Diagnosing arthrogryposis multiplex congenita: a review

Early Diagnosis and Management of Arthrogryposis Multiplex Congenita in a Neonate: A Case Study

Arthrogryposis multiplex congenita (AMC) is a rare condition characterized by multiple joint contractures at birth, affecting two or more body areas. The clinical examination revealed physical abnormalities indicative of AMC, including joint contractures, clubfeet, and scoliosis. The diagnostic evaluation confirmed the clinical suspicion, and prompt management was initiated to address respiratory distress and potential sepsis. Early diagnosis and multidisciplinary care are essential for optimizing outcomes in neonates with AMC. We present the case of a one-day-old neonate who exhibited immediate respiratory distress upon birth and was born via a lower segment cesarean section (LSCS) to a 31-year-old mother. This case underscores the importance of recognizing prenatal ultrasound findings suggestive of AMC and implementing appropriate postnatal care strategies for affected neonates. Early diagnosis and multidisciplinary care are essential for optimizing outcomes in neonates with AMC.

Bilateral Sprengel Deformities, Mirror Movements Synkinesis, and Arthrogryposis Multiplex Congenita: A Novel Combination

Introduction

Bilateral Sprengel deformities, mirror movements synkinesis, and arthrogryposis are described in different combinations in various syndromes but never together.

Case Report

We present a 12-year-old girl who presented with bilateral shoulder deformities and difficulty in coordination while writing. On examination, she was noted to have bilateral Sprengel deformities with flexion contractures of upper-limb joints and mirror movements of both upper and lower-limb joints.

Conclusion

In the light of relevant literature, we may speculate that these three have a causal relation and even a genetic basis but further studies are needed to prove the same.

[Nerve Transfers in Children with Non-traumatic Amyoplasia]

BACKGROUND

The treatment of obstetric brachial plexus palsy through primary reconstruction and nerve transfers has been established in the past decades. In the case of non-traumatic diseases that lead to flaccid paralysis and the inability to move the extremities, such as transverse myelitis (TM) or arthrogryposis multiplex congenita (AMC), which can have a wide variety of causes, the focus has been on rehabilitative therapy so far, while surgical interventions have been used to a lesser extent, e. g., in the form of osteotomies or muscle transfers. Our aim is to establish nerve transfers as a surgical option to improve mobility in non-traumatic amyoplasia.

PATIENTS

This work presents the needs-adapted treatment of a total of 23 patients (aged 4 months to 64 months, 18 with AMC and 5 with TM) using nerve transfers on the upper extremity.

RESULTS

We were able to show that early nerve transfers in the upper extremity enabled the reanimation of muscles in both AMC and TM.

CONCLUSION

This work shows that the treatment of non-traumatic amyoplasia in children with selective nerve grafts is a successful method. Nerve transfers allow patients to gain or regain important functions for managing independent everyday life. The surgical methods have been established in the treatment of traumatic nerve injuries. They are well-known and can be carried out safely. We believe that this is an important treatment option for paediatric patients with paralysis associated with TM or AMC, which should also be known to the treating physicians.

The science of uncertainty guides fetal-neonatal neurology principles and practice: diagnostic-prognostic opportunities and challenges

Fetal-neonatal neurologists (FNNs) consider diagnostic, therapeutic, and prognostic decisions strengthened by interdisciplinary collaborations. Bio-social perspectives of the woman's health influence evaluations of maternal-placental-fetal (MPF) triad, neonate, and child. A dual cognitive process integrates "fast thinking-slow thinking" to reach shared decisions that minimize bias and maintain trust. Assessing the science of uncertainty with uncertainties in science improves diagnostic choices across the developmental-aging continuum. Three case vignettes highlight challenges that illustrate this approach. The first maternal-fetal dyad involved a woman who had been recommended to terminate her pregnancy based on an incorrect diagnosis of an encephalocele. A meningocele was subsequently identified when she sought a second opinion with normal outcome for her child. The second vignette involved two pregnancies during which fetal cardiac rhabdomyoma was identified, suggesting tuberous sclerosis complex (TSC). One woman sought an out-of-state termination without confirmation using fetal brain MRI or postmortem examination. The second woman requested pregnancy care with postnatal evaluations. Her adult child experiences challenges associated with TSC sequelae. The third vignette involved a prenatal diagnosis of an open neural tube defect with arthrogryposis multiplex congenita. The family requested prenatal surgical closure of the defect at another institution at their personal expense despite receiving a grave prognosis. The subsequent Management of Myelomeningocele Study (MOMS) would not have recommended this procedure. Their adult child requires medical care for global developmental delay, intractable epilepsy, and autism. These three evaluations involved uncertainties requiring shared clinical decisions among all stakeholders. Falsely negative or misleading positive interpretation of results reduced chances for optimal outcomes. FNN diagnostic skills require an understanding of dynamic gene-environment interactions affecting reproductive followed by pregnancy exposomes that influence the MPF triad health with fetal neuroplasticity consequences. Toxic stressor interplay can impair the neural exposome, expressed as anomalous and/or destructive fetal brain lesions. Functional improvements or permanent sequelae may be expressed across the lifespan. Equitable and compassionate healthcare for women and families require shared decisions that preserve pregnancy health, guided by person-specific racial-ethnic, religious, and bio-social perspectives. Applying developmental origins theory to neurologic principles and practice supports a brain health capital strategy for all persons across each generation.

Physical therapy of temporomandibular disorder in a child with arthrogryposis multiplex congenita: A case report and literature review

BACKGROUND

Arthrogryposis multiplex congenita (AMC) is a rare congenital disorder characterized by the occurrence of polyarticular contractures. Temporomandibular disorders (TMD) affect 25% of patients with arthrogryposis.

CLINICAL PRESENTATION

In this case report, the authors describe rehabilitation of a child between 8 and 24 months of age with AMC accompanied by Pierre-Robin Sequence. Physiotherapy directed to the TMJ included manual therapy, food intake training, and sensory training.

CONCLUSION

Increase in the mobility of the TMJ and improvement in food intake, swallowing, speech, and breathing were achieved. Further research is necessary for investigating the effects of the proposed protocol of physiotherapy on a larger number of children with AMC and co-occurrence of TMD.

Survival in Mudejar Spain in the Middle Ages (thirteenth-fourteenth centuries): Ancient Rare Diseases-an uncommon diagnosis in archaeological human remains

PURPOSE

The finding of severe skeletal alterations in ancient remains could give us useful information not only about the pathologies of the individual per se, as it could infer the state of health of a population.

METHODS

From the findings of the Mudéjar Cemetery of Uceda (Guadalajara, Central Spain) where a total of 116 burials with almost complete skeleton were recovered, an interesting individual is presented (palaeopathological perspective). The individual 114UC corresponds to a male of 20-25 years old and its age goes back to the thirteenth-fourteenth centuries.

RESULTS

The first inspection showed the presence of serious alterations especially in the lumbar spine and pelvic girdle. Seven vertebrae (from T11 to L5) showed an unusual posterior fusion only in the postzygapophyseal joints. The pelvis, after being accurately assembled and congruence verified by X-ray and CT scan, showed a noticeable asymmetry of both iliac wings together with a coxa magna protusa (Otto's pelvis), severe anteversion of both cup hips and osteochondritis of the right femoral head. The posterior-slope of both tibias reached about 10°.

CONCLUSIONS

The differential diagnoses lead us to think of Arthrogryposis Multiplex Congenita as the most probable diagnosis. We analyzed the same biomechanical aspects after taking into account some patterns that give us information about a possible mobility in the first stage of life. We discuss the very few other cases described both from artworks and in the palaeopathological record. To our knowledge, this case could be the oldest published case of AMC worldwide.

Long term ophthalmic complications of distal arthrogryposis type 5D

BACKGROUND

Distal Arthrogryposis type 5D (DA5D) is a rare genetic disease, expressed phenotypically by skeletal and ocular abnormalities.

MATERIALS AND METHODS

Two sisters, ages 42 and 46 years old, were ascertained, both diagnosed with arthrogryposis and unusual ophthalmic late expressions of the disease. They were examined and followed up by both ophthalmologists and medical geneticists. Molecular analysis was performed and population screening followed among healthy individuals of the same ethnic background who reside in the same village.

RESULTS

The two sisters expressed myogenic ptosis with poor levator palpebrae function, limitation in up gaze, lagophthalmos, refractive errors, corneal scarring and vascularization along with severe distal arthrogryposis. The newly reported features were: significant lower lid retraction, causing inferior scleral show. Sanger sequencing of the coding regions of ECEL1 gene revealed a homozygous deletion of 46 bps. The carrier frequency is 1:24 (4.2% carriers) in the probands' village.

CONCLUSIONS

We diagnosed two patients with DA5D carrying a homozygous pathogenic genetic variant previously reported only once. We report the late ophthalmologic manifestations of this rare disorder and emphasize the importance to recognize possible long-term ophthalmic complications. Measures are needed to diagnose this rare disorder at a younger age and to address ophthalmic and orthopedic complications that might be prevented. We revealed the causative genetic variant and a carrier frequency of 1:24 for DA5D, in the probands' village, thus enabling accurate genetic counselling and justifying genetic testing to the residents of this village as a diagnostic and preventive measure.

A novel mutation in NEB causing foetal nemaline myopathy with arthrogryposis during early gestation

Nemaline myopathies are a clinically and genetically heterogeneous group of congenital myopathies, mainly characterized by muscle weakness, hypotonia and respiratory insufficiency. Here, we report a male foetus of consanguineous parents with a severe congenital syndrome characterized by arthrogryposis detected at 13 weeks of gestation. We describe severe complex dysmorphic facial and musculoskeletal features by post mortem fetal examination confirming the prenatal diagnosis. Histomorphological and ultrastructural studies of skeletal muscle reveal mini-rods in myotubes caused by a novel homozygous splice-site mutation in NEB (NM_001164508, chr2:g.152,417,623C>A GRCh37.p11 | c.19,102-1G>T ENST00000397345.3). No rods were seen in the myocardium. We discuss the relevance of this mutation in the context of nemaline myopathies associated with early developmental musculoskeletal disorders.

Obstetric complications in pregnancies with life-limiting malformations

PURPOSE OF REVIEW

The implementation of palliative care at birth has led to a significant rise in the number of couples who choose to continue with pregnancies complicated by life-limiting malformations (LLMs). Prenatal counselling and appropriate antenatal/perinatal management in these cases are poorly studied and may pose significant challenges. The purpose of this review is to outline specific obstetric risks and to suggest management for mothers who choose to continue with pregnancies with the most common LLMs.

RECENT FINDINGS

In pregnancies complicated by LLMs where parents opt for expectant management, clinicians should respect parental wishes, whilst openly sharing potential serious maternal medical risks specific for the identified abnormalities. The focus of both antenatal and perinatal care should be maternal wellbeing rather than foetal survival. Follow-up ultrasound examinations and maternal surveillance should be aimed at achieving timely diagnosis and effective management of obstetric complications. A clear perinatal plan, agreed with the couples by a multi-disciplinary team including a foetal medicine specialist, a neonatologist and a geneticist, is crucial to reduce maternal morbidity.

SUMMARY

This review provides a useful framework for clinicians who face the challenges of counselling and managing cases complicated by LLMs where parents opt for pregnancy continuation.

Association Between Arthrogryposis and Mortality in Infants With Congenital Zika Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Intrauterine Zika virus infection is associated with neurological disorders and other problems, including such as impaired visual and hearing function and orthopedic abnormalities, including arthrogryposis. We systematically investigated the prevalence of arthrogryposis in infants with congenital Zika syndrome and the respective risk of mortality.

METHODS

We conducted a systematic review and meta-analysis of reports published in PubMed, Web of Science, SCOPUS, and World Health Organization Global Index Medicus databases, using the keywords Zika virus and arthrogryposis and related terms.

RESULTS

After screening titles and abstracts, a total of four studies were included. Arthrogryposis was not associated with increased risk for fetal demise (risk ratio, 3.33; 95% confidence interval, 0.73 to 15.26). However, arthrogryposis was associated with a 13-fold increased risk of mortality in neonates with congenital Zika syndrome (risk ratio, 13.11; 95% confidence interval, 3.74 to 45.92) than neonates with congenital Zika syndrome but without arthrogryposis.

CONCLUSIONS

Neonates with both congenital Zika syndrome and arthrogryposis had higher morbidity and mortality risks, making it necessary to implement protocols for the early identification of neuromuscular changes and appropriate management of patients.

A review of the orthopedic interventions and functional outcomes among a cohort of 114 children with arthrogryposis multiplex congenita

PURPOSE

Arthrogryposis multiplex congenita (AMC) refers to a large heterogeneous group of conditions involving joint contractures in two or more different areas of the body. Contractures can lead to decreased range of motion and strength, and affect ambulation and autonomy. The aim of this study was to describe the orthopedic interventions and functional outcomes of a large cohort of children with AMC followed in a pediatric orthopedic center.

METHODS

A retrospective chart review of all children diagnosed with AMC followed at Shriners Hospital for Children - Canada (SHC) between January 1979 and July 2016 was conducted. One hundred twenty patients were identified, of whom six were excluded due to misdiagnosis or insufficient chart information. One hundred fourteen were retained. Patient demographics, AMC classification, comorbidities, operative and non-operative treatments received as well as community ambulation status, level of autonomy in self-care and transfers at latest follow-up were recorded.

RESULTS

There were 54 males and 60 females with a mean age at last clinic visit of 10 years 3 months. Amyoplasia and distal arthrogryposis (DA) were equally represented in our sample, 47 (41.2%) and 49 (43.0%) participants respectively, with the category Other comprising the remaining 18 (15.8%) participants. Children with DA had less involvement of the proximal joints than those in the two other groups. Contractures and deformities of the foot and ankle were the most prevalent, affecting 91.5% with Amyoplasia, 85.7% with DA and 83.3% in the Other category. Contractures of the shoulder and elbow were more common among individuals with Amyoplasia and those categorized Other than those with DA. In terms of walking ability, 98% of participants with DA were independent ambulators. Walking ability varied among the Other participants. Similarly, most children with DA were independent in self-care and transfers at the most recent follow-up.

CONCLUSION

The relatively large sample size of this study allowed for a better insight into the challenges associated with AMC management. These findings demonstrated the need for genetic testing to provide accurate diagnosis and classification, along with the use of standardized outcome tools to measure effectiveness of interventions. As AMC is rare, multi-site prospective studies are needed to improve research opportunities, develop functional measures specific to AMC and disseminate findings on a wider scale.

Orthopedic findings in arthrogryposis and congenital Zika syndrome: A case series

BACKGROUND

Congenital arthrogryposis (CA) consists of congenital joint contractures that affect at least two joints in different parts of the body. Approximately, 80% of CA cases are neurogenic, with changes to the formation, structure or functioning of the central and/or peripheral nervous systems. Most abnormalities are triggered either by motoneurons decreased activation in the corticospinal tract or by direct motoneurons injury. There had been few reports in the literature correlating congenital infection in humans with arthrogryposis until 2015. CA has recently been described associated with congenital Zika syndrome (CZS).

METHODS

The objective of this study was to investigate and describe accurately the arthrogrypotic alterations in infants diagnosed with CZS and thus, suggest a possible pattern of orthopedic impairment. A total of 198 medical records of infants with CZS were evaluated. According to inclusion and exclusion criteria, 17 infants were included in the present study. Arthrogrypotic joints were orthopedically evaluated in four segments: right, left, upper, and lower limbs. All the four segments were assessed independently.

RESULTS

Flexed wrists were the most frequently observed manifestation, associated with ulnar deviation (35.29%). Deformities were also commonly found in the third and fourth fingers (64.70%). Hip dislocation was found in 58.82% of the patients and talipes equinovarus and equinovalgus ankles were found in 29.41 and 23.52%.

CONCLUSION

There was a particular pattern of joint impairment related to CZS and arthogrypotic alterations of infants evaluated in this study.

Development of self-feeding behavior in children with typical development and those with arm movement impairments

Self-feeding is a critical self-care skill that unites motor abilities (e.g., grasping and transporting utensils/food to the mouth) and cognitive abilities (e.g., using a spoon as a tool). This cross-sectional study assessed self-feeding behavior in a sample of 38 children with typical development (TD) and compared it between 18 of those children and 18 age- and sex-matched peers with arm movement impairments (MI). Children were assessed with a bowl of cereal and two spoons presented in four different orientations. Results suggested that children with MI were less successful than their TD peers in both motor aspects (e.g., grasp and transport of food and utensils) and cognitive aspects (correct grasp across spoon orientations) of self-feeding. Novel findings highlight: (a) interesting differences in visual attention between children with TD or MI; (b) the role of hand-preference in the correct grasping of the spoon(s) and effective self-feeding; (c) the positive relation between motor and cognitive aspects of self-feeding; and (d) that greater variability of self-feeding behavior relates to improved performance of cognitive aspects of the task. These results identify challenging components of self-feeding for children with MI that should be targeted by early interventions and assistive technologies aimed at increasing self-feeding independence.

Rare etiology of arthrogryposis multiplex congenita at term: congenital cytomegalovirus infection

Background

Arthrogryposis multiplex congenita is the presence of multiple congenital contractures of two or more body parts. Congenital cytomegalovirus (CMV) infection is a rare etiology of arthrogryposis.

Case presentation

We report a case of intrauterine fetal akinesia and arthrogryposis multiplex congenita delivered at term with subsequent neonatal demise. Placental pathology and autopsy revealed congenital CMV infection.

Conclusions

Evaluation for potential CMV infection is an important part of the arthrogryposis evaluation which is often missed due to lack of maternal infectious symptoms during pregnancy.

Fetal akinesia deformation sequence, arthrogryposis multiplex congenita, and bilateral clubfeet: Is motor assessment of additional value for in utero diagnosis? A 10-year cohort study

Objective

The diagnosis of fetal akinesia deformation sequence (FADS) is a challenge. Motor assessment is of additional value to advanced ultrasound examinations (AUE) for in utero FADS diagnosis before 24 weeks of gestation.

Methods

All consecutive fetuses with greater than or equal to two contractures on the 20 week structural anomaly scan (2007–2016) were included. Findings at AUE, including motor assessment were analysed and related to outcome.

Results

Sixty‐six fetuses fulfilled the inclusion criteria. On the basis of the first AUE, FADS was suspected in 13 of 66, arthrogryposis multiplex congenita (AMC) in 12 of 66, bilateral pes equinovares (BPEV) in 40 of 66, and Holt‐Oram syndrome in one of 66. On the basis of the first motor assessment, the suspected diagnosis changed in 19 of 66, in 13 of 66 worsening to FADS, six of 66 amelioration from FADS, and confirmed FADS in seven of 13. The result was 20 FADS, seven AMC, and 38 BPEV. Second AUE in 44 fetuses showed additional contractures in two of eight FADS, and one intrauterine fetal death (IUFD). The second motor assessment changed the diagnosis in three of 43, one worsening from BPEV into FADS, two ameliorations from FADS, and confirmed FADS in seven by deterioration of motility. The result was nine FADS, six AMC, and 29 BPEV.

Conclusion

The results suggest that motor assessment has additional value to distinguish between FADS, AMC, and BPEV.

Systematic motor assessment for differentiation, quality, and quantity of the movements has been performed in a high risk population for FADS.¹

This analysis revealed abnormal quality in all fetuses with deterioration in a 2‐week period, reduced differentiation in the majority and only half showed abnormal quantity.

This study evaluates whether motor assessment in addition to advanced ultrasound examination in case of multiple contractures, supports the timely diagnosis of FADS.

Short-term foetal immobility temporally and progressively affects chick spinal curvature and anatomy and rib development

Congenital spine deformities may be influenced by movements in utero, but the effects of foetal immobility on spine and rib development remain unclear. The purpose of the present study was to determine (1) critical time-periods when rigid paralysis caused the most severe disruption in spine and rib development and (2) how the effects of an early, short-term immobilisation were propagated to the different features of spine and rib development. Chick embryos were immobilised once per single embryonic day (E) between E3 and E6 and harvested at E9. To assess the ontogenetic effects following single-day immobilisation, other embryos were immobilised at E4 and harvested daily between E5 and E9. Spinal curvature, vertebral shape and segmentation and rib development were analysed by optical projection tomography and histology. The results demonstrated that periods critical for movement varied for different aspects of spine and rib development. Single-day immobilisation at E3 or E4 resulted in the most pronounced spinal curvature abnormalities, multiple wedged vertebrae and segmentation defects, while single-day immobilisation at E5 led to the most severe rib abnormalities. Assessment of ontogenetic effects following single-day immobilisation at E4 revealed that vertebral segmentation defects were subsequent to earlier vertebral body shape and spinal curvature abnormalities, while rib formation (although delayed) was independent from thoracic vertebral shape or curvature changes. A day-long immobilisation in chicks severely affected spine and rib development, highlighting the importance of abnormal foetal movements at specific time-points and motivating targeted prenatal monitoring for early diagnosis of congenital scoliosis.

Pena-Shokeir syndrome: current management strategies and palliative care

Pena-Shokeir syndrome (PSS) type 1, also known as fetal akinesia deformation sequence, is a rare genetic syndrome that almost always results in intrauterine or early neonatal death. It is characterized by markedly decreased fetal movements, intrauterine growth restriction, joint contractures, short umbilical cord, and features of pulmonary hypoplasia. Antenatal diagnosis can be difficult. Ultrasound features are varied and may overlap with those of Trisomy 18. The poor prognosis of PSS is due to pulmonary hypoplasia, which is an important feature that distinguishes PSS from arthrogryposis multiplex congenital without pulmonary hypoplasia, which has a better prognosis. If diagnosed in the antenatal period, a late termination of pregnancy can be considered following ethical discussion (if the law allows). In most cases, a diagnosis is only made in the neonatal period. Parents of a baby affected with PSS require detailed counseling that includes information on the imprecise recurrence risks and a plan for subsequent pregnancies.

Use Of Ankle Immobilization In Evaluating Treatments To Promote Longitudinal Muscle Growth In Mice

INTRODUCTION

Difficulty in modeling congenital contractures (deformities of muscle-tendon unit development that include shortened muscles and lengthened tendons) has limited research of new treatments.

METHODS

Early immobilization of the ankle in prepuberal mice was used to produce deformities similar to congenital contractures. Stretch treatment, electrostimulation, and local intramuscular injection of a follistatin analog (FST-288) were assessed as therapeutic interventions for these deformities.

RESULTS

Ankle immobilization at full plantarflexion and 90 ° created tendon lengthening and muscle shortening in the tibialis anterior and soleus. Stretch treatment produced minimal evidence for longitudinal muscle growth and electrostimulation provided no additional benefit. Stretch treatment with FST-288 produced greater longitudinal muscle growth and less tendon lengthening, constituting the best treatment response.

DISCUSSION

Ankle immobilization recapitulates key morphologic features of congenital contracture, and these features can be mitigated by a combination of stretch and pharmacological approaches that may be useful in patients. Muscle Nerve 58: 718-725, 2018.

Difficult airway management in children and young adults with arthrogryposis

Objective

To review current evidence and experience with anesthesia and airway management issues in children and young adults with arthrogryposis.

Data sources

Review of existing world literature and description of personal experience at a center for children's orthopedic surgery and rehabilitation over 2 decades.

Methods

Description of common problems and their solutions in this unusual and diverse group of patients.

Results

Arthrogryposis multiplex congenital includes more than 400 conditions that lead to congenital joint contractures affecting more than one body area. Among the many causes of arthrogryposis, 50%–65% fall into two large categories – amyoplasia and distal arthrogryposis. There is general agreement that best function in children with arthrogryposis is achieved through early mobilization of joint contractures. Children with arthrogryposis average >5 operative procedures during childhood. Anesthesia for these procedures may be complicated by limited jaw mobility and mouth opening, restricted lung development, positioning difficulties, difficult venous access and concerns about increased risk for malignant hyperthermia. 75% of arthrogryposis patients do not have a difficult airway. For those with a history of airway problems or those meeting criteria for a difficult airway, careful advanced planning helps to assure safe and successful surgery. We describe several specialized techniques for endotracheal intubation of children with arthrogryposis.

Conclusions

Children and young adults with arthrogryposis are a diverse group. Many pose unique challenges for airway and surgical management. Review of individual anesthesia records and careful advanced planning by a coordinated, experienced airway team can lead to best outcomes from arthrogryposis surgery.

Arthrogryposis in children: Etiological assessments and preparation of a protocol for etiological investigations

INTRODUCTION

Arthrogryposis is a descriptive term defining a sign. It describes a set of joint contractures, sometimes identifiable in utero, present from birth and nonprogressive. This term includes a heterogeneous group of diseases, of neurological, neuromuscular, genetic or mechanical origin. The common physiopathological mechanism is fetal immobility syndrome. Two types of classification have been developed: a clinical one (types I, II and III) and an etiological one. The main aim of this study was to define a standardized protocol for etiological investigation based on a descriptive analysis of the various etiologies identified in a population of children followed up for arthrogryposis. Its secondary aim was to assess first the comprehensiveness and relevance of the complementary assessment and second the way in which the classifications proposed by Professor Judith Goslin Hall are applied.

MATERIAL AND METHODS

Retrospective multicenter observational study. We enrolled pediatric patients with arthrogryposis being treated at a reference center for neuromuscular diseases, i.e., in three university hospital pediatric neurology units, between February 1997 and January 2017.

RESULTS

Forty-two patients (25 boys and 17 girls) were enrolled. According to the clinical classification (Hall et al.), this population consisted of eight cases of type 1 arthrogryposis (19.1%), 14 type II (33.3%) and 20 type III (47.6%). The main etiology was neurological (19.1%), predominantly involving problems with gyration of a polymicrogyria type. Myopathic origin accounted for 9.5% of the population, predominantly involving genotyped distal arthrogryposis (ECEL1 gene). Additional tests produced a diagnosis of 25% type I, 43% type II and 75% type III.

CONCLUSION

Arthrogryposis is a sign suggesting multiple etiologies. The main ones are neurological. Several genes have recently been identified, explaining the physiopathological mechanisms. The diagnostic process must be rigorous and coordinated within a multidisciplinary team, following a shared protocol for analysis.

Cervical Stenosis in Adult Arthrogryposis: A Case Report and Review of the Literature

Arthrogryposis multiplex congenita is a rare, nonprogressive congenital disorder that describes a constellation of conditions characterized by multiple joint contractures. Spinal pathology and deformity are common; however, the majority of the literature on arthrogryposis is focused on pediatric management. There exist very few reports on long-term outcomes and management of adults with arthrogryposis. We present a case of cervical spinal stenosis in an adult female with arthrogryposis that underwent posterior cervical decompression and fusion. A review of spine-related sequelae seen in adults with arthrogryposis and considerations for spinal surgery for these patients is discussed.

Prenatal Sonographic Detection of Multiple Congenital Anomalies: A Case of Severe Arthrogryposis Multiplex Congenita (AMC)

This case study describes an obstetrical patient who presented for a routine second-trimester morphology sonogram in which the fetus was found to have arthrogryposis multiplex congenita. Other abnormalities visualized included a single umbilical artery, hypoplastic nasal bone, polyhydramnios, and poorly visualized lateral ventricles. Amniocentesis demonstrated a normal microarray with a negative result for cytomegalovirus and toxoplasmosis. This case study highlights the utility of prenatal sonography to identify functional abnormalities of the fetal musculoskeletal system.

Artrogriposis múltiple congénita: espectro de deformidades en el miembro superior, a propósito de una serie de casos

Introducción. La artrogriposis múltiple comprende un grupo complejo de patologías que producen disminución de la movilidad articular. Su tratamiento está enfocado en mejorar la movilidad con rehabilitación y cirugía en algunos casos.Objetivo. Mostrar las deformidades por artrogriposis en el miembro superior, los tipos de tratamiento y sus resultados.Materiales y métodos. Se estudiaron 27 casos (19 operados) que fueron agrupados de acuerdo a compromiso distal en dedos o muñeca o proximal en codo y hombroResultados. El compromiso principal fue de muñecas y dedos, solo se presentaron dos casos con afectación única del codo. Las cirugías comprendieron z-plastias, liberación de placa palmar y fijación de articulaciones; en la muñeca se realizó liberación de partes blandas, fijación provisional y artrodesis. Se dio un caso de liberación del tríceps, otro de liberación de un pterigio y otro de transferencia muscular para flexión de codo.Conclusión. En miembros superiores hay disminución o ausencia de pliegues en zonas de flexión, rotación interna del hombro, limitación marcada de flexión de codo y de la muñeca en flexión y desviación cubital. En los dedos se encontró camptodactilia y aducción del pulgar. Las cirugías mejoraron la función para las actividades diarias. El tratamiento es individualizado y de acuerdo al grado de afectación.

Arthrogryposis multiplex congenita in utero: radiologic and pathologic findings

Arthrogryposis multiplex congenita (AMC) refers to the development of multiple joint contractures affecting two or more areas of the body prior to birth. It affects approximately 1 in 3000 individuals, mostly reported in individuals of Asian, African and European descent with equal incidence in males and females. Arthrogryposis is associated with over 400 medical conditions and 350 known genes with considerable variability in phenotypic expression. The primary underlying mechanism is decreased fetal movement during development. Prenatal imaging is crucial in early diagnosis by identifying fetal movement limitations and the presence of club foot or joint contractures. Postnatal autopsy confirms the diagnosis and extent of associated congenital anomalies and provides a valuable source of DNA material. Molecular methods are particularly useful in delineating novel gene mutations, locus heterogeneity and phenotype genotype correlation. Prenatal evaluation with early diagnosis via image scanning and further genetic surveillance give the opportunity for family counseling concerning future pregnancy management and expected neonatal morbidity and mortality.

Zika virus congenital syndrome: experimental models and clinical aspects

Viral infections have long been the cause of severe diseases to humans, increasing morbidity and mortality rates worldwide, either in rich or poor countries. Yellow fever virus, H1N1 virus, HIV, dengue virus, hepatitis B and C are well known threats to human health, being responsible for many million deaths annually, associated to a huge economic and social cost. In this context, a recently introduced flavivirus in South America, called Zika virus (ZIKV), led the WHO to declare in February 1st 2016 a warning on Public Health Emergency of International Concern (PHEIC). ZIKV is an arbovirus of the Flaviviridae family firstly isolated from sentinels Rhesus sp. monkeys at the Ziika forest in Uganda, Africa, in 1947. Lately, the virus has well adapted to the worldwide spread Aedes aegypti mosquito, the vector for DENV, CHIKV, YFV and many others. At first, it was not considered a threat to human health, but everything changed when a skyrocketing number of babies born with microcephaly and adults with Guillain-Barré syndrome were reported, mainly in northeastern Brazil. It is now well established that the virus is responsible for the so called congenital Zika syndrome (CZS), whose most dramatic features are microcephaly, arthrogryposis and ocular damage. Thus, in this review, we provide a brief discussion of these main clinical aspects of the CZS, correlating them with the experimental animal models described so far.

Spectrum of Spinal Cord, Spinal Root, and Brain MRI Abnormalities in Congenital Zika Syndrome with and without Arthrogryposis

BACKGROUND AND PURPOSE

Arthrogryposis is among the malformations of congenital Zika syndrome. Similar to the brain, there might exist a spectrum of spinal cord abnormalities. The purpose of this study was to explore and describe in detail the MR imaging features found in the spinal cords, nerve roots, and brains of children with congenital Zika syndrome with and without arthrogryposis.

MATERIALS AND METHODS

Twelve infants with congenital Zika syndrome (4 with arthrogryposis and 8 without) who had undergone brain and spinal cord MR imaging were retrospectively selected. Qualitative and quantitative analyses were performed and compared between groups.

RESULTS

At visual inspection, both groups showed reduced thoracic spinal cord thickness: 75% (6/8) of the group without arthrogryposis and 100% (4/4) of the arthrogryposis group. However, the latter had the entire spinal cord reduced and more severely reduced conus medullaris anterior roots (respectively, P = .002 and .007). Quantitative differences were found for conus medullaris base and cervical and lumbar intumescences diameters (respectively, P = .008, .048, .008), with more prominent reduction in arthrogryposis. Periventricular calcifications were more frequent in infants with arthrogryposis (P = .018).

CONCLUSIONS

Most infants had some degree of spinal cord thickness reduction, predominant in the thoracic segment (without arthrogryposis) or in the entire spinal cord (with arthrogryposis). The conus medullaris anterior roots were reduced in both groups (thinner in arthrogryposis). A prominent anterior median fissure of the spinal cord was absent in infants without arthrogryposis. Brain stem hypoplasia was present in all infants with arthrogryposis, periventricular calcifications, in the majority, and polymicrogyria was absent.

An arthrogrypotic medical doctor with cervical kyphosis and thoracic lordoscoliosis

Management of spinal deformities in a patient with arthrogryposis can be challenging for spine surgeons. The literature about the accompaniment of scoliosis; the most common spine deformity reported in arthrogryposis, is still poor. Moreover, the development of cervical kyphosis and thoracic lordoscoliosis in a patient with arthrogryposis is much rare. This paper reports a 26-year-old medical doctor with arthrogryposis who had underwent thoracic lordoscoliosis surgery about ten years ago with T6-L1 internal rods and is now presented with cervical kyphosis and C3-C4 cord stenosis, which made him a candidate for cervical cord decompression surgery.

Antenatal ultrasonography findings and magnetic resonance imaging in a case of Pena-Shokeir phenotype

Pena-Shokeir phenotype is a lethal anomaly characterized by neurogenic arthrogryposis, craniofacial anomalies, and pulmonary hypoplasia. This syndrome should be distinguished from trisomy 18 and arthrogryposis multiplex congenita for better counseling and establishing fetal prognosis. We present the case of a pregnant woman diagnosed with a Pena-Shokeir phenotype affected fetus at 24 weeks of gestation. Prenatal ultrasonography and fetal magnetic resonance imaging detected persistent hyperextension of the lumbar spine, micrognathia, absent septum pellucidum, and all characteristic features of Pena-Shokeir phenotype. Karyotyping was performed to exclude fetal chromosomal anomalies. Antenatal ultrasonography is an essential tool in the diagnosis of Pena-Shokeir phenotype while fetal magnetic resonance imaging is necessary to identify any associated anomalies of central nervous system.

Carpal Coalitions and Metacarpal Synostoses: A Review

Background: Carpal coalition and metacarpal synostosis are uncommon congenital anomalies of the carpus and hand. Methods: A comprehensive review of the literature was performed to help guide surgical and non-surgical treatment of carpal coalition and metacarpal synostosis. Results: The embryology, epidemiology, medical and surgical management, and associated outcomes are detailed. Conclusions: Most patients with these disorders will likely benefit from conservative measures. Surgery should be considered in patients with pain and limitations in wrist and hand function.

Autopsy and Postmortem Studies Are Concordant: Pathology of Zika Virus Infection Is Neurotropic in Fetuses and Infants With Microcephaly Following Transplacental Transmission

CONTEXT

-Pathology studies have been important in concluding that Zika virus infection occurring in pregnant women can result in vertical transmission of the agent from mother to fetus. Fetal and infant autopsies have provided crucial direct evidence that Zika virus can infect an unborn child, resulting in microcephaly, other malformations, and, in some cases, death.

OBJECTIVE

-To better understand the etiologic role and mechanism(s) of Zika virus in causing birth defects such as microcephaly, this communication analyzes the spectrum of clinical and autopsy studies reported from fetuses and infants who developed intrauterine Zika virus infection, and compares these findings with experimental data related to Zika virus infection.

DESIGN

-Retrospective analysis of reported clinical, autopsy, pathology, and related postmortem studies from 9 fetuses and infants with intrauterine Zika virus infection and microcephaly.

RESULTS

-All fetuses and infants examined demonstrated an overlapping spectrum of gross and microscopic neuropathologic abnormalities. Direct cytopathic effects of infection by the Zika virus were confined to the brain; in cases where other organs were evaluated, no direct viral effects were identified.

CONCLUSIONS

-There is concordance of the spectrum of brain damage, reinforcing previous data indicating that the Zika virus has a strong predilection for cells of the fetal central nervous system following vertical transmission. The occurrence of additional congenital abnormalities suggests that intrauterine brain damage from Zika virus interferes with normal fetal development, resulting in fetal akinesia. Experimental in vitro and in vivo studies of Zika virus infection corroborate the human autopsy findings of neural specificity.

Congenital Zika syndrome with arthrogryposis: retrospective case series study

OBJECTIVE

To describe the clinical, radiological, and electromyographic features in a series of children with joint contractures (arthrogryposis) associated with congenital infection presumably caused by Zika virus.

DESIGN

Retrospective case series study.

SETTING

Association for Assistance of Disabled Children, Pernambuco state, Brazil.

PARTICIPANTS

Seven children with arthrogryposis and a diagnosis of congenital infection presumably caused by Zika virus during the Brazilian microcephaly epidemic.

MAIN OUTCOME MEASURES

Main clinical, radiological, and electromyographic findings, and likely correlation between clinical and primary neurological abnormalities.

RESULTS

The brain images of all seven children were characteristic of congenital infection and arthrogryposis. Two children tested positive for IgM to Zika virus in the cerebrospinal fluid. Arthrogryposis was present in the arms and legs of six children (86%) and the legs of one child (14%). Hip radiographs showed bilateral dislocation in seven children, subluxation of the knee associated with genu valgus in three children (43%), which was bilateral in two (29%). All the children underwent high definition ultrasonography of the joints, and there was no evidence of abnormalities. Moderate signs of remodeling of the motor units and a reduced recruitment pattern were found on needle electromyography (monopolar). Five of the children underwent brain computed tomography (CT) and magnetic resonance imaging (MRI) and the remaining two CT only. All presented malformations of cortical development, calcifications predominantly in the cortex and subcortical white matter (especially in the junction between the cortex and white matter), reduction in brain volume, ventriculomegaly, and hypoplasia of the brainstem and cerebellum. MRI of the spine in four children showed apparent thinning of the cord and reduced ventral roots.

CONCLUSIONS

Congenital Zika syndrome should be added to the differential diagnosis of congenital infections and arthrogryposis. The arthrogryposis was unrelated to the abnormalities of the joints themselves, but was possibly of neurogenic origin, with chronic involvement of central and peripheral motor neurones leading to deformities as a result of fixed postures in utero. Based on the neurophysiological observations, we suggest two possible mechanisms: tropism of neurones, with involvement of peripheral and central motor neurones, or a relation with vascular disorders.

Phenotypical expression of reduced mobility during limb ontogeny in frogs: the knee-joint case

Movement is one of the most important epigenetic factors for normal development of the musculoskeletal system, particularly during genesis and joint development. Studies regarding alterations to embryonic mobility, performed on anurans, chickens and mammals, report important phenotypical similarities as a result of the reduction or absence of this stimulus. The precise stage of development at which the stimulus modification generates phenotypic modifications however, is yet to be determined. In this work we explore whether the developmental effects of abnormal mobility can appear at any time during development or whether they begin to express themselves in particular phases of tadpole ontogeny. We conducted five experiments that showed that morphological abnormalities are not visible until Stages 40–42. Morphology in earlier stages remains normal, probably due to the fact that the bones/muscles/tendons have not yet developed and therefore are not affected by immobilization. These results suggest the existence of a specific period of phenotypical expression in which normal limb movement is necessary for the correct development of the joint tissue framework.

Arthrogryposis: an update on clinical aspects, etiology, and treatment strategies

Arthrogryposes - multiple joint contractures - are a clinically and etiologically heterogeneous class of diseases, where accurate diagnosis, recognition of the underlying pathology and classification are of key importance for the prognosis as well as for selection of appropriate management. This treatment remains challenging and optimally in arthrogrypotic patients should be carried out by a team of specialists familiar with all aspects of arthrogryposis pathology and treatment modalities: rehabilitation, orthotics and surgery. In this comprehensive review article, based on literature and clinical experience, the authors present an update on current knowledge on etiology, classifications and treatment options for skeletal deformations possible in arthrogryposis.

De novo TUBB2B mutation causes fetal akinesia deformation sequence with microlissencephaly: An unusual presentation of tubulinopathy

Tubulinopathies are increasingly emerging major causes underlying complex cerebral malformations, particularly in case of microlissencephaly often associated with hypoplastic or absent corticospinal tracts. Fetal akinesia deformation sequence (FADS) refers to a clinically and genetically heterogeneous group of disorders with congenital malformations related to impaired fetal movement. We report on an early foetal case with FADS and microlissencephaly due to TUBB2B mutation. Neuropathological examination disclosed virtually absent cortical lamination, foci of neuronal overmigration into the leptomeningeal spaces, corpus callosum agenesis, cerebellar and brainstem hypoplasia and extremely severe hypoplasia of the spinal cord with no anterior and posterior horns and almost no motoneurons. At the cellular level, the p.Cys239Phe TUBB2B mutant leads to tubulin heterodimerization impairment, decreased ability to incorporate into the cytoskeleton, microtubule dynamics alteration, with an accelerated rate of depolymerization. To our knowledge, this is the first case of microlissencephaly to be reported presenting with a so severe and early form of FADS, highlighting the importance of tubulin mutation screening in the context of FADS with microlissencephaly.

ECEL1 mutation causes fetal arthrogryposis multiplex congenita

Arthrogryposis multiplex congenita (AMC) is a descriptor for the clinical finding of congenital fixation of multiple joints. We present a consanguineous healthy couple with two pregnancies described with AMC due to characteristic findings on ultrasonography of fixated knee extension and reduced fetal movement at the gestational age of 13 weeks + 2 days and 12 weeks + 4 days. Both pregnancies were terminated and postmortem examinations were performed. The postmortem examinations confirmed AMC and suggested a diagnosis of centronuclear myopathy (CNM) due to characteristic histological findings in muscle biopsies. Whole exome sequencing (WES) was performed on all four individuals and the outcome was filtered by application of multiple filtration parameters satisfying a recessive inheritance pattern. Only one gene, ECEL1, was predicted damaging and had previously been associated with neuromuscular disease or AMC. The variant found ECEL1 is a missense mutation in a highly conserved residue and was predicted pathogenic by prediction software. The finding expands the molecular basis of congenital contractures and the phenotypic spectrum of ECEL1 mutations. The histological pattern suggestive of CNM in the fetuses can expand the spectrum of genes causing CNM, as we propose that mutations in ECEL1 can cause CNM or a condition similar to this. Further investigation of this is needed and we advocate that future patients with similar clinical presentation or proven ECEL1 mutations are examined with muscle biopsy. Secondly, this study illustrates the great potential of the clinical application of WES in couples with recurrent abortions or stillborn neonates.

Arthrogryposis Multiplex Congenita Related to Third-Trimester Basal Ganglia Ischemia: A Case Report

Arthrogryposis multiplex congenita is a syndromic condition defined by contracture of 2 or more joints. A large range of etiologies has been reported such as neuromuscular disorders (peripheral dysfunction), chromosomal abnormalities, or cerebral malformations (central dysfunction) leading to fetal immobility. Severity of arthrogryposis depends on the etiology and duration of fetal immobility. The authors report a 34 gestational weeks infant presenting with severe diffuse arthrogryposis symptoms and respiratory failure at birth. Her mother experienced cardiac arrest at 29 gestational weeks due to carbon monoxide intoxication. Fetal magnetic resonance imaging revealed extensive corticospinal tract lesions. Antenatal ischemia of the deep gray matter needs to be considered as a possible arthrogryposis cause.

Intrafamilial Variable Hearing Loss in TRPV4 Induced Spinal Muscular Atrophy

Objective:

Mutations in the transient receptor potential vanilloid 4 gene ( TRPV4) can induce a great diversity of neuropathies. Together with these neuropathies, hearing loss can occur. This study is focused on providing an audiometric phenotype description of a Dutch family with spinal muscular atrophy caused by a mutation in TRPV4.

Methods:

A neurological examination was repeated and pure tone and speech audiometry were performed.

Results:

A large variety in neurological symptoms as well as variation in audiometric characteristics was observed. The severity of hearing loss is mild to moderate and the audiogram configuration is highly variable. The hearing loss of these patients has a progressive nature in general. The frequencies that deteriorate significantly differ between family members. When compared to presbyacusis patients, speech recognition scores of patients with a TRPV4 mutation are not clearly different.

Conclusion:

The function of TRPV4 in the inner ear is still elusive but it is suggested that TRPV4 is required for maintenance of cochlear function in stress conditions, like acoustic injury. We can neither confirm nor reject this based on the results obtained in this family. Therefore, one might consider advising patients with a TRPV4 mutation to avoid exposure to environmental influences such as noise exposure.

Cervical stenosis in a patient with arthrogryposis: case report

Study Design Case report. Objective Amyoplasia-type arthrogryposis is a rare congenital disease that presents as multiple contractures involving various areas of the body. To the authors' knowledge, there have been no reports of adults with amyoplasia in the current literature. We report a case of an adult patient with cervical stenosis in the setting of amyoplasia. Patients and Methods A 48-year-old patient with amyoplasia and over 30 previous orthopedic reconstructive surgeries presented with neck pain radiating down his left shoulder and into the fingers, dysesthesia in his fingertips, and left-sided periauricular headache. A diagnosis of central spinal canal stenosis and bilateral foraminal stenosis at C3-C7 with radiculopathy was made based on computed tomography scans. Because of a prior right-side sternocleidomastoid muscle transfer, a left-side C3-C4, C5-C7 anterior cervical discectomy and fusion procedure was performed. Results The patient experienced significant improvement in symptoms that was transient. Symptoms returned to preoperative values after 1 year, despite significant and persistent improvement in stenosis. Conclusions Both amyoplasia and cervical stenosis can manifest in neurologic symptoms. Distinguishing the causing pathology can be challenging. The radiographic improvement of cervical stenosis in a patient with amyoplasia is not always associated with long-standing pain relief.

Successful pregnancy in a woman with arthrogryposis multiplex congenita

Arthrogryposis multiplex congenita refers to a clinical condition or syndrome characterised by multiple congenital contractures that affect two or more different areas of the body. Of the cases reported so far, an important percentage had to be terminated before pregnancy term, predominantly by caesarean section. We describe a 36 year-old woman who wanted to conceive. A multidisciplinary approach was set from the preconceptional period and special attention was given to respiratory function, potential anaesthetic difficulties and thromboembolic risks. She delivered by caesarean section at 38 weeks. This case emphasises the possibility of achieving a term delivery in these patients and points out the importance of a multidisciplinary team, specially of obstetricians and anaesthesiologists.

Expanding the phenotypic spectrum of ECEL1-related congenital contracture syndromes

Using a combination of homozygosity mapping and whole-exome sequencing (WES), we identified a novel missense c.1819G>A mutation (G607S) in the endothelin-converting enzyme-like 1 (ECEL1) gene in a consanguineous pedigree of Turkish origin presenting with a syndrome of camptodactyly, scoliosis, limited knee flexion, significant refractive errors and ophthalmoplegia. ECEL1 mutations were recently reported to cause recessive forms of distal arthrogryposis. This report expands on the molecular basis and the phenotypic spectrum of ECEL1-associated congenital contracture syndromes.