and mean length of stay was 1.6 days postoperatively. The complication rates were as follows: dislocations, 19 (0.72%); DVT, 12 (0.45%); fractures, 13 (0.49%); infections, 49 (1.85%); and nerve injuries, 11 (0.42%). These findings demonstrate the anterior approach to THA has very low complication rates and acceptably low rates of infection. In addition, the minimally invasive THA has an acceptably low duration and a substantially reduced length of stay compared with more traditional THA approaches. [Orthopedics. 2020;43(3):e147-e150.].

Human intracerebroventricular (ICV) injection of autologous, non-engineered, adipose-derived stromal vascular fraction (ADSVF) for neurodegenerative disorders: results of a 3-year phase 1 study of 113 injections in 31 patients.

We have chosen to test the safety of human intracerebroventricular (ICV) brain injections of autologous non-genetically-modified adipose-derived stromal vascular fraction (ADSVF). In this IRB-approved trial, 24 patients received ICV ADSVF via an implanted reservoir between 5/22/14 and 5/22/17. Seven others were injected via their ventriculo-peritoneal shunts. Ten patients had Alzheimer's disease (AD), 6 had amyotrophic lateral sclerosis (ALS), 6 had progressive multiple sclerosis (MS-P), 6 had Parkinson's "Plus" (PD+), 1 had spinal cord injury, 1 had traumatic brain injury, and 1 had stroke. Median age was 74 (range 41-83). Injections were planned every 2-3 months. Thirty-one patients had 113 injections. Patients received SVF injection volumes of 3.5-20 cc (median:4 cc) containing 4.05 × 105 to 6.2 × 107 cells/cc, which contained an average of 8% hematopoietic and 7.5% adipose stem cells. Follow-up ranged from 0 to 36 months (median: 9.2 months). MRIs post injection(s) were unchanged, except for one AD patient whose hippocampal volume increased from < 5th percentile to 48th percentile (NeuroQuant® volumetric MRI). Of the 10 AD patients, 8 were stable or improved in tests of cognition. Two showed improvement in P-tau and ß-amyloid levels. Of the 6 MS-P patients all are stable or improved. Four of 6 ALS patients died of disease progression. Twelve of 111 injections (11%) led to 1-4 days of transient meningismus, and mild temperature elevation, which resolved with acetaminophen and/or dexamethasone. Two (1.8% of injections) required hospitalization for these symptoms. One patient (0.9% of injections) had his reservoir removed and later replaced for presumed infection. In this Phase 1 safety trial, ADSVF was safely injected into the human brain ventricular system in patients with no other treatment options. Secondary endpoints of clinical improvement or stability were particularly promising in the AD and MS-P groups. These results will be submitted for a Phase 2 FDA-approved trial.

Blood pressure normalization post-jugular venous balloon angioplasty.

OBJECTIVE: This study is the first in a series investigating the relationship between autonomic nervous system dysfunction and chronic cerebrospinal venous insufficiency in multiple sclerosis patients. We screened patients for the combined presence of the narrowing of the internal jugular veins and symptoms of autonomic nervous system dysfunction (fatigue, cognitive dysfunction, sleeping disorders, headache, thermal intolerance, bowel/bladder dysfunction) and determined systolic and diastolic blood pressure responses to balloon angioplasty. METHODS: The criteria for eligibility for balloon angioplasty intervention included ≥ 50% narrowing in one or both internal jugular veins, as determined by the magnetic resonance venography, and ≥ 3 clinical symptoms of autonomic nervous system dysfunction. Blood pressure was measured at baseline and post-balloon angioplasty. RESULTS: Among patients who were screened, 91% were identified as having internal jugular veins narrowing (with obstructing lesions) combined with the presence of three or more symptoms of autonomic nervous system dysfunction. Balloon angioplasty reduced the average systolic and diastolic blood pressure. However, blood pressure categorization showed a biphasic response to balloon angioplasty. The procedure increased blood pressure in multiple sclerosis patients who presented with baseline blood pressure within lower limits of normal ranges (systolic ≤ 105 mmHg, diastolic ≤ 70 mmHg) but decreased blood pressure in patients with baseline blood pressure above normal ranges (systolic ≥ 130 mmHg, diastolic ≥ 80 mmHg). In addition, gender differences in baseline blood pressure subcategories were observed. DISCUSSION: The coexistence of internal jugular veins narrowing and symptoms of autonomic nervous system dysfunction suggests that the two phenomena may be related. Balloon angioplasty corrects blood pressure deviation in multiple sclerosis patients undergoing internal jugular vein dilation. Further studies should investigate the association between blood pressure deviation and internal jugular veins narrowing, and whether blood pressure normalization affects Patient's clinical outcomes.

Transvascular autonomic modulation: a modified balloon angioplasty technique for the treatment of autonomic dysfunction in multiple sclerosis patients.

PURPOSE: To describe the use of transvascular autonomic modulation (TVAM) to improve cardiovascular autonomic nervous system (ANS) dysfunction in multiple sclerosis (MS) patients, comparing the safety and efficacy of this modified technique with traditional balloon angioplasty. METHODS: Twenty-one MS patients (11 men; mean age 48.7±13.0 years) who presented with symptoms of cardiovascular ANS dysfunction underwent TVAM. These patients were compared with age/sex-matched MS patients (10 men; 49.3±11.1 years) in the same stages of the disease who presented with chronic cerebrospinal venous insufficiency (CCSVI) and who underwent venous balloon angioplasty. TVAM involved the coupling of balloon angioplasty of the internal jugular veins with the application of external manual compression and dilation of the azygos and renal veins; unlike traditional angioplasty for CCSVI, which treats only abnormal veins (≥50% stenosis or static valve), all targeted vessels were treated with TVAM regardless of the presence of an abnormality. The effect of TVAM on ANS function was indicated by determining heart rate variability based on the electrocardiographic R-R interval lengths using vector analysis to derive the mean circular resultant (MCR) and the expiration/inspiration (E/I) ratio, the Valsalva ratio, and the 30:15 postural ratio at 24 hours after intervention. RESULTS: Left renal vein compression was common among the TVAM patients and resulted in ≥50% luminal compromise in 10 of 21 patients. Azygos vein abnormalities (a static valve) were identified in 5 patients. Overall, 18 patients met the diagnostic criteria for CCSVI with at least one lesion >50%, but only 10 lesions were considered treatable by traditional balloon angioplasty. After intervention, the R-R interval values, including the 30:15 postural ratio (p=0.01), the MCR (p=0.1), and E/I ratio (p=0.1), were higher for the TVAM patients compared to the control group. The safety profile of the TVAM procedure was similar to that of traditional balloon angioplasty. CONCLUSION: The combination of balloon angioplasty of anatomically normal veins coupled with external compression during dilation of these veins can improve indicators of ANS dysfunction. The safety and efficacy of TVAM in MS patients observed in this pilot study is encouraging, paving the way for the treatment of dysautonomia in pathological states other than MS. Further studies should investigate TVAM in a larger MS cohort.