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Burden of Surgical Treatment for the Management of Cervical Myelopathy in Mucopolysaccharidoses: A Systematic Review. Brain Sci 2022; 13:brainsci13010048. [PMID: 36672030 PMCID: PMC9856616 DOI: 10.3390/brainsci13010048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/18/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
Mucopolysaccharidoses (MPSs) are a rare group of heterogeneous genetic and metabolic disorders, caused by loss of functions of several enzymes that are involved in glycosaminoglycan catabolism. Their progressive accumulations in cells, tissues, and consequently, organs lead to several clinical manifestations, such as musculoskeletal involvement. Indeed, the most common manifestation in the central nervous system is represented by cervical spinal stenosis due to bony alterations or dural thickening. Cervical involvement can commonly cause myelopathy and instability exerting severe symptoms. A prompt diagnosis and treatment of the aforementioned conditions is mandatory to ensure a better quality of life in patients with such debilitating disorders. Nevertheless, a clear consensus about their management (i.e., surgical or not) is still lacking, leading to an inevitable delay. This review aims to investigate and discuss the main causes of myelopathy in patients with mucopolysaccharidoses, available therapeutic strategies, and the impact and role of surgery on the neurological outcome.
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Abstract
Hereditary myelopathies are an important and likely underappreciated component of neurogenetic disease. While previously distinctions have been made by age of onset, the growing power and availability of high-quality neuroimaging and next-generation sequencing are increasingly expanding classical phenotypes and diminishing the utility of age-based classifications. Increasingly, cases of "atypical" disease presentations are challenging past assumptions regarding the age of onset and survival in many disorders and identifying allelic syndromes in others. Despite this, there is poor awareness of the potential for spinal involvement in many diseases that typically affect the brain. Broadly speaking, congenital myelopathies can be neuroanatomically grouped into motor neuron, axonopathy, spinocerebellar, cerebroleukodystrophy, and pan-neuraxis (generally central nervous system predominant with associated axonopathy) disorders.Here, we review hereditary causes of myelopathy, organized by neuroanatomy, and highlight atypical presentations. We discuss findings concerning an underlying genetic etiology for myelopathy, as well as practical, technical, and ethical considerations of diagnostic genetic testing.
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Affiliation(s)
- Melissa A Walker
- Division of Child Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Cantone M, Lanza G, Le Pira A, Barone R, Pennisi G, Bella R, Pennisi M, Fiumara A. Adjunct Diagnostic Value of Transcranial Magnetic Stimulation in Mucopolysaccharidosis-Related Cervical Myelopathy: A Pilot Study. Brain Sci 2019; 9:brainsci9080200. [PMID: 31416150 PMCID: PMC6721402 DOI: 10.3390/brainsci9080200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/05/2019] [Accepted: 08/10/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cervical myelopathy (CM) is a common cause of morbidity and disability in patients with mucopolysaccharidosis (MPS) and, therefore, early detection is crucial for the best surgical intervention and follow-up. Transcranial magnetic stimulation (TMS) non-invasively evaluates the conduction through the cortico-spinal tract, also allowing preclinical diagnosis and monitoring. METHODS Motor evoked potentials (MEPs) to TMS were recorded in a group of eight patients with MPS-related CM. Responses were obtained during mild tonic muscular activation by means of a circular coil held on the "hot spot" of the first dorsal interosseous and tibialis anterior muscles, bilaterally. The motor latency by cervical or lumbar magnetic stimulation was subtracted from the MEP cortical latency to obtain the central motor conduction time. The MEP amplitude from peak to peak to cortical stimulation and the interside difference of each measure were also calculated. RESULTS TMS revealed abnormal findings from both upper and lower limbs compatible with axonal damage and demyelination in six of them. Notably, a subclinical cervical spinal disease was detected before the occurrence of an overt CM in two patients, whereas TMS signs compatible with a CM of variable degree persisted despite surgery in all treated subjects. CONCLUSIONS TMS can be viewed as an adjunct diagnostic test pending further rigorous investigations.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant'Elia Hospital, ASP Caltanissetta, Via Luigi Russo 6, 93100 Caltanissetta, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95125 Catania, Italy.
- Department of Neurology IC, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018 Troina, Italy.
| | - Alice Le Pira
- Referral Center for Inherited Metabolic Diseases, Department of Clinical and Experimental Medicine, University of Catania. Via Santa Sofia 78, 95125 Catania, Italy
| | - Rita Barone
- Child Neurology and Psychiatry, Department of Clinical and Experimental Medicine, University of Catania, Via Santa Sofia 78, 95125 Catania, Italy
| | - Giovanni Pennisi
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95125 Catania, Italy
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, Section of Neurosciences, University of Catania, Via Santa Sofia 78, 95125 Catania, Italy
| | - Manuela Pennisi
- Department of Biological and Biotechnological Sciences, University of Catania, Via Santa Sofia 78, 95125 Catania, Italy
| | - Agata Fiumara
- Referral Center for Inherited Metabolic Diseases, Department of Clinical and Experimental Medicine, University of Catania. Via Santa Sofia 78, 95125 Catania, Italy
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Adjunct Diagnostic Value of Transcranial Magnetic Stimulation in Mucopolysaccharidosis-Related Cervical Myelopathy: A Pilot Study. Brain Sci 2019. [PMID: 31416150 DOI: 10.3390/brainsci9080200.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cervical myelopathy (CM) is a common cause of morbidity and disability in patients with mucopolysaccharidosis (MPS) and, therefore, early detection is crucial for the best surgical intervention and follow-up. Transcranial magnetic stimulation (TMS) non-invasively evaluates the conduction through the cortico-spinal tract, also allowing preclinical diagnosis and monitoring. METHODS Motor evoked potentials (MEPs) to TMS were recorded in a group of eight patients with MPS-related CM. Responses were obtained during mild tonic muscular activation by means of a circular coil held on the "hot spot" of the first dorsal interosseous and tibialis anterior muscles, bilaterally. The motor latency by cervical or lumbar magnetic stimulation was subtracted from the MEP cortical latency to obtain the central motor conduction time. The MEP amplitude from peak to peak to cortical stimulation and the interside difference of each measure were also calculated. RESULTS TMS revealed abnormal findings from both upper and lower limbs compatible with axonal damage and demyelination in six of them. Notably, a subclinical cervical spinal disease was detected before the occurrence of an overt CM in two patients, whereas TMS signs compatible with a CM of variable degree persisted despite surgery in all treated subjects. CONCLUSIONS TMS can be viewed as an adjunct diagnostic test pending further rigorous investigations.
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An Evidence-based Approach to the Management of Children With Morquio A Syndrome Presenting With Craniocervical Pathology. Spine (Phila Pa 1976) 2018; 43:E1443-E1453. [PMID: 29901537 DOI: 10.1097/brs.0000000000002743] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series OBJECTIVE.: The aim of this study was to review clinical and radiological outcomes of craniovertebral surgery in children with Morquio A syndrome (Mucopolysaccharidosis type IVA) and develop an evidence-based management algorithm. SUMMARY OF BACKGROUND DATA Myelopathy secondary to craniovertebral pathology is a common cause of neurological disability in Morquio A syndrome. Previously unresolved surgical controversies include the value of surveillance, surgical indications, and operative technique. METHODS A retrospective case-based review of children with Morquio A syndrome and craniovertebral pathology seen in a tertiary referral pediatric center from 1992 to 2016 was performed. Patients treated nonoperatively and operatively were included. Medical records and imaging were reviewed to determine clinical and radiological findings at initial assessment, before cervical spine surgery, early postoperative period, and final follow-up. The clinical outcomes of interest were neurological status and mobility at follow-up, complications, and need for further surgery. RESULTS Twenty-seven patients were included. Surgical indications were radiological evidence of cervicomedullary compression alone (six cases) or with clinical evidence of myelopathy (12 cases). Eighteen patients (median age 6.2 years, range 3.5-15.9 years) underwent surgery, with median follow-up of 8.5 years. Occiput to upper cervical spine fusion with C1 decompression was performed in all cases with the addition of autologous calvarial graft in young patients (12 cases) and occipital-cervical plate fixation in older children (six cases). Neurological improvement occurred in 38% of cases but by one functional level only. Six of nine conservatively treated patients remained independent walkers. CONCLUSION Surgery for craniovertebral pathology is required in the majority of children with Morquio A syndrome. Close clinical and radiological surveillance is essential for timely intervention. Occiput to cervical fusion is safe and feasible even in young patients and improves clinical and radiological parameters. LEVEL OF EVIDENCE 4.
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Sampayo-Cordero M, Miguel-Huguet B, Pardo-Mateos A, Moltó-Abad M, Muñoz-Delgado C, Pérez-López J. Agreement between the results of meta-analyses from case reports and from clinical studies regarding the efficacy of laronidase therapy in patients with mucopolysaccharidosis type I who initiated enzyme replacement therapy in adult age: An example of case reports meta-analyses as an useful tool for evidence-based medicine in rare diseases. Mol Genet Metab 2018; 123:69-75. [PMID: 29336994 DOI: 10.1016/j.ymgme.2018.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/04/2018] [Accepted: 01/04/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Case reports might have a prominent role in the rare diseases field, due to the small number of patients affected by one such disease. A previous systematic review regarding the efficacy of laronidase therapy in patients with mucopolysaccharidosis type I (MPS-I) who initiated enzyme replacement therapy (ERT) in adult age has been published. The review included a meta-analysis of 19 clinical studies and the description of eleven case reports. It was of interest to perform a meta-analysis of those case reports to explore the role of such meta-analyses as a tool for evidence-based medicine in rare diseases. METHODS The study included all case reports with standard treatment regimen. Primary analysis was the percentage of case reports showing an improvement in a specific outcome. Only when that percentage was statistically higher than 5%, the improvement was confirmed as such. The outcomes that accomplished this criterion were ranked and compared to the GRADE criteria obtained by those same outcomes in the previous meta-analysis of clinical studies. RESULTS There were three outcomes that had a significant improvement: Urine glycosaminoglycans, liver volume and 6-minute walking test. Positive and negative predictive values, sensitivity and specificity for the results of the meta-analysis of case reports as compared to that of clinical studies were 100%, 88.9%, 75% and 100%, respectively. Accordingly, absolute (Rho=0.82, 95%CI: 0.47 to 0.95) and relative agreement (Kappa=0.79, 95%CI: 0.593 to 0.99) between the number of case reports with improvement in a specific outcome and the GRADE evidence score for that outcome were good. Sensitivity analysis showed that agreement between the meta-analysis of case reports and that of the clinical studies were good only when using a strong confirmatory strategy for outcome improvement in case reports. CONCLUSIONS We found an agreement between the results of meta-analyses from case reports and from clinical studies in the efficacy of laronidase therapy in patients with MPS-I who initiated ERT in adult age. This agreement suggests that combining case reports quantitatively, rather than analyzing them separately or qualitatively, may improve conclusions in the field of rare diseases.
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Affiliation(s)
| | | | | | - Marc Moltó-Abad
- Unit of Rare Diseases, Hospital Vall d'Hebron, Barcelona, Spain
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Williams N, Challoumas D, Ketteridge D, Cundy PJ, Eastwood DM. The mucopolysaccharidoses: advances in medical care lead to challenges in orthopaedic surgical care. Bone Joint J 2017; 99-B:1132-1139. [PMID: 28860391 DOI: 10.1302/0301-620x.99b9.bjj-2017-0487] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/09/2017] [Indexed: 11/05/2022]
Abstract
The mucopolysaccharidoses (MPS) are a group of inherited lysosomal storage disorders with clinical manifestations relevant to the orthopaedic surgeon. Our aim was to review the recent advances in their management and the implications for surgical practice. The current literature about MPSs is summarised, emphasising orthopaedic complications and their management. Recent advances in the diagnosis and management of MPSs include the recognition of slowly progressive, late presenting subtypes, developments in life-prolonging systemic treatment and potentially new indications for surgical treatment. The outcomes of surgery in these patients are not yet validated and some procedures have a high rate of complications which differ from those in patients who do not have a MPS. The diagnosis of a MPS should be considered in adolescents or young adults with a previously unrecognised dysplasia of the hip. Surgeons treating patients with a MPS should report their experience and studies should include the assessment of function and quality of life to guide treatment. Cite this article: Bone Joint J 2017;99-B:1132-9.
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Affiliation(s)
- N Williams
- University of Adelaide, 72 King William St, North Adelaide, Australia
| | - D Challoumas
- Cambridge University Hospitals, Hills Road, Cambridge, CB2 0QQ, UK
| | - D Ketteridge
- University of Adelaide, 72 King William St, North Adelaide, Australia
| | - P J Cundy
- University of Adelaide, 72 King William St, North Adelaide, Australia
| | - D M Eastwood
- Great Ormond St Hospital for Children, London, WC1N 3JH, UK
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Pérez-López J, Morales-Conejo M, López-Rodríguez M, Hermida-Ameijeiras Á, Moltó-Abad M. Efficacy of laronidase therapy in patients with mucopolysaccharidosis type I who initiated enzyme replacement therapy in adult age. A systematic review and meta-analysis. Mol Genet Metab 2017; 121:138-149. [PMID: 28410878 DOI: 10.1016/j.ymgme.2017.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/07/2017] [Accepted: 04/07/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The efficacy of starting enzyme replacement therapy (ERT) in adults with Muchopolysaccharidosis Type I (MPS-I) is controversial. Evaluating the benefits reported by patients initiating ERT with laronidase at adult age might help physicians decide whether the use of ERT in these patients is worthwhile from a clinical point of view. OBJECTIVE To assess every effectiveness variable modified in MPS-I patients who initiated laronidase at adult age. METHODS A systematic search of the literature, from inception to July 2016, was conducted using MEDLINE, EMBASE, CENTRAL and LILACS to identify randomized trials or observational studies including ≥1 MPS-I patients with ERT initiated in adult age (≥18years) and evaluating ERT efficacy. A meta-analysis of studies evaluating the same effectiveness outcome was performed and the evidence was rated according to GRADE criteria. Heterogeneity was assessed by the Chi-squared test and the I-squared statistic. Case reports were excluded from meta-analysis but their main outcomes were separately evaluated. The decrease in urine glycosaminoglycans (uGAGs) levels as patient percentage with reduction in uGAGs and with normalization was the primary outcome. RESULTS Nineteen clinical studies and 12 case reports were selected. ERT decreased uGAG levels (high evidence) and liver volume (high), improved 6-min walking test (6MWT) (moderate) and increased blood anti-ERT antibody levels (high). There was no conclusive results (low or very low evidence) regarding improvement/stabilization of respiratory function, change in shoulder flexion, cardiac improvement/stabilization, improvement in symptoms of nocturnal hypoventilation and sleep apnea, improvement in quality of life, visual acuity, otolaryngologic function, bone mineral density or effectiveness of intrathecal therapy. LIMITATIONS Excluding case reports, there was no study conducted specifically in the target population (ERT ≥18years). Data were from subgroup analyses of selected studies. There was a great heterogeneity between designs and clinical outcomes evaluated. CONCLUSIONS ERT improves uGAGs and liver volume in MPS-I patients initiating therapy as adults, although the putative clinical benefit associated to these improvements is unclear. Moderate evidence was shown for improvement in 6MWT. Systematic review registration number (PROSPERO): 42,016,041,306.
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Affiliation(s)
| | | | | | - Álvaro Hermida-Ameijeiras
- Unit of Inborn Errors of Metabolism, Department of Internal Medicine, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Marc Moltó-Abad
- Unit of Rare Diseases, Hospital Vall d'Hebron, Barcelona, Spain
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Peck SH, Casal ML, Malhotra NR, Ficicioglu C, Smith LJ. Pathogenesis and treatment of spine disease in the mucopolysaccharidoses. Mol Genet Metab 2016; 118:232-43. [PMID: 27296532 PMCID: PMC4970936 DOI: 10.1016/j.ymgme.2016.06.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/03/2016] [Accepted: 06/03/2016] [Indexed: 12/21/2022]
Abstract
The mucopolysaccharidoses (MPS) are a family of lysosomal storage disorders characterized by deficient activity of enzymes that degrade glycosaminoglycans (GAGs). Skeletal disease is common in MPS patients, with the severity varying both within and between subtypes. Within the spectrum of skeletal disease, spinal manifestations are particularly prevalent. Developmental and degenerative abnormalities affecting the substructures of the spine can result in compression of the spinal cord and associated neural elements. Resulting neurological complications, including pain and paralysis, significantly reduce patient quality of life and life expectancy. Systemic therapies for MPS, such as hematopoietic stem cell transplantation and enzyme replacement therapy, have shown limited efficacy for improving spinal manifestations in patients and animal models. Therefore, there is a pressing need for new therapeutic approaches that specifically target this debilitating aspect of the disease. In this review, we examine how pathological abnormalities affecting the key substructures of the spine - the discs, vertebrae, odontoid process and dura - contribute to the progression of spinal deformity and symptomatic compression of neural elements. Specifically, we review current understanding of the underlying pathophysiology of spine disease in MPS, how the tissues of the spine respond to current clinical and experimental treatments, and discuss future strategies for improving the efficacy of these treatments.
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Affiliation(s)
- Sun H Peck
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, United States; Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, United States
| | - Margret L Casal
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, United States
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, United States; Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, United States
| | - Can Ficicioglu
- Division of Human Genetics and Metabolism, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, United States
| | - Lachlan J Smith
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, United States; Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, United States.
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Langereis EJ, van Vlies N, Wijburg FA. Diagnosis, classification and treatment of mucopolysaccharidosis type I. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1016908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jurecka A, Marucha J, Jurkiewicz E, Różdżyńska-Świątkowska A, Tylki-Szymańska A. Enzyme replacement therapy in an attenuated case of mucopolysaccharidosis type I (Scheie syndrome): a 6.5-year detailed follow-up. Pediatr Neurol 2012; 47:461-5. [PMID: 23127271 DOI: 10.1016/j.pediatrneurol.2012.08.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 08/13/2012] [Indexed: 10/27/2022]
Abstract
We present the 6.5-year follow-up of a boy with Scheie syndrome whose therapy was initiated at age 2.5 years. Detailed anthropometric features, echocardiography, ophthalmologic and audiologic examinations, psychologic tests, joint range of motion, skeletal radiographs, ultrasound studies of liver and spleen volumes, urinary glycosaminoglycans, and antibodies were documented. After 6.5 years of enzyme replacement therapy, the patient experienced a decline in overall status, and the disease progressed significantly despite treatment. The patient's height at age 9 was equal to that at age 6. The patient developed heart insufficiency and a deterioration of airway flow. The patient's intelligence quotient remained unchanged, i.e., at the average level of 86 on the Terman-Merill Scale. Magnetic resonance imaging revealed cervical spinal canal stenosis and marked spinal cord compression with myelopathy. A worsening of carpal tunnel syndrome was also evident. Ophthalmologic evaluation revealed increased central corneal thickness and intraocular pressure. In audiologic assessment, the patient's results were similar to those after 3 years of treatment. The only benefit involved temporarily improved passive and active shoulder flexion. Overall, the benefit of enzyme replacement therapy with laronidase on Scheie syndrome appeared minimal.
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Affiliation(s)
- Agnieszka Jurecka
- Department of Metabolic Diseases, Children's Memorial Health Institute, Warsaw, Poland.
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Piller Puicher E, Tomanin R, Salvalaio M, Friso A, Hortelano G, Marin O, Scarpa M. Encapsulated engineered myoblasts can cure Hurler syndrome: preclinical experiments in the mouse model. Gene Ther 2011; 19:355-64. [DOI: 10.1038/gt.2011.94] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Total Hip Arthroplasty in Mucopolysaccharidosis Type IH. Case Rep Orthop 2011; 2011:832439. [PMID: 23259102 PMCID: PMC3504198 DOI: 10.1155/2011/832439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 12/28/2011] [Indexed: 11/17/2022] Open
Abstract
Children affected by mucopolysaccharidosis (MPS) type IH (Hurler Syndrome), an autosomal recessive metabolic disorder, are known to experience a range of musculoskeletal manifestations including spinal abnormalities, hand abnormalities, generalised joint stiffness, genu valgum, and hip dysplasia and avascular necrosis. Enzyme therapy, in the form of bone marrow transplantation, significantly increases life expectancy but does not prevent the development of the associated musculoskeletal disorders. We present the case of a 23-year-old woman with a diagnosis of Hurler syndrome with a satisfactory result following uncemented total hip arthroplasty.
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