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

Emergency Department closed reduction of dislocated THR: the REDDTHR Prospective Multi-centre Study

INTRODUCTION

Dislocation is a potentially devastating complication severely affecting outcomes post total hip arthroplasty (THR). We aimed to assess the efficacy and safety of closed reduction of a dislocated THR within the Emergency Department (ED).

METHODS

A prospective multi-centre study was conducted over a 1-year period from November 2020 to December 2021 within 10 hospitals based in the East of England. Collected data included patient demographics, agent used for sedation, hospital length of stay, implant type and discharge destination. Patients were analysed according to whether successful reduction was performed in the ED or not. The primary outcome was length of stay, with secondary outcomes including discharge destination and pain post-procedure.

RESULTS

We studied 99 patients with an average age of 77.02 years, with 39 (39%) patients being male. 11 patients had revision hip replacements and 88 patients had primary THRs. 57 (57.6%) underwent closed reduction in the Emergency department, of which 44 (77.2%) were successful. Successful closed reduction was significantly associated with lower patient age (p = 0.02), lower American society of Anesthesiologists (ASA) score (p < 0.01) and use of propofol (p < 0.01). Patients who underwent successful ED closed reduction had a lower hospital stay than those that did not (1 vs. 3 days, p < 0.01), however there was no significant difference in discharge destination.

CONCLUSIONS

When adopted, success following closed reduction is increased in younger patients with less comorbidities following use of propofol sedation. Following sedation, patients have a significantly shorter hospital stay. Increasing uptake of closed reduction of THR dislocation within the ED in suitable patients with evidence-based best practice protocols will maximise patient outcomes whilst allowing efficient resource utilisation.

The incidence of hip dislocation after posterior approach primary total hip arthroplasty: comparison of two different posterior repair techniques

INTRODUCTION

Total hip arthroplasty (THA) remains one of the most successful orthopedic surgical procedures. The posterior approach is associated with a higher incidence of post-operative dislocations than others. Adequate posterior soft tissue repair techniques, including capsulorrhaphy and transosseous bone sutures in the greater trochanter effectively reduce the dislocation rate. Post-operative "posterior hip precautions" were historically believed to reduce dislocation risks, although not clearly proven. The first protocol consists of capsulorrhaphy with the prescription of post-operative posterior hip precautions (TT) and the second, transosseous bone sutures without precautions (TB). This study aims to determine the optimal protocol to decrease the dislocation rate following posterior approach primary THA.

MATERIALS AND METHODS

A 10-year retrospective case-control chart review analyzed demographic, pre-, intra-, and post-surgical parameters. Primary outcomes were the difference in dislocation and revision surgery rates between protocols. Secondary outcomes included the incidence of recurrent dislocations and the identification of predictors of dislocation.

RESULTS

2,242 THAs were reviewed and 26 (1.2%) resulted in dislocation. Increased age (p = 0.04) ASA score (p = 0.03) and larger acetabular cup size (p < 0.001) were associated with heightened risk. Tendon to tendon (TT) repair saw a 1.62% dislocation rate versus 0.98% for tendon-to-bone (TB) repair, although statistically insignificant (p = 0.2). Transosseous repair resulted in recurrent dislocations for 8/16 (50%) patients compared to 6/10 (60%) in the suture group (p ≤ 0.001). No significance was found for prescription of posterior hip precautions.

CONCLUSIONS

To our knowledge, this is the first study to perform a direct comparison of TT repair with posterior precautions to TB repair without posterior precautions. Similarity in dislocation rate, decreased recurrent events and the alleviated patient burden from precautions leads the authors to recommend the TB repair without precautions for a successful THA.