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Smilde BJ, Botman E, de Ruiter RD, Smit JM, Teunissen BP, Lubbers WD, Schwarte LA, Schober P, Eekhoff EMW. Monitoring and Management of Fibrodysplasia Ossificans Progressiva: Current Perspectives. Orthop Res Rev 2022; 14:113-120. [PMID: 35480068 PMCID: PMC9035442 DOI: 10.2147/orr.s337491] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/02/2022] [Indexed: 11/23/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP), sometimes known as myositis ossificans progressiva, is an ultra-rare disease in which bone is formed in muscular tissue, tendons and ligaments. This is known as heterotopic ossification (HO). FOP is caused by a heterozygous mutation in the highly conserved ACVR1/ALK2 gene which affects about 1 in 1.5–2 million individuals. At birth, patients with the predominant R206H mutation only exhibit a bilateral hallux valgus. During childhood, heterotopic bone formation develops in a typical pattern, affecting the axial muscles first before appendicular body parts are involved. HO can start spontaneously but is often elicited by soft tissue trauma or medical procedures. After soft tissue injury, an inflammatory process called a flare-up can start, followed by the formation of HO. HO leads to a limited range of motion, culminating in complete ankylosis of nearly all joints. As a result of HO surrounding the thorax, patients often suffer from thoracic insufficiency syndrome (TIS). TIS is the most common cause of a limited life expectancy for FOP patients, with a median life expectancy of 56 years. Management is focused on preventing soft-tissue injury that can provoke flare-ups. This includes prevention of iatrogenic damage by biopsies, intramuscular injections and surgery. Anti-inflammatory medication is often started when a flare-up occurs but has a poor basis of evidence. Several forms of potential treatment for FOP are being researched in clinical trials. Progression of the disease is monitored using CT and 18F-NaF PET/CT combined with functional assessments. Patients are regularly evaluated for frequently occurring complications such as restrictive lung disease. Here, we review the current management, monitoring and treatment of FOP.
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Affiliation(s)
- Bernard J Smilde
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Internal Medicine Section Endocrinology, Amsterdam, the Netherlands
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Tissue Function and Regeneration, Amsterdam, the Netherlands
| | - Esmée Botman
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Internal Medicine Section Endocrinology, Amsterdam, the Netherlands
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Tissue Function and Regeneration, Amsterdam, the Netherlands
| | - Ruben D de Ruiter
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Internal Medicine Section Endocrinology, Amsterdam, the Netherlands
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Tissue Function and Regeneration, Amsterdam, the Netherlands
| | - Jan Maerten Smit
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Plastic, Reconstructive and Hand Surgery, Amsterdam, the Netherlands
| | - Berend P Teunissen
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, the Netherlands
| | - Wouter D Lubbers
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology, Amsterdam, the Netherlands
| | - Lothar A Schwarte
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology, Amsterdam, the Netherlands
| | - Patrick Schober
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology, Amsterdam, the Netherlands
| | - E Marelise W Eekhoff
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Internal Medicine Section Endocrinology, Amsterdam, the Netherlands
- Amsterdam UMC, Amsterdam Bone Center, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Tissue Function and Regeneration, Amsterdam, the Netherlands
- Correspondence: E Marelise W Eekhoff, Department of Internal Medicine section Endocrinology, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands, Tel +31 204440588, Email
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Kamal G, Gupta A, Batla S, Gupta N. Anaesthetic management of a child with stone man syndrome: Look before you leap! Indian J Anaesth 2017; 61:266-268. [PMID: 28405043 PMCID: PMC5372410 DOI: 10.4103/0019-5049.202168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Stone Man syndrome or fibrodysplasia ossificans progressiva (FOP) is an extremely rare (1 in 2 million) genetic disorder characterised by ectopic ossification of the skeletal and connective tissues leading to progressive fusion of axial and appendicular skeleton. Surgery and anaesthesia-induced trauma can lead to disease flare-up if due precautions are not taken and disable the patient further. However, rarity of the disease may lead to its common misdiagnosis and anaesthesiologist may be caught unaware. There is relative paucity of literature regarding anaesthetic management of children with FOP. Videolaryngoscopes (VLs) provide a non-line-of-sight view and require less anterior force to visualise the glottis, may provide an alternative to fibreoptic intubation for airway management in such cases. Use of VL has only been reported once in an adult with FOP for nasotracheal intubation. We describe the successful anaesthetic management of an 11-year-old child with FOP and anticipated difficult airway.
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Affiliation(s)
- Geeta Kamal
- Department of Anaesthesia, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Anju Gupta
- Department of Anaesthesia, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Sapna Batla
- Department of Anaesthesia, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco.Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
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Kilmartin E, Grunwald Z, Kaplan FS, Nussbaum BL. General anesthesia for dental procedures in patients with fibrodysplasia ossificans progressiva: a review of 42 cases in 30 patients. Anesth Analg 2014; 118:298-301. [PMID: 24361843 DOI: 10.1213/ane.0000000000000021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is a rare genetic condition characterized by progressive heterotopic ossification of skeletal muscle and soft connective tissues, leading to progressive ankylosis of all joints of the axial and appendicular skeleton. Cervical spine fusion, ankylosis of the temporomandibular joints, thoracic insufficiency syndrome, restrictive chest wall disease, and sensitivity to oral trauma complicate airway management and anesthesia and pose life-threatening risks. METHODS We conducted a retrospective chart review at 1 institution of patients with FOP who underwent general anesthesia (GA) for dental procedures. RESULTS Thirty patients underwent 42 general anesthetics. In 35 of 42 cases, GA was induced after the airway was secured by an awake fiberoptic intubation. In 4 of 42 cases, all of them pediatric, GA was first induced with maintenance of spontaneous ventilation, and the trachea was then intubated using a fiberoptic scope. In 2 cases, 1 adult and 1 pediatric, GA was first induced, and the trachea was then intubated using a GlideScope. In 1 case, the patient had a cuffed tracheostomy device in place that was accessed for GA. In 36 of 42 cases, the patients were discharged home on the same day as their dental procedure. No significant postoperative complications were encountered. CONCLUSIONS GA can be administered safely to patients with FOP for dental procedures with attention to perioperative and airway management using a multidisciplinary approach. An awake nasal fiberoptic intubation should be considered the first choice for airway management. Most patients can be discharged home on the same day as their dental procedure.
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Affiliation(s)
- Elaine Kilmartin
- From the Department of Anesthesiology, Jefferson Medical College; Departments of Orthopaedic Surgery and Medicine, Perelman School of Medicine; Department of Oral and Maxillofacial Surgery/Dentistry, Jefferson Medical College; and Department of Pediatric Dentistry, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Mortazavi H, Eshghpour M, Niknami M, Saeedi M. Stone man: a case report. IRANIAN JOURNAL OF RADIOLOGY 2012; 10:37-40. [PMID: 23599712 PMCID: PMC3618904 DOI: 10.5812/iranjradiol.10302] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 11/26/2012] [Accepted: 12/01/2012] [Indexed: 11/17/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare hereditary connective tissue disease characterized by the progressive ectopic ossification of ligaments, tendons, and facial and skeletal muscles throughout life. Symptoms begin in childhood as localized soft tissue swellings. Immobility and articular dysfunction appear with involvement of the spine and proximal extremities. The temporomandibular joint (TMJ) is a critical component involved in the maxillofacial region, resulting in severe limitation of masticatory function, although TMJ involvement is rare. The aim of this article is to present a 28-year-old man with dental problems and slowly progressive limitation of motion in the jaw, knees, shoulders and hips as well as neck distortion.
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Affiliation(s)
- Hamed Mortazavi
- Department of Oral Medicine, Faculty of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Eshghpour
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdi Niknami
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Mahdi Niknami, Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran. Tel.: +98-4113355965, E-mail:
| | - Morteza Saeedi
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Tumolo M, Moscatelli A, Silvestri G. Anaesthetic management of a child with fibrodysplasia ossificans progressiva. Br J Anaesth 2006; 97:701-3. [PMID: 17003066 DOI: 10.1093/bja/ael251] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Fibrodysplasia Ossificans Progressiva (FOP) is a rare inherited disease in which progressive ossification of striated muscles leads to severe disability and respiratory impairment early in life and there are associated characteristic congenital skeletal malformations. Although this condition may prove demanding for the anaesthetist, few reports are available regarding anaesthesia in paediatric patients. We review the clinical features of the disease relevant to anaesthesia and describe the perioperative care of an 18-month-old boy with FOP who underwent endoscopic third-ventriculostomy for hydrocephalus associated with a brainstem mass. We emphasize the importance of an appropriate anaesthetic management of these patients, as inadequate care may lead to exacerbation of the disease with permanent sequelae.
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Affiliation(s)
- M Tumolo
- Department of Anaesthesia and Intensive Care, Giannina Gaslini Children's Hospital Largo Gerolamo Gaslini 5, 16147 Genova Quarto, Italy.
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Eregie CO, Bekederemo V. A case report of rapidly progressive fibrodysplasia (myositis) ossificans progressiva. ANNALS OF TROPICAL PAEDIATRICS 1997; 17:289-92. [PMID: 9425386 DOI: 10.1080/02724936.1997.11747900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We present the case of a 4-year-old boy who was the first in his family to be diagnosed as having fibrodysplasia ossificans progressiva, which was radiologically confirmed. The initial recurrence of the swellings, which were completely painless, is highlighted. The bilateral clinodactyly is also noted. It is suggested that when onset and confirmed diagnosis are in early childhood the disease is rapidly progressive.
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Affiliation(s)
- C O Eregie
- Institute of Child Health, University of Benin, Benin City, Nigeria
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