Location of Initial Closed Reduction Attempt Significantly Increases Cost and Length of Stay in Total Hip Arthroplasty.

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.

Prospective comparison of dysphagia following anterior cervical discectomy and fusion (ACDF) with and without rhBMP-2.

BACKGROUND CONTEXT: Previous studies have called into question the safety of using rhBMP-2 in anterior cervical fusion due to the possibility of airway compromise and dysphagia. A retrospective chart review identified a significant increase in the severity of dysphagia after II-level ACDF with rhBMP-2 compared to patients who did not receive rhBMP-2. To date, this topic has not been studied prospectively. PURPOSE: Compare the incidence of dysphagia following anterior cervical discectomy and fusion (ACDF) when recombinant human bone morphogenetic protein-2 (rhBMP-2) is used with allograft compared to allograft alone. STUDY DESIGN: Prospective cohort study. PATIENT SAMPLE: A total of 114 patients completed a baseline SWAL-QOL survey and met the inclusion criteria. Thirty-nine patients underwent I- or II-level ACDF with allograft plus 0.5mg rhBMP-2/level. 44 patients underwent ACDF with allograft alone. Thirty-one patients undergoing a lumbar decompression were enrolled in a third cohort to control for dysphagia secondary to intubation. OUTCOME MEASURES: The primary outcome measure was the 14-point SWAL-QOL dysphagia questionnaire. Other patient factors obtained from anesthesia and operative records were examined to evaluate their potential relationship to postoperative dysphagia. METHODS: The 14-point SWAL-QOL questionnaire was administered at multiple time points (pre-op, post-op 7 days, 6 weeks, 6 months, and at least 1 year). Multivariable repeated-measures analysis was applied to data. RESULTS: Baseline adjusted SWAL-QOL means 7 days after surgery were significantly different between the three study groups. These differences resolved by 6 weeks postoperative, beyond which point there were no differences. At final follow-up, baseline adjusted SWAL-QOL means at 1 year were similar for the three study groups. CONCLUSIONS: This single-center study of anterior cervical surgery demonstrated that the addition of rhBMP-2 to an ACDF increased postoperative dysphagia at 7 days after surgery, but these patients recover to levels comparable to those who underwent ACDF without rhBMP-2 or lumbar surgery within 6 weeks.

Analyzing parsicle screws as a viable alternative to pars screws and pedicle screws for C2 posterior instrumentation fixation.

INTRODUCTION: This study examined the possible clinical utility of "parsicle screws" in securing C2 instrumentation. METHODS: Ten patients' C2 vertebrae were virtually reconstructed using computer-aided design software. Pedicle, pars, and parsicle screws were virtually placed in the vertebrae. RESULTS: In addition to establishing the trajectory and theoretical safety of parsicle screws, this study determined that parsicle screws were significantly longer than pars screws (p = 0.005). CONCLUSION: The additional length of parsicle screws may improve construct stability. As such, parsicle screws should be examined as an alternative to pars screws in patients unable to receive C2 pedicle screws.

Variability in length of stay following neuromuscular spinal fusion.

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.

Integrative genomics identifies candidate microRNAs for pathogenesis of experimental biliary atresia.

BACKGROUND: Biliary atresia is a fibroinflammatory obstruction of extrahepatic bile duct that leads to end-stage liver disease in children. Despite advances in understanding the pathogenesis of biliary atresia, very little is known about the role of microRNAs (miRNAs) in onset and progression of the disease. In this study, we aimed to investigate the entire biliary transcriptome to identify miRNAs with potential role in the pathogenesis of bile duct obstruction. RESULTS: By profiling the expression levels of miRNA in extrahepatic bile ducts and gallbladder (EHBDs) from a murine model of biliary atresia, we identified 14 miRNAs whose expression was suppressed at the times of duct obstruction and atresia (≥2 fold suppression, P < 0.05, FDR 5%). Next, we obtained 2,216 putative target genes of the 14 miRNAs using in silico target prediction algorithms. By integrating this result with a genome-wide gene expression analysis of the same tissue (≥2 fold increase, P < 0.05, FDR 5%), we identified 26 potential target genes with coordinate expression by the 14 miRNAs. Functional analysis of these target genes revealed a significant relevance of miR-30b/c, -133a/b, -195, -200a, -320 and -365 based on increases in expression of at least 3 target genes in the same tissue and 1st-to-3rd tier links with genes and gene-groups regulating organogenesis and immune response. These miRNAs showed higher expression in EHBDs above livers, a unique expression in cholangiocytes and the subepithelial compartment, and were downregulated in a cholangiocyte cell line after RRV infection. CONCLUSIONS: Integrative genomics reveals functional relevance of miR-30b/c, -133a/b, -195, -200a, -320 and -365. The coordinate expression of miRNAs and target genes in a temporal-spatial fashion suggests a regulatory role of these miRNAs in pathogenesis of experimental biliary atresia.