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Tomonaga S, Yoshimura I, Kanazawa K, Yamamoto T. Arthroscopic ankle arthrodesis in two alkaptonuria patients. BMJ Case Rep 2023; 16:e254300. [PMID: 37880174 PMCID: PMC10603461 DOI: 10.1136/bcr-2022-254300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Abstract
Alkaptonuria is a very rare disorder in which homogentisic acid accumulates due to a deficiency in the activity of homogentisic acid 1,2 dioxygenase. This deficiency results in deposition of a yellowish-brown pigment in connective tissue. Such deposition is termed 'ochronosis' and leads to deterioration in the formation and structure of proteoglycans in hyaline cartilage. These actions lead to fragmentation and rapid destructive arthritis. Often, ochronotic arthritis appears at 40-60 years of age, and many patients are treated symptomatically. Here, we report two patients (three ankles) with ochronotic arthritis who were treated with ankle arthrodesis. In all cases, the postoperative clinical score improved, but the time needed for fusion was prolonged and symptomatic subtalar arthropathy developed in the early postoperative period.
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Affiliation(s)
- Seiya Tomonaga
- Department of Orthopedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Ichiro Yoshimura
- Faculty of Sports and Health Science, Fukuoka University, Fukuoka, Japan
| | - Kazuki Kanazawa
- Department of Orthopedic Surgery, Fukuoka Seisyukai Hospital, Fukuoka, Japan
| | - Takuaki Yamamoto
- Department of Orthopedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Lazaro JS, Lutz R, Deirmengian GK. Bilateral Patellar Tendon Rupture Following Total Knee Arthroplasty in a Patient With Alkaptonuria: A Case Report. Cureus 2023; 15:e38597. [PMID: 37288202 PMCID: PMC10241992 DOI: 10.7759/cureus.38597] [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] [Accepted: 05/05/2023] [Indexed: 06/09/2023] Open
Abstract
Alkaptonuria (AKU) is a rare hereditary disorder of tyrosine degradation. The disorder is characterized by the accumulation of a pigment called homogentisic acid. Its accumulation can lead to the breakdown of connective tissue, including tendons. This report presents a 46-year-old male with a history of bilateral total knee arthroplasty (TKA) who sustained bilateral patellar tendon rupture after an acute injury. A single-stage bilateral knee revision with direct repair of the extensor mechanism augmented with Achilles allograft was performed. The procedure was successful, and the patient had an excellent post-operative outcome at one year post-operatively. This case attempts to highlight the possible complications from AKU in order to better counsel patients with this condition who are undergoing TKA.
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Affiliation(s)
| | - Rex Lutz
- Orthopedic Surgery, Jefferson Health New Jersey, Stratford, USA
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Ding H, Wang L, Feng GJ, Song YM, Liu LM. Case report: Thoracolumbar spinal stenosis associated with alkaptonuria. Front Surg 2023; 9:1040715. [PMID: 36684124 PMCID: PMC9852044 DOI: 10.3389/fsurg.2022.1040715] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/08/2022] [Indexed: 01/07/2023] Open
Abstract
Background Alkaptonuria is a rare autosomal genetic disorder with an incidence of about 1 in 1 million per year. Spinal involvement often manifests in the later stages of the disease. However, this is the first report of the presentation of thoracolumbar spinal stenosis. Case presentation We report the case of a 61-year-old female patient with significant thoracolumbar stenosis symptoms. The patient had obvious kyphosis with preoperative lower extremity muscle strength grade 2/5. Symptoms and imaging signs initially suggested ankylosing spondylitis. This patient was classified into motor incomplete injury (ASIA C). However, the patient was found to have melanin deposits on the sclera and skin, and the urine was darkened at rest. CT and MRI both suggested no bone bridge connection between vertebrae, which was the key difference between ankylosing spondylitis and alkaptonuria in imaging. Most importantly, urine specimen testing and intraoperative pathology demonstrated alkaptonuria. The patient underwent spinal decompression and vertebral body fixation. Postoperative recovery was good: the patient had significantly relieved pain and could stand and walk. Conclusion This case is the first report of thoracolumbar spinal stenosis associated with alkaptonuria involving the spine.
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Dawod MS, Alswerki MN, Darabah AJ, Satari AO, Alrwashdeh AO, Alaqarbeh ZN, Alisi MS. Reverse Total Shoulder Arthroplasty in Alkaptonuric Shoulder: Case Presentation, Review of Literature, and Technical Considerations. Orthop Res Rev 2023; 15:69-77. [PMID: 37091223 PMCID: PMC10115201 DOI: 10.2147/orr.s402214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/06/2023] [Indexed: 04/25/2023] Open
Abstract
Importance Alkaptonuric shoulder arthropathy is a challenging clinical entity in arthroplasty. In this report, we describe an atypical presentation, technical considerations, a literature review, and some recommendations of significant benefits to shoulder surgeons. Objective The author's objective in this report is to illustrate the deleterious metabolic effects of ochronosis on cartilage and the development of early arthritis. Design This is a case report study, done in May 2021. Setting Middle East, Jordan. Introduction Alkaptonuria is a metabolic disease of amino acid metabolism that can affect multiple organ systems, including the musculoskeletal system. The musculoskeletal system manifestations usually involve the spine, knee, and, uncommonly, the shoulder. Tissue ochronosis caused by alkaptonuria can cause significant damage to the joint and surrounding soft tissue envelope. In this case, we presented a patient who has end-stage glenohumeral arthritis and rotator cuff arthropathy secondary to ochronosis. Case Presentation In this case report, we present a 42-year-old male patient who presented to the clinic with severe right shoulder pain and limitations of the range of motion, especially with abduction. The patient underwent radiographic assessment, which showed a rotator cuff arthropathy combined with advanced degenerative changes of the right glenohumeral joint. The patient underwent reverse total shoulder arthroplasty. After the surgery and on follow-up later on for a period of one year and after a period of physiotherapy and rehabilitation, the patient showed remarkable improvement in the pain and range of motion. Conclusion Alkaptonuria can have a detrimental effect on the articular cartilage and the surrounding soft tissue envelope, which might manifest clinically as early degenerative arthritis changes in a young adult patient. Shoulder involvement is extremely rare and can manifest with substantial injury to the glenohumeral joint; whenever such extensive damage is present, shoulder arthroplasty is the best treatment.
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Affiliation(s)
- Moh’d S Dawod
- Mutah University, Faculty of Medicine, Al-karak, Jordan
| | - Mohammad N Alswerki
- Jordan University Hospital, Amman, Jordan
- Correspondence: Mohammad N Alswerki, Jordan University Hospital, Queen Rania Al-Abdullah Street – Aljubeiha / P.O. Box 13046, Amman, 11942, Jordan, Email
| | | | - Anas O Satari
- Mutah University, Faculty of Medicine, Al-karak, Jordan
| | | | | | - Mohammed S Alisi
- Jordan University Hospital, Amman, Jordan
- Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine
- Ministry of Health, Gaza, Palestine
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Bernini A, Spiga O, Santucci A. Structure-Function Relationship of Homogentisate 1,2-dioxygenase: Understanding the Genotype-Phenotype Correlations in the Rare Genetic Disease Alkaptonuria. Curr Protein Pept Sci 2023; 24:380-392. [PMID: 36880186 DOI: 10.2174/1389203724666230307104135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/16/2023] [Accepted: 01/26/2023] [Indexed: 03/08/2023]
Abstract
Alkaptonuria (AKU), a rare genetic disorder, is characterized by the accumulation of homogentisic acid (HGA) in organs, which occurs because the homogentisate 1,2-dioxygenase (HGD) enzyme is not functional due to gene variants. Over time, HGA oxidation and accumulation cause the formation of the ochronotic pigment, a deposit that provokes tissue degeneration and organ malfunction. Here, we report a comprehensive review of the variants so far reported, the structural studies on the molecular consequences of protein stability and interaction, and molecular simulations for pharmacological chaperones as protein rescuers. Moreover, evidence accumulated so far in alkaptonuria research will be re-proposed as the bases for a precision medicine approach in a rare disease.
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Affiliation(s)
- Andrea Bernini
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Italy
| | - Ottavia Spiga
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Italy
| | - Annalisa Santucci
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Italy
- Centro Regionale Medicina di Precisione, Siena, Italy
- ARTES 4.0, Pontedera, Italy
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Grasso D, Geminiani M, Galderisi S, Iacomelli G, Peruzzi L, Marzocchi B, Santucci A, Bernini A. Untargeted NMR Metabolomics Reveals Alternative Biomarkers and Pathways in Alkaptonuria. Int J Mol Sci 2022; 23:ijms232415805. [PMID: 36555443 PMCID: PMC9779518 DOI: 10.3390/ijms232415805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/04/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
Alkaptonuria (AKU) is an ultra-rare metabolic disease caused by the accumulation of homogentisic acid (HGA), an intermediate product of phenylalanine and tyrosine degradation. AKU patients carry variants within the gene coding for homogentisate-1,2-dioxygenase (HGD), which are responsible for reducing the enzyme catalytic activity and the consequent accumulation of HGA and formation of a dark pigment called the ochronotic pigment. In individuals with alkaptonuria, ochronotic pigmentation of connective tissues occurs, leading to inflammation, degeneration, and eventually osteoarthritis. The molecular mechanisms underlying the multisystemic development of the disease severity are still not fully understood and are mostly limited to the metabolic pathway segment involving HGA. In this view, untargeted metabolomics of biofluids in metabolic diseases allows the direct investigation of molecular species involved in pathways alterations and their interplay. Here, we present the untargeted metabolomics study of AKU through the nuclear magnetic resonance of urine from a cohort of Italian patients; the study aims to unravel molecular species and mechanisms underlying the AKU metabolic disorder. Dysregulation of metabolic pathways other than the HGD route and new potential biomarkers beyond homogentisate are suggested, contributing to a more comprehensive molecular signature definition for AKU and the development of future adjuvant treatment.
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Affiliation(s)
- Daniela Grasso
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Michela Geminiani
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Silvia Galderisi
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Gabriella Iacomelli
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Luana Peruzzi
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Barbara Marzocchi
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
| | - Annalisa Santucci
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
- Centro Regionale Medicina di Precisione, 53100 Siena, Italy
- ARTES 4.0, 56025 Pontedera, Italy
| | - Andrea Bernini
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Via A, Moro 2, 53100 Siena, Italy
- Correspondence:
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Khalifa AA, Moustafa MMA, Bakr H, Abdelaal AM. Ipsilateral hip and knee joints ochronotic arthropathy treated by total joint replacement, a case report. BULLETIN OF THE NATIONAL RESEARCH CENTRE 2022; 46:76. [DOI: 10.1186/s42269-022-00764-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/12/2022] [Indexed: 09/01/2023]
Abstract
Abstract
Background
Ochronotic arthropathy affecting the hip and knee joints is one of the musculoskeletal manifestations of alkaptonuria which results from a tyrosine amino acid metabolism disorder. The condition has no definitive management; however, end-stage joint arthritis is well treated by total joint replacement.
Case presentation
We present a case of a healthy male patient who presented with left hip and bilateral knee (more on the left side) progressive pain and limitation of motion how was diagnosed as having advanced arthritis and was treated by total hip and total knee replacement for the left hip and knee joints respectively. Intraoperatively, the tissues had blackish discoloration characterizing ochronosis. This patient was diagnosed as having ochronotic arthropathy based on the intraoperative findings.
Conclusions
Accurate diagnosis of ochronotic arthropathy could only be reached intraoperatively; furthermore, end-stage joint arthritis could be treated efficiently by total joint replacement surgery.
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