Артрогрипоз: виды, причины и пренатальная диагностика

Arthrogryposis (AMC) describes congenital joint contracture in two or more areas of the body. It derives its name from Greek, literally meaning 'curving of joints' (arthron, 'joint'; grȳpōsis, late Latin form of late Greek grūpōsis, 'hooking'). Children born with one or more joint contractures have abnormal fibrosis of the muscle tissue causing muscle shortening, and therefore are unable to perform active extension and flexion in the affected joint or joints. AMC has been divided into three groups: amyoplasia, distal arthrogryposis, and syndromic. Amyoplasia is characterized by severe joint contractures and muscle weakness. Distal arthrogryposis mainly involves the hands and feet. Types of arthrogryposis with a primary neurological or muscle disease belong to the syndromic group. Every joint in the body, when affected, displays typical signs and symptoms: for example, the shoulder (internal rotation); wrist (volar and ulnar); hand (fingers in fixed flexion and thumb in palm); hip (flexed, abducted and externally rotated, frequently dislocated); elbow (extension and pronation) and foot clubfoot and less commonly congenital vertical talus. Range of motion can be different between joints because of the different deviations. Some types of arthrogryposis like amyoplasia have a symmetrical joint/limb involvement, with normal sensations.

Research of arthrogryposis has shown that anything that inhibits normal joint movement before birth can result in joint contractures. Myasthenia gravis of the mother leads also in rare cases to arthrogryposis. The major cause in humans is fetal akinesia, however, this is disputed lately.

Research on prenatal diagnosis has shown that a diagnosis can be made prenatally in approximately 50% of fetuses presenting arthrogryposis. It could be found during routine ultrasound scanning showing a lack of mobility and abnormal position of the foetus. Arthrogryposis ectodermal dysplasia other anomalies, also known as Cote Adamopoulos Pantelakis syndrome, Trichooculodermovertebral syndrome, TODV syndrome and Alves syndrome. Arthrogryposis epileptic seizures migrational brain disorder. Arthrogryposis IUGR thoracic dystrophy, also known as Van Bervliet syndrome. Arthrogryposis like disorder, also known as Kuskokwim disease. Arthrogryposis like hand anomaly and sensorineural deafness. Arthrogryposis multiplex congenita CNS calcification. Arthrogryposis multiplex congenita distal (AMCD), also known as X linked spinal muscular atrophy type 2. Gordon syndrome, also known as distal arthrogryposis type 3. Arthrogryposis multiplex congenita, distal type 2A, also known as Freeman–Sheldon syndrome. Arthrogryposis multiplex congenita, distal type 2B, also known as Sheldon–Hall syndrome. Arthrogryposis multiplex congenita neurogenic type (AMCN). This particular type of AMC has been linked to the AMCN gene on locus 5q35. Arthrogryposis multiplex congenita pulmonary hypoplasia, also with a large number of synonyms. Arthrogryposis multiplex congenita whistling face, also known as Illum syndrome. Arthrogryposis multiplex congenita, distal type 1 (AMCD1). Arthrogryposis multiplex with deafness, inguinal hernias, and early death. This syndrome is suspected to be inherited in an X linked or autosomal recessive fashion. Arthrogryposis renal dysfunction cholestasis syndrome, also known as ARC Syndrome. Another form has been related to mutations in the leucine rich glioma inactivated 4 (LGI4) gene.

The treatment of arthrogryposis includes occupational therapy, physical therapy, splinting and surgery. The primary long term goals of these treatments are increasing joint mobility and muscle strength and the development of adaptive use patterns that allow for walking and independence with activities of daily living. Since arthrogryposis has many different types, the treatment varies between patients depending on the symptoms.

Children with the amyoplasia type of arthrogryposis usually have flexion and ulnar deviation of the wrists.

The soft tissue envelope in congenital contractual conditions such as clasped or arthrogrypotic thumbs is often deficient in two planes, the thumb index web and the flexor aspect of the thumb. There is often an appearance of increased skin at the base of the index finger that is part of the deformity. This tissue can be used to resurface the thumb index web after a comprehensive release of all the tight structures to allow for a larger range of motion of the thumb. This technique is called the index rotation flap. The flap is taken from the radial side of the index finger. It is proximally based at the distal edge of the thumb index web. The flap is made as wide as possible, but still small enough to close with the excessive skin on the palmar side of the index finger. The flap is rotated around the tightest part of the thumb to the metacarpophalangeal joint of the thumb, allowing for a larger range of motion.

Generally, foot surgery is usually reserved for patients with a walking or ambulatory potential. Foot surgery may also be indicated to assist brace and orthosis fitting and hence promote supported standing. The most common foot deformity in arthrogryposis is club feet or talipes equinovarus. In the early years of life the serial casting according to the Ponseti method usually yields good results. The Ponseti method can also be used as a first line treatment in older and more resistant cases. In such severe and neglected cases bony surgery in the form of foot osteotomies and arthrodesis is usually indicated. It is usually accompanied by soft tissue surgery in the form of release of contracted tendon and capsular structures. In older patients near skeletal maturity joint fusion or arthrodesis may be indicated as well. Less frequent patients with arthrogryposis may develop congenital vertical talus also known as rocker bottom foot. Similarly, congenital vertical talus is classically managed by serial casting according to the reversed Ponseti method. Resistant or recurrent cases may be offered an extensive soft tissue release. However this is fraught with risk of foot stiffness and pain in the long term. Talectomy or excision of the talus to give room for creation of plantigrade foot has been practiced. Naviculectomy or midtarsal resection arthroplasty represents a less invasive option with satisfactory short term results.

AMC is considered non progressive, so with proper medical treatment things can improve. The joint contractures will not get worse than they are at the time of birth. There is no way to resolve or cure AMC completely but with proper treatment most children make significant improvements in their range of motion and ability to move their limbs, which enables them to carry out daily activities and live relatively normal lives. Therapeutic interventions that are cornerstones in the treatment of AMC include: stretching and range of motion exercises, physical, occupational and speech therapy, splinting and serial casting. Surgical intervention may also improve joint mobility and function. Other positive prognostic factors for independent walking are active hips and knees, hip flexion contractures of less than 20 degrees and knee flexion contractures of less than 15 degrees without severe scoliosis. Congenital clubfoot is the most common single contracture and its prevalence is one in 500 live births.