Monitoring and Management of Fibrodysplasia Ossificans Progressiva: Current Perspectives

Ilizarov technique for treating elbow stiffness caused by myositis ossificans: A case report

BACKGROUND

Myositis ossificans (MO) is a rare disease involving the formation of bone outside the musculoskeletal system. While surgical intervention is the main treatment approach, preventing recurrence and standardized rehabilitation are also crucial. Here, we present a surgical strategy to prevent the recurrence of MO.

CASE SUMMARY

A 28-year-old female patient was admitted for the first time for a comminuted fracture of the left olecranon. However, incorrect postoperative rehabilitation resulted in the development of elbow joint stiffness with ectopic ossification, causing a loss of normal range of motion. The patient was diagnosed with MO based on physical examination, X-ray findings, and clinical presentation. We devised a surgical strategy to remove MO, followed by fixation with an Ilizarov frame, and implemented a scientifically reasonable rehabilitation plan. The surgery lasted for 3 h with an estimated blood loss of 45 mL. A drainage tube was placed after surgery, and fluid was aspirated through ultrasound-guided puncture. The patient experienced a significant reduction in joint stiffness after surgery. In the final follow-up at 9 mouths, there was evident improvement in the range of motion of the elbow joint, and no other symptoms were reported.

CONCLUSION

The Ilizarov frame is an advantageous surgical technique for facilitating rehabilitation after MO removal. It offers benefits such as passive recovery, individualized treatment, and prompt recovery.

Entheseal surface (Sharpey's fiber insertion) alterations identify past trauma; bone base robusticity, level of routine activity

Sharpey's fiber alterations, referred to as entheseal reaction or enthesopathy, have long been considered an indicator of daily activities. Such semantic transformation seems to conflate processes which alter the characteristics of tendonous and ligamentous attachments to bone with the rugosity and extent of their base/footprint. Rather than reflecting normal activities, it is suggested that surface reactions are actually the response to the application of sudden or unconditioned repetitive stresses-analogous to stress fractures. Thus, they are distinct from enlargement of the base/footprint, the bone remodeling process responsible for the robusticity of the area to which the enthesis attaches, which is actually a measure of actual muscle activity. Surface reactions in attachment areas represent injury, be it mechanical stress fracture-equivalents or inflammation-derived. Bone base/footprint is the reaction of the enthesis to stresses of routine physical activities. The character of underlying bone supporting Sharpey's fibers may be augmented by applied stress, but there is neither a physiologic mechanism nor is there evidence for significant addition of Sharpey's fibers beyond ontogeny. Behavior is responsible for the physiologic response of robusticity; spiculation, pathology.

Fibrodysplasia Ossificans Progressiva Mimics Generalized Dystonia Disorder: A Case Report

Fibrodysplasia ossificans progressiva (FOP) is an autosomal dominant disorder characterized by congenital deformities of the big toes and the progressive formation of extra-skeletal bone within soft tissues. The underlying genetic cause of FOP is mostly due to gain-of-function mutations in the AVCR1/ALK2 genes. These mutations cause aberrant bone morphogenetic protein (BMP) signaling pathways and eventually result in cumulative musculoskeletal impairment. FOP has a prevalence of approximately one in every 2 million people worldwide, with nearly 90% of patients being misdiagnosed, possibly leading to an underestimation of its true prevalence. To the best of our knowledge, there are only three reported cases in Saudi Arabia. We report a case of a 21-year-old female patient, a product of a consanguineous marriage, referred to the neurology clinic for new-onset dysphagia and dysarthria in association with progressive painful muscle stiffness, which started at the age of four years. The diagnosis of generalized dystonia disorder was suspected, but eventually the whole exome sequencing showed a pathogenic missense mutation in the ACVR1 gene, confirming the diagnosis of FOP. FOP is a rare, debilitating disorder that can be difficult to diagnose and manage. Current research efforts are focused on early diagnosis and a high index of suspicion to help prevent unnecessary investigations and procedures, slow the progression of the disease, and promote patients' quality of life and long-term outcomes.

Context-dependent TGFβ family signalling in cell fate regulation

The transforming growth factor-β (TGFβ) family are a large group of evolutionarily conserved cytokines whose signalling modulates cell fate decision-making across varying cellular contexts at different stages of life. Here we discuss new findings in early embryos that reveal how, in contrast to our original understanding of morphogen interpretation, robust cell fate specification can originate from a noisy combination of signalling inputs and a broad range of signalling levels. We compare this evidence with novel findings on the roles of TGFβ family signalling in tissue maintenance and homeostasis during juvenile and adult life, spanning the skeletal, haemopoietic and immune systems. From these comparisons, it emerges that in contrast to robust developing systems, relatively small perturbations in TGFβ family signalling have detrimental effects at later stages in life, leading to aberrant cell fate specification and disease, for example in cancer or congenital disorders. Finally, we highlight novel strategies to target and amend dysfunction in signalling and discuss how gleaning knowledge from different fields of biology can help in the development of therapeutics for aberrant TGFβ family signalling in disease.

Direct BMP signaling to chordoblasts is required for the initiation of segmented notochord sheath mineralization in zebrafish vertebral column development

The vertebral column, with the centra as its iteratively arranged building blocks, represents the anatomical key feature of the vertebrate phylum. In contrast to amniotes, where vertebrae are formed from chondrocytes and osteoblasts deriving from the segmentally organized neural crest or paraxial sclerotome, teleost vertebral column development is initiated by chordoblasts of the primarily unsegmented axial notochord, while sclerotomal cells only contribute to later steps of vertebrae formation. Yet, for both mammalian and teleostean model systems, unrestricted signaling by Bone Morphogenetic Proteins (BMPs) or retinoic acid (RA) has been reported to cause fusions of vertebral elements, while the interplay of the two signaling processes and their exact cellular targets remain largely unknown. Here, we address this interplay in zebrafish, identifying BMPs as potent and indispensable factors that, as formerly shown for RA, directly signal to notochord epithelial cells/chordoblasts to promote entpd5a expression and thereby metameric notochord sheath mineralization. In contrast to RA, however, which promotes sheath mineralization at the expense of further collagen secretion and sheath formation, BMP defines an earlier transitory stage of chordoblasts, characterized by sustained matrix production/col2a1 expression and concomitant matrix mineralization/entpd5a expression. BMP-RA epistasis analyses further indicate that RA can only affect chordoblasts and their further progression to merely mineralizing cells after they have received BMP signals to enter the transitory col2a1/entpd5a double-positive stage. This way, both signals ensure consecutively for proper mineralization of the notochord sheath within segmented sections along its anteroposterior axis. Our work sheds further light onto the molecular mechanisms that orchestrate early steps of vertebral column segmentation in teleosts. Similarities and differences to BMP's working mechanisms during mammalian vertebral column formation and the pathomechanisms underlying human bone diseases such as Fibrodysplasia Ossificans Progressiva (FOP) caused by constitutively active BMP signaling are discussed.

Knowledge and awareness about fibrodysplasia ossificans progressiva among dental students

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder which is autosomal dominant distinguished by congenital malformations of large toes and flare ups, etc. It is a disorder of connective tissue, with heterotopic ossifications seen with skeletal muscles, tendons, and cartilages and also called as Stone man disease, myositis ossificans, and Munchmeyer disease. The main objective of the study is to assess and create the awareness about FOP among dental students. An online-based survey was conducted among 103 dental students, undergraduates and postgraduates. About 20 questionnaires were prepared and circulated among the students through the "Google forms" across Chennai. A survey questionnaire asked about the knowledge of fibrodysplasia, its causes, treatment, and diagnosis was enquired. Thus, the data obtained were analyzed statistically using the SPSS software. In our study, about 64% were undergraduates and 35% of them were postgraduates. About 66% of the participants were aware of fibrodysplasia and 32% of them were not aware. Most of the undergraduate students were more aware of fibrodysplasia (40%) when compared to postgraduates (29%). However, this is statistically not significant. Fibrodysplasia ossificans reported to have a high incidence in 1 in 2 million people worldwide. Hence, an early diagnosis of this disorder can prevent further complications. Although the survey has provided significant knowledge about fibrodysplasia, awareness still has to be created among dental students.