Scapular fixation in muscular dystrophy

Effect of taping on scapular kinematics of patients with facioscapulohumeral muscular dystrophy

The aim of this study is to investigate the effects of scapular taping on scapular kinematics by three-dimensional electromagnetic system during shoulder elevation in facioscapulohumeral muscular dystrophy patients. A total of 11 patients with facioscapulohumeral muscular dystrophy were included in the study. Scapular anterior-posterior tilt, upward-downward rotation, and internal-external rotations were evaluated using the three-dimensional electromagnetic system during the elevation of the upper limbs in the scapular plane before and after kinesio taping. For maximum humerothoracic elevation, there were no differences between the patients before and after taping on both dominant (p = 0.72) and non-dominant sides (p = 0.64). For scapular internal rotation, upward rotation, and posterior tilt, there were no differences between patients before and after taping during humerothoracic elevation on both dominant and non-dominant sides (p > 0.05). These results showed us that the excessive and abnormal movements of the scapula observed during the humeral elevation in facioscapulohumeral muscular dystrophy patients cannot be supported with flexible methods like kinesio taping. Therefore, we recommend to evaluate the scapula position by applying flexible and rigid taping to the patients who can reach over 90^o in humerothoracic elevation in future studies.

Management strategies in facioscapulohumeral muscular dystrophy

Facioscapulohumeral muscular dystrophy (FSHD) also known as Landouzy-Dejerine disease, is an autosomal-dominant disorder of the skeletal muscles with the name according to the various muscle groups it affects: the face, shoulders and upper arms. It is the third most common genetic degenerative disorder of the skeletal muscles without specific patterns in all the affected individuals. At present there is no cure for the disease but numerous management strategies are available to improve the quality of life and prevent further degeneration of various muscle groups. This review aims to provide an insight on the management strategies for FSHD patients including both lifestyle and medical intervention.

Protein kinase A activation inhibits DUX4 gene expression in myotubes from patients with facioscapulohumeral muscular dystrophy

Facioscapulohumeral muscular dystrophy (FSHD) is among the most prevalent of the adult-onset muscular dystrophies. FSHD causes a loss of muscle mass and function, resulting in severe debilitation and reduction in quality of life. Currently, only the symptoms of FSHD can be treated, and such treatments have minimal benefit. The available options are not curative, and none of the treatments address the underlying cause of FSHD. The genetic, epigenetic, and molecular mechanisms triggering FSHD are now quite well-understood, and it has been shown that expression of the transcriptional regulator double homeobox 4 (DUX4) is necessary for disease onset and is largely thought to be the causative factor in FSHD. Therefore, we sought to identify compounds suppressing DUX4 expression in a phenotypic screen using FSHD patient-derived muscle cells, a zinc finger and SCAN domain-containing 4 (ZSCAN4)-based reporter gene assay for measuring DUX4 activity, and ∼3,000 small molecules. This effort identified molecules that reduce DUX4 gene expression and hence DUX4 activity. Among those, β₂-adrenergic receptor agonists and phosphodiesterase inhibitors, both leading to increased cellular cAMP, effectively decreased DUX4 expression by >75% in cells from individuals with FSHD. Of note, we found that cAMP production reduces DUX4 expression through a protein kinase A-dependent mode of action in FSHD patient myotubes. These findings increase our understanding of how DUX4 expression is regulated in FSHD and point to potential areas of therapeutic intervention.

Facioscapulohumeral distrophy and physiotherapy: a literary review

[Purpose] The purpose of this review was to critically evaluate the literature concerning the physiotherapy of facioscapulohumeral dystrophy, and to determine an effective protocol for physiotherapy treatments, which can be adapted to patient characteristics. [Methods] A bibliographic research was carried out of research papers held in the following databases: PUBMED, PEDRO, MEDLINE, EDS BASE INDEX. The inclusion criteria for acceptance of the studies to the review were randomized controlled trials (RCTs) concerning a sample no smaller than 10 people and a medium- or long-term report of the results achieved. [Results] Just six of the works satisfied the inclusion criteria, and just three of them were useful for the review. However, these studies were difficult to compare. [Conclusion] At present, there are few studies concerning facioscapulohumeral dystrophy in the literature, and the few that are available rule out the utility of the techniques used. Therefore, more RCTs of new treatment strategies are needed.

Thoracoscapular Fusion for Winging of the Scapula with Screw Fixation for Fascioscapulohumeral Dystrophy (Modified Copeland-Howard Procedure)

INTRODUCTION

This article describes our technique of thoracoscapular fusion with screw fixation for treatment of winging of the scapula in patients with fascioscapulohumeral dystrophy.

STEP 1 PREOPERATIVE EVALUATION

Perform the Horwitz test.

STEP 2 POSITION THE PATIENT AND MARK THE SKIN FOR THE OPERATION

With the patient on a Montreal mattress, position the arms in 90° to 110° of elevation in the scapular plane and approximately 90° of external rotation and mark the skin.

STEP 3 SURGICAL APPROACH

Make an incision along the medial scapular edge, incise the trapezius muscle, and detach the levator scapula, rhomboid major, and rhomboid minor muscles.

STEP 4 PREPARE THE SCAPULA

Do not decorticate the scapula to avoid weakening it.

STEP 5 SELECT AND PREPARE THE RIBS

Expose three or four ribs subperiosteally, from their superior border to avoid the neurovascular bundle.

STEP 6 DRILL THE SCAPULA AND RIBS

Drill the ribs with a McDonald dissector underneath them to prevent damage to the pleura.

STEP 7 HARVEST AND INTRODUCE BONE GRAFT OR USE BONE-GRAFT SUBSTITUTE AND CLOSE

Pack bone chips or bone-graft substitute between the ribs and the deep surface of the scapula.

STEP 8 POSTOPERATIVE IMMOBILIZATION AND REHABILITATION

An adjustable brace with the arm in 60° of abduction and 30° of forward flexion is worn for three months.

RESULTS

Between July 1997 and July 2010, a thoracoscapular fusion was performed in thirty-five shoulders of twenty-four patients with fascioscapulohumeral dystrophy15.IndicationsContraindicationsPitfalls & Challenges.

Facioscapulohumeral muscular dystrophy

Facioscapulohumeral muscular dystrophy (FSHD), a dominantly inherited disorder, is the third most common dystrophy after Duchenne and myotonic muscular dystrophy. No known effective treatments exist for FSHD. The lack of an understanding of the underlying pathophysiology remains an obstacle in the development of targeted therapeutic interventions. The genetic defect is a loss of a critical number of a repetitive element (D4Z4) in the 4q subtelomeric region. The loss of the repeats results in specific changes in chromatin structure, although neither the molecular nor the cellular consequences of this change are known. Nevertheless, these epigenetic changes in chromatin structure offer a potential therapeutic target. This review discusses current management strategies in FSHD as well as potential therapeutic interventions to slow down or reverse the progressive muscle atrophy and weakness.

Fixation of winged scapula in facioscapulohumeral muscular dystrophy

OBJECTIVE

To verify if stabilizing the scapulothoracic joint without arthrodesis could lead to functional improvement of shoulder range of motion and clinical improvement of winged scapula, we incorporated four additional patients into our previous analysis to determine if the results obtained were long lasting, and to compare this fixation with the other techniques described in the literature, balancing the benefits with the complications.

DESIGN

A retrospective study.

PARTICIPANTS

Thirteen patients with bilateral winged scapula affected by facioscapulohumeral muscular dystrophy. Nine of these patients had been analyzed in our previous study.

METHODS

Patients were operated on by bilateral fixing of the scapula to the rib cage using metal wires without arthrodesis (scapulopexy).

RESULTS

All patients experienced improvement in active range of motion of the shoulder and all of them had clinical improvement with complete resolution of the winged scapula. In all twenty-six surgical interventions of scapulopexy, a stable and long-lasting fixation of the scapula to the rib cage was achieved. The complications strictly associated to the surgical technique encountered were one pneumothorax, which was resolved spontaneously, and one wire breakage without trauma. Average follow-up was 10 years (range, 3 to 18 years).

CONCLUSION

The scapulopexy used in this extended series of patients consisted of repositioning the scapula and fixing it to four ribs by using metal wires without performing arthrodesis. This technique has a low rate of complications, is reproducible, safe and effective, resulting in clinical and functional improvement.