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Part I
Amy L. McIntosh, MDPediatric Orthopedic Surgeon
Mayo ClinicRochester, Minnesota
Orthopedic Aspects of Stickler Syndrome
Amy L. McIntosh, MD
Pediatric Orthopedic SurgeonMayo Clinic
Rochester, Minnesota
Stickler Syndrome
• Aka: Hereditary Progressive Arthro-ophthalmopathy
• 1st described (1965): Gunnar Stickler
• Pediatrician
Gunnar B. Stickler
• German born: (June 1925) Peterskirchen, Bavaria.
• Graduated from medical school in Munich (1949)
• Immigrated to US (1951).• Appointed to the staff of the Mayo Clinic
(1957).• Chairman of Pediatrics (1969)• Retired (1989)
What we knew in 1965
• SS inherited in an autosomal dominant pattern.
• Eye findings:• Myopia• Retinal detachment
• Joint findings:• Abnormal development of the articular surface• Premature degenerative changes• hypermobility
What we know today
• Underlying etiology of SS appears to be changes in genes encoding collagen subunits– COL2A1– COL11A1 come together to form collagen
strands– COL11A2
• Collagen strands are the scaffolds for many connective tissues
Cartilage
• Bundles of collagen form together to provide a structure around cells that form cartilage
What does cartilage do in our bodies?
1. Initial model of bones when born• seems to be unaffected in Stickler
Syndrome
2. Growth of bones in children (aka: growth plate)
3. Smooth, lubricating surface in our joints
Cartilage Growth Plate
Femur
Tibia
Growth Plate in Stickler Syndrome
Normal “Stickler”Normal Diagram
Garofalo et al PNAS 1991
Lubrication and Cushioning of Joints
Result – Mild Bone Shape Abnormalities
Round BallRound Socket
(Round) Ball Oval Socket
How does this add up for Stickler Syndrome?
• Spondyloepiphyseal dysplasia
– Spondylo = spine
– Epiphyseal = ends (joints) of bones
– Dysplasia = alteration in shape or structure
What do we know about skeletal changes in Stickler Syndrome?
• Majority of our data comes from the NIH / NHGRI natural history and molecular studies
• Cross sectional study of patients seen at the NIH Clinical Center
Rose: Spine2001
Diagnostic Utility of Skeletal Analysis
Spine
• Analyzed thorocolumbar (chest and low back vertebra) in 53 patients– Age 1-70– 24 families– Correlated findings with back
pain
Scoliosis (30%)
• Abnormal curve of the spine in the frontal plane– Present in 1/3rd of patients– Equally present in children
and adults– Generally mild – only 1/18
patients required surgery
Kyphosis (43%)
• Abnormal rounding of the back
• Present in 43% of patients– Adolescents and adults
• Not associated with back pain
Schmorl’s Nodes /Endplate Abnormalities
Endplate Abnormalities (74%)
• Caused by weakened bone endplates
• Seen in 74% overall– Seem to come with age– Present in 94% of adults
• Associated with back pain
Spondylolysis/Spondylolisthesis (11%)
Spine
• Only one adult patient was free of spine abnormalities
• Back pain present in 2/3rds of patients > 5 yo– Associated with adult age,
endplate abnormalities, and Schmorl’s nodes
Spine: Treatment
What do we make of this?1. Most DO NOT require surgical treatment
2. These findings can help in the recognition and diagnosis of Stickler Syndrome
3. Treatment will be discussed more later.