Joint Replacements in Individuals With Skeletal Dysplasias: One Institution's Experience and Response to Operative Complications

Total Knee Arthroplasty in Patients Who Have Skeletal Dysplasia: A Center's Experience With a Mean 9-Year Follow-Up

BACKGROUND

Total knee arthroplasty (TKA) in patients who have skeletal dysplasia (SD) is a technically challenging surgery due to deformity, joint contracture, and associated comorbidities. Patients presenting with this condition have traditionally been treated with conservative measures, leading to poor outcomes. The aim of this study was to follow-up on patients who had SD following TKA, specifically with regards to clinical outcomes.

METHODS

A total of 31 knees (22 patients) with SD that had undergone TKA in our institution were included in our study. The mean follow-up from index surgery was 110.3 months (range: 20 to 291). The type of dysplasia, implant used, and clinical outcomes with patient-reported outcome measures are presented.

RESULTS

There were 8 patients (36.3%) who had a diagnosis of achondroplasia, followed by multiple epiphyseal dysplasia (31.8%) and spondyloepiphyseal dysplasia (22.7%). There were 14 men and 8 women who had a mean age of 51 years (range: 28 to 73). Custom implants were required in 12 cases (38.7%), custom jigs were used in 6 cases (19.4%), and robotic-assisted surgery was used in 2 (6.5%) TKAs. Hinged prostheses were used in 17 cases (54.8%), posterior-stabilized in 9 (29.0%), and cruciate-retaining implants in 5 (16.1%). There was 1 patient who sustained an intraoperative medial tibial plateau fracture treated with concomitant open reduction and internal fixation. There was 1 revision that occurred during the follow-up period with a patella resurfacing for continued anterior knee pain. Postoperatively, Oxford Knee Scores improved on average by 12.2 points. The 10-year and 20-year all-cause revision-free survival was 96.8, respectively.

CONCLUSIONS

Despite the technical challenges and complexity associated with this unique patient cohort, we demonstrated excellent implant survivorship and clinical outcomes post-TKA with mid-term to long-term follow-up of more than 20 years. We recommend preoperative cross-sectional imaging for precise planning and implant templating with multidisciplinary team decision-making. Despite our results, functional outcomes remain inferior to primary arthroplasty within the general population, although we still recommend this treatment modality to appropriately counseled patients.

LEVEL OF EVIDENCE

III.

Outcomes of Lower Extremity Total Joint Arthroplasty in Patients With Skeletal Dysplasia: A Systematic Review

Background

Patients with genetic skeletal dysplasias often require lower extremity total joint arthroplasty (TJA) due to early joint degeneration; however, little data exists regarding the outcomes of TJA in this population. Our purpose was to review the literature to determine the complication rates, revision rates, implant survivorship, and patient-reported outcomes of total knee arthroplasty and total hip arthroplasty (THA) in those with genetic skeletal dysplasias.

Methods

A systematic literature review of online databases (PubMed and Google Scholar) was conducted. Studies that reported the outcomes of THA or total knee arthroplasty in patients with genetically confirmed skeletal dysplasias were included. Case reports and studies that defined dysplasia based on height alone were excluded. Fourteen studies met the criteria for data extraction and analysis.

Results

Our review yielded a sample of 596 skeletal dysplasia patients with a median follow-up of 6.01 years (1.7-15.9). Mean age was 54.04 years, and mean body mass index was 29.1 kg/m2. Cementless fixation was utilized in 65.7% of THAs, while all knees were cemented. Hip implant survivorship was 79% at 10 years and 56% at 20 years. Knee implant survivorship was 92% at 10 years and 46% at 20 years. Hip and knee revisions were 15.3% and 13.5%, respectively. The most common indication was aseptic loosening and polyethylene wear. Patient-reported outcomes improved across all domains.

Conclusions

The literature regarding lower extremity TJA in those with genetic skeletal dysplasias demonstrates appropriate 10-year implant survivorship and improvement in patient-reported outcomes across all survey domains.

Total hip arthroplasty in patients with common pediatric hip orthopedic pathology

Purpose

Literature regarding total hip arthroplasty for pediatric hip diseases is scarce. This review aims to portray the various orthopedic conditions of childhood that can lead to significant impairment of the hip joint and, ultimately, to total hip arthroplasty in adolescence and adulthood.

Methods

In total, 61 out of 3666 articles were selected according to (1) the diagnosis of one of the 12 pediatric hip pathologies (Legg-Perthes-Calvé disease, developmental dysplasia of the hip, slipped capital femoral epiphysis, neuromuscular hip dysplasia, post-traumatic avascular necrosis of the proximal femur, juvenile rheumatoid arthritis, achondroplasia, spondyloepiphyseal dysplasia, mucopolysaccharidosis, mucolipidosis, hip infections, and tumors) that required total hip arthroplasty; (2) minimum follow-up of 16 months; (3) assessed outcome with a clinical or radiologic score; (4) Methodological Items for Non-Randomized Studies quality score of 9 or higher. The following information for each pathology was retrieved: mean age at total hip arthroplasty, reason for total hip arthroplasty, type of total hip arthroplasty, surgical technique, mean follow-up, and outcomes.

Results

Overall, the mean age at total hip arthroplasty for pediatric hip disease is in the sixth and seventh decade, except for tumors and skeletal dysplasias. The reason for performing total hip arthroplasty is often osteoarthrosis and abnormal anatomy. Prosthesis types change based on patient's conditions and technological advances; custom-made implants are used for tumors, juvenile rheumatoid arthritis, and skeletal dysplasias; for other diseases, the most frequent are modular cementless implants. Outcomes are generally good, and all studies portray functional and pain improvements.

Conclusion

Total hip arthroplasty is performed more frequently than in the past in patients with pediatric hip pathologies; it enhances patients' quality of life by reducing pain and improving function. However, revision rate in these patients is not negligible.

A scoping review of nutrition issues and management strategies in individuals with skeletal dysplasia

PURPOSE

Skeletal dysplasia are heterogeneous conditions affecting the skeleton. Common nutrition issues include feeding difficulties, obesity, and metabolic complications. This systematic scoping review aimed to identify key nutrition issues, management strategies, and gaps in knowledge regarding nutrition in skeletal dysplasia.

METHODS

The databases Ovid MEDLINE, Ovid EMBASE, Ebsco CINAHL, Scopus, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews were searched. Reference lists and citing literature for included studies were searched. Eligible studies included participants with skeletal dysplasia and described: anthropometry, body composition, nutrition-related biochemistry, clinical issues, dietary intake, measured energy or nutrition requirements, or nutrition interventions.

RESULTS

The literature search identified 8509 references from which 138 studies were included (130 observational, 3 intervention, 2 systematic reviews, and 3 clinical guidelines). Across 17 diagnoses identified, most studies described osteogenesis imperfecta (n = 50) and achondroplasia or hypochondroplasia (n = 47). Nutrition-related clinical issues, biochemistry, obesity, and metabolic complications were most commonly reported, and few studies measured energy requirements (n = 5).

CONCLUSION

Nutrition-related comorbidities are documented in skeletal dysplasia; yet, evidence to guide management is scarce. Evidence describing nutrition in rarer skeletal dysplasia conditions is lacking. Advances in skeletal dysplasia nutrition knowledge is needed to optimize broader health outcomes.

High Satisfaction and Activity Levels After Total Hip Arthroplasty in Patients Under Age 21

BACKGROUND

With improved materials and bearing surfaces, the use of total hip arthroplasty (THA) in young patients is increasing. Functional outcomes and activity level are particularly relevant in this higher-demand patient population. There is a paucity of data on patient-reported outcomes and activity levels after THA in extremely young (<21 years old) patients.

METHODS

We identified 196 patients (222 hips) who underwent THA at age <21 years at our institution from 1982 to 2018. After applying exclusion criteria, 113 of 160 (70.6%) patients (129 hips) were available for follow-up. Patient activity levels and functional outcomes were evaluated using the UCLA activity score, Forgotten Joint Score (FJS), Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and a validated 5-question satisfaction survey. Survivorship and reasons for revision were recorded.

RESULTS

The mean age at surgery was 17.0 ± 2.8 years, and the mean follow-up was 13.2 years (range 2-38 years). The most common indications for THA were osteonecrosis (34%) and juvenile idiopathic arthritis (30%). The mean UCLA activity score was 5.9 ± 2.0, and 64% of patients reported a score ≥6. The mean FJS was 57.9 ± 31.0. The mean Hip Disability and Osteoarthritis Outcome Score for Joint Replacement score was 84.6 ± 16.6. Ninety percent of patients reported that they were very or somewhat satisfied with their surgery. At final follow-up, 27 of 129 (20.9%) hips had undergone revision surgery.

CONCLUSION

THA performed in patients under 21 years of age with end-stage hip disease allows for high levels of activity and satisfaction postoperatively, with most patients being able to participate in moderate recreational activities. These data may be useful for surgeons in planning for and counseling extremely young patients indicated for THA.

Total knee arthroplasty in a young patient with achondroplasia

Achondroplasia is a genetic skeletal dysplasia, characterised by dwarfism, with upper and lower limb deformities, that can lead to knee osteoarthritis; the surgical treatment is a challenge due to the particular joint anatomy variances. We present a 40-year-old woman, affected by achondroplasia with severe left knee osteoarthritis; the patient was treated conservatively with poor results. Between the ages of 12 and 17 years, she underwent multiple operative procedures for lower limb lengthening and a partial correction of the valgus deformity, by applying an external fixator. The patient was successfully treated with cemented posterior stabilised, fixed-bearing, total knee arthroplasty. The patient affected by achondroplasia, with severe knee osteoarthritis, should be considered for total joint replacement, which can be carried out with or without additional extra-articular osteotomy for alignment correction. Due to skeletal dysplasia in joint deformities, knee replacement requires careful preoperative planning and special technical considerations.

Total Knee Arthroplasty in Spondyloepiphyseal Dysplasia with Irreducible Congenital Dislocation of the Patella: Case Report and Literature Review

Background

Spondyloepiphyseal dysplasia is the clinical term applied to a group of rare genetic disorders with primary involvement of the vertebrae and epiphyses, predisposing the afflicted individuals toward the premature development of osteoarthritis. There are few reports concerning joint replacement therapy in these patients, particularly describing the role of total hip arthroplasty. In this report, we describe the anatomical and technical aspects of spondyloepiphyseal dysplasia that must be considered during surgical planning and performance of total knee arthroplasty.

Case Presentation

A 49-year old woman with a history of spondyloepiphyseal dysplasia suffered from severe osteoarthritis of the knee and irreducible congenital dislocation of the patella. After careful preoperative evaluations and planning, the knee joint deformity was solved by knee joint replacement with realignment of the extensor mechanism using quadricepsplasty. After 2 years of surgery, the patient showed no pain and was able to walk with the help of elbow crutches. The Hospital for Special Surgery knee score increased from preoperative 51 points to 85 points during the final follow-up. The postoperative range of motion increased to final flexion of 0–115°.

Conclusion

The advances made so far in the medical care for patients with skeletal dysplasia have improved their overall survival during adulthood. The case report described herein demonstrates the numerous challenges and technical aspects of a successful total knee arthroplasty in cases of spondyloepiphyseal dysplasia, highlighting the need to consider skeletal and soft tissue abnormalities of skeletal dysplasia during the planning and performance of joint replacement surgery.