The patient, a Medicare fee-for-service enrollee, has profound mental retardation due to Down syndrome. She was born following a full-term pregnancy with no complications. The diagnosis of Down syndrome was evident at the time of birth, and she was placed in an institution shortly thereafter. She has lived at the same center for the past 37 years. Although nonverbal, she can express her feelings and needs through gestures and facial expressions and using signs that she has learned through a speech-language program at the developmental center. The patient’s medical history is significant for Tourette’s disorder, hypothyroidism, degenerative cervical disc disease, mild spastic paraplegia, hearing impairment, allergic rhinitis and inactive hepati-tis-B surface antigen (HBsAg) carrier state. Other than the persistence of HBsAg, she has never demonstrated any increased rate of infection.
As she approached the age of 40, she developed a limp, and ambulation appeared to be painful. X-rays at that time were interpreted as showing chronic subluxation of the right hip with deformity of the right femoral head and moderate loss of joint space. The consulting orthopedic surgeon recommended antiinflammatory medication. Get smart and save money! Buy female pink viagra online
During the subsequent years, her arthritic symptoms progressed so that, by the age of 43, she was only able to walk for short distances using a walker, relying on a wheelchair for most locomotion. She was frequently in severe pain, especially in the morning when she could barely stand without support. At this time, x-rays demonstrated bilateral acetabular dysplasia with uncovering of both femoral heads. The right femoral head was eroded by 40%. Can’t afford your medication? Buy Levaquin 500 mg
Because of the progression of symptoms, repeat orthopedic consultation was sought. The first orthopedic surgeon consulted, in December 2001, considered a Girdlestone procedure (excision of the femoral head) to relieve pain, but this would not allow for the possibility of restored independent ambulation. As this recommendation was not considered to be appropriate for the well-being of the patient, other opinions were sought. Both a second (December 2001) and third (January 2002) consultant seemed reluctant to accept someone with Down syndrome as a candidate for total hip replacement. Finally, a fourth orthopedic surgeon, one with previous experience with patients with Down syndrome, accepted this woman as a candidate for total hip replacement. The procedure was performed shortly thereafter, in April 2002, without complications. Following the surgery, the patient was able to resume independent ambulation, relatively free from pain (Table 1).
Table 1. Timeline of events from diagnosis to surgery
|June 22, 2000||X-rays reveal bilateral acetabular dysplasia with uncovering of both femoral heads;|
|right femoral head eroded by 40%.|
|December 4, 2001||Orthopedic Consultation: surgeon suggests Girdlestone procedure.|
|December 10, 2001||Orthopedic Consultation: surgeon reluctant to accept patient as candidate for THR.|
|January 27, 2002||Orthopedic Consultation: surgeon reluctant to accept patient as candidate for THR.|
|April 2, 2002||Surgeon accepts patient and performs procedure without complications.|