Down Syndrome Increases the Risk of Short-Term Complications After Total Hip Arthroplasty

Patients With Down Syndrome and Total Hip and Total Knee Arthroplasty: Outcome Measures Show Increased Risk of Perioperative Complications

BACKGROUND

Patients with Down syndrome (DS) are being considered for total joint arthroplasty. There is limited literature regarding outcomes of patients with DS after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Data were abstracted from the 2010 to 2021 Q1 PearlDiver M151 database. THA and TKA osteoarthritis adult patients with and without DS were identified. Patients were matched 1:10. Ninety-day postoperative events and 2-year revision rates were compared.

RESULTS

For THA, 154 patients with DS were matched with 1,532 patients without DS. For TKA, 150 patients with DS were matched with 1,495 patients without DS. On multivariable logistic regression, THA and TKA patients with DS were at markedly greater odds of postoperative events including any adverse event, sepsis, minor adverse event, urinary tract infection (UTI), acute kidney injury (AKI), and pneumonia. For both THA and TKA, 2-year revision rates were not increased for those with DS.

DISCUSSION

This study represents the largest cohorts for matched patients with DS undergoing THA or TKA through 90 days postoperatively. For both procedures, DS patients were found to have greater risk of several adverse events, but not 2-year revisions. These findings may help guide perioperative risk assessment, patient/family counseling, and care pathways.

Is primary total hip arthroplasty in patients with Down's syndrome associated with increased complications at 2 years follow-up?

INTRODUCTION

Previous reports on primary total hip arthroplasty (THA) in patients with Down's syndrome (DS) are often small and/or lack a comparison cohort, and thus it is challenging to draw meaningful conclusions about this group. The purpose of this study was to report on the post-operative complications in patients with DS undergoing primary THA, compared to a non-DS cohort.

METHODS

In this retrospective study, we evaluated patients from 2010 to 2018 using a national database. We assessed surgical complications: closed reduction for dislocation, revision, resection, periprosthetic fracture, and infection in patients with a diagnosis of DS undergoing primary THA and compared them to a THA group of patients without DS. Patients undergoing THA for hip fractures were excluded. Complications were evaluated at 90 days and 2 years. Multivariable logistic regression analysis was used to adjust for age, sex, body mass index, and Charlson comorbidity index.

RESULTS

At 90 days patients with DS had an increased risk of revision (OR 3.1, CI 1.14-8.41), but no significant risk of resection (OR 5.24, CI 0.73-37.8), closed reduction (OR 2.03, CI 0.28-14.59), infection (OR 1.48, CI 0.6-3.62), or periprosthetic fracture (OR 1.97, CI 0.27-14.14). At 2 years patients with DS had an increased risk of periprosthetic fracture (OR 5.88, CI 1.84-18.78), but no significant increased risk of revision (OR 1.82, CI 0.66-5.01), resection (OR 2.37, CI 0.33-17.17), or infection (OR 0.65, CI 0.2-2.07).

CONCLUSIONS

Primary THA in patients with DS is associated with increased 90-day revision, and periprosthetic fracture at 2 years.

Healthy Ageing and Intellectual Disability study: summary of findings and the protocol for the 10-year follow-up study

INTRODUCTION

The Healthy Ageing and Intellectual Disability (HA-ID) study is a prospective multicentre cohort study in the Netherlands that started in 2008, including 1050 older adults (aged ≥50) with intellectual disabilities (ID). The study is designed to learn more about the health and health risks of this group as they age. Compared with the amount of research in the general population, epidemiological research into the health of older adults with ID is still in its infancy. Longitudinal data about the health of this vulnerable and relatively unhealthy group are needed so that policy and care can be prioritised and for guiding clinical decision making about screening, prevention and treatment to improve healthy ageing.

METHODS AND ANALYSIS

This article presents a summary of the previous findings of the HA-ID study and describes the design of the 10-year follow-up in which a wide range of health data will be collected within five research themes: (1) cardiovascular disease; (2) physical activity, fitness and musculoskeletal disorders; (3) psychological problems and psychiatric disorders; (4) nutrition and nutritional state; and (5) frailty.

ETHICS AND DISSEMINATION

Ethical approval for the 10-year follow-up measurements of the HA-ID study has been obtained from the Medical Ethics Review Committee of the Erasmus MC, University Medical Centre Rotterdam (MEC-2019-0562).

TRIAL REGISTRATION NUMBER

This cohort study is registered in the Dutch Trial Register (NTR number NL8564) and has been conducted according to the principles of the Declaration of Helsinki.

Perioperative care of adults with Down syndrome: a narrative review

Because of enhanced life expectancy due to medical and surgical therapeutic advances, it is estimated that there are more adults than children living with Down syndrome (DS), or trisomy 21, in the United States. Therefore, DS can no longer be considered a syndrome limited to the pediatric population. These patients are presenting for surgery and anesthesia in adult care settings, where anesthesiologists will encounter these patients more frequently. As these patients age, their commonly associated co-morbidities not only progress, but they also develop other cardiac, respiratory, gastrointestinal, and neurologic conditions. The manifestations and consequences of chronic disease can present new challenges for the anesthesiologist and require expertise and judgement to minimize patient risk. The purpose of this narrative review is to describe the common pediatric co-morbidities associated with DS and discuss the age-acquired manifestations. Additionally, considerations for anesthetic care of the adult with DS will be presented, including the preoperative assessment, intraoperative management, and postoperative care.

Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review

OBJECTIVES

To produce a narrative synthesis of published academic and grey literature focusing on patient safety outcomes for people with learning disabilities in an acute hospital setting.

DESIGN

Scoping review with narrative synthesis.

METHODS

The review followed the six stages of the Arksey and O'Malley framework. We searched four research databases from January 2000 to March 2021, in addition to handsearching and backwards searching using terms relating to our eligibility criteria-patient safety and adverse events, learning disability and hospital setting. Following stakeholder input, we searched grey literature databases and specific websites of known organisations until March 2020. Potentially relevant articles and grey literature materials were screened against the eligibility criteria. Findings were extracted and collated in data charting forms.

RESULTS

45 academic articles and 33 grey literature materials were included, and we organised the findings around six concepts: (1) adverse events, patient safety and quality of care; (2) maternal and infant outcomes; (3) postoperative outcomes; (4) role of family and carers; (5) understanding needs in hospital and (6) supporting initiatives, recommendations and good practice examples. The findings suggest inequalities and inequities for a range of specific patient safety outcomes including adverse events, quality of care, maternal and infant outcomes and postoperative outcomes, in addition to potential protective factors, such as the roles of family and carers and the extent to which health professionals are able to understand the needs of people with learning disabilities.

CONCLUSION

People with learning disabilities appear to experience poorer patient safety outcomes in hospital. The involvement of family and carers, and understanding and effectively meeting the needs of people with learning disabilities may play a protective role. Promising interventions and examples of good practice exist, however many of these have not been implemented consistently and warrant further robust evaluation.

Adverse outcomes after major surgery in children with intellectual disability

AIM

To evaluate outcomes after major surgery in children and adolescents with intellectual disability.

METHOD

We used 2004 to 2013 claims data from Taiwan's National Health Insurance programme to conduct a nested cohort study, which included 220 292 surgical patients aged 6 to 17 years. A propensity score matching procedure was used to select 2173 children with intellectual disability and 21 730 children without intellectual disability for comparison. Logistic regression was used to calculate the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the postoperative complications and 30-day mortality associated with intellectual disability.

RESULTS

Children with intellectual disability had a higher risk of postoperative pneumonia (OR 2.16, 95% CI 1.48-3.15; p<0.001), sepsis (OR 1.67, 95% CI 1.28-2.18; p<0.001), and 30-day mortality (OR 2.04, 95% CI 1.05-3.93; p=0.013) compared with children without intellectual disability. Children with intellectual disability also had longer lengths of hospital stay (p<0.001) and higher medical expenditure (p<0.001) when compared with children with no intellectual disability.

INTERPRETATION

Children with intellectual disability experienced more complications and higher 30-day mortality after surgery when compared with children without intellectual disability. There is an urgent need to revise the protocols for the perioperative care of this specific population.

WHAT THIS PAPER ADDS

Surgical patients with intellectual disability are at increased risk of postoperative pneumonia, sepsis, and 30-day mortality. Intellectual disability is associated with higher medical expenditure and increased length of stay in hospital after surgical procedures. The influence of intellectual disability on postoperative outcomes is consistent in both sexes and those aged 10 to 17 years. Low income and a history of fractures significantly impacts postoperative adverse events for patients with intellectual disability.

Pneumonia and respiratory infections in Down syndrome: A scoping review of the literature

Pneumonia and respiratory infections impact infants and children with Down syndrome; pneumonia is a leading cause of mortality in adults with Down syndrome. We aimed to review the literature to evaluate gaps and address key questions. A series of key questions were formulated a priori to inform the search strategy and review process; addressed prevalence, severity, etiology, risk factors, preventive methods, screening, and financial costs, potential benefits or harms of screening. Using the National Library of Medicine database, PubMed, detailed literature searches on pneumonia and respiratory infections in Down syndrome were performed. Previously identified review articles were also assessed. The quality of available evidence was then evaluated and knowledge gaps were identified. Forty-two relevant original articles were identified which addressed at least one key question. Study details including research design, internal validity, external validity, and relevant results are presented. Pneumonia and respiratory infections are more prevalent and more severe in individuals with Down syndrome compared to healthy controls through literature review, yet there are gaps in the literature regarding the etiology of pneumonia, the infectious organism, risk factors for infection, and to guide options for prevention and screening. There is urgent need for additional research studies in Down syndrome, especially in the time of the current COVID-19 pandemic.

Management of recurrent hip dislocation in Down Syndrome using modified Ganz periacetabular osteotomy: Follow up after 5 years

Recurrent hip dislocation in a Down Syndrome patient with dysplastic hip is a very rare and challenging case to treat even for an expert orthopaedic hip surgeon. Least compliant patient and family, lowly educated with low socioeconomic status, young age and several anatomical variations forces limited option as a treatment. Several literatures mentioned Despite requiring only minimal implant, this technically demanding surgery requires a thorough understanding of the hip anatomy. This is the first case worldwide reporting 5 year follow up of dysplastic hip with DS treated successfully with periacetabular osteotomy (PAO) technique. An eighteen years old female with DS had multiple posterior hip dislocation episodes since 3 years prior our hospital admission. A modified Ganz PAO was performed under image intensifier guide. Patient was able to talk and hip was never dislocated again within 5 years follow up. Ganz periacetabular osteotomy, although a technically demanding surgery, is a preferable treatment in recurrent hip dislocation for Down Syndrome patient with good to excellent clinical and radiological outcome.

Co-occurring medical conditions in adults with Down syndrome: A systematic review toward the development of health care guidelines. Part II

Adults with Down syndrome (DS) represent a unique population who are in need of clinical guidelines to address their medical care. Many of these conditions are of public health importance with the potential to develop screening recommendations to improve clinical care for this population. Our workgroup previously identified and prioritized co-occurring medical conditions in adults with DS. In this study, we again performed detailed literature searches on an additional six medical conditions of clinical importance. A series of key questions (KQ) were formulated a priori to guide the literature search strategy. Our KQs focused on disease prevalence, severity, risk-factors, methodologies for screening/evaluation, impact on morbidity, and potential costs/benefits. The available evidence was extracted, evaluated and graded on quality. The number of participants and the design of clinical studies varied by condition and were often inadequate for answering most of the KQ. Based upon our review, we provide a summary of the findings on hip dysplasia, menopause, acquired cardiac valve disease, type 2 diabetes mellitus, hematologic disorders, and dysphagia. Minimal evidence demonstrates significant gaps in our clinical knowledge that compromises clinical decision-making and management of these medically complex individuals. The creation of evidence-based clinical guidance for this population will not be possible until these gaps are addressed.

Down Syndrome and Postoperative Complications in Children Undergoing Intestinal Operations

OBJECTIVE

This paper intends to evaluate the association between Down Syndrome (DS) and postoperative medical and surgical complications and inpatient postoperative mortality in pediatric patients undergoing intestinal operations.

METHODS

The 2012 Kids' Inpatient Database was queried to compare short-term postoperative medical and surgical complications and in-patient mortality among patients with DS undergoing intestinal operations to a cohort without DS using inverse probability weighting. Subset analysis was performed for patients undergoing intestinal operations exclusive of gastrostomy placement. Adverse treatment effects were calculated for the outcomes of interest.

RESULTS

Of 17,026 pediatric patients undergoing intestinal operations, 444 had DS. In unadjusted analysis, medical complications (urinary tract infection, deep venous thrombosis, sepsis, pneumonia) occurred in 7.9% of patients with DS, compared to 14.1% of those without (p < 0.001). Surgical complications (wound disruption, hemorrhage, superficial or deep wound infection) occurred in 3.5% of patients with DS, compared to 4.6% of those without (p = 0.34), and in-patient mortality occurred in 0.3% of patients with DS, compared to 2.7% of those without (p = 0.009). Adverse treatment effects (ATE) calculated after inverse probability weighting demonstrated no difference for medical or surgical complications but a significantly decreased mortality with DS.

CONCLUSIONS

Contrary to common perception and data extrapolated from the adult literature, pediatric patients with DS have neither higher medical nor surgical complication rates after intestinal operations. Similar to patients undergoing congenital heart surgery, pediatric patients with DS have a lower postoperative inpatient mortality after these general operations compared to those without DS. Mechanisms influencing risks in DS patient remain unknown.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Hip Instability in Patients With Down Syndrome

The incidence of hip instability in children with Down syndrome is 1% to 7%. The natural history is often progressive, with the typical onset of hypermobility of the hip evolving to habitual dislocation, persistent subluxation, and fixed dislocation, and eventually leading to the loss of independent mobility. Treatment focuses on stabilizing the hip joint and depends on the patient's age and the severity of the disease. Typically, surgical intervention is recommended for the treatment of patients with habitual dislocation, subluxation, and complete dislocation of the hip. When indicated, surgical management must take into account associated anatomic abnormalities of the femur and acetabulum. Hip instability in Down syndrome may persist despite surgical intervention and remains a difficult condition to manage.

Mid-Term Results of Periacetabular Osteotomy for the Treatment of Hip Dysplasia Associated with Down Syndrome: Minimum Follow-up of Five Years

BACKGROUND

The treatment of hip dysplasia in patients with Down syndrome is challenging. We investigated the clinical, functional, and radiographic outcomes of periacetabular osteotomy (PAO) as well as factors associated with its failure at a minimum of 5 years of follow-up.

METHODS

Between 1992 and 2011, 19 patients with Down syndrome (26 hips) underwent PAO at a mean age of 16.2 ± 4.7 years. Hip pain and function were assessed with use of the modified Harris hip score (HHS) and the Gross Motor Function Classification System (GMFCS). The criteria for PAO failure were progression of osteoarthritis with a recommendation for total hip arthroplasty or hip arthrodesis, or an HHS of <60 points. Preoperative and most recent radiographs were assessed for measurement of the lateral and anterior center-edge angles, Tönnis angle, extrusion index, and anterior and posterior wall indices, and for evaluation of the Tönnis grade of osteoarthritis.

RESULTS

At an average follow-up of 13.1 ± 5.2 years (range, 5.4 to 24 years), 13 (62%) of 21 hips with an HHS demonstrated good or excellent HHS results (median, 91 points; interquartile range, 65 to 96 points). Ninety-five percent of the patients were independent in ambulation. All radiographic parameters significantly improved after PAO. Eight (31%) of the 26 hips were considered to have failed the procedure. Tönnis grade-2 osteoarthritis (4 hips compared with 1 hip; p = 0.008; odds ratio [OR] = 17.00) and older patient age at the time of the procedure (19.6 ± 6.7 compared with 14.7 ± 2.4 years; p = 0.017; OR = 1.36 per year) were demonstrated to be factors associated with PAO failure in an analysis of hips that failed compared with those without failure at the time of latest follow-up.

CONCLUSIONS

PAO improves radiographic deformity and helps to preserve independent ambulation in patients with hip dysplasia and Down syndrome. Although nearly 70% of the hips were preserved at an average of 13 years postoperatively, 1 in 3 hips met the criteria for failure, which was associated with older age at the time of the procedure and a moderate osteoarthritis grade (Tönnis grade 2).

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Periprosthetic Fractures Associated With Primary Total Hip Arthroplasty

BACKGROUND

Periprosthetic fracture (PPF) is a rare but devastating complication of primary total hip arthroplasty (THA). While PPF is associated with increased morbidity and mortality, early revision rate, and poor patient outcome, there is a paucity of data on patient and hospital-dependent risk factors. Using a large administrative database, we investigated epidemiology and the risk factors associated with perioperative PPF after primary THA.

METHODS

We performed a retrospective review of the National Inpatient Sample records from 2006 to 2011 and identified 1062 PPFs of 1,187,969 patients using International Classification of Diseases, Ninth Revision code for PPF (996.44). We then analyzed sociodemographic characteristics, comorbidities, and hospital characteristics of our study population.

RESULTS

The overall incidence of PPF in National Inpatient Sample database was 0.089% (8.9 per 10,000 THAs). Patient-dependent risk factors were: female (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.67-2.22), low household income (OR 1.4, 95% CI 1.18-1.65), Medicaid (OR 1.89, 95% CI 1.39-2.57), and uninsured (OR 2.74, 95% CI 1.63-4.61). Patients with malnutrition and hemiparesis/hemiplegia were associated 10-fold and 6-fold risk of PPF. Nonteaching hospitals (OR 1.15, 95% CI 1.01-1.32), hospitals in northeast (OR 1.29, 95% CI 1.04-1.59), and rural hospitals (OR 1.27, 95% CI 1.06-1.53) had higher incidence of PPF.

CONCLUSION

Our study demonstrates that the incidence of PPF was low in our study population, and greater awareness is needed when performing primary THAs in patients with risk factors identified in our study to prevent PPF.

Early Postoperative Outcomes After Total Joint Arthroplasty in Patients With Multiple Myeloma

BACKGROUND

Multiple myeloma is the most common primary bone malignancy and is increasingly becoming a chronic condition, but little is known about its impact in the perioperative arthroplasty setting. We sought to determine whether patients with multiple myeloma undergoing elective total joint arthroplasty would be at increased risk for in-hospital complications and death, prolonged length of stay, and nonroutine discharge.

METHODS

Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified 6,054,344 patients undergoing elective primary total joint arthroplasty, of whom 2381 (0.039%) with multiple myeloma. Comparisons of perioperative outcomes were performed by multivariable logistic regression modeling.

RESULTS

Patients with multiple myeloma were more likely to suffer several postoperative complications, including thromboembolic events (odds ratio [OR]: 2.97, 95% CI: 2.32-3.81), surgical site infection (OR: 2.82, 95% CI: 1.59-5.01), acute renal failure (OR: 1.93, 95% CI: 1.59-2.37), and induced mental disorder (OR: 1.57, 95% CI: 1.21-2.04). A diagnosis of multiple myeloma was also associated with higher risk for blood transfusion (OR: 2.14, 95% CI: 1.97-2.33), prolonged hospital stay (OR: 2.04, 95% CI: 1.86-2.23), and nonroutine discharge (OR: 1.33, 95% CI: 1.21-1.45) but was not associated with greater in-hospital mortality.

CONCLUSION

Patients with multiple myeloma are at increased risk for early postoperative complications (especially surgical site infection and thromboembolic events) and resource utilization after elective joint arthroplasty. Greater awareness of multiple myeloma and its health consequences may contribute to improvements in the perioperative management of total joint arthroplasty patients.

Patients With Multiple Myeloma Have More Complications After Surgical Treatment of Hip Fracture

Objectives:

Bone lesions from multiple myeloma may lead to pathological fracture of the proximal femur, requiring either fixation or arthroplasty. Little is known about the impact of multiple myeloma on hip fracture care. We investigated whether the patients with multiple myeloma undergoing surgical treatment of hip fractures would be at increased risk for adverse outcomes versus patients who sustain a hip fracture without multiple myeloma.

Methods:

Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified 2 440 513 patients older than 50 years of age with surgically treated hip fractures. Of which, 4011 (0.2%) were found to have multiple myeloma. We compared perioperative outcomes between the patients with multiple myeloma and the nonmultiple myeloma patients using multivariable logistic regression modeling.

Results:

Patients with multiple myeloma were more likely to have several postoperative complications, such as in-hospital pneumonia (odds ratio [OR]: 1.31, 95% confidence interval [CI]: 1.14-1.51), sepsis (OR: 1.72, 95% CI: 1.32-2.25), surgical site infection (OR: 1.66, 95% CI: 1.38-2.00), and acute renal failure (OR: 1.28, 95% CI: 1.14-1.43). We found that myeloma was not associated with increased inpatient mortality, myocardial infarction, respiratory failure, thromboembolic events, or pulmonary embolism.

Conclusion:

Patients with multiple myeloma are at increased risk for immediate postoperative complications following surgical treatment of hip fractures including in-hospital pneumonia, surgical site infection, and acute renal failure but not hospital mortality, when compared to hip fracture patients without multiple myeloma. Perioperative management of hip fractures in patients with myeloma may be optimized by increased awareness of these risks in this subset of patients.