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Frizzell K, Kozin SH, Zlotolow DA. Bipolar Latissimus Dorsi Transfer for Arthrogryposis Multiplex Congenita: Minimum 10-Month Follow-Up. J Hand Surg Am 2020; 45:1084.e1-1084.e7. [PMID: 32616410 DOI: 10.1016/j.jhsa.2020.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 03/25/2020] [Accepted: 04/28/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine the outcomes of patients who have undergone bipolar latissimus dorsi transfer for loss of elbow flexion in arthrogryposis multiplex congenita (AMC). METHODS This study retrospectively evaluated 6 cases (5 patients) of bipolar latissimus dorsi transfer performed to restore active elbow flexion in pediatric patients with AMC. Elbow range of motion and strength were evaluated before and after surgery. Functional outcomes were evaluated by the patients' ability to perform activities of daily living. Complications and patient satisfaction were also evaluated at final follow-up. RESULTS The patients were a mean age of 7.8 ± 3 years. The mean follow-up was 30.2 months (range, 10-44 months). At most recent follow-up, all cases reported improved function of the surgical extremity when performing activities of daily living and overall satisfaction. The postoperative active range of motion was 76° ± 14°. All cases had active elbow flexion against gravity. One patient was noted to have decreased muscle activation of the transfer 6 months after surgery, but strength improved by the 10-month follow-up. No other complications were noted. CONCLUSIONS We recommend bipolar latissimus dorsi transfer as a reliable option to restore functional elbow flexion in patients with AMC. Meticulous pedicle handling and assessment of the latissimus dorsi viability is paramount. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Kaela Frizzell
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA.
| | - Scott H Kozin
- Department of Orthopaedic Surgery, Shriners Hospital for Children Philadelphia, Philadelphia, PA
| | - Dan A Zlotolow
- Department of Orthopaedic Surgery, Shriners Hospital for Children Philadelphia, Philadelphia, PA
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Desai D, Stiene D, Song T, Sadayappan S. Distal Arthrogryposis and Lethal Congenital Contracture Syndrome - An Overview. Front Physiol 2020; 11:689. [PMID: 32670090 PMCID: PMC7330016 DOI: 10.3389/fphys.2020.00689] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/27/2020] [Indexed: 12/20/2022] Open
Abstract
Distal arthrogryposis (DA) is a skeletal muscle disorder which can be classified under a broader term as Arthrogryposis multiplex contractures. DA is characterized by the presence of joint contractures at various parts of the body, particularly in distal extremities. It is identified as an autosomal dominant and a rare X-linked recessive disorder associated with increased connective tissue formation around joints in such way that immobilizes muscle movement causing deformities. DA is again classified into various types since it manifests as a range of conditions representing different etiologies. Myopathy is one of the most commonly listed etiologies of DA. The mutations in sarcomeric protein-encoding genes lead to decreased sarcomere integrity, which is often associated with this disorder. Also, skeletal disorders are often associated with cardiac disorders. Some studies mention the presence of cardiomyopathy in patients with skeletal dysfunction. Therefore, it is hypothesized that the congenitally mutated protein that causes DA can also lead to cardiomyopathy. In this review, we will summarize the different forms of DA and their clinical features, along with gene mutations responsible for causing DA in its different forms. We will also examine reports that list mutations also known to cause heart disorders in the presence of DA.
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Affiliation(s)
- Darshini Desai
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Danielle Stiene
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Taejeong Song
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Sakthivel Sadayappan
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
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James MA, Millar KL, Manske MC, Van Heest AE. Posterior Elbow Capsulotomy and Triceps Lengthening for Elbow Extension Contracture in Children with Arthrogryposis Multiplex Congenita. JBJS Essent Surg Tech 2020; 10:ST-D-19-00030. [PMID: 32368405 DOI: 10.2106/jbjs.st.19.00030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Posterior elbow capsulotomy plus triceps lengthening facilitates passive elbow flexion in children with arthrogryposis multiplex congenita, allowing independent function for activities of daily living, such as feeding and self-care of the face and hair. Description The posterior aspect of the distal end of the humerus and the olecranon are identified by palpation and exposed via a curvilinear incision over the posterior aspect of the elbow. Identifying the osseous landmarks can be challenging in some patients. The ulnar nerve is identified and protected. The triceps tendon is isolated, and z-lengthening is performed. Next, the posterior elbow capsule is incised proximal to the tip of the olecranon to expose the joint surface, and the arthrotomy is continued incrementally along the medial and lateral capsule until elbow flexion increases by ≥40°, or past 90° (maximum, 120°), with contact between the lengthened ends of the triceps tendon for repair. The triceps tendon is then repaired in the elongated position. After the wound is closed, the elbow is placed in flexion and immobilized in a cast. Alternatives Alternative treatments include passive stretching exercises to increase elbow flexion. Rationale Elbow extension contractures result in substantial limitations in the activities of daily living for children with arthrogryposis multiplex congenita. Those who fail to attain at least 90° of elbow flexion with passive stretching in the first year of life benefit from posterior elbow release and triceps lengthening. In addition, children with <30° of passive elbow flexion are at risk of developing valgus instability of the elbow from passive flexion exercises because the axis of rotation of the elbow is difficult to detect. Once passive elbow flexion is attained, such children may be candidates for tendon transfers allowing active elbow flexion.
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Affiliation(s)
- Michelle A James
- Shriners Hospital for Children-Northern California, Sacramento, California.,University of California Davis School of Medicine, Sacramento, California
| | - Kelsey L Millar
- University of California Davis School of Medicine, Sacramento, California
| | - M Claire Manske
- Shriners Hospital for Children-Northern California, Sacramento, California.,University of California Davis School of Medicine, Sacramento, California
| | - Ann E Van Heest
- Shriners Hospital for Children-Twin Cities, Minneapolis, Minnesota.,Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Richards C, Ramirez R, Kozin S, Zlotolow D. The Effects of Age on the Outcomes of Elbow Release in Arthrogryposis. J Hand Surg Am 2019; 44:898.e1-898.e6. [PMID: 30660396 DOI: 10.1016/j.jhsa.2018.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 10/03/2018] [Accepted: 11/23/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The goal of this study was to observe the effects of posterior elbow release on children with arthrogryposis at various age points: before the age of 2, between the ages of 2 and 3, and after the age of 3. METHODS This study was a retrospective chart review of patients with arthrogryposis who underwent a posterior elbow release for an elbow extension contracture between 2007 and 2014 at one institution. Eighteen procedures in 13 patients, who had a minimum follow-up of at least 2 years, were included in the study. Patients were divided into 3 groups based on their age at the time of surgery: <2 years old, 2-3 years old, and >3 years old. Comparisons of the pre- and postoperative passive arcs of motion were made. RESULTS The average preoperative arc of motion was 16° (0° to 30°) for the children younger than 2, 33.5° (5° to 60°) for the children 2-3, and 45° (25° to 80°) for the children older than 3. The average postoperative arc of motion was 88.2° (70° to 103°), 60° (15° to 85°), and 54.33° (23° to 70°) for the respective age groups. There was a clinically important difference in the postoperative arc of motion between the children less than 2 years old and both the children 2-3 years old and older than 3 years. CONCLUSIONS This study demonstrates that children who underwent posterior elbow release before the age of 2 had a clinically important increase in their postoperative flexion and overall passive arc of elbow motion compared with older children at medium-term follow-up. The data suggest that earlier release may be better at restoring total passive arc of elbow motion. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
| | | | - Scott Kozin
- Shriner's Hospital for Children of Philadelphia, Philadelphia, PA
| | - Dan Zlotolow
- Shriner's Hospital for Children of Philadelphia, Philadelphia, PA
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Rodriguez LM, Bickley C, Russo S, Barnes D, Gagnon M, Hamdy R, Veilleux LN. Perspectives on gait and motion analysis in the management of youth with arthrogryposis multiplex congenita. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 181:404-409. [PMID: 31359604 DOI: 10.1002/ajmg.c.31728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/09/2019] [Accepted: 07/14/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Luisa M Rodriguez
- Motion Analysis Center, Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania, United-States
| | - Christina Bickley
- Motion Analysis Center, Shriners Hospitals for Children-Houston, Houston, Texas, United-States.,Texas Woman's University, School of Physical Therapy, Houston, Texas, United-States
| | - Stephanie Russo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center-Hamot, Erie, Pennsylvania, United-States
| | - Douglas Barnes
- Motion Analysis Center, Shriners Hospitals for Children-Houston, Houston, Texas, United-States
| | - Marianne Gagnon
- Motion Analysis Center, Shriners Hospitals for Children-Canada, Montréal, Quebec, Canada.,Department of Surgery, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
| | - Reggie Hamdy
- Motion Analysis Center, Shriners Hospitals for Children-Canada, Montréal, Quebec, Canada.,Department of Surgery, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
| | - Louis-Nicolas Veilleux
- Motion Analysis Center, Shriners Hospitals for Children-Canada, Montréal, Quebec, Canada.,Department of Surgery, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
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Ramirez RN, Richards CJ, Kozin SH, Zlotolow DA. Combined Elbow Release and Humeral Rotational Osteotomy in Arthrogryposis. J Hand Surg Am 2017; 42:926.e1-926.e9. [PMID: 28716382 DOI: 10.1016/j.jhsa.2017.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 05/08/2017] [Accepted: 06/07/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to determine if a simultaneous posterior elbow release and humeral osteotomy to correct both the elbow extension contracture and the humeral internal rotation contracture in children with arthrogryposis can produce similar results as a posterior elbow release alone. METHODS This study was a retrospective chart review of consecutive patients with arthrogryposis treated surgically for elbow extension contracture between 2007 and 2014. A total of 43 procedures in 36 patients had adequate available follow-up data and were included in the study. The postoperative range of motion reported was measured at the early follow-up (3-6 months), midterm follow-up (between 1 and 2 years), and the most recent long-term follow-up (after 2 years) from the date of surgery. Patients were grouped into 2 groups (simultaneous and release) based on the necessity of performing an ipsilateral humeral rotation osteotomy at the time of the release. RESULTS At early follow-up, patients in both groups increased their total arc of motion. There was a significant difference in extension and arc of motion at midterm follow-up (between 1 and 2 years) between the simultaneous and the release groups with the simultaneous group significantly losing both terminal extension and total arc of motion. At more than 2 years follow-up, there remained a statistically significant difference in arc of motion, with the release group having a significantly larger arc of motion. Patients who underwent dual plating had a much larger arc of motion at early follow-up than the K-wire or single-plate fixation group, despite having similar preoperative extension, flexion, and arc of motion. This difference was also significant at late follow-up. CONCLUSIONS Patients with posterior release alone had significantly greater improvement in total arc of motion and significantly better elbow extension than patients who underwent a simultaneous humeral osteotomy. However, rigid fixation with early mobilization may yield results comparable with the release alone group. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Rey N Ramirez
- Department of Orthopaedics, Cooper University Hospital, Camden, NJ
| | | | - Scott H Kozin
- Shriners Hospital for Children of Philadelphia, Philadelphia, PA
| | - Dan A Zlotolow
- Shriners Hospital for Children of Philadelphia, Philadelphia, PA
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Distal Humerus External Rotation Osteotomy for Hand Position in Arthrogryposis. J Hand Surg Am 2017; 42:473.e1-473.e7. [PMID: 28389082 PMCID: PMC5494597 DOI: 10.1016/j.jhsa.2017.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/13/2017] [Accepted: 03/01/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE In the amyoplasia type of arthrogryposis, a reverse pronated grasp pattern is often seen. We hypothesized that repositioning the hands, through distal humerus external rotation osteotomies (DHO), would allow for palm-to-palm grasp without arm cross-over and would improve function and parent/patient satisfaction. METHODS The medical records of all patients treated surgically for arthrogryposis were reviewed at the Shriners Hospital for Children, St. Louis, MO. From 2012 to 2014, 9 patients (14 extremities) had undergone a DHO. All patients had preoperative and postoperative video recordings of functional activities and we assessed functional changes after osteotomies. Preoperative upper extremity position was graded as 1, palms facing midline; 2, palm facing posterior; and 3, palms facing away from midline. Postoperative Pediatric Outcomes Data Collection Instrument (PODCI) questionnaires were obtained and parent satisfaction was evaluated. RESULTS Mean patient age at the time of surgery was 6.5 years. Five patients underwent bilateral DHOs. All patients had 3 or fewer additional procedures on an upper extremity during the study period. All patients had an improved resting posture of the upper extremity after DHO surgery, with a mean change of 51° (range, 15°-90°). Grasp pattern was altered in 13 extremities; there was a change in hand position of at least 1 grade and 5 had complete change from 3 to 1, palms facing away from midline to facing toward midline. There was a wide range in postoperative PODCI scores for function, but Happiness scores were high, mean 89 (range, 60-100). Parents universally stated the procedure improved the child's function "a great deal." There were 2 complications: 1 periprosthetic humerus facture with recurrence of the internal rotation and 1 patient with scarring of the triceps requiring tenolysis. CONCLUSIONS The DHO is an effective procedure for correcting the internal rotation position of the upper extremity in arthrogryposis and the surgery improves hand opposition with minimal complications. Universally, there was perceived improved function with high postoperative PODCI Happiness scores. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Kowalczyk B, Feluś J. Arthrogryposis: an update on clinical aspects, etiology, and treatment strategies. Arch Med Sci 2016; 12:10-24. [PMID: 26925114 PMCID: PMC4754365 DOI: 10.5114/aoms.2016.57578] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 03/04/2014] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jarosław Feluś
- Department of Orthopedics, University Children's Hospital, Krakow, Poland
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Zlotolow DA, Tiedeken NC. Reorientation osteotomy for the atypical clasp thumb in children with arthrogryposis. Tech Hand Up Extrem Surg 2014; 18:165-169. [PMID: 25111762 DOI: 10.1097/bth.0000000000000059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Congenital thumb contractures are a well described but complex deformity to manage. Thumb contractures are common in patients with arthrogryposis. Many patients with arthrogryposis develop a supination, adduction, and flexion contracture at the thumb carpometacarpal join. Despite some thumb function, their thumb position and contracted first webspace precludes effective pinch or grasp, with the thumb opposing only to the palmar space. An extension, reorientation metacarpal osteotomy that places thumb in an efficient position has the potential to improve function in of these patients. This report provides a new classification system for congenital thumb deformities that can dictate management based upon thumb joint positions. We describe a previously unreported, arthrogrypotic thumb contracture that can be managed with an extension/pronation metacarpal osteotomy with simultaneous widening of the first webspace.
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Affiliation(s)
- Dan A Zlotolow
- *Shriners Hospitals for Children †Albert Einstein Medical Center, Philadelphia, PA
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Du J, Aichmair A, Lykissas M, Girardi F. Cervical stenosis in a patient with arthrogryposis: case report. EVIDENCE-BASED SPINE-CARE JOURNAL 2014; 5:57-62. [PMID: 24715873 PMCID: PMC3969424 DOI: 10.1055/s-0034-1368669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 12/16/2013] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Jerry Du
- Weill Cornell Medical College, New York, New York, United States
| | - Alexander Aichmair
- Department of Spine and Scoliosis Surgery, Hospital for Special Surgery, New York, New York, United States
| | - Marios Lykissas
- Department of Spine and Scoliosis Surgery, Hospital for Special Surgery, New York, New York, United States
| | - Federico Girardi
- Weill Cornell Medical College, New York, New York, United States ; Department of Spine and Scoliosis Surgery, Hospital for Special Surgery, New York, New York, United States
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