RESUMEN
Background: Prosthetic hip dislocation remains one of the most frequent complications following total hip replacement. Dislocations are predominantly managed by a closed reduction in the emergency department (ED) or the operating room (OR). This study aimed to evaluate how the location of an initial closed reduction attempt impacts a patient's course of care including length of stay (LOS) and cost of care. Material and methods: A retrospective chart review was performed on all patients presenting to a single ED with a unilateral prosthetic hip dislocation from 2009 to 2019. A total of 108 patients were identified. Data collected included patient demographics, ED/hospital course, and hospital charges. Results: Seventy-four patients (69%) had initial reduction attempted in the ED (65/74, 88% were successful), while 34 patients (31%) went directly to OR (100% successful with closed reduction). Failed closed reduction in ED or direct to OR resulted in a greater LOS and rate of placement to a skilled nursing facility following discharge. Median hospital charges for successful ED reduction were $6,837, while failed ED closed reduction or direct to OR resulted in median charges of $27,317 and $20,481, respectively. Conclusion: Many patients successfully underwent closed reduction in the ED, and there was no difference in complications, independent of where the reduction was first performed. Patients undergoing reduction in the OR had greater LOS and cost of care, independent of whether a reduction attempt was performed and failed in the ED, than those successfully reduced in the ED.
RESUMEN
BACKGROUND: Patients with neuromuscular scoliosis (NMS) who undergo posterior spinal fusion (PSF) often have long, protracted hospital stays because of numerous comorbidities. Coordinated perioperative pathways can reduce length of hospitalization (LOH) without increasing complications; however, a subset of patients may not be suited to rapid mobilization and early discharge. METHODS: 197 patients with NMS underwent PSF at a single hospital by two surgeons with a post-operative care pathway emphasizing early mobilization, rapid transition to enteral feeds, and discharge prior to first bowel movement. Average LOH was 4.9 days for all patients. Patients were divided into quartiles (< 3 days, 3-5 days, 5-7 days, > 7 days) based on their LOH, and their charts were retrospectively reviewed for preoperative, intraoperative, and postoperative factors associated with their LOH. RESULTS: Age at surgery, gender, the need for tube feeds, and specific underlying neuromuscular disorder were not significant predictors of LOH; however, severely involved cerebral palsy (CP) patients (GMFCS 4/5) were more likely to have extended stays than GMFCS 1-3 patients (p = 0.02). Radiographic predictors of LOH included major coronal Cobb angle (p = 0.002) and pelvic obliquity (p = 0.02). Intraoperative predictors included longer surgical times, greater numbers of levels fused and need for intraoperative or postoperative blood transfusion (p < 0.05). The need for ICU admission and development of a pulmonary complication were significantly more likely to fall into the extended LOH group (p < 0.05). CONCLUSIONS: Several variables have been identified as significant predictors of LOH after PSF for NMS in the setting of a standardized discharge pathway. Patients with smaller curves and less complex surgeries were more amenable to accelerated discharge. Conversely, patients with severe CP with large curves and pelvic obliquity requiring longer surgeries with more blood loss may not be ideal candidates. These data can be used to inform providers' and families' post-operative expectations. LEVEL OF EVIDENCE: Therapeutic Level III.
