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

doi:10.1016/j.arth.2015.09.031

The Journal of Arthroplasty

Volume 31, Issue 2, February 2016, Pages 368-372

https://doi.org/10.1016/j.arth.2015.09.031 Get rights and content

Abstract

Background

Down syndrome is the most common chromosomal abnormality and is associated with degenerative hip disease. Because of the recent increase in life expectancy for patients with this syndrome, orthopaedic surgeons are likely to see an increasing number of these patients who are candidates for total hip arthroplasty (THA).

Methods

Using Nationwide Inpatient Sample (NIS) data from 1998 to 2010, we compared the short-term adverse outcomes of THA among 241 patients with Down syndrome and a matched 723-patient cohort. Specifically, we assessed: (1) incidence of THA; (2) perioperative medical and surgical complications during the primary hospitalization; (3) length of stay; and (4) hospital charges.

Results

The annual mean number of patients with Down syndrome undergoing THA was 19. Compared to matched controls, Down syndrome patients had an increased risk of perioperative (OR, 4.33; P < .001), medical (OR, 4.59; P < .001) and surgical (OR, 3.51; P < .001) complications during the primary hospitalization. Down syndrome patients had significantly higher incidence rates of pneumonia (P = .001), urinary tract infection (P < .001), and wound hemorrhage (P = .027). The mean lengths of stay for Down syndrome patients were 26% longer (P < .001), but there were no differences in hospital charges (P = .599).

Conclusion

During the initial evaluation and pre-operative consultation for a patient with Down syndrome who is a candidate for THA, orthopaedic surgeons should educate the patient, family and their clinical decision makers about the increased risk of medical complications (pneumonia and urinary tract infections), surgical complications (wound hemorrhage), and lengths of stay compared to the general population.

Section snippets

Study Population

The NIS is the largest all-payer inpatient database in the United States and is part of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality. The NIS data is derived from a subset of hospitals in states that make their data available to the HCUP project and that can be matched to American Hospital Association survey data. To obtain nationwide estimates, the NIS developed a weighting system using the American Hospital Association hospital

Results

Between 1998 and 2010, 543 085 patients in the NIS were admitted to the hospital for THA. Within this patient cohort, 241 (0.04%) had a documented diagnosis of Down syndrome. The annual mean number of patients with Down syndrome undergoing THA was 18.54, reaching a peak of 37 in 2005 and a nadir of 11 in 2003. There was no observed trend in frequency of THA among patients with Down syndrome (Fig. 1).

Compared to all controls, patients with Down syndrome had a younger mean age (42.22 vs 65.12

Discussion

In this large nationwide United States study, we found that the number of patients with Down syndrome undergoing THA has fluctuated over the past decade. Compared to controls, patients with Down syndrome had an increased risk of perioperative medical and surgical complications, particularly pneumonia, urinary tract infection, and wound hemorrhage. These patients also have longer lengths of stay, but no differences in hospital charges during their admission for THA.

Patients with Down syndrome

Acknowledgments

We thank Vidushan Nadarajah for his help with literature review. We also thank the HCUP Data Partners who contribute annually to the NIS. A full listing of participants can be found at <http://www.hcup-us.ahrq.gov/hcupdatapartners.jsp>.

References (39)

V.R. Collins et al.
Is Down syndrome a disappearing birth defect?
The Journal of Pediatrics
(2008)
M. Galli et al.
Joint stiffness and gait pattern evaluation in children with Down syndrome
Gait & Posture
(2008)
R.A. Deyo et al.
Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases
Journal of Clinical Epidemiology
(1992)
A.E. Gross et al.
Total hip arthroplasty in Down syndrome patients: an improvement in quality of life: replacement arthroplasty in Down syndrome (RADS) study group
The Journal of Arthroplasty
(2013)
M.S. Caird et al.
Down syndrome in children: the role of the orthopaedic surgeon
The Journal of the American Academy of Orthopaedic Surgeons
(2006)
G. Cocchi et al.
International trends of Down syndrome 1993–2004: Births in relation to maternal age and terminations of pregnancies
Birth Defects Research Part A: Clinical and Molecular Teratology
(2010)
Centers for Disease C
Prevention. Improved national prevalence estimates for 18 selected major birth defects--United States, 1999–2001
MMWR Morbidity and Mortality Weekly Report
(2006)
D.M. Mann
Alzheimer's disease and Down's syndrome
Histopathology
(1988)
V.M. Kriss
Down syndrome: imaging of multiorgan involvement
Clinical Pediatrics
(1999)
A.F. Morris et al.
Measurements of neuromuscular tone and strength in Down's syndrome children
Journal of Mental Deficiency Research
(1982)

K.H. Pitetti et al.

Isokinetic arm and leg strength of adults with Down syndrome: a comparative study

Archives of Physical Medicine and Rehabilitation

(1992)

S.J. Tredwell et al.

Instability of the upper cervical spine in Down syndrome

Journal of Pediatric Orthopaedics

(1990)

K. Uno et al.

Occipitoatlantal and occipitoaxial hypermobility in Down syndrome

Spine

(1996)

Y. Matsuda et al.

Atlanto-occipital hypermobility in subjects with Down's syndrome

Spine

(1995)

V.P. Prasher et al.

Podiatric disorders among children with Down syndrome and learning disability

Developmental Medicine and Child Neurology

(1995)

D. Concolino et al.

Early detection of podiatric anomalies in children with Down syndrome

Acta Paediatrica

(2006)

V. Cimolin et al.

Gait patterns in Prader-Willi and Down syndrome patients

Journal of Neuroengineering and Rehabilitation

(2010)

N. Angelopoulou et al.

Bone mineral density and muscle strength in young men with mental retardation (with and without Down syndrome)

Calcified Tissue International

(2000)

F. Baptista et al.

Bone mineral mass in males and females with and without Down syndrome

Osteoporosis International

(2005)

Cited by (19)

Management of recurrent hip dislocation in Down Syndrome using modified Ganz periacetabular osteotomy: Follow up after 5 years
2020, Annals of Medicine and Surgery
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.
Down Syndrome and Postoperative Complications in Children Undergoing Intestinal Operations
2019, Journal of Pediatric Surgery
Citation Excerpt :
Missing data variables in the original KID dataset were imputed using STATA multiple imputation algorithms. Variables chosen for inclusion in a multivariable regression model calculating risk factors for adverse outcomes were selected based on a priori assumptions, published reports on perioperative risk factors in patient with DS, and available KID data points [13,14]. They included: presence of DS, gender, age, race, insurance type, operation type, and presence of congestive heart failure.
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.
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.
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.
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 III, retrospective comparative study.
Total hip arthroplasty in patients with Trisomy 21: Systematic review and exploratory patient level analysis
2019, Surgeon
Citation Excerpt :
The full publications for the remaining 29 citations were obtained and of these 18 studies were further excluded: main reasons including the focus of the study was on hip dysplasia rather than hip arthroplasty, no outcomes, irrelevant data or the inability to link patients to outcomes within the study. Nine studies (published 11 times with minor changes) were used in the review.9–17 This process is illustrated in Fig. 4.
Trisomy 21 is the most common chromosomal disorders in humans; it is caused by an extra copy of chromosome number 21. This extra chromosomal material causes widespread abnormalities involving nearly every part of human body. Hip disorders are the second most serious musculoskeletal disorder in patients with T21 with a reported incidence between 2 and 28%. The outcomes of these hip disorders in patients with T21 are much less favorable than similar hip diagnoses in normal patients and a substantive number of these patients develop severe osteoarthritis that require total hip arthroplasty (THA). The outcome of THA in this cohort of patient is not well studied.
A modified Cochrane review methodology has been utilized in this review. An extended literature search was performed of the medical databases. A hierarchical approach was used to include relevant studies. Search, published papers and extracted data were checked by authors independently then jointly to ensure accuracy.
Nine studies (321 patients with Trisomy 21) who underwent total hip arthroplasty (THA) were included. The functional hip scores (Harris and WOMAC hip scores) improved substantively after hip arthroplasty. The 5-year cumulative revision rate was 7.5%; twice as high as age matched control. Medical and surgical complications were 3 times higher than matched controls.
Total hip arthroplasty can be offered to patients with T21 and severe arthritis although the increased revision and complication rates must be appreciated by patients and care givers.
Combining acetabular and femoral morphology improves our understanding of the down syndrome hip
2018, Clinical Biomechanics
Hip instability is frequent in patients with Down syndrome. Recent studies have suggested that skeletal hip alterations are responsible for this instability; however, there are currently no studies simultaneously assessing femoral and acetabular anatomy in subjects with Down syndrome in the standing position. The aim was to analyze the three-dimensional anatomy of the Down syndrome hip in standing position.
Down syndrome subjects were age and sex-matched to asymptomatic controls. All subjects underwent full body biplanar X-rays with three-dimensional reconstructions of their pelvises and lower limbs. Parameter means and distributions were compared between the two groups.
Forty-one Down syndrome and 41 control subjects were recruited. Acetabular abduction (mean = 52° [SD = 9°] vs. mean = 56° [SD = 8°]) and anteversion (mean = 14° [SD = 8°] vs. mean = 17.5° [SD = 5°]) as well as posterior acetabular sector angle (mean = 91° [SD = 7°] vs. mean = 94° [SD = 7°]) were significantly lower in Down syndrome subjects compared to controls (P < 0.01). Anterior acetabular sector angle (mean = 62° [SD = 10°] vs. mean = 59° [SD = 7°]; P < 0.01) was significantly higher in Down syndrome compared to controls. The distributions of acetabular anteversion (P = 0.002;V = 0.325), femoral anteversion (P = 0.004;V = 0.309) and the instability index (P < 0.001;V = 0.383) were significantly different between the two groups, with subjects with Down syndrome having both increased anteversion and retroversion for each of these parameters.
Subjects with Down syndrome were found to have a significantly altered and more heterogeneous anatomy of their proximal hips compared to controls. This heterogeneity suggests that treatment strategies of hip instability in Down syndrome should be subject-specific and should rely on the understanding of the underlying three-dimensional anatomy of each patient.
Increased complications in pediatric surgery are associated with comorbidities and not with Down syndrome itself
2018, Journal of Surgical Research
Down syndrome (DS) is a genetic condition associated with multiple comorbidities. While physicians may perceive that DS patients have more postoperative complications, the literature remains unclear. This study compared postoperative complications for children with and without DS who underwent abdominal and thoracic procedures.
The National Surgical Quality Improvement Program Pediatric was queried for patients aged <18 years, who underwent abdominal and noncardiac thoracic operations (by Current Procedural Terminology codes) from 2012 to 2015. The analysis compared patients based on the presence or absence of DS. The primary outcome was a composite of all postoperative complications as defined by the National Surgical Quality Improvement Program Pediatric. The analysis utilized chi-square, Student's t-test, and univariate and multiple logistic regression.
There were 91,478 patients included, of which 1476 (1.6%) had a diagnosis of DS. Patients with DS had higher rates of preoperative nutritional support (38.8% versus 15.0%), developmental delay (61.9% versus 10.4%), and cardiac risk factors (76.5% versus 13.8%). The overall rate of postoperative complications was 11.1%, with a greater proportion in DS patients (16.2% versus 10.8%, P < 0.001). On univariate analysis, DS was associated with increased odds of postoperative complications (odds ratio 1.6 95% confidence interval 1.4-1.9) compared with the non-DS group; however, DS was not a risk factor after adjusting for other covariates (adjusted odds ratio 0.86 95% confidence interval 0.7-1.1).
A higher proportion of postoperative complications were observed in patients with DS. However, after adjusting for other risk factors, DS was not an independent risk factor. The increased rate of complications is likely related to the presence of multiple comorbidities in DS.
Perioperative Periprosthetic Fractures Associated With Primary Total Hip Arthroplasty
2017, Journal of Arthroplasty
Citation Excerpt :
However, Thien et al [13] and SooHoo et al [30] reported low PPF incidence of 0.07% and 0.01% in their respective studies, which is similar to our finding. One explanation of our results may be secondary to coder's unfamiliarity with the ICD-9-CM code for PPF which was newly introduced in 2005, and PPFs may have been underreported during the coding process [35-37]. Our finding reaffirms that female gender is a risk factor for PPF, and this may be due to its increased association with osteoporosis and remaining structural bone, which is consistent with previously published studies [10,15,18-20,25].
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.
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.
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.
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.

View all citing articles on Scopus

: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.09.031.

: Ethical Review: A copy of the letter from our institution’s ethical review board regarding the exempt status of this project has been attached.

: Authorship: KI, MRB, AVM and MAM designed the study. MRB, DCP and KI gathered the data. MRB, DCP and BHK analyzed the data. MRB, BHK, DCP, KI, AVM and MAM wrote the initial draft. MAM and AVM ensured the accuracy of the data and analysis.

View full text

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

Abstract

Background

Methods

Results

Conclusion

Section snippets

Study Population

Results

Discussion

Acknowledgments

The Journal of Pediatrics

Gait & Posture

Journal of Clinical Epidemiology

The Journal of Arthroplasty

Down syndrome in children: the role of the orthopaedic surgeon

The Journal of the American Academy of Orthopaedic Surgeons

International trends of Down syndrome 1993–2004: Births in relation to maternal age and terminations of pregnancies

Birth Defects Research Part A: Clinical and Molecular Teratology

Prevention. Improved national prevalence estimates for 18 selected major birth defects--United States, 1999–2001

MMWR Morbidity and Mortality Weekly Report

Alzheimer's disease and Down's syndrome

Histopathology

Down syndrome: imaging of multiorgan involvement

Clinical Pediatrics

Measurements of neuromuscular tone and strength in Down's syndrome children

Journal of Mental Deficiency Research

Isokinetic arm and leg strength of adults with Down syndrome: a comparative study

Archives of Physical Medicine and Rehabilitation

Instability of the upper cervical spine in Down syndrome

Journal of Pediatric Orthopaedics

Occipitoatlantal and occipitoaxial hypermobility in Down syndrome

Spine

Atlanto-occipital hypermobility in subjects with Down's syndrome

Spine

Podiatric disorders among children with Down syndrome and learning disability

Developmental Medicine and Child Neurology

Early detection of podiatric anomalies in children with Down syndrome

Acta Paediatrica

Gait patterns in Prader-Willi and Down syndrome patients

Journal of Neuroengineering and Rehabilitation

Bone mineral density and muscle strength in young men with mental retardation (with and without Down syndrome)

Calcified Tissue International

Bone mineral mass in males and females with and without Down syndrome

Osteoporosis International