Re-alignment-procedures for skeletal dysplasia in three patients with genetically diverse syndromes

OBJECTIVE

Disruption to endochondral ossification leads to delayed and irregular bone formation and can result in a heterogeneous group of genetic disorders known as osteochondrodysplasias. These genetic disorders arise through disturbances in the complex processes of skeletal growth causing development of unsightly skeletal deformities. METHODS : Each syndrome was diagnosed on the basis of detailed clinical and radiographic assessment. Lower limb deformities were the prime presenting feature.

RESULTS

Here are presented three patients with diverse genetic syndromes, namely Wolcott-Rallison syndrome (WRS), Kniest dysplasia (KD) and Desbuquois dysplasia (DS). Genetic testing was performed in the patients with WRS and DS. The diagnosis of KD was made purely on a clinical and radiographic basis. Variable orthopaedic interventions to realign these patients' lower limbs were implemented with the aim of improving their balance and gait.

CONCLUSIONS

The aim of this paper is twofold. The first part is to outline the importance of diagnosing the causes of various skeletal abnormalities in patients with osteochondrodysplasias by phenotypic and genotypic characterization. The second part is to demonstrate our techniques for surgical corrections in patients with joint laxity and malalignment and show how far techniques for growth modulation, re-alignment and ligament reconstruction have advanced.

Spinal and extraspinal deformities in a patient with dysspondyloenchondromatosis

Anisospondyly (irregularly shaped vertebral bodies) and enchondroma-like lesions in the metaphyseal and diaphyseal portions of the long tubular bones are the characteristic features in patients with dysspondyloenchondromatosis (DSC). Thoraco-lumbar scoliosis and windswept deformity of the lower limbs were the major abnormalities encountered in this patient. To the best of our knowledge this is the first case report delineating the spine pathology via reformatted CT scan and the correction of a windswept deformity by means of temporary hemiepiphysiodesis in a patient with (DSC).

Mutations at Ser331 in the HSN type I gene SPTLC1 are associated with a distinct syndromic phenotype

Mutations in the serine palmitoyltransferase subunit 1 (SPTLC1) gene are the most common cause of hereditary sensory neuropathy type 1 (HSN1). Here we report the clinical and molecular consequences of a particular mutation (p.S331Y) in SPTLC1 affecting a patient with severe, diffuse muscle wasting and hypotonia, prominent distal sensory disturbances, joint hypermobility, bilateral cataracts and considerable growth retardation. Normal plasma sphingolipids were unchanged but 1-deoxy-sphingolipids were significantly elevated. In contrast to other HSN patients reported so far, our findings strongly indicate that mutations at amino acid position Ser331 of the SPTLC1 gene lead to a distinct syndrome.

Treatment of varus deformities of the lower limbs in patients with achondroplasia and hypochondroplasia

Angular deformities of the lower limbs are a common clinical problem encountered in pediatric orthopaedic practices particularly in patients with osteochondrodysplasias. The varus deformity is more common than the valgus deformity in achondroplasia and hypochondroplasia patients because of the unusual growth of the fibulae than that of the tibiae. We retrospectively reviewed six patients (four patients with achondroplasia and two patients with hypochondroplsia) with relevant limb deformities due to the above-mentioned entities. All patients manifested significant varus deformity of the lower limbs. Detailed phenotypic characterization, radiologic and genetic testing was carried out as baseline diagnostic tool. We described the re-alignment procedures, which have been applied accordingly. Therefore, bilateral multi-level procedures, multi-apical planning and limb lengthening have been successfully applied. While recognition of the underlying syndromic association in patients who are manifesting angular deformities is the baseline for proper orthopaedic management, this paper demonstrates how to evaluate and treat these complex patients.

Musculo-skeletal abnormalities in patients with Marfan syndrome

Background

A leptosomic body type is tall and thin with long hands. Marfanoid features may be familial in nature or pathological, as occurs in congenital contractual arachnodactyly (Beal’s syndrome) and Shprintzen-Goldberg syndrome mimicking some of the changes of Marfan syndrome, although not accompanied by luxation of lens and dissecting aneurysm of aorta.

Methods

In this article we collected eight patients who were consistent with the diagnosis of Marfan syndrome via phenotypic and genotypic characterization.

Results

Our patients manifested a constellation of variable presentations of musculo-skeletal abnormalities ranging from developmental dysplasia of the hip, protrusio acetabuli, leg length inequality, patellar instability, scoliosis, to early onset osteoarthritis. Each abnormality has been treated accordingly.

Conclusion

This is the first paper which includes the diagnosis and the management of the associated musculo-skeletal abnormalities in patients with Marfan syndrome, stressing that patients with Marfan syndrome are exhibiting great variability in the natural history and the severity of musculo-skeletal abnormalities.

Radiographic and tomographic analysis in patients with stickler syndrome type I

OBJECTIVE

To further investigate the underlying pathology of axial and appendicular skeletal abnormalities such as painful spine stiffness, gait abnormalities, early onset osteoarthritis and patellar instability in patients with Stickler syndrome type I. Radiographic and tomographic analyses were organized.

METHODS

From a series of Stickler syndrome patients followed from early life to late childhood. Ten patients (6 boys and four girls of different ethnic origins were consistent with the diagnosis of Stickler syndrome type I ). Phenotypic characterization was the baseline tool applied for all patients and genotypic correlation was performed on four families

RESULTS

A constellation of axial abnormalities namely; anterolateral ossification of the anterior longitudinal spinal ligament with subsequent fusion of two cervical vertebrae, early onset Forestier disease (progressive spinal hyperostosis with subsequent vertebral fusion on top of bridging osteophytes and "Bamboo-like spine" resembling ankylosing spondylitis) and severe premature spine degeneration were evident. Appendicular abnormalities in connection with generalized epiphyseal dysplasia were the underlying aetiology in patients with Intoeing gait and femoral anteversion, early onset severe osteoarthritis of the weight bearing joint. Remarkable trochleo-patellar dysplasia secondary to severe osteoarthritis causing effectively the development of patellar instability was additional pathology. Mutation of COL2A1 has been confirmed as the causative gene for Stickler syndrome type I CONCLUSION: We concluded that conventional radiographs and the molecular determination of a COL2A1 in patients with (Stickler syndrome type I) are insufficient tools to explain the reasons behind the tremendous magnitude of axial and appendicular skeletal abnormalities. We were able to modify the criteria of the clinical phenotype as designated by Rose et al in accordance with the novel axial and appendicular criteria as emerged from within our current study.

Pathomorphologic findings of wrist arthroscopy in children and adolescents with chronic wrist pain

PURPOSE

The purposes of this diagnostic study were to show pathomorphologic findings of children and adolescents with persistent wrist pain and to compare these arthroscopic findings with preoperative magnetic resonance imaging (MRI).

METHODS

A total of 41 arthroscopies in 39 patients were retrospectively reviewed. The patients underwent diagnostic wrist arthroscopy because of persistent wrist pain after at least 3 months of unsuccessful conservative treatment. Of the patients, 22 (56.4%) reported an injury before the onset of pain. The mean age at arthroscopy was 15.3 years (range, 9.8 to 19.4 years), and the mean duration between the onset of symptoms and arthroscopic exploration was 19.9 months (range, 3.0 to 121.0 months).

RESULTS

Among all affected wrists, 33 (80.5%) showed a triangular fibrocartilage complex (TFCC) tear on arthroscopy, with 75.6% also showing other pathomorphologic findings. Retrospectively, the condition of the TFCC was correctly identified by MRI in only 17 wrists (41.5%). In contrast, 23 wrists were incorrectly classified as having "no tear" whereas arthroscopy later indeed showed a TFCC tear. Concerning the TFCC, MRI and arthroscopy showed a significant difference of outcome (P < .01), indicating low agreement (κ = 0.09) for the outcome of the 2 methods. A larger proportion of TFCC tears was found for patients with injuries (91.3%) as compared with the other patients (66.7%), although this was not significant on statistical analysis (P = .11). No significant difference in the time to surgery was found between patients with TFCC tears and those without TFCC tears classified by MRI (P = .76) and by arthroscopy (P = .99).

CONCLUSIONS

Wrist arthroscopy in children and adolescents with chronic wrist pain shows TFCC lesions in a high percentage. However, most of these lesions have not been correctly identified by MRI before arthroscopy. Thus diagnostic wrist arthroscopy may be recommended to rule out underlying pathologies and initiate further therapeutic steps.

LEVEL OF EVIDENCE

Level III, diagnostic study of nonconsecutive patients.

Radiographic early to midterm results of distraction osteogenesis in radial longitudinal deficiency

PURPOSE

To analyze early to midterm radiographic results after forearm lengthening in children with radial longitudinal deficiency.

METHODS

We conducted a retrospective chart review of patients with radial longitudinal deficiency undergoing distraction osteogenesis with an Ilizarov device. We retrospectively reviewed 8 lengthening procedures in 6 children with respect to distraction details and assessed anteroposterior and lateral radiographs of the hand and forearm of the preoperative and postoperative follow-up investigations.

RESULTS

The mean age at time of ulna lengthening was 9.9 years (range, 6.3-14.0 y). The mean follow-up period was 4.7 years (range, 1.0-8.5 y). Mean lengthening of the ulna was 7.0 cm (range, 3.5-8.7 cm), and the mean length gain of the ulna compared with its preoperative length was 75% (range, 42% to 103%). The mean ulna bowing was 25° preoperatively (range, 7° to 42°), 6° after forearm distraction (range, 0° to 14°), and 17° at latest follow-up (range, 0° to 45°). The mean hand-forearm angle was 25° of radial deviation preoperatively (range, 15° ulnar to 60° radial deviation), 11° of radial deviation after distraction (range, 0° to 41°), and 23° at latest follow-up (range, 0° to 45°). We encountered 2 major complications: 1 ulna fracture after removal of the Ilizarov device and 1 insufficient bone regenerate during lengthening.

CONCLUSIONS

We achieved both deformity correction and improvement of limb length after distraction osteogenesis with an Ilizarov device. However, some of the deformity-in particular, ulnar bowing and radial deviation of the hand-recurred at midterm follow-up.

Dysmorphic facies and diffuse posterior spine ankylosis in a patient with unusual form of spondyloenchondrodysplasia (Spranger type IV)

We describe a male patient, who was seen for the first time at the age of 8 years because of short trunk dwarfism. Spine radiographs showed platyspondyly with irregular areas of increased and decreased mineralization (irregular spotted appearance within lytic lesions located along the posterior vertebral bodies of the entire spine). Skeletal survey showed no enchondromatous lesions of the short/long tubular bones. At the age of 17, progressive spine stiffness associated with stooping posture developed. 3DCT scanning showed pathological transformation of the spinal enchondromas into generalized ossification and thickening of the posterior vertebral elements (vertebral laminae, supraspinal, and interspinal ligaments, respectively) causing effectively the development of a diffuse posterior spinal ankylosis. We report what might be a unique subtype of spondyloenchondrodysplasia (Spranger type IV).

Coxa vara in conjunction with metaphyseal dysostosis

We describe a rare case of unilateral development of coxa vara secondary to metaphyseal dysostosis encountered in a 6-year-old boy. Family history and radiographic documentation revealed a 31-year-old father with a typical clinical history. Proximal femoral intertrochanteric valgus osteotomy and a revision cup (Allofit) have been performed for the child and his father respectively.

Windswept deformity in a patient with Schwartz-Jampel syndrome

A 13-year-old boy presented with the overall phenotypic and genotypic characterisation of Schwarz-Jampel syndrome (SJS). Windswept deformity was a major orthopaedic abnormality. Prompt diagnostic measures were applied to this patient associated with several orthopaedic procedures to move closer to acceptable appearance and function.

Mid-diaphyseal Endosteal Thickening With Subsequent Medullary Narrowing in a Patient With Hallermann-Streiff Syndrome

We report on a 5-year-old girl who presented with the full clinical criteria of Hallermann-Streiff syndrome (HSS). Classically, overtubulation (thin and gracile) bones are the characteristic and constant features in HSS. Interestingly, our present patient manifested unusual mid-diaphyseal endosteal thickening with subsequent medullary narrowing (defective endosteal resorption). To the best of our knowledge no previous reports described such unusual feature in a patient with HSS.

Does open reduction of the developmental dislocated hip increase the risk of osteonecrosis?

BACKGROUND

Osteonecrosis (ON) of the femoral head is one of the main complications associated with treatment of developmental dysplasia of the hips (DDH). The reported rates of ON vary widely between 6% and 48%, suggesting varying factors in these studies influence the rate. Several studies suggest open reduction combined with femoral shortening provides protection against ON. However, it is unclear whether confounders such as failed Pavlik harness treatment, preliminary traction, closed versus open reduction, and redislocation influence the rate of ON.

QUESTIONS/PURPOSE

We therefore asked whether open reduction with concomitant osteotomies without femoral shortening, redislocation, and secondary surgical procedures for residual acetabular dysplasia influenced the rate of ON.

METHODS

We retrospectively reviewed 64 children (78 hips) hospitalized with developmental dislocation of the hip between January 1998 and February 2007. Patients younger than 12 months were treated with closed or open reduction. Open reduction combined with concomitant pelvic and femoral osteotomies was performed in patients past walking age. ON was diagnosed from radiographs obtained at last followup. We used logistic regression analysis to identify predictors for the development of ON. The minimum followup was 3.2 years (mean, 6.8 years; range, 3.2-11.5 years).

RESULTS

The overall rate of ON was 40%. Patients who underwent open reduction combined with concomitant osteotomies, experienced redislocation, or required secondary reconstructive procedures after initial reduction were at higher risk for having ON develop.

CONCLUSIONS

We advocate early reduction of the dislocated hip in the first year of life to avoid the need for concomitant osteotomies combined with open reduction.

[Congenital dislocation of the knee (CDK)]

Congenital dislocation of the knee (CDK) is a rare deformity presenting itself either as an isolated idiopathic entity or in the context of syndromes like arthrogryposis, myelodysplasia or Larsen syndrome. Patients can be diagnosed clinically after childbirth based on hyperextension of the knee. Confirmation of the diagnosis is done by X-ray or sonography. Many theories concerning the pathogenesis have been proposed since CDK was described; according to recent literature fibrosis and contracture of the m. quadriceps is the most likely reason. Therapy should start as soon as possible after birth, conservatively using redressing casts or operatively in syndromal conditions aiming for reduction. The prognosis concerning re-dislocation is benign; a good outcome was shown for idiopathic CDK.

Wrist arthroscopy in children and adolescents: a single surgeon experience of thirty-four cases

PURPOSE

The purpose of this study was to report our experience of wrist arthroscopy in children and adolescents with chronic wrist pain in a retrospective single surgeon series. Therefore, technical differences or obstacles compared to standard wrist arthroscopy in adults, and complications were highlighted.

METHODS

A retrospective data review of all patients undergoing wrist arthroscopy between 2002 and 2011 was performed. The basic inclusion criteria was chronic, therapy refractory wrist pain for more than three months in children and adolescents aged 18 years and younger. In total, 34 arthroscopies in 27 girls and six boys were reviewed. The mean age at time of arthroscopic exploration was 14.6 years (range, 9.8-17.9 years).

RESULTS

A total of 28 wrists showed a triangular fibrocartilage complex (TFCC) tear (82.4%). In 26 of 34 (76.5%) inspected wrist joints additional pathologies besides TFCC tears were documented. As a consequence, 14 arthroscopic TFCC resections, two arthroscopic TFCC repairs and seven open resection arthroplasties were performed. Other concomitant procedures (e.g., ulna shortening) were performed in 25 patients (26 wrists) because of predisposing malformations. No intraoperative or postoperative complications related to the arthroscopies were observed. No relevant technical differences to wrist arthroscopy in adults were experienced apart from cases of major anatomical malformations.

CONCLUSIONS

Wrist arthroscopy has been shown to be a safe procedure to detect and treat paediatric wrist disorders. Nevertheless, we believe that this procedure should only be carried out by well-trained, experienced hand surgeons.

The diagnosis and management of patients with idiopathic osteolysis

Idiopathic osteolysis or disappearing bone disease is a condition characterized by the spontaneous onset of rapid destruction and resorption of a single bone or multiple bones. Disappearing bone disorder is a disease of several diagnostic types. We are presenting three patients with osteolysis who have different underlying pathological features. Detailed phenotypic assessment, radiologic and CT scanning, and histological and genetic testing were the baseline diagnostic tools utilized for diagnosis of each osteolysis syndrome. The first patient was found to have Gorham-Stout syndrome (non-heritable). The complete destruction of pelvic bones associated with aggressive upward extension to adjacent bones (vertebral column and skull base) was notable and skeletal angiomatosis was detected. The second patient showed severe and aggressive non-hereditary multicentric osteolysis with bilateral destruction of the hip bones and the tarsal bones as well as a congenital unilateral solitary kidney and nephropathy. The third patient was phenotypically and genotypically compatible with Winchester syndrome resulting in multicentric osteolysis (autosomal recessive). Proven mutation of the (MMP2-Gen) was detected in this third patient that was associated with 3MCC deficiency (3-Methylcrontonyl CoA Carboxylase deficiency). The correct diagnoses in our 3 patients required the exclusion of malignant osteoclastic tumours, inflammatory disorders of bone, vascular disease, and neurogenic arthropathies using history, physical exam, and appropriate testing and imaging. This review demonstrates how to evaluate and treat these complex and difficult patients. Lastly, we described the various management procedures and treatments utilized for these patients.

Management of progressive genu varum in a patient with Dyggve-Melchior-Clausen syndrome

We describe the orthopaedic management of progressive genu varum in a child who manifested the full phenotypic characterization of Dyggve-Melchior-Clausen syndrome.

The aetiology behind torticollis and variable spine defects in patients with Müllerian duct/renal aplasia-cervicothoracic somite dysplasia syndrome: 3D CT scan analysis

The aim of the article is fourfold; firstly, to detect the aetiology of torticollis in patients with Müllerian duct/renal aplasia-cervicothoracic somite dysplasia syndrome; secondly, spine pathology in Müllerian duct/renal aplasia-cervicothoracic somite dysplasia syndrome varies considerably from one patient to another and there are remarkable differences in severity and localization; thirdly, mismanagement of congenital spine pathology is a frequent cause of morbid/fatal outcome; and fourthly, the application of prophylactic surgical treatment to balance the growth of the spine at an early stage is mandatory. Reformatted CT scans helped in exploring the craniocervical and the entire spine in these patients. The reason behind torticollis ranged between aplasia of the posterior arch of the atlas, assimilation of the atlas and extensive fusion of the lower cervical vertebrae (bilateral failure of segmentation) in four patients; in one patient, in addition to the hypoplastic posterior arch of the atlas, we observed ossification of the anterior and the posterior longitudinal spinal ligaments giving rise to a block vertebrae-like suggestive of early senile ankylosing vertebral hyperostosis (Forestier disease). Scoliosis at different spine levels was attributable to variable spine defects. Pelvic ultrasound showed the classical renal agenesis in four patients; whereas in one patient, the MRI showed pelvic cake kidney (renal fused ectopia) associated with ovarian, uterine and vaginal abnormalities. This is the first exploratory study on the craniocervical and the entire spine in a group of patients with MURCS association.

Facial dysmorphism associated with distinctive spine abnormalities in a girl and her mother: novel syndromic association

Facial dysmorphism associated with distinctive spine abnormalities has been encountered in a girl and her mother. A three-dimensional reformatted spinal computed tomography scan showed a combination of distinctive abnormalities such as failure of anterior formation of the vertebral bodies, malsegmentation, and Forestier disease. Mutations were not found in the GDF6 gene. We describe a hitherto undescribed autosomal dominant entity.

Maternal attitudes towards prenatal diagnosis of idiopathic clubfoot

OBJECTIVES

To examine maternal attitudes towards prenatal diagnosis of idiopathic clubfoot and to determine the incidence of false-negative ultrasound examinations.

METHODS

Surveys were mailed to mothers of patients with clubfoot born between 2000 and 2007 who were treated at either Sinai Hospital of Baltimore or Orthopaedic Hospital Speising. Exclusion criteria were underlying syndrome, genetic abnormality and multiple pregnancy. The survey asked the mother whether she had had any ultrasound examinations before her child was born, whether any of these had shown clubfoot, and whether she would have preferred to find out about her child's clubfoot before birth or after birth.

RESULTS

Mothers completed 220 (USA, 105 surveys; Austria, 115 surveys) of 401 mailed surveys. The prenatal detection rate was 60% in the USA compared with 25% in Austria (P = 0.001). Overall, 74% of mothers indicated a preference for prenatal diagnosis and 24% indicated a preference for postnatal diagnosis of the condition. Of 92 patients diagnosed prenatally, 96% of mothers indicated a preference for a prenatal diagnosis. Of 128 patients diagnosed postnatally, 58% of mothers indicated a preference for prenatal diagnosis, 38% for postnatal diagnosis and 4% were undecided.

CONCLUSIONS

The diagnosis of clubfoot is still often missed during routine ultrasound examination. When a prenatal diagnosis is made, most mothers appreciate having this information. However, when prenatal diagnosis is missed, a significant proportion of mothers seem to accept the false-negative diagnosis retrospectively.

Recurrence of axial malalignment after surgical correction in congenital femoral deficiency and fibular hemimelia

PURPOSE

Recurrent genu valgum deformity complicates treatment of congenital femoral deficiencies (CFD) and fibular hemimelia (FH). We analysed factors influencing recurrence.

METHODS

Patients who underwent limb lengthening or deformity correction for CFD and/or FH were reviewed. Radiographs after surgery and after a minimum of a further six months were analysed. Change in parameters of mechanical axis deviation per month (∆ MAD/month) and of angle per month were calculated. These parameters were tested against cofactors patient age, baseline MAD, type of CFD and FH, severity of ball-and-socket joints, ankle-joint stiffness, absence of cruciate ligaments and resection of the fibular anlage.

RESULTS

Recurrent valgus deformity was found in 23 of the 42 limbs included with a mean change of MAD of 23.4 mm (5-60 mm). There was no significant difference between patients with ∆ MAD/month <0.5 mm versus >1 mm regarding MAD in the first radiograph and patient age. CFD cases Pappas types VII and VIII showed a ∆ MAD/month of 1.6 mm, whereas milder cases of Pappas IX showed a ∆ MAD/month of 0.8. Mild FH (type Ia) showed a mean ∆ MAD/month of 0.39 mm, whereas mean ∆ MAD/month for FH type Ib/II was 0.72 mm. In FH type II cases, mean ∆ MAD/month was 0.79 mm after resection of the fibular anlage compared with 1.98 mm in those without resection.

CONCLUSIONS

Recurrence in FH and CFD was not dependent on patient age but partly on FH and CFD type. Limbs with more severe ball-and-socket knee joints showed more recurrence. Overcorrection depending deformity type should be performed.