The Ehlers-Danlos syndrome: recognition, characterization, and importance of a milder variant of the classic form. A preliminary study

Orthognathic Surgery in Ehlers-Danlos Syndrome: Review of the Literature and Case Report

EDS (Ehlers-Danlos Syndrome) is a heterogenous group of inheritable connective tissue disorders that commonly precludes patients from being elective surgical candidates. Patients with EDS are at a higher risk of increased bleeding, delayed wound healing, and temporomandibular joint pain refractory to treatment. Historically, patients with EDS and TMJ disorders are considered inappropriate surgical candidates due to a higher risk of delayed wound healing, increased risk for uncontrolled post-surgical bleeding, and unsubstantiated outcomes in regards to elective orthognathic surgery. A review of the literature demonstrates a paucity of data accounting the use of orthognathic surgery and maxillary-mandibular advancement in patients with EDS. The present study reports on the use of orthognathic double jaw surgery in a patient with a known diagnosis of hypermobile EDS, history of TMJ subluxation and pain. This case describes a 47-year-old woman with a history of hypermobile EDS who presented with Angle Class II malocclusion, Class II skeletal pattern, and clockwise rotation of the occlusal plane associated with pain at the bilateral TMJs. She underwent maxillary-mandibular advancement with counterclockwise rotation of the occlusal plane and genioplasty. The surgery was without complications, and at 22 months follow up, the patient healed uneventfully with improvement of pain and range of motion. This case report demonstrates that with diligent patient selection, orthognathic surgery in patients with EDS can be safe and effective and should not be an absolute contraindication.

Case report: Multiple gastrointestinal perforations in a rare musculocontractural Ehlers–Danlos syndrome with multiple organ dysfunction

A 36-year-old male with congenital equinovarus deformity was admitted to the hospital due to worsen deformity. He was known to have ear perforation in childhood. After hospitalization, he received equinovarus correction surgery, fourth toe osteotomy, and external fixation for right foot during the procedure. During his hospital stay, the patient has been treated with multiple gastrointestinal perorations, accompanied with multiple organ dysfunction and fragile soft tissues. During his in-hospital stay, multiple organ dysfunctions were observed, including the heart, kidney, liver, and intestines. In order to identify the mutation site, whole-exome sequencing (WES) was performed, and further verified with Sanger sequencing analysis in this patient. One-site mutation located at CHST14 [c.883_884del, p (Phe295Cysfs*5)] was identified in this patient, whereas this mutation was not observed in other 100 healthy controls. Also, this variant has not been reported in public databases (ExAC and gnomAD). Our report showed that unanticipated multiple tissue deformation observed the musculocontractural EDS patient was caused by mutation located at CHST14 [c.883_884del, p (Phe295Cysfs*5)] induced truncated CHST14 protein.

Joint hypermobility

Joint hypermobility is an area of neglect in rheumatology. That is not to say it is overlooked by rheumatologists. It is spotted when sought, but for many unfortunate patients, here the story ends. The act of recognition becomes the goal in itself rather than the medium through which effective therapy can be provided. This chapter serves to reinforce the clinical and epidemiological importance of a common disorder whose significance is under-appreciated and impact largely ignored. In contradistinction to our earlier chapter, published in 2000, which took for its remit the heritable disorders of connective tissue in general, the current one focuses on the commonly encountered (so-called benign) joint hypermobility syndrome, its recognition, epidemiology, clinical features and management according to the most recent literature.

Type III Ehlers-Danlos syndrome: correlations among clinical signs, ultrasound, and histologic findings in a study of 35 cases

BACKGROUND

Patients with type III Ehlers-Danlos syndrome show hypermobile joints, luxation, and minimal atrophic scars. The disease has an incidence of 9-16% and the molecular defect that underlies this subtype is unknown. In order to widen diagnostic investigations in type III Ehlers-Danlos syndrome, skin and articular areas were studied by ultrasound (US) test.

METHODS

Thirty-five patients, 20 women and 15 men, aged from 18 to 25 years, with type III Ehlers-Danlos syndrome were enrolled in this study. Patients showed hypermobile joints (35 cases), minimal atrophic wrinkled scars (35 cases), and a few ice-pick acne scars. Hypermobility of phalangeal joints was studied by means of the Beighton scoring system and by a US test (performed by Sonora Logic 400 MD unit with 10 MHz probe). The following US parameters were considered: the distance of the intra-articular space and the thicknesses of the extensor tendon and of the overhanging dermis and subcutis.

RESULT

US reports showed an increase in distance of the intra-articular space and a reduction in the thickness of the extensor tendon and of the dermis and subcutis covering it. The dermis showed high and homogeneous echogenicity with irregular hyperechogenic lines.

CONCLUSION

The Beighton scoring system, the US findings, and the aspect and diameter of the scars suggested that the disease can be divided into three different stages which allow the correlation, over progressive intervals of values, of the articular hypermobility and atrophic wrinkled scars. Our results showed that US test is able to confirm the clinical diagnosis and to evaluate the seriousness of hypermobile joints.

Spontaneous rupture of bladder diverticula in a girl with Ehlers-Danlos syndrome

A 5-year-old girl with Ehlers-Danlos syndrome presented with acute abdominal pain and anuria caused by a spontaneous perforation of bladder diverticula. Conservative treatment was successful.

Hereditary epidermolytic palmoplantar keratoderma (Vörner type) in a family with Ehlers-Danlos syndrome

We describe a kindred in whom epidermolytic palmoplantar keratoderma occurred in association with Ehlers-Danlos syndrome type III (benign hypermobility syndrome). This kindred consisted of 27 members of four generations, 14 of whom had palmoplantar keratoderma (PPK). Of those who had palmoplantar keratoderma, 6 had Ehlers-Danlos type III (EDS II). The proband presented with diffuse, symmetrical hyperkeratotic plaques that were yellow and sharply demarcated, covering the entire palms and soles, in addition to marked large and small joint flexibility and skin hyperextensibility. A biopsy specimen from the palm revealed features of epidermolytic hyperkeratosis with acanthosis. To our knowledge, this is the first report of PPK in a family with Ehlers-Danlos syndrome. Linkage analysis of these two clinical traits showed that the genes responsible for PPK and EDS III are not closely linked, and therefore are not immediately adjacent. However, linkage at greater genetic distances could not be excluded.

The Relationship between Knee Hyperextension and Articular Pathology in the Anterior Cruciate Ligament Deficient Knee

The purpose of this study was to determine whether there was a relationship between knee hyperextension and intra-articular pathology in 100 consecutive patients whose sole ligament injury was an arthroscopically confirmed anterior cruciate ligament (ACL) rupture. Hyperextension of both knees was measured using a supine heel-height measurement of high reliability. There was more articular damage to the total joint, lateral joint, and lateral meniscus in patients who hyperextended than in those who did not. There was more articular damage to the total joint and medial joint in patients who were chronically ACL deficient than in those who were acutely or subacutely ACL deficient. The results demonstrate that individuals with ACL injuries whose knees hyperextend 3 cm or more sustain significantly more joint damage at the time of injury than in those whose knees hyperextend less than 3 cm. This study further defines the role of knee hyperextension in ACL injuries and offers a useful and reliable means of measuring knee hyperextension.

Ehlers-Danlos syndrome type II: importance of recognition

We report a case of Ehlers-Danlos syndrome Type II presenting with subtle clinical features and discuss the importance of early recognition of this disorder. A 16 year old Caucasian schoolgirl presented with soft tissue swellings on her fingers. There was a history of poor wound healing and prematurity and a family history of miscarriages. Clinical examination revealed hypermobile joints, hyperelastic skin and a 'cigarette paper' scar at the site of a previous minor surgical excision. Management consisted of genetic counselling and advice concerning career choice, recreational activities, as well as future pregnancy and surgery. This subtype of Ehlers-Danlos syndrome is probably fairly common in the community. While it may present with subtle clinical features, recognition is important so that counselling can be offered at a young age in order to avoid the major consequences that may arise during pregnancy and surgery.

Complications of chemical peeling

In spite of controlled wounding with chemical peeling agents, complications may occur, resulting in patient and physician dissatisfaction. Precautions and factors causing these complications are examined, and relative contraindications to chemical peeling are discussed.