Orthopaedic management of the Ehlers-Danlos syndromes

Total hip arthroplasty outcomes in Ehlers-Danlos patients: data from the Statewide Planning and Research Cooperative System

INTRODUCTION

Ehlers-Danlos syndromes (EDS) are genetic connective tissue disorders affecting multiple organ systems that frequently result in connective tissue hyperlaxity and early osteoarthritis. Short- and long-term outcomes after primary total hip arthroplasty (THA) in this patient population remain poorly characterised. The primary purpose of this study is to compare postoperative outcomes and survivorship after primary THA in patients with and without EDS.

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for all patients undergoing primary elective THA between September 2009 and December 2020. Patients with EDS were identified using ICD9 and ICD10 diagnosis codes. Given the relatively low incidence of EDS in this patient population, the cohort was propensity-matched 1:10 to patients without diagnosis of EDS based on demographics characteristics and medical comorbidities as measured by the Elixhauser Comorbidity Index.

RESULTS

A total of 66 THA patients with and 660 without EDS were included in each group after 1:10 propensity-matching. There were no significant differences in baseline characteristics or THA indications. Early postoperative outcomes such as length of hospital stay and discharge disposition were similar. Emergency Room visits and inpatient readmission rates at 3 months postoperatively did not significantly differ between groups. Patients with EDS had a higher overall revision rate compared to those without (15.0% vs. 3.2%, p < 0.001). Revision free survival after primary THA in patients with EDS was significantly lower than those without EDS at 9-year follow-up. Cox proportional hazard regression demonstrated EDS patients had 7-times higher risk of revision (hazard ratio [HR] 7.43; 95% CI, 3.46-16.00; p < 0.001). Lastly, revision due to instability insignificantly trended higher in the EDS cohort (HR 2.29; 95% CI, 0.95-5.49; p = 0.063).

CONCLUSIONS

EDS patients undergoing primary THA have increased rate of all cause revision and demonstrate decreased revision free survival compared to non-EDS THA patients.

Midterm Outcomes of Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability in Ehlers-Danlos Syndrome

Background

Patellar instability is frequently encountered in patients with Ehlers-Danlos syndrome (EDS). The clinical outcomes of isolated medial patellofemoral ligament reconstruction (MPFLR) for patellar instability in patients with EDS are unknown.

Purpose

To evaluate midterm clinical outcomes of isolated MPFLR for patellar instability in patients with EDS and factors affecting these outcomes.

Study Design

Case series; Level of evidence, 4.

Methods

In a retrospective study, 31 patients (n = 47 knees) with EDS and patellar instability who underwent isolated MPFLR for recurrent patellar instability between 2008 and 2017 and had a minimum 2-year follow-up were identified. Preoperative radiographic images were measured for anatomic risk factors. Clinical outcomes-including postoperative complications-were evaluated. Factors associated with MPFLR failure were identified. Postoperative patient-reported outcomes (PROs)-including the pediatric version of the International Knee Documentation Committee, the Kujala score, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale, the Banff Patellofemoral Instability Instrument 2.0, and the Knee injury and Osteoarthritis Outcome Score-were collected, and factors affecting PRO scores were analyzed.

Results

The mean age of the cohort was 14.9 ± 2 years. At a mean follow-up of 7.2 years, 18 of 47 (38.3%) knees required reoperations, of which 9 of 47 (19.1%) knees required revision stabilization for recurrent patellar instability. Also, 7 of 31 knees (22.6%) with autografts failed compared with 2 of 16 (12.5%) with allografts (P = .69). For autografts, 6 of 17 (35.3%) failures occurred with gracilis, but 0 of 13 (0%) occurred with semitendinosus (P = .02). Compared with patients without failures, patients with failed primary MPFLR were significantly younger (P = .0005) and were able to touch the palm to the floor with their knees extended (P = .03). For radiographic parameters, the patellar height and tilt were significantly higher in the failure group. The postoperative PROs were suboptimal at a mean follow-up of 5.2 years. All but 1 patient were satisfied with the final outcome.

Conclusion

At the midterm follow-up, 38.3% of patients with EDS required further surgery after isolated MPFLR for patellar instability; half of these revisions (19.1%) were to address recurrent instability. Recurrent instability after isolated MPFLR was more likely in younger patients and those who could touch the palm to the floor with their knees extended. Postoperative PROs were inferior; nonetheless, patient satisfaction was high.

Increased Opioid Use in Patients With Ehlers-Danlos Syndrome Before and After Total Hip Arthroplasty

Background

Ehlers-Danlos syndrome (EDS), a disorder affecting synthesis of collagen, typically presents with chronic pain, hypermobility, and early osteoarthritis. EDS patients undergoing total hip arthroplasty (THA) are at risk of dislocation and revision. Opioid use and impact on outcomes among this population remain unknown.

Methods

A retrospective review was performed with a large national database querying the International Classification of Disease, tenth revision procedure codes identifying 1,244,368 primary THAs from 2015-2020. Two hundred thirty-eight EDS patients underwent THA and were propensity matched with population control based on age, sex, and obesity when comparing opioid prescription. To compare dislocation and revision outcomes, EDS patients were stratified into those receiving opioid prescriptions and those not. Multivariate analysis evaluated the association.

Results

EDS patients were more likely prescribed opioids 90 days before (49.1% vs 34.7.0%, P < .0001) and after THA (59.7% vs 41.2%, P < .0001), with more preoperatively (1163.6 mme ±1562.8, P < .0001) and postoperatively (900.1 mme ±1235.9, P < .0001) than controls. In EDS patients prescribed opioids 90 days before THA, dislocation rate was 12.8% vs 7.1% not prescribed (odds ratio 2.08, 95% confidence interval 0.85-5.1). 14.8% of EDS patients who received opioids 90 days after THA dislocated vs 2.1% not prescribed (odds ratio 8.13, 95% confidence interval 1.87-35.7).

Conclusions

EDS patients are more likely prescribed opioids before and after THA. Opioid prescription was associated with risk of dislocation, though we caution interpretation of causation. However, this suggests that the risks of worse outcomes in EDS patients undergoing THA are multifactorial. We should look at strategies to reduce opioid use prior to THA.

Evaluating the effects of two different kinesiology taping techniques on shoulder range of motion and proprioception in patients with hypermobile Ehlers-Danlos syndrome: a randomized controlled trial

Background

Ehlers-Danlos syndrome (EDS) is a common group of inherited connective tissue disorders with a prevalence as high as 0.75%-2% of the population. Physical manifestations include pain and decreased proprioception, especially in more mobile joints, such as the shoulder. The kinesiology tape (K-Tape) is often used to treat patients with shoulder dysfunction. The effectiveness of the K-Tape is uncertain, and there is a lack of studies specifically studying the K-Tape in an EDS population.

Purpose

The purpose of this study was to compare the short-term effects of two different K-Tape procedures on shoulder active joint reposition (AJR) and active range of motion (AROM) in patients with hypermobile EDS (hEDS) and shoulder pain.

Methods

All participants were recruited from the EDS support groups and presented with shoulder pain. Baseline demographic information was obtained for each participant, after which AROM and AJR were assessed. The participants were randomized to receive one of two K-Tape procedures. Testing was repeated immediately post-taping and 48 h post-taping.

Results

Significant improvements in shoulder external (F = 10.917, p < 0.001) and internal (F = 11.736, p < 0.001) rotations were seen from baseline to immediately post-taping and baseline to 48 h post-taping in the experimental K-Tape group. There were no significant differences in the shoulder rotation in the control K-Tape group and no significant differences in either group for shoulder flexion or AJR at any time point (p > 0.05).

Conclusion

K-Tape may offer short-term improvements in shoulder rotation AROM in patients with hEDS and shoulder pain.

Effects of compression garments on balance in hypermobile Ehlers-Danlos syndrome: a randomized controlled trial

PURPOSE

To evaluate the immediate and 4-week effects of compression garments (CG) on balance using a force platform during 8 different visual, static, and dynamic conditions in hypermobile Ehlers-Danlos Syndrome (hEDS) patients.

METHODS

Thirty-six participants were randomly assigned to a group: physiotherapy alone (PT, n = 19) or physiotherapy and daily CG wearing for 4 weeks (PT + CG, n = 17). Both attended 12 physiotherapy sessions (strengthening, proprioception, and balance exercises) for 4 weeks. Primary outcome: sway velocity of the centre of pressure (COP) measured before, immediately with the CG, and at 4 weeks. Secondary outcomes: ellipse area, Romberg quotient, and pain.

RESULTS

Sway velocity in dynamic conditions decreased immediately with the CG. After 4 weeks of intervention, sway velocity (95% CI 4.36-39.23, effect size 0.93) and area (95% CI 146-3274, effect size 0.45) on the laterally oscillating platform with eyes-closed improved more in the PT + CG group than the PT group. Romberg quotient on foam cushion improved more in the PT + CG than the PT group. Pain decreased in both groups after 4 weeks with no between-group difference.

CONCLUSION

CG combined with physiotherapy improved dynamic balance measured with COP variables significantly more than physiotherapy alone in people with hEDS.

TRIAL REGISTRATION

NCT03359135.

Patient interest in the development of a center for Ehlers-Danlos syndrome/hypermobility spectrum disorder in the Chicagoland region

BACKGROUND

The Ehlers-Danlos Syndromes (EDS) are a group of connective tissue disorders that are hereditary in nature and characterized by joint hypermobility and tissue fragility. The complex nature of this unique patient population requires multidisciplinary care, but appropriate centers for such care do not exist in large portions of the country. Need for more integrated services has been identified in Chicagoland, or Chicago and its suburbs. In order to explore and begin to address barriers to seeking appropriate care facing EDS patients in this region, we developed an online survey which we circulated through EDS social media groups for Chicagoland patients.

RESULTS

Three hundred and nine unique respondents participated. We found that there exists a strong medical need for and interest in the development of a center in the region, and participants reported that, if made available to them, they would make extensive and regular use of such a facility.

CONCLUSIONS

We conclude that the establishment of a collaborative medical center specializing in the diagnosis and treatment of EDS, Hypermobility Spectrum Disorder, and related disorders in the Chicagoland area would greatly benefit patients by providing comprehensive care, alleviate the burden on overworked healthcare providers, and contribute to the sustainability of medical facilities.

Ehlers-Danlos Syndrome is Associated with Increased Rates of Adjacent Segment Disease Following TLIF: A Propensity Matched Study

BACKGROUND

Ehlers-Danlos syndrome (EDS) is a collection of connective tissue disorders which are often associated with tissue laxity and disc degeneration. However, the implications of EDS on the risk of adjacent segment disease (ASD) after transforaminal lumbar interbody fusion (TLIF) are not well described. The objective of this study is to compare the rates of ASD among patients with EDS and those without EDS.

METHODS

Patients who underwent 1-3 level TLIF for degenerative disc disease between 2010-2022 were identified using the PearlDiver Mariner all-claims insurance database. Patients with all types of EDS were included. Patients undergoing surgery for tumors, trauma, or infection were excluded. 1:1 propensity matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with ASD in a linear regression model. The primary outcome measure was the development of ASD. The secondary outcomes were the development of pseudoarthrosis, medical complications, and surgical complications.

RESULTS

Propensity matching resulted in 2 equal groups of 85 patients who did or did not have EDS and underwent 1-3 level TLIF. Patients without EDS were less likely to experience ASD (RR 0.18, 95% CI 0.09-0.35, P < 0.001). There was no significant difference between the 2 patient groups with regards to a diagnosis of pseudoarthrosis, and there was no significant difference for all-cause medical and surgical complications between the 2 patient groups.

CONCLUSIONS

After propensity matching to control for confounding variables, the findings of this study suggest that EDS may be associated with an increased risk of ASD following TLIF. Future studies are needed to corroborate these findings.

Bilateral Patellofemoral Ligament Reconstruction for Patellar Instability in Ehlers-Danlos Syndrome: A Case Report

CASE

We report the case of an 11-year-old boy with Ehlers-Danlos syndrome (EDC) who exhibited simultaneous medial and lateral patellar instability. The patient presented with a medial patellar dislocation, and subsequently, the patella became very unstable both medially and laterally. Despite distal realignment, the patellar instability was so significant that he underwent simultaneous reconstruction of the medial and lateral patellofemoral ligament using the semitendinosus tendon, with a good result.

CONCLUSION

Simultaneous reconstruction of the medial and lateral patellofemoral ligament is an effective method in cases of extreme patellar instability, such as the EDS case.

Developmental Foot Deformities in Patients with Connective Tissue Disorders

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Foot deformities make up a large percentage of all orthopaedic complaints in patients with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, Larsen syndrome, and osteogenesis imperfecta.

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Some common causes of foot deformities in these conditions include increased ligament laxity, hypotonia, and hypermobility of the joints.

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Treatment options for syndromic foot deformities include the use of foot orthoses, physical therapy, bracing, and various surgical procedures.

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There is limited evidence supporting the use of surgical intervention to correct foot deformities associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, Larsen syndrome, and osteogenesis imperfecta. Therefore, further research is needed to determine the short-term and long-term outcomes of these procedures.

Evaluating the effects of two different kinesiology taping techniques on shoulder pain and function in patients with hypermobile Ehlers-Danlos syndrome

Background

Ehlers-Danlos Syndrome (EDS) is a group of inherited connective tissue disorders which predominantly affects women and has a prevalence as high as 1 in 5,000 individuals. Hypermobile EDS (hEDS) is the most common subtype of EDS and is characterized by multi-joint pain, particularly in large joints such as the shoulder. Physical therapy is often utilized to address the pain, physical impairments, and functional loss in patients with EDS. Kinesiology Tape (KT) is an intervention commonly used by physical therapists for treating shoulder pain and dysfunction. Studies related to the effectiveness of KT in patients with shoulder pain is equivocal and there are a lack of studies specifically studying the effects of KT in an EDS population.

Purpose

The purpose of this study was to assess the efficacy and short-term effects of two different KT techniques on shoulder pain and function in individuals with hEDS and shoulder pain.

Methods

Participants were recruited from EDS support groups in the New England area of the United States; were diagnosed with hEDS by their physician; and had shoulder pain. Baseline demographic information was obtained for each participant followed by completion of 4 patient reported outcome (PRO) measures: the Upper Extremity Functional Index, QuickDASH (Disabilities of the Arm, Shoulder, & Hand), Shoulder Pain and Disability Index, and the Western Ontario Shoulder Instability Index. Current pain level, average pain over the past 24 h, and worst pain over the past 24 h were recorded using the numeric pain rating scale (NPRS). Subjects were randomly assigned to receive either an experimental shoulder KT procedure or a control shoulder taping. Immediately after taping, the NPRS was reassessed. Subjects then returned 48 h later to repeat the NPRS and PRO measures.

Results

There was no significant difference between the experimental and control tape groups for any outcome measure. There was a significant improvement from pre-taping to 48-hours post taping for each of the 4 PRO measures with large effect sizes (p < 0.001; ƞ _p ² = .517-.719). Likewise, average, and worst pain over the last 24 h significantly improved with large effect sizes over the same period (p = 0.005; ƞ _p ² = .225 and p < 0.001; ƞ _p ² = .382, respectively). Current NPRS levels significantly improved from pre-tape to immediately post-tape (p = .023, ƞ _p ² = .131) and was maintained through the 48-hour follow up, although no further improvement was seen.

Conclusion

KT is an inexpensive and relatively safe intervention that is easy to apply and can offer temporary improvements in pain and function for patients with EDS and shoulder pain.

A Comprehensive Review: Chronic Pain Sequelae in the Presence of Ehlers-Danlos Syndrome

PURPOSE OF REVIEW

Patients diagnosed with Ehlers-Danlos syndromes (EDS), and especially those with the hypermobility subtype, often experience a diverse range of acute and chronic pain conditions throughout their lifetime. These can present in a variety of different phenotypes and comorbidities, making it difficult to develop structured treatment protocols. This review seeks to summarize the current literature to address old and novel treatments for EDS.

RECENT FINDINGS

Historically, medications and surgery have been used to treat patients with EDS but with low efficacy. Newer therapies that have shown promising effects for both decreasing pain and increasing quality of life include physical/occupational therapy, transcutaneous electrical nerve stimulation units, trigger point injections, low-dose naltrexone, and laser therapy. In addition, addressing the psychosocial aspects of pain with EDS through methods like cognitive behavioral therapy and patient education has shown to be vital in minimizing pain. Most research also emphasizes that pain management should not only focus on pain reduction, but on helping reduce symptoms of hypermobility, central sensitization, and fatigue to make an impactful difference. Research on pain in EDS is still limited with good clinical practice guidelines often limited by poor sample size and lack of clinical studies. Treatment options should be structured based on the specific type of pain pathology and presenting symptoms of each patient and their comorbidities. Future research should attempt to prioritize larger sample sizes, clear definitions of EDS subtypes, randomized trials for treatment efficacy, and more studies dedicated to non-musculoskeletal forms of pain.

Craniocervical instability in patients with Ehlers-Danlos syndrome: controversies in diagnosis and management

Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population.

Ehlers-Danlos: A Literature Review and Case Report in a Colombian Woman with Multiple Comorbidities

Ehlers-Danlos syndromes (EDS) are a heterogeneous group of genetically transmitted connective tissue disorders that directly affect collagen synthesis, with a broad range of symptoms. Case presentation: This study presents a clinical case of a Colombian woman with myopathic EDS and multiple comorbidities taking 40 years of medical history to make the right diagnosis. This article also presents a review of the current literature on EDS, not only to remind the syndrome but also to help the clinician correctly identify symptoms of this diverse syndrome. Conclusion: A multidisciplinary approach to the diagnosis of the patient, including clinical and molecular analysis, and neuropsychological and psychological assessment, is important to improve the treatment choice and the outcome prediction of the patients.

Respiratory manifestations in the Ehlers-Danlos syndromes

Persons with the Ehlers-Danlos syndromes (EDS) report a wide range of respiratory symptoms, most commonly shortness of breath, exercise limitation, and cough. Also reported are noisy breathing attributed to asthma, difficulty with deep inhalation, and inspiratory thoracic pain. The literature consists of case reports and small cross-sectional and cohort studies. One case-control study estimated twofold to threefold greater respiratory disease burden among persons with EDS as compared to controls. The differential diagnosis for symptoms is broad. Structural alterations include pectus deformities, scoliosis, recurrent rib subluxations, and tracheobronchomalacia, associated with varying degrees of physiologic impairment. Those with vascular EDS have an increased risk of pneumothorax, intrapulmonary bleeding, cysts, and nonmalignant fibrous nodules. Functional aerodigestive manifestations such as inducible laryngeal obstruction may be misdiagnosed as asthma, with gastro-esophageal dysmotility and reflux as common contributing factors. Inflammatory manifestations include costochondritis, bronchiectasis, and localized respiratory allergic and nonallergic mast cell activation. Cranio-cervical instability can dysregulate respiratory control pathways. There is a need for careful phenotyping using standardized clinical tools and patient-reported outcomes and continuing collaboration with aerodigestive specialists including otolaryngologists and gastroenterologists. Also needed is further evaluation of respiratory symptoms in persons with hypermobility spectrum disorders. Personalized monitoring strategies are invaluable for interpretation and long-term management of respiratory symptoms.

Shoulder arthroplasty is a viable option in patients with Ehlers-Danlos syndrome

BACKGROUND

Patients with Ehlers-Danlos syndrome (EDS) have high rates of shoulder instability, which place them at increased risk for instability-related arthropathy. Many studies have assessed outcomes for both primary and revision shoulder instability procedures in this patient population, but there is a paucity of data regarding the outcome of shoulder arthroplasty in EDS patients. The purpose of this study is to evaluate the results and complications of shoulder arthroplasty (SA) performed in a cohort of patients with EDS and compare them to a matched cohort of patients with no EDS.

METHODS

Over an 11-year period, 10 patients with EDS were identified at a single institution who underwent primary SA (6 anatomic total shoulder arthroplasties [aTSAs], 4 reverse shoulder arthroplasties [RTSAs]). Shoulders were evaluated at a mean follow-up of 60 months (range 25-97 months). This cohort was matched 1:2 based on age, sex, and year of surgery, with patients who underwent SA for either primary osteoarthritis (OA) for aTSA or cuff tear arthropathy for RTSA. EDS patients had a mean age of 55 years, mean body mass index of 26.1, and were all female. The primary outcome measures were postoperative pain, range of motion, complications, and reoperations.

RESULTS

SA produced similar postoperative pain, range of motion, complications, and reoperations in patients with EDS vs. controls. EDS patients improved pre- to postoperative visual analog scale (VAS) pain score (6.5 to 1.7, P < .001), elevation (96° to 138°, P = .04), and external rotation (36° to 57°, P = .16). Three EDS patients sustained postoperative complications (2 instability and 1 acromial fracture); however, no shoulder was reoperated.

CONCLUSIONS

EDS patients undergoing SA can expect outcomes comparable to patients with primary OA or cuff tear arthropathy, with clinically meaningful improvements in pain and range of motion. Although EDS patients had no statistically significant increase in complications when compared to controls, their absolute rate of overall complications (3/10 patients; 30%) and postoperative instability (2/10 patients; 20%) in this small case series was relatively high and should be considered when performing SA.

Occupational Therapy Interventions for Clients with Ehlers-Danlos Syndrome (EDS) in the Presence of Postural Orthostatic Tachycardia Syndrome (POTS)

Postural orthostatic tachycardia syndrome (POTS) is often seen in clients with Ehlers-Danlos syndrome (EDS), primarily hypermobile EDS. Research has shown clients with EDS and POTS may experience limitations affecting not only their physical function, but also their social, emotional, and mental well-being. Using a client-centered approach, occupational therapy practitioners assess health, well-being, symptomatology (fatigue, muscle pain, dizziness, etc.), participation and engagement in occupation, and provide interventions to improve quality of life. This paper will address occupational therapy interventions to treat common symptomatology for clients with EDS in the presence of POTS, including environmental modifications, use of adaptive equipment and orthoses, exercise and fall prevention, energy conservation and pacing, sleep hygiene, and routine and habit development to promote optimal engagement in meaningful occupations.

Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome

Shoulder instability in hypermobile Ehlers-Danlos syndrome can result in lifelong pain and functional disability. Treatment in this population is complicated by the severe degree of instability as well as the underlying abnormalities of the joint connective tissue. Appropriate care for these patients requires a thorough understanding of the natural history of their disease, knowledge of the available treatment options, and certain special considerations. This article reviews the pathoanatomy, recognition, and management of shoulder instability in the patient with hypermobile Ehlers-Danlos syndrome.

A review of respiratory manifestations and their management in Ehlers-Danlos syndromes and hypermobility spectrum disorders

BACKGROUND

Ehlers-Danlos Syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) are a heterogeneous group of heritable genetic connective tissue disorders with multiple characteristics including joint hypermobility, tissue fragility, and multiple organ dysfunction. Respiratory manifestations have been described in EDS patients, but have not been systematically characterized. A narrative review was undertaken to describe the respiratory presentations and management strategies of individuals with EDS and HSD.

METHODS

A broad literature search of Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL was undertaken from inception to November 2020 of all study types, evaluating EDS/ HSD and pulmonary conditions. This narrative review was limited to adult patients and publications in English.

RESULTS

Respiratory manifestations have generally been described in hypermobile EDS (hEDS), classical and vascular EDS subtypes. Depending on EDS subtype, they may include but are not limited to dyspnea, dysphonia, asthma, sleep apnea, and reduced respiratory muscle function, with hemothorax and pneumothorax often observed with vascular EDS. Respiratory manifestations in HSD have been less frequently characterized in the literature, but exertional dyspnea is the more common symptom described. Respiratory symptoms in EDS can have an adverse impact on quality of life. The respiratory management of EDS patients has followed standard approaches with thoracotomy tubes and pleurodesis for pleural manifestations, vocal cord strengthening exercises, continuous positive pressure support for sleep apnea, and exercise training. Reduced respiratory muscle function in hEDS patients responds to inspiratory muscle training.

CONCLUSION

Respiratory symptoms and manifestations are described in EDS and HSD, and have generally been managed using conservative non-surgical strategies. Research into the prevalence, incidence and specific respiratory management strategies in EDS and HSD is needed to mitigate some of the associated morbidity.

Gastrointestinal medication burden among persons with the Ehlers-Danlos syndromes

BACKGROUND

The Ehlers-Danlos syndromes (EDSs) are a group of heritable disorders of connective tissue associated with an increased prevalence of both structural and functional GI conditions.

METHODS

We used 10 years (2005-2014) of administrative claims data comprised of 4294 people with clinician-diagnosed EDS, aged 5-62 years, and compared their frequency of GI drug prescription claims to their age-, sex-, state of residence-, and earliest claim date-matched controls. We categorized the GI medications into the following groups: acid suppressants, anti-emetics, irritable bowel syndrome drugs, and visceral hypersensitivity (VHS) medications.

KEY RESULTS

Compared to controls, a significantly higher proportion of persons with EDS had prescription claims for at least one GI drug group, as well as for drugs in each of the four GI drug groups included in our study. By age-group, 25.7% children and 45.1% adults with EDS had prescription claims for at least one GI drug group compared with only 7.4% and 21.0% of controls, respectively (p < 0.0001). By gender, 44.0% of women and 25.3% of men with EDS had prescription claims for at least one class of GI drugs compared with 19.2% and 9.6% of controls, respectively (p < 0.0001).

CONCLUSIONS AND KEY INFERENCES

Predominant medication burden occurs among women with EDS, beginning peri-pubertally for anti-emetics and VHS drugs. High GI medication burden underscores previous evidence that GI dysmotility is common among persons with EDS.

Multiple odontogenic keratocysts in Ehlers-Danlos syndrome: a rare case report

BACKGROUND

An odontogenic keratocyst is a lesion characterized by aggressive and infiltrative growth. The lesion is characterized by the existence of satellite microcysts (microtumours) and frequent recurrence (up to 30%). Ehlers-Danlos syndrome is a condition in which collagen production or its post-translational modifications are affected. Defects in connective tissues cause symptoms, which range from mild joint hypermobility to life-threatening complications.

CASE PRESENTATION

We present an extremely rare case of an 11-year old girl with Ehlers-Danlos syndrome and coexistence of multiple odontogenic keratocysts.

CONCLUSIONS

This case shows mainly atypical or rare association between multiple odontogenic keratocysts and Ehlers-Danlos syndrome.

Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes

The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.

Interrater and Intrarater Reliability of the Beighton Score: A Systematic Review

Background:

The Beighton score is commonly used to assess the degree of hypermobility in patients with hypermobility spectrum disorder. Since proper diagnosis and treatment in this challenging patient population require valid, reliable, and responsive clinical assessments such as the Beighton score, studies must properly evaluate efficacy and effectiveness.

Purpose:

To succinctly present a systematic review to determine the inter- and intrarater reliability of the Beighton score and the methodological quality of all analyzed studies for use in clinical applications.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review of the MEDLINE, Embase, CINAHL, and SPORTDiscus databases was performed. Studies that measured inter- or intrarater reliability of the Beighton score in humans with and without hypermobility were included. Non-English, animal, cadaveric, level 5 evidence, and studies utilizing the Beighton score self-assessment version were excluded. Data were extracted to compare scoring methods, population characteristics, and measurements of inter- and intrarater reliability. Risk of bias was assessed with the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) 2017 checklist.

Results:

Twenty-four studies were analyzed (1333 patients; mean ± SD age, 28.19 ± 17.34 years [range, 4-71 years]; 640 females, 594 males, 273 unknown sex). Of the 24 studies, 18 reported raters were health care professionals or health care professional students. For interrater reliability, 5 of 8 (62.5%) intraclass correlation coefficients and 12 of 19 (63.2%) kappa values were substantial to almost perfect. Intrarater reliability was reported as excellent in all studies utilizing intraclass correlation coefficients, and 3 of the 7 articles using kappa values reported almost perfect values. Utilizing the COSMIN criteria, we determined that 1 study met “very good” criteria, 7 met “adequate,” 15 met “doubtful,” and 1 met “inadequate” for overall risk of bias in the reliability domain.

Conclusion:

The Beighton score is a highly reliable clinical tool that shows substantial to excellent inter- and intrarater reliability when used by raters of variable backgrounds and experience levels. While individual components of risk of bias among studies demonstrated large discrepancy, most of the items were adequate to very good.

Carpometacarpal Arthroplasty and Ulnar Collateral Ligament Reconstruction in a Patient with Suspected Ehlers-Danlos Syndrome: A Case Report and Review of the Literature

Ehlers-Danlos syndrome (EDS) is a disorder that presents with a heterogeneous constellation of symptoms, ranging from clinically silent to rapidly deteriorating. It is a multisystemic connective tissue disorder that may result in any number of manifestations, with joint hypermobility being a classic manifestation. We present a case of a 58-year-old woman, with suspected EDS, who presented with several years' history of bilateral thumb pain, with imaging and physical examination findings consistent with bilateral thumb carpometacarpal (CMC) arthritis with metacarpophalangeal joint (MPJ) hypermobility. The Beighton hypermobility score was consistent with suspected EDS. Our patient underwent thumb CMC arthroplasty with ulnar collateral ligament (UCL) reconstruction.

Systemic manifestations of Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is a multifaceted debilitating disease. Affected patients are at risk for complications such as joint hypermobility and cardiac disease, but the prevalence, course, and management of these conditions are not well understood. The objective of this retrospective cohort study was to investigate the demographic characteristics and systemic manifestations in EDS. We performed a retrospective analysis of 98 EDS patients seen in a physical medicine and rehabilitation clinic between January 2015 and April 2019. Charts were reviewed for demographic information, subtype of EDS, characteristics of musculoskeletal pain, and presence of certain systemic comorbid diagnoses: autonomic dysfunction, headaches/migraines, gastrointestinal conditions, cardiovascular anomalies, mast cell activation syndrome, and temporomandibular joint dysfunction. Of 98 patients, 75 were diagnosed with EDS-hypermobile type (EDS-HT); 94 patients were women, and the mean age was 36.7 years. On average, each patient reported involvement of 5.4 joints, with the shoulder, knee, and lumbar spine as the most common. The average number of comorbid systemic conditions was 2.8, of which autonomic dysfunction was the most common. This study aims to provide a better understanding of this disease to promote earlier and more accurate diagnoses to guide treatment and prevent complications.

The Ehlers-Danlos syndromes

The Ehlers-Danlos syndromes (EDS) are a heterogeneous group of hereditary disorders of connective tissue, with common features including joint hypermobility, soft and hyperextensible skin, abnormal wound healing and easy bruising. Fourteen different types of EDS are recognized, of which the molecular cause is known for 13 types. These types are caused by variants in 20 different genes, the majority of which encode the fibrillar collagen types I, III and V, modifying or processing enzymes for those proteins, and enzymes that can modify glycosaminoglycan chains of proteoglycans. For the hypermobile type of EDS, the molecular underpinnings remain unknown. As connective tissue is ubiquitously distributed throughout the body, manifestations of the different types of EDS are present, to varying degrees, in virtually every organ system. This can make these disorders particularly challenging to diagnose and manage. Management consists of a care team responsible for surveillance of major and organ-specific complications (for example, arterial aneurysm and dissection), integrated physical medicine and rehabilitation. No specific medical or genetic therapies are available for any type of EDS.

Primary Total Hip Arthroplasty in Patients With Ehlers-Danlos Syndrome: A Retrospective Matched-Cohort Study

Background

Ehlers-Danlos syndromes (EDSs) are connective-tissue disorders resulting in joint laxity. Soft-tissue stability is a concern in these patients when they undergo total hip arthroplasty (THA). Our purpose was to compare THAs in the population with EDS with a matched control undergoing THA for osteoarthritis.

Methods

Thirteen patients with EDS underwent THA from 1997 to 2017. Matching was 1:3 with a control group of patients who underwent THA for osteoarthritis. Matching was based on the gender, age, and length of follow-up.

Results

We found no difference in demographics or postoperative Harris Hip Scores between the cohorts (P > .05). Two patients (15.4%) with EDS and 2 patients (5.1%) in the control group suffered a dislocation. We found no difference in the reoperation or revision rate between the groups (P = .28).

Conclusion

Patients with EDS have a significant improvement in postoperative Harris Hip Scores after THA. These patients also have a high dislocation rate after surgery, and alternative approaches and technologies such as dual-mobility components should be considered to reduce the rate of dislocation in this population.

Custom-Made Foot Orthoses Reduce Pain and Fatigue in Patients with Ehlers-Danlos Syndrome. A Pilot Study

Background: Pain and fatigue are major clinical manifestations in patients with Ehlers-Danlos Syndrome (EDS). The aim of this study is to measure change of the effects of custom-made foot orthotics on some manifestations related to EDS, such as foot pain, foot functionality, fatigue, and quality of life. Methods: Thirty-six patients with EDS wore foot orthoses for three months. Foot pain, foot-related disability, foot functionality, fatigue, and quality of life were measured using the 11-point Numeric Rating Scale, the Manchester Foot Pain and Disability Index, the Foot Function Index, the Fatigue Severity Score, and the 12-Item Short Form Health Survey questionnaires, respectively, at the beginning and after 3 months. Results: Participants demonstrated significantly improved foot pain (p = 0.002), disability related to foot pain (p < 0.001), foot functionality (p = 0.001), fatigue (p < 0.007), and mental health-related quality of life (p = 0.016). The physical health-related quality of life did not show significant changes. Conclusions: The use of custom-made foot orthoses help in the management of the symptoms by participants. This study could contribute to the foot specialists being considered as an additional member in multidisciplinary teams that are trying to develop an approach for patients with EDS.

Joint Hypermobility as a Predictor of Mechanical Loading in Dancers

CONTEXT

Dance requires the performance of complex movements that may exceed normal anatomical range. However, in hypermobile individuals, this may have implications for injury and performance.

OBJECTIVES

The aim of the study was to investigate the efficacy of the Beighton score (BS) in predicting mechanical loading in dancers in hypermobile and nonhypermobile dancers with consideration of accelerometer placement and lumbar flexion hypermobility.

DESIGN

Cohort study, clinical measurement.

SETTING

University.

PARTICIPANTS

A total of 34 dancers had their joint hypermobility assessed by the BS. Participants completed the Dance Aerobic Fitness Test with a global positioning device incorporating a triaxial accelerometer located at the cervico-thoracic junction (C7) and one at the midbelly of the gastrocnemius.

MAIN OUTCOME MEASURES

Accelerometry data were used to calculate PlayerLoad total, PlayerLoad medial-lateral, PlayerLoad anterior-posterior, and PlayerLoad vertical. Physiological response was measured via heart rate and fatigue response by rate of perceived exertion.

RESULTS

The total BS was a poor predictor of all mechanical loading directions with PlayerLoad anterior-posterior C7 (r = .15) and PlayerLoad total lower limb (r = .20) the highest values. Multiple linear regression was a better predictor with values of C7 (r = .43) and lower limb (r = .37). No significant difference existed between hypermobile and nonhypermobile subjects for mechanical loading values for all stages of the Dance Aerobic Fitness Test and for heart rate and fatigue responses.

CONCLUSIONS

The BS is not a good predictor of mechanical loading which is similar in hypermobile and nonhypermobile dancers for all levels of the Dance Aerobic Fitness Test. Mechanical loading and fatigue responses are similar between hypermobile and nonhypermobile dancers.

Diagnosed prevalence of Ehlers-Danlos syndrome and hypermobility spectrum disorder in Wales, UK: a national electronic cohort study and case-control comparison

OBJECTIVES

To describe the epidemiology of diagnosed hypermobility spectrum disorder (HSD) and Ehlers-Danlos syndromes (EDS) using linked electronic medical records. To examine whether these conditions remain rare and primarily affect the musculoskeletal system.

DESIGN

Nationwide linked electronic cohort and nested case-control study.

SETTING

Routinely collected data from primary care and hospital admissions in Wales, UK.

PARTICIPANTS

People within the primary care or hospital data systems with a coded diagnosis of EDS or joint hypermobility syndrome (JHS) between 1 July 1990 and 30 June 2017.

MAIN OUTCOME MEASURES

Combined prevalence of JHS and EDS in Wales. Additional diagnosis and prescription data in those diagnosed with EDS or JHS compared with matched controls.

RESULTS

We found 6021 individuals (men: 30%, women: 70%) with a diagnostic code of either EDS or JHS. This gives a diagnosed point prevalence of 194.2 per 100 000 in 2016/2017 or roughly 10 cases in a practice of 5000 patients. There was a pronounced gender difference of 8.5 years (95% CI: 7.70 to 9.22) in the mean age at diagnosis. EDS or JHS was not only associated with high odds for other musculoskeletal diagnoses and drug prescriptions but also with significantly higher odds of a diagnosis in other disease categories (eg, mental health, nervous and digestive systems) and higher odds of a prescription in most disease categories (eg, gastrointestinal and cardiovascular drugs) within the 12 months before and after the first recorded diagnosis.

CONCLUSIONS

EDS and JHS (since March 2017 classified as EDS or HSD) have historically been considered rare diseases only affecting the musculoskeletal system and soft tissues. These data demonstrate that both these assertions should be reconsidered.

Recognizing and Effectively Managing Hypermobility-Related Conditions

Hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) can cause widespread or chronic pain, fatigue, and proprioceptive and coordination deficits resulting in functional restrictions. These conditions are common and often unrecognized, and patients are likely to present in physical therapy for musculoskeletal injuries, pain, or coordination deficits. Although physical therapy is considered central to managing these conditions, many patients report pain and iatrogenic injuries due to inappropriate interventions. The diagnostic classification for these conditions was revised in 2017 to supersede previous diagnostic categories of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome-hypermobility type/type III. It is now known that these conditions affect multiple body systems and not just joints and that patients require a holistic approach. This Perspective article will describe the 2017 diagnostic classification system, clinical presentation, examination, evaluation, and management of patients with HSD/hEDS. Both adult and pediatric cases are presented to illustrate the patient management concepts discussed. This knowledge can lead to more effective management of this patient population.

Bilateral Medial and Lateral Patellofemoral Ligament Reconstruction in a Patient with Hypermobility Type Ehlers-Danlos Syndrome: A Case Report

CASE

Medial patellar instability (MPI) is a known sequela of previous lateral retinacular release. Literature on surgical intervention is scarce. We present a case of a 35-year-old woman with hypermobility type Ehlers-Danlos syndrome, with bilateral iatrogenic MPI (IMPI) and lateral patellar instability. This condition led to a marked decrease in quality of life, 10/10 persistent pain, and frequent dislocation events. She was successfully treated surgically, and at 2 years had 0/10 pain and no further dislocations.

CONCLUSIONS

Our technique for medial and lateral patellofemoral ligament reconstruction is a viable intervention for patients with IMPI, even in the setting of underlying collagen disorder.

Outcomes of Primary Total Knee Arthroplasty in Patients With Ehlers-Danlos Syndromes

BACKGROUND

Ehlers-Danlos syndromes (EDS) are connective tissue disorders that cause defects in collagen synthesis or processing, resulting in joint hypermobility. Following total knee arthroplasty (TKA), concern exists that hypermobility will affect the outcome as prosthesis relies on soft tissues for stability. The purpose of this study is to investigate the outcome of TKA in the setting of EDS compared to patients undergoing TKA for osteoarthritis (OA).

METHODS

We identified 16 patients (20 knees) with EDS who underwent a TKA between 2001 and 2016. Patients were matched 1:2 (n = 40) on age, gender, body mass index, and surgical date to patients undergoing TKA for OA.

RESULTS

We found no difference in age, body mass index, or follow-up between the cohorts (P > .05). EDS patients had significantly more surgical interventions prior to TKA (P = .03) and were more likely to require constrained components (x² = 0.002). Following TKA, 4 patients in the EDS group and 9 patients in the matched cohort underwent a reoperation for any reason including 1 revision in the EDS cohort and 3 in the OA cohort. We found no significant difference in reoperation or revision rates between the cohorts (P > .05). There was no difference in Knee Society Scores between groups at last follow-up (P = .63) or radiographic evidence of loosening.

CONCLUSION

Although patients with EDS were more likely to require a constrained component, they are not at increased risk of revision or reoperation following TKA in the intermediate term.

Factors affecting quality of life in children and adolescents with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders

Hypermobile Ehlers-Danlos syndrome (hEDS) is a hereditary disorder of connective tissue, often presenting with complex symptoms can include chronic pain, fatigue, and dysautonomia. Factors influencing functional disability in the pediatric hEDS population are incompletely studied. This study's aims were to assess factors that affect quality of life in children and adolescents with hEDS. Individuals with hEDS between the ages 12-20 years and matched parents were recruited through retrospective chart review at two genetics clinics. Participants completed a questionnaire that included the Pediatric Quality of Life Inventory (PedsQL™), PedsQL Multidimentional Fatigue Scale, Functional Disability Inventory, Pain-Frequency-Severity-Duration Scale, the Brief Illness Perception Questionnaire, measures of anxiety and depression, and helpful interventions. Survey responses were completed for 47 children and adolescents with hEDS/hypermobility spectrum disorder (81% female, mean age 16 years), some by the affected individual, some by their parent, and some by both. Clinical data derived from chart review were compared statistically to survey responses. All outcomes correlated moderately to strongly with each other. Using multiple regression, general fatigue and pain scores were the best predictors of the PedsQL total score. Additionally, presence of any psychiatric diagnosis was correlated with a lower PedsQL score. Current management guidelines recommend early intervention to prevent disability from deconditioning; these results may help identify target interventions in this vulnerable population.

Comparison of tetradecyl sulfate versus polidocanol injections for stabilisation of joints that regularly dislocate in an Ehlers-Danlos population

OBJECTIVES

To determine whether there is similarity between tetradecyl sulfate and polidocanol in stabilising a joint from dislocating in patients with Ehlers-Danlos syndrome (EDS).

METHOD

A retrospective analysis of patients with EDS in a sole-practice clinic in New Zealand. Patients must have had the diagnosis of EDS, had easily dislocatable joints, had treatment and at least 3 months' follow-up. 0.11% tetradecyl sulfate solution, or 0.25% polidocanol solution, was injected to ligament attachments (enthesis) on the side of the joints where they dislocated. Patients were deemed successfully treated if their affected joints were no longer dislocated over a minimum of 3 months' follow-up (out to 3 years).

RESULTS

Of 250 patients at the time of the study, 46 fitted the criteria. There were 37 treated with tetradecyl sulfate and nine with polidocanol. For the tetradecyl group there were a total of 305 injections around 97 joints: mean 3.1, range 1-22, median 2. For the polidocanol group there were 36 injections around 19 joints: mean 1.9, range 1-8, median 2. The difference of means between group 1 (tetradecyl) and group 2 (polidocanol) is 1.2, CIs 0.34 to 2.98. All patients had no further dislocations of treated joints unless they had a major new injury (two patients).

CONCLUSION

There was no difference between the two groups for stabilising joints from dislocating. These two agents appear promising for treating patients with recurrent joint dislocations in the setting of EDS. Prospective multicentre randomised controlled trials are needed to confirm these data.

Ehlers-Danlos syndromes: state of the art on clinical practice guidelines

Objective

To report the effort of the European Reference Network for Rare and Complex CONnective tissue and musculoskeletal diseases NETwork working group on Ehlers-Danlos syndromes (EDS) and related disorders to assess current available clinical practice guidelines (CPGs) specifically addressed to EDS, in order to identify potential clinician and patient unmet needs.

Methods

Systematic literature search in PUBMED and EMBASE based on controlled terms (MeSH and Emtree) and keywords of the disease and publication type (CPGs). All the published articles were revised in order to identify existing CPGs on diagnosis, monitoring and treatment of EDS.

Results

Literature revision detected the absence of papers reporting good quality CPGs to optimise EDS patient care. The current evidence-based literature regarding clinical guidelines for the EDS was limited in size and quality, and there is insufficient research exploring the clinical features and interventions, and clinical decision-making are currently based on theoretical and limited research evidences.

Conclusions

Many clinician and patient unmet needs have been identified.

The Beighton score as a predictor of Brighton criteria in sport and dance

OBJECTIVES

To determine the efficacy of using the Beighton joint hypermobility score as a predictor of Brighton criteria components, considering the influence of gender and sports participation.

DESIGN

Cross sectional study design.

SETTING

A University.

PARTICIPANTS

Sixty-five female rugby players, 38 male rugby players, 61 netball players, 42 female dancers, 40 male controls and 40 female controls.

MAIN OUTCOME MEASURES

The Beighton score was assessed using the Beighton and Horan Joint Mobility Index. The Brighton criteria was used to assess joint hypermobility syndrome. A binary logistic regression was performed for a pooled sample (n = 286), and subsequently for gender and sport to assess the Beighton score as a predictor of Brighton criteria.

RESULTS

Beighton scores were found to be a predictor of arthralgia (P = 0.002), dislocation and subluxation (P = 0.048) in the pooled analysis; a predictor of dislocation and subluxation (P = 0.047) in males and arthralgia (P = 0.001) in females. Beighton scores were a predictor of arthralgia in female rugby (P = 0.003) and in female controls (P = 0.012).

CONCLUSIONS

The potential of the Beighton score to predict joint arthralgia and dislocation/subluxation may allow clinicians to implement effective injury prevention strategies.