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Hasan M, Muhammad H, Cein CR, Ahmad H, Baskara AANN. Orthopedic Surgical Management of Complicated Congenital Popliteal Pterygium Syndrome: A Case Report. Orthop Res Rev 2023; 15:47-57. [PMID: 37008989 PMCID: PMC10051030 DOI: 10.2147/orr.s392024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 03/09/2023] [Indexed: 04/04/2023] Open
Abstract
Introduction Popliteal pterygium syndrome (PPS) is a rare autosomal-dominant condition that causes fixed flexion deformity of the knee. The popliteal webbing and shortening of the surrounding soft tissue could limit the functionality of the affected limb unless it is surgically corrected. We reported a case of PPS in a pediatric patient encountered in our hospital. Case A 10-month-old boy came with a congenital abnormally flexed left knee with bilateral undescended testis and syndactyly of the left foot. The left popliteal pterygium extending from the buttock to the calcaneus was observed, with an associated fixed flexion contracture of the knee and equine position of the ankle. Normal vascular anatomy was seen in the angiographic CT scan; therefore, multiple Z-plasty and fibrotic band excision were performed. The sciatic trunk was exposed on the popliteal level, and the fascicular segment was excised from the distal stump and sutured to the proximal stump under the microscope to extend the sciatic nerve for approximately 7 cm. No postoperative complications were reported. Multiple tendons and soft tissue reconstruction were performed when the patient was 2-year-old to correct the adductus and equine deformity of the left foot. Discussion Surgical correction for popliteal pterygium demands staged techniques to deal with the shortened structure. In our case, multiple Z-plasty were performed, and the fibrotic band was excised until its base with meticulous consideration of the underlying neurovascular bundle. Fascicular shifting technique for sciatic nerve lengthening can be considered in unilateral popliteal pterygium with difficulty extending the knee due to shortened sciatic nerve. The unfavorable outcome of nerve conduction disturbance resulting from the procedure may be multifactorial. Still, the existing foot deformity, including a certain degree of pes equinovarus could be treated by multiple soft tissue reconstructions and adequate rehabilitation to achieve the desired outcome. Conclusion Multiple soft tissue procedures resulted in acceptable functional outcomes. However, the nerve grafting procedure is still a challenging task. Further study is required to explore the technique in optimizing the nerve grafting procedure for popliteal pterygium.
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Affiliation(s)
- Meirizal Hasan
- Department of Orthopedic and Traumatology, Sardjito General Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Hilmi Muhammad
- Division of Pediatric Orthopedic, Department of Orthopedic and Traumatology, Sardjito General Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Correspondence: Hilmi Muhammad, Department of Orthopedics and Traumatology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Jl. Kesehatan No. 1, Yogyakarta, 55281, Indonesia, Email
| | - C Rayhan Cein
- Department of Orthopedic and Traumatology, Sardjito General Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Husein Ahmad
- Department of Orthopedic and Traumatology, Sardjito General Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Anak Agung Ngurah Nata Baskara
- Department of Orthopedic and Traumatology, Sardjito General Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Carrera-García L, Natera-de Benito D, Dieterich K, de la Banda MGG, Felter A, Inarejos E, Codina A, Jou C, Roldan M, Palau F, Hoenicka J, Pijuan J, Ortez C, Expósito-Escudero J, Durand C, Nugues F, Jimenez-Mallebrera C, Colomer J, Carlier RY, Lochmüller H, Quijano-Roy S, Nascimento A. CHRNG-related nonlethal multiple pterygium syndrome: Muscle imaging pattern and clinical, histopathological, and molecular genetic findings. Am J Med Genet A 2019; 179:915-926. [PMID: 30868735 DOI: 10.1002/ajmg.a.61122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/05/2019] [Accepted: 02/06/2019] [Indexed: 12/15/2022]
Abstract
Mutations in the CHRNG gene cause autosomal recessive multiple pterygium syndrome (MPS). Herein we present a long-term follow-up of seven patients with CHRNG-related nonlethal MPS and we compare them with the 57 previously published patients. The objective is defining not only the clinical, histopathological, and molecular genetic characteristics, but also the type and degree of muscle involvement on whole-body magnetic resonance imaging (WBMRI). CHRNG mutations lead to a distinctive phenotype characterized by multiple congenital contractures, pterygium, and facial dysmorphism, with a stable clinical course over the years. Postnatal abnormalities at the neuromuscular junction were observed in the muscle biopsy of these patients. WBMRI showed distinctive features different from other arthrogryposis multiple congenita. A marked muscle bulk reduction is the predominant finding, mostly affecting the spinal erector muscles and gluteus maximus. Fatty infiltration was only observed in deep paravertebral muscles and distal lower limbs. Mutations in CHRNG are mainly located at the extracellular domain of the protein. Our study contributes to further define the phenotypic spectrum of CHRNG-related nonlethal MPS, including muscle imaging features, which may be useful in distinguishing it from other diffuse arthrogryposis entities.
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Affiliation(s)
- Laura Carrera-García
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
| | - Daniel Natera-de Benito
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
| | - Klaus Dieterich
- Département de Génétique et Procréation, CHU de Grenoble Alpes, Grenoble Cedex 9, France
| | - Marta G G de la Banda
- Neuromuscular Unit, Department of Pediatric Neurology, Intensive Care and Rehabilitation, Raymond Poincaré University Hospital (AP-HP; UVSQ Paris Saclay), Garches, France
| | - Adrien Felter
- Department of Medical Radiology, Raymond Poincaré University Hospital (AP-HP; UVSQ Paris Saclay), Garches, France
| | - Emili Inarejos
- Department of Radiology, Hospital Universitari Sant Joan de Deu, Barcelona, Spain
| | - Anna Codina
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
| | - Cristina Jou
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain.,Department of Pathology, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Monica Roldan
- Confocal Microscopy Unit, Department of Pathology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Francesc Palau
- Department of Genetic and Molecular Medicine, Hospital Sant Joan de Déu, Barcelona, Spain.,Laboratory of Neurogenetics and Molecular Medicine, Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Barcelona, Spain.,Division of Pediatrics, University of Barcelona School of Medicine, Barcelona, Spain
| | - Janet Hoenicka
- Laboratory of Neurogenetics and Molecular Medicine, Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Centro de Investigación Biomédica en Salud Mental (CIBERSAM), Barcelona, Spain
| | - Jordi Pijuan
- Laboratory of Neurogenetics and Molecular Medicine, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Carlos Ortez
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
| | - Jessica Expósito-Escudero
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
| | - Chantal Durand
- Department of Radiology, CHU de Grenoble Alpes, Grenoble, France
| | | | - Cecilia Jimenez-Mallebrera
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
| | - Jaume Colomer
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
| | - Robert Y Carlier
- Department of Medical Radiology, Raymond Poincaré University Hospital (AP-HP; UVSQ Paris Saclay), Garches, France
| | - Hanns Lochmüller
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany.,Centro Nacional de Análisis Genómico (CNAG-CRG), Center for Genomic Regulation, Barcelona Institute of Science and Technology (BIST), Barcelona, Spain.,Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Canada and Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Susana Quijano-Roy
- Neuromuscular Unit, Department of Pediatric Neurology, Intensive Care and Rehabilitation, Raymond Poincaré University Hospital (AP-HP; UVSQ Paris Saclay), Garches, France
| | - Andres Nascimento
- Neuromuscular Unit, Neuropaediatrics Department, Institut de Recerca Hospital Universitari Sant Joan de Deu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
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Marques FBC, de Morais LS, Squeff LR, de Souza MMG, Bolognese AM. Escobar Syndrome-An Multidisciplinary Approach for an Excellent Outcome With 3 Years of Follow-Up. Cleft Palate Craniofac J 2019; 56:970-977. [PMID: 30654650 DOI: 10.1177/1055665618823416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This case report intends to provide the facial characteristics of Escobar syndrome and to describe the orthodontic treatment of a 12-year-old female patient diagnosed with it. Escobar syndrome, a variant of the multiple pterygium syndrome, is a rare disorder with many systemic, facial, and oral manifestations.The patient presented with mixed dentition, severe dolichofacial pattern, increased lower facial height, convex profile, severe anterior open bite, maxillary hypoplasia, and mandibular retrognatism. The multidisciplinary approach included soft cleft palate repair, orthodontic treatment, orthognathic surgery, restorative cosmetic dentistry, speech therapy, and physiotherapy. Despite the limitations imposed by the syndrome, this report illustrates how the multidisciplinary treatment approach aided in the correction of occlusal function and facial esthetics and improvement in the quality of life of the patient with Escobar syndrome.
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Affiliation(s)
- Fernanda Blaudt C Marques
- 1 Department of Pedodontics and Orthodontics, Dental School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Liliane Siqueira de Morais
- 2 Department of Pediatric Dentistry and Orthodontics, Dental School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luciana Rougemont Squeff
- 2 Department of Pediatric Dentistry and Orthodontics, Dental School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Margareth Maria Gomes de Souza
- 2 Department of Pediatric Dentistry and Orthodontics, Dental School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Maria Bolognese
- 2 Department of Pediatric Dentistry and Orthodontics, Dental School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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