THA may benefit patients with Down syndrome who have OA

Issue: January 2011

ORLANDO, Fla. — Osteoarthritis of the hip in patients with Down syndrome can be effectively treated with total hip arthroplasty, according to an orthopedic investigator.

“If you look at the literature, somewhere between 8% and 28% of individuals with Down syndrome develop osteoarthritis,” John J. Callaghan, MD, said at the 2010 Current Concepts in Joint Replacement Winter Meeting, here.

Factors impacting THA

According to Callaghan, an increased life expectancy of individuals with Down syndrome, along with improved health care and biomaterials, favor total hip arthroplasty (THA) in this patient population. However, general factors such as noncompliance, young age, cardiac abnormalities, cervical instability and proneness to infection may compromise THA in these patients. Hip-specific factors that can impact the procedure in this population include instability, dysplasia, deformed femoral necks, narrow femoral canals and technically challenging surgery.

John Callaghan, MD
John J. Callaghan

Callaghan stressed the importance of relying on the health care team in combating compromising factors such as noncompliance.

“Their caregivers are the most important members of your health care team and usually includes one or both parents or a special needs social worker,” he said. “As many of you know, these patients tend to have incredibly great parents with good support systems at home.”

Multicenter study

Callaghan and colleagues conducted a multicenter study that included 25 patients with Down syndrome who underwent THA. Two-thirds of the patients had dysplasia. The average follow-up was 105 months.

Cementless acetabular fixation with screws was used in all cases. All but one femoral component was cementless, and constrained liners were used in eight cases.

Five of the 25 hips required revision — one each for femoral loosening, periprosthetic fracture, acetabular component recurrent dislocation, acetabular component wear and metallosis, and infection.

“These people are living a lot longer, and we will see that they will have the same problems that other THA patients will have,” Callaghan said.

The average Harris Hip Score improved from 42 to 83 points, which is somewhat lower than what is expected in the general THA patient population, Callaghan said.

“Total hip replacement is a reliable treatment for patients with osteoarthritis and Down syndrome. Anesthetic challenges are the cardiac abnormalities and cervical instability,” he said.

Reference:
Callaghan JJ. The down syndrome patient: Not a downer. Paper #31. Presented at the 2010 Current Concepts in Joint Replacement Winter Meeting. December 8-11. Orlando.

John J. Callaghan, MD, can be reached at University of Iowa Hospital, Department of Orthopaedics, 200 Hawkins Drive, Iowa City, IA 52242; 319-356-3110; e-mail: john-callaghan@uiowa.edu. He has received royalties for intellectual property transfer from DePuy.

In our practice, these patients are often in an assisted-living environment, and they have a great support system. The faster you get them back to their support system, the better they do. In this particular patient population, I have just gone straight to a constrained liner scenario and that has worked the best for me.

— Bernard N. Stulberg, MD
Cleveland Clinic
Cleveland, Ohio
He has direct financial interests with Stryker and Exactech.

I think the important part of the message is the fact that these patients do have significant hip disease, and the hip disease is actually based on their Down syndrome. They have increased joint laxity, shallow acatabula, they are prone to Legg-Perthes disease and so forth.

I think years ago these patients were just neglected because there wasn't any good technology to address them. So now, because we have much better implants and — particularly — constrained cups, we can actually do hip replacements and get good results.

Of all of the patients with Down syndrome that I’ve operated on, which is nine, all were living with their families. They were not institutionalized, and their families were amazingly supportive. Their families would recognize that they were in a lot of pain, and they wanted to do something about it. And that was the big difference, rather than just say, “Well they can’t walk very far. They’ll be in a wheelchair,” and so forth. Their families were very proactive in seeing if anything was available.

The interesting thing was that their families always took them home immediately after the surgery, rather than going to rehab, and they always came to every single visit. I think without that support system, I’d be very reluctant to operate on these patients.

— Allan E. Gross, MD, FRCS(C)
University of Toronto
Ontario, Canada
He is a consultant for Zimmer, Inc.

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