Orthopaedic Considerations for the Adult With Osteogenesis Imperfecta

Postoperative screw pullout of severe spondylolisthesis in osteogenesis imperfecta: a case report with 3-year follow-up

Introduction and importance

Osteogenesis imperfecta (OI) is a rare skeletal disorder characterized by bone fragility and deformities in both paediatric and adult populations. The occurrence of severe spondylolisthesis in OI patients is even more infrequent. However, there is no consensus regarding the optimal treatment approach for OI patients afflicted with severe spondylolisthesis. The selection of surgical procedures and the effective management of postoperative complications present significant challenges in this context.

Case presentation

A 30-year-old male patient diagnosed with OI type IV (Sillence classification) underwent the lumbar laminectomy and postero-lateral fusion due to severe spondylolisthesis (grade Ⅲ). Following the surgery, the patient experienced postoperative screw pullout while on bedrest. However, aside from experiencing back pain, there were no neurological symptoms present. To address this issue, the patient received salvage treatment in the form of cast immobilization combined with bisphosphonates. At the 3-year follow-up, the patient exhibited absence of sciatic nerve pain and reported mild numbness in the lower extremities. Moreover, the patient demonstrated the ability to ambulate a distance exceeding 1500 m. Nevertheless, the persistence of sexual dysfunction was observed.

Clinical discussion

This study presented the initial instance of surgical complications observed in patients with severe spondylolisthesis and OI. This highlights the importance to exercise meticulous caution and thoroughness when assessing surgical interventions.

Conclusion

In cases where the fixation fails to offer adequate biomechanical stability, the administration of bisphosphonates and robust immobilization remains crucial, even in the presence of complications.

Z-osteotomy for uniplanar femoral shaft deformity correction in an adolescent with osteogenesis imperfecta

Osteogenesis imperfecta (OI) is commonly associated with fragility fractures. It is due to abnormality in the quantity and quality of collagen type 1 caused by mutations in COL1A1 and COL1A2 genes. Patients with OI would also have blue sclera, ligament hyperlaxity, dentinogenesis imperfecta, hearing abnormality, and short stature. Surgical management is preferred to conservative treatment in long bone fractures. For malunited fractures, Sofield-Millar or multiple osteotomies at different sites of deformities are performed with additional intramedullary device to stabilize the bone. This is a case of femur fracture with multilevel CORAs in an adolescent patient with post-trauma OI in which z-osteotomies were performed and stabilized with titanium elastic nails resulting in good outcomes clinically and radiologically.

Challenges of total knee arthroplasty in osteogenesis imperfecta: case report and literature review

The majority of adults with mild osteogenesis imperfecta report significant functional impairment due to musculoskeletal concerns. Knee osteoarthritis is common in these patients. Although total knee arthroplasty has become a highly efficient surgical technique for osteoarthritis, this procedure remains uncommon in patients with osteogenesis imperfecta. This current case report describes the important clinical aspects of osteogenesis imperfecta that must be considered during the planning and performance of a total knee replacement. A 62-year-old female patient with a history of osteogenesis imperfecta suffered from severe osteoarthritis of the knee with valgus deformity. Two years after posterior stabilized total knee arthroplasty, her Hospital for Special Surgery knee score had improved from preoperative 53 points to 85 points at the final follow-up. The current case report describes the crucial technical aspects of a successful total knee replacement in this uncommon scenario. Underlying deformities and concomitant pathologies constitute specific surgical challenges. Special care should be taken to protect the patient from potential complications.

Total Hip Replacements in Patients with Rare Pathologic Conditions Affecting Bone

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As a result of the advances in surgical technique and implant design, total hip arthroplasty (THA) is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone.

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Posttraumatic or congenital deformities associated with fragile or pathologic bone are frequently encountered and necessitate diligent preoperative planning.

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Surgeons should be prepared to evaluate and manage intraoperative iatrogenic fracture.

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While there is limited evidence to date, components made with computer-assisted design can be considered, given the unique and highly variable patient population.

Addition of a Distal Femur Locking Plate to Augment Total Hip Arthroplasty in Osteogenesis Imperfecta: A Case Report

CASE

We present a 55-year-old woman with osteogenesis imperfecta (OI) who underwent total hip arthroplasty (THA). She developed aseptic loosening of the femoral stem and was revised to a longer stem necessitating 2 osteotomies because of the proximal femur varus deformity. This was complicated by implant subsidence. She ultimately required another revision adding a distal femur locking plate to augment construct stability.

CONCLUSION

The abnormal anatomy and suboptimal bone properties in patients with OI present unique challenges when performing THA. More aggressive prophylactic fixation to improve construct stability and prevent fracture may be necessary in this patient population.

Hip Arthroplasty in Patients with Osteogenesis Imperfecta

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Osteogenesis imperfecta (OI) is a rare congenital disorder that affects connective tissue.

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Modern medicine has mitigated the mortality that is associated with OI, allowing patients to live a near-normal life span.

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The degenerative process in OI is probably accelerated because of subclinical intra-articular fractures, joint laxity, and distorted femoral and acetabular anatomy.

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Total hip arthroplasty is seldom performed in patients with OI; it is technically difficult due to bone fragility, deformity, soft-tissue alteration, acetabular protrusion, the risk of intraoperative and postoperative fractures, and joint laxity.

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This review highlights that patients with OI need hip arthroplasty procedures at an early age and that early revision surgery can be expected. New-generation uncemented implants may improve implant survivorship.

Three-Dimensional Printing and Computer Navigation for Correction of Multiple Deformities in Osteogenesis Imperfecta: A Case Report

CASE

A 44-year-old man with osteogenesis imperfecta presented with multiple debilitating musculoskeletal deformities. Bi-level osteotomies, assisted by 3-dimensional (3D)-printed patient-specific cutting guides, were performed to correct extraarticular valgus and procurvatum tibial deformities. Concomitant computer-navigated total knee arthroplasty was performed to restore neutral mechanical alignment. Postoperative x-ray showed good correction of deformities, and 1 year postoperatively, the patient is able to walk unaided with significant resolution of knee pain.

CONCLUSION

3D-printed osteotomy guides and computer navigation can be instrumental in procedures requiring a high degree of precision. With sufficient training, modern orthopaedic technologies can be implemented by surgeons themselves and combined to facilitate precise and personalized management of challenging conditions.

Functional outcomes of an adult with osteogenesis imperfecta after rehabilitation post bilateral Girdlestone procedure

This is a case of a 54-year-old woman managed as a case of osteogenesis imperfecta type 1 who sustained a left subtrochanteric fracture and eventual ankylosis of both hips after surgery and immobilisation. These injuries rendered her bedridden, maximally assisted in transitions and transfers, and unable to be positioned past 30° of backrest elevation. The patient underwent a bilateral Girdlestone procedure and had tailored progressive postoperative rehabilitation in both the inpatient and outpatient settings. The patient also continued to receive bisphosphonates during her preoperative and postoperative period, to improve bone stock and aid in relieving pain. Through the efforts of a team of physiatrists, geneticists and orthopaedic surgeons, the patient was able to achieve pain-free sitting, independent transitions and short-distance ambulation, which have allowed her to care for herself more effectively and return to her work and activities of daily living.

Leg lengthening and deformity correction in rare bone diseases: a multidisciplinary approach

Congenital and acquired conditions presenting with leg length discrepancy, leg deformity or short stature are not only a challenge for paediatric orthopaedic surgeons in terms of treatment options but may also involve a number of medical specialties due to the complex clinical manifestations of the diseases. Various surgical treatment options are available for these rare genetic diseases, including bone lengthening and growth inhibition techniques for lower limb discrepancy, as well as guided growth and other surgical procedures for correction of angular deformities. Surgical techniques may be similar, but the treatment plans and specific multidisciplinary approaches may differ. The present report is focused on paediatric orthopaedic and multidisciplinary aspects of the treatment of rare bone diseases. We address the clinical presentation of these diseases, gait and surgical procedures for conditions such as achondroplasia, X‑linked hypophosphatemia and osteogenesis imperfecta. We also provide a short overview of other rare bone diseases.

Physical function in UK adults with osteogenesis imperfecta: a cross-sectional analysis of the RUDY study

We describe the physical function in adults with osteogenesis imperfecta (OI) and explored clinical and non-clinical factors related to its impairment. Our data showed that physical dysfunction is a common feature of adults with OI, varying by OI severity, and mediated by the presence and quality of pain and fatigue symptoms.

INTRODUCTION

There is a paucity of data describing physical function in adults with osteogenesis imperfecta (OI). We investigated the effects of OI and its severity on physical function and explored the relationship between physical function and number of fractures and symptomatology.

METHODS

Adults with OI of different types were recruited from the RUDY study, an ongoing UK-based prospective cohort study. Participants completed demographic and clinical questions and questionnaires. These assessed physical function (SF-36), mobility (EQ-5D-5L and NEADL), fatigue (FACIT-F), and pain (SF-MQ-2). Scores were compared using parametric or non-parametric statistical analyses, whereas correlations between outcomes were examined using univariate and multivariate regression analysis.

RESULTS

Seventy-eight adults with OI aged 43.5 ± 14.5 years were enrolled (type I, 32; type III, 11; type IV, 10; unknown type, 26). Physical function (PCS, SF-36) was significantly lower in all participants than normative values (p < 0.001) and in type III than type I (p = 0.008). Mobility was significantly different across the types (EQ-5D-EL, p = 0.007; NEADL, p < 0.001), with type III having more severe problems, followed by types IV, unknown, and I. Physical function was associated with OI type (r = 0.26; p = 0.021), presence and quality of pain (r = - 0.57; p < 0.0001), and fatigue (r = - 0.51; p < 0.0001). Multivariate analysis revealed that physical function correlated independently with age, OI type, fatigue, and non-neuropathic pain.

CONCLUSIONS

Individuals with OI display a marked deterioration in physical function during adulthood. This impairment varies in severity according to the OI phenotype and is associated with the presence of non-neuropathic pain and fatigue.

Cardiopulmonary Status in Adults with Osteogenesis Imperfecta: Intrinsic Lung Disease May Contribute More Than Scoliosis

BACKGROUND

Osteogenesis imperfecta (OI) is a heterogeneous group of collagen-related disorders characterized by osteopenia, bone fractures, spine deformities, and nonskeletal complications. Cardiopulmonary complications are the major cause of morbidity and mortality in adults with OI. The cause of such problems was often attributed solely to the presence of large scoliosis curves affecting pulmonary function and, indirectly, cardiovascular health. However, recent studies suggest this may not be the case. Therefore, determining the relationships and causative agents of cardiopulmonary problems in patients with OI, specifically pulmonary impairment, is important to improving the overall wellbeing, quality of life, and survival of these patients.

QUESTIONS/PURPOSES

(1) Is cardiopulmonary fitness in OI solely related to the presence of scoliosis? (2) What is the prevalence of heart and lung complications in this adult population? (3) Does the presence of pulmonary impairment impact quality of life in adults with OI?

METHODS

This is a prospective observational cross-sectional study. Within 1 year, each participant (n = 30) completed pulmonary function testing, echocardiogram, ECG, chest CT, AP spine radiography, and quality-of-life assessments (SF-36, St. George's Respiratory Questionnaire, Functional Outcomes of Sleep Questionnaire, and Pittsburgh Sleep Quality Index). In terms of pulmonary function, we differentiated restrictive and obstructive physiology using the ratio of forced expiratory volume over one second to forced vital capacity (FEV1/FVC), with restrictive lung physiology defined as FEV1/FVC > 0.8 and obstructive lung physiology as FEV1/FVC < 0.7. Spine radiographs were evaluated for scoliosis. Chest CT images were reviewed to qualitatively assess the lungs. The statistical analysis involved a Kruskall-Wallis test with Bonferroni's correction and a bivariate correlation analysis using Spearman's rho correlation coefficient (p < 0.05).

RESULTS

Sixteen of 23 participants with restrictive lung physiology had scoliosis; their ages ranged from 19 years to 67 years. There was no correlation between the magnitude of the scoliosis curve and deficient pulmonary function (R = 0.08; p = 0.68). Seven participants had normal pulmonary function. The average scoliosis curve was 44 ± 29°. Thirteen participants had abnormal ECG findings while 10 had abnormal echocardiogram results. All but two individuals with abnormal chest CT results were found to have bronchial wall thickening. There were no differences in pulmonary or cardiac findings between OI types, except for FVC and total lung capacity, which were lower in individuals with Type III OI than in those with other types of OI. FEV1/FVC correlated with St. George's Respiratory Questionnaire (R = 0.429; p = 0.02) but not with Functional Outcomes of Sleep Questionnaire (R = -0.26; p = 0.19) or SF-36 scores (physical component summary: R = -0.037, p = 0.85; mental component summary: R = -0.204, p = 0.29).

CONCLUSIONS

The lack of a relationship between decreased pulmonary function and the severity of scoliosis suggests that restrictive lung physiology in this population is likely because of factors intrinsic to OI and not entirely because of thoracic cage deformities. The fact that pulmonary impairment influences self-perceived quality of life exemplifies how detrimental such complications may be to everyday functioning. This also reinforces the importance of determining the underlying cause of cardiopulmonary impairment in this population to set clear clinical guidelines of care.

LEVEL OF EVIDENCE

Level II, prognostic study.

Combined technique of titanium telescopic rods and external fixation in osteogenesis imperfecta patients: First 12 consecutive cases

Introduction

The major limitation of any intramedullary telescopic system is rotational and longitudinal instability. The combination of telescopic system with an external fixator in patients with osteogenesis imperfecta (OI) demonstrated advantages of stability, early weight-bearing and rehabilitation. This study aimed to examine the outcomes of deformity correction by combined technique uniting titanium telescopic rod and reduced Ilizarov frame in children with types III or IV of OI with a minimum 1-year follow-up.

Material and methods

The study included 12 children with OI who underwent femoral deformity correction (20 segments) or tibial deformity correction (4 segments) by combined technique. The children ranged in age between 2 years and 3 months and 12 years and 4 months (mean: 8.9 ± 2.02 years) at the time of the rodding. Parameters of surgery, clinical examination data, data of 3D gait analysis were assessed in the study.

Results

External fixation lasted 35.8 ± 13.2 days in average. Neither loss of threaded fixation in the distal femoral and tibial epiphyses and apophysis of the greater trochanter nor migration of the rod into the knee and ankle joints were observed in follow-up. No secondary rotational or longitudinal bone displacement was noted. Telescoping gain related to spontaneous growth assessed at one-year follow-up control was 13.7 mm in the tibia and 15.9 mm in the femur. There were no deep infection or neurologic complications. The alignment measured by radio anatomical reference angles was maintained throughout the follow-up period.Gait abnormalities in postoperative period were caused by bulk and weight of EF: external hip rotation, slight external angle of foot progression, increased stride width and increased hip abduction angle. The second feature was reduced ROM in sagittal plane at all levels associated with significantly reduced ankle plantarflexion, hip and knee joint moments in comparison to kinetics of limb without EF. These abnormalities resolved by the one-year assessment.

Conclusion

The combination of titanium telescopic rod with reduced external fixation is reliable advantage in reconstructive orthopaedic surgery for OI children. Reduced external fixation allows to overcome inconveniencies of longitudinal and rotational instability of telescopic systems. Children were able to walk with weight-bearing since early postoperative period because of external fixation. Gait temporary changes were influenced by external device size and by strategy to reduce pin site pain.

Plethora of Traumatic Lesions of Bilateral Knee Extensor Mechanism in Osteogenesis Imperfecta

INTRODUCTION

Injuries to the quadriceps extensor mechanism are rare in patients with Osteogenesis Imperfecta (OI). To the best of our knowledge, non-union of the patella in OI, either as an isolated problem or in combination with an acute fracture, has not been previously reported.

CASE REPORT

We describe how we surgically approached both the fracture and the non-union simultaneously. The surgical technique and steps are described in detail. Post-operative course was uneventful and the outcome was favorable, with full return of function for the patient.

CONCLUSION

A review of various knee extensor mechanism injuries in OI is described as illustrated in a single patient. The unusual simultaneous surgical treatment of a non-union and an acute fracture in the same patella shows that despite the severely compromised bone in this rare bone disease the bone still has a capacity to heal with a functional outcome.

Patients with musculoskeletal dysplasia undergoing total joint arthroplasty are at increased risk of surgical site Infection

INTRODUCTION

Musculoskeletal dysplasias (MSD) are inherited conditions of abnormal cartilage and bone development and remodeling which include, amongst others, multiple epiphyseal dysplasia (MED), spondyloepiphyseal dysplasia (SED), achondroplasia, and hypochondroplasia. The aim of this study was to compare patient characteristics and in-hospital complications between MSD and non-MSD patients undergoing total joint arthroplasty (TJA).

HYPOTHESIS

MSD patients undergoing TJA are at increased risk of in-hospital post-operative complications and mortality compared to non-MSD patients.

MATERIALS AND METHODS

The Nationwide Inpatient Sample (NIS) from the years 2005 to 2014 was used for this retrospective cohort study. International Classification of Diseases, Clinical Modifications (ICD-9-CM) procedure codes identified primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures and were used to separate MSD and non-MSD patients. Patients with trauma or malignancy as primary diagnoses, non-elective procedures, revision procedures, and concurrent bilateral surgeries were excluded. Patients were compared using linear regression or multivariate logistic regression analysis to control for confounders. All statistical analyses were performed taking into account the NIS sampling scheme and associated sampling weights.

RESULTS

A total of 1,255 patients comprised the MSD group and 8,027,181 patients the non-MSD group. MSD patients were younger than non-MSD patients (50.9 vs. 65.8 years, p<0.001), with less comorbidities including: hypertension (40.2% vs. 64.5%, p<0.001), coronary artery disease (5.5% vs. 12.9%, p<0.001), diabetes mellitus (9.4% vs. 19.0%, p<0.001), and hypothyroidism (7.8% vs. 14.7%, p=0.002). MSD patients had higher risks of surgical site infection (0.8% vs. 0.2%; OR, 4.16; 95% CI, 1.03-16.75; p=0.044), and perioperative hemorrhage (2.1% vs. 0.7%; OR, 3.20; 95% CI, 1.32-7.76; p=0.010).

DISCUSSION

MSD patients undergoing TJA were younger with less co-morbidity compared to non-MSD patients, and had no significant difference in overall perioperative medical and surgical complication rates. However, they are at increased risk for surgical site infection and perioperative hemorrhage possibly due to the anatomical complexity encountered.

LEVEL OF EVIDENCE

III, Retrospective Cohort.

Total knee arthroplasty in osteogenesis imperfecta

Osteogenesis imperfecta is a genetic disease resulting in abnormal collagen formation, with multiple clinical manifestations. Advancements in medical and surgical treatments have prolonged the life expectancy of these patients in recent decades. As a result, orthopedic surgeons are likely to be faced with the challenge of performing arthroplasty in these patients on a more frequent basis. Here, we describe a patient with osteogenesis imperfecta and subsequent severe osteoarthritis prompting primary total knee arthroplasty. This rare case presents an opportunity to explore special considerations unique to this patient population, including comorbid bone defects, the need for using extramedullary guides, careful alignment of prostheses to accommodate abnormalities in limb axes, and equipment utilization.

Use of flexible intramedullary nailing in combination with an external fixator for a postoperative defect and pseudarthrosis of femur in a girl with osteogenesis imperfecta type VIII: a case report

Telescopic rodding has been developed in order to obtain long-lasting osteosynthesis in the growing long bones of children with osteogenesis imperfecta (OI). The major and still unsolved drawback of any telescopic rod or nail design is a lack of rotational stability and, currently, no telescopic system allows immediate weight-bearing. When these problems are associated with insufficient longitudinal bone stability and diminished healing capacity, the result can be unfavourable causing secondary bone fragment displacement, delayed or non-union. This article presents a case report of operative treatment in a 9-year-old girl affected with OI type VIII complicated with postoperative defect and pseudarthrosis of the femur causing functional impairment with loss of walking ability. A combination of intramedullary flexible nailing and minimal external fixation was applied for treatment of femoral defect-pseudarthrosis in a girl of 9 years with OI type VIII. Intramedullary and extramedullary nails with wrapping of titanium nickel mesh subperiosteally provided osteosynthesis and deformity correction of the tibia of a small intramedullary canal diameter. Upright standing and walking with progressive weight-bearing was started 4 days after surgery. There were no septic or vascular complications nor complications related to Ilizarov fixator. Radiographs demonstrated bone union in the femur 46 days after surgery. At the follow-up visit 9 months after fixator removal, clinical alignment remained excellent without any relapse of deformity. Bone remodelling with restitution of medullary canal was noted on lower limb radiographs. The patient was able to stand and walk without pain with an aide or walker. At the follow-up visit 17 months after fixator removal, there was no decrease in achieved functional abilities and the treatment outcome remained satisfactory. Use of an external fixator with intramedullary nailing for treatment of postoperative pseudarthrosis in patient with severe OI (recessive form of OI, type VIII) provides longitudinal, rotational and angular stability. Furthermore, this approach ensured early functional activity and walking with full weight-bearing, both favourable conditions for bone tissue regeneration. The external fixator was applied for a short period and only for additional stability and not for progressive deformity correction or other manipulation. In addition, the combination of intramedullary and extramedullary nailing and subperiosteal titanium nickel mesh seems to be promising for osteosynthesis in the deformity correction of bones with small diameter in children with OI.

Corrective osteotomy with retrograde Fassier-Duval nail in an osteogenesis imperfecta patient with bilateral genu valgum: A case report

RATIONALE

The treatment of osteogenesis imperfecta (OI) requires a multidisciplinary approach to maximize function and reduce fracture incidence. The aim of this case report was to discuss an alternative surgical approach to stabilize a corrective osteotomy using the Fassier Duval (FD) system in an OI patient.

PATIENT CONCERNS

A 20-year-old OI woman presented with left thigh pain, gait disturbance, and bilateral genu valgus deformities.

DIAGNOSES

Physical examination and standing radiographs revealed bilateral genu valgum with previous fixation implants in the femoral and the left tibia.

INTERVENTIONS

Staged surgery was performed. A previous Ender pin was removed from the left femur, and a FD nail was inserted in a retrograde fashion. An intercondylar fracture was encountered while inserting the female rod in the distal left femur. After removal of a previous Rush pin from the right femur, several complications were also encountered during FD nailing of the right femur. The tip threads of the FD male nail could not achieve adequate anchorage in the region of the greater trochanter. To prevent male nail dropping, a horizontal stop Kirschner pin was inserted close to the distal end of the female nail.

OUTCOME

Despite perioperative problems such as rod dropping and occurrence of an intercondylar fracture of the left distal femur, bilateral retrograde nailing using the FD system was successful. An accurate entry portal is important when performing retrograde rodding. In addition, reaming the portal to a larger diameter in order to accommodate the large head of the female nail can prevent intraoperative intercondylar split, especially when combined with an osteotomy at the distal femur.

LESSONS

Selection of the proper surgical technique is dependent on both the surgeon's experience and the condition of the patient. Although not an optimal device, a FD nail can be used as an IM nail for corrective osteotomy at the distal femur in an adult OI patient with a small femoral IM canal.

Using humeral nail for surgical reconstruction of femur in adolescents with osteogenesis imperfecta

Osteogenesis imperfecta (OI) is a rare inherited connective tissue disorder caused by mutation of collagen which results in a wide spectrum of clinical manifestations including long bone fragility fractures and deformities. While the treatment for these fractures was recommended as using intramedullary fixation for minimizing stress concentration, the selection of the best implant in the adolescent OI patients for the surgical reconstruction of femur was still problematic, due to anatomy distortion and implant availability. We are reporting the surgical modification by using a humeral nail for femoral fixation in three adolescent OI patients with favorable outcomes.

Osteogenesis imperfecta

Skeletal deformity and bone fragility are the hallmarks of the brittle bone dysplasia osteogenesis imperfecta. The diagnosis of osteogenesis imperfecta usually depends on family history and clinical presentation characterized by a fracture (or fractures) during the prenatal period, at birth or in early childhood; genetic tests can confirm diagnosis. Osteogenesis imperfecta is caused by dominant autosomal mutations in the type I collagen coding genes (COL1A1 and COL1A2) in about 85% of individuals, affecting collagen quantity or structure. In the past decade, (mostly) recessive, dominant and X-linked defects in a wide variety of genes encoding proteins involved in type I collagen synthesis, processing, secretion and post-translational modification, as well as in proteins that regulate the differentiation and activity of bone-forming cells have been shown to cause osteogenesis imperfecta. The large number of causative genes has complicated the classic classification of the disease, and although a new genetic classification system is widely used, it is still debated. Phenotypic manifestations in many organs, in addition to bone, are reported, such as abnormalities in the cardiovascular and pulmonary systems, skin fragility, muscle weakness, hearing loss and dentinogenesis imperfecta. Management involves surgical and medical treatment of skeletal abnormalities, and treatment of other complications. More innovative approaches based on gene and cell therapy, and signalling pathway alterations, are under investigation.