Dominant Multiple Epiphyseal Dysplasia

NORD gratefully acknowledges Robert P. Stanton, MD, FACS, Department of Orthopedics, Nemours Children's Clinic, and R. Curtis Rogers, MD, Senior Clinical Geneticist, Greenwood Genetic Center-Greenville Office, for assistance in the preparation of this report.

Synonyms of Dominant Multiple Epiphyseal Dysplasia

MED
AD-MED
Autosomal Dominant Multiple Epiphyseal Dysplasia
dMED

Subdivisions of Dominant Multiple Epiphyseal Dysplasia

Multiple Epiphyseal Dysplasia Type 1 (EDM1)
Multiple Epiphyseal Dysplasia Type 2 (EDM2)
Multiple Epiphyseal Dysplasia Type 3 (EDM3)
Multiple Epiphyseal Dysplasia Type 5 (EDM5)
Multiple Epiphyseal Dysplasia Type 6 (EDM6)

General Discussion

Summary

Dominant multiple epiphyseal dysplasia is a general term for a group of genetic disorders characterized by skeletal malformations (dysplasia) including those affecting bones of the hands, feet, and knees. Joint pain, particularly of the hips or knees, is also common and often develops during childhood. Initial signs may include pain in the hips and knees following exercise. Progressive joint disease, particularly of the large weight-bearing bones, is common. Dominant multiple epiphyseal dysplasia is caused by mutations in certain genes. Five different genes are known to cause the disorder.

Introduction

Multiple epiphyseal dysplasia is a broad term for a group of disorders characterized by abnormal development of the bone and cartilage of the epiphyses, which are the rounded ends or “heads” of the long bones of the arms or legs. In the past, the disorder was subdivided into the milder Ribbing type and the more severe Fairbank type. These terms are no longer used. Researchers now know that multiple epiphyseal dysplasia represents a group or family of at least six disorders that are separated by the underlying genetic mutation that causes each subtype. Most subtypes are inherited in an autosomal dominant manner. One form, multiple epiphyseal dysplasia type 4, is inherited in an autosomal recessive manner. (NORD has a separate report on this disorder.)

Signs & Symptoms

The specific signs and symptoms of these disorders can vary from one person to another, even among those with the same subtype. Onset is usually in early childhood. Pain in the hips and knees following exercise is usually the initial sign of these disorders. Affected children may fatigue easily. Some affected children develop a waddling manner of walking (abnormal gait). Growth deficiency occurs in childhood and some children may be short for their age (mild to moderate short stature). Adult height is usually normal, but in the shorter range. An individual’s arms and legs may be short in comparison to the torso, which can become apparent during childhood. These growth features may be mild and difficult to appreciate.

Some young children may exhibit low muscle tone and reduced muscle strength (muscular hypotonia), knee and finger joints that stretch farther than normal (hypermobility), and restricted movement of the elbows.

Affected individuals also experience early onset of inflammation, pain and stiffness in affected joints (early-onset arthritis) that can develop into chronic joint pain (arthralgia). Joint problems can begin as early as 5 or 6 years of age, but is more likely to occur in the 30s. Multiple joints may be affected, particularly in adolescents. The knees and hips are commonly affected and deformation of the hips may occur. Joint pain is usually worse after physical exercise. Pain and loss of motion in the shoulders may occur in adulthood. Some individuals develop deformity or rigidity of affected joints due to shortening or hardening of muscles, tendons or other tissue (contractures). In severe cases, progressive joint damage can potentially result in significant disability and the need for joint replacement in the 30s or 40s.

In rare cases, additional symptoms may occur including a hip deformity in which the thigh bone is angled toward the center of the body (cox vara), bowed legs (genu varum), and ‘knock knees’ (genu valgum), a condition in which the legs bend inward so that when a person is standing the knees will touch even if the ankles and feet are apart. Another rare finding, known as a double-layered or double patella, may be associated with certain forms of dominant multiple epiphyseal dysplasia. The patella, or the kneecap, is the triangular bone that protects the front of the knee joint. A double patella has two bony (osseous) layers instead of one with cartilage in between. A double patella may not be associated with any symptoms (asymptomatic) or may lead to frequent dislocations, knee pain, and potentially functional disability of the knee.

Causes

Dominant multiple epiphyseal dysplasia is caused by a mutation in specific genes. Genes provide instructions for creating proteins that play a critical role in many functions of the body. When a mutation of a gene occurs, the protein product may be faulty, inefficient, or absent. Depending upon the functions of the particular protein, many organ systems of the body can be affected.

Genetic diseases are determined by the combination of genes for a particular trait that are on the chromosomes received from the father and the mother. Dominant genetic disorders occur when only a single copy of an abnormal gene is necessary for the appearance of the disease. The abnormal gene can be inherited from either parent, or can be the result of a new mutation (gene change) in the affected individual. The risk of passing the abnormal gene from affected parent to offspring is 50% for each pregnancy regardless of the sex of the resulting child.

Dominant multiple epiphyseal dysplasia type 1 is caused by mutations in the cartilage oligomeric matrix protein (COMP) gene. The majority of cases (more than 70%) of multiple epiphyseal dysplasia are caused by mutations in the COMP gene. Investigators have determined that the gene is located on the short arm (p) of chromosome 19 (19p13.11). Chromosomes, which are present in the nucleus of human cells, carry the genetic information for each individual. Human body cells normally have 46 chromosomes. Pairs of human chromosomes are numbered from 1 through 22 and the sex chromosomes are designated X and Y. Males have one X and one Y chromosome and females have two X chromosomes. Each chromosome has a short arm designated “p” and a long arm designated “q”. Chromosomes are further sub-divided into many bands that are numbered.

Dominant multiple epiphyseal dysplasia type 2 is caused by mutations in the collagen type IX alpha-2 (COL9A2) gene. The gene is located on the short arm of chromosome 1 (1p34.2).

Dominant multiple epiphyseal dysplasia type 3 is caused by mutations in the collagen type IX alpha-3 (COL9A3) gene. The gene is located on the long arm 20q13.33.

Dominant multiple epiphyseal dysplasia type 5 gene is caused by mutations in the matrilin 3 (MATN3) gene. The gene is located on the short arm of chromosome 2 (2p24.1).

Dominant multiple epiphyseal dysplasia type 6 is caused by mutations in the collagen type IX alpha-1 (COL9A1) gene. The gene is located on the long arm of chromosome 6 (6q13).

The COMP and MATN3 genes create (encode) proteins that are found in the extracellular matrix, which is a network of tissue that provides support to cells. The proteins encoded by these genes are found in the part of the extracellular matrix surrounding cells that make up the ligaments or tendons, as well as nearby cartilage-forming cells known as chondrocytes. The exact functions of these proteins are not fully understood.

The COL9A2, COL9A3, and COL9A1 genes create (encode) various parts of type IX collagen, a protein that is essential to the development and strengthening of connective tissue. Connective tissue, which is the material between cells of the body, is made up of collagen of which there are several different varieties found in the body. Type IX collagen is an important part of cartilage.

Researchers have determined that the progression and severity of dominant multiple epiphyseal dysplasia may vary based upon the gene involved and the specific mutation present in a gene as well as the specific location of the mutation in the gene. This is known as genotype-phenotype correlation. For example, the three genes associated with type IX collagen are more likely to have severe joint involvement with the knees, while the hips are spared or only mildly affected. MATN3 mutations are associated with hip abnormalities that are more severe than those seen in individuals with a COL9A2 mutation, but less severe than those seen in individuals in a COMP mutation. Significant involvement of the head of the thigh bone (femoral epiphysis) is more likely with COMP mutations than other mutations. Researchers are studying these disorders to further understand the specific genotype-phenotype correlations.

Although five different genes known to cause dominant multiple epiphyseal dysplasia, many cases cannot be linked to any of these genes suggesting that additional, as-yet-unidentified genes may also cause the disorder. The known genes are estimated to account for less than half of the overall cases of this disorder.

Affected Populations

Dominant multiple epiphyseal dysplasia affects males and females in equal numbers. The exact incidence and prevalence is unknown, but multiple epiphyseal dysplasia, collectively, has been estimated to occur in approximately 1 in 20,000 people in the general population. Because some cases go undiagnosed or misdiagnosed, determining the true frequency these disorders in the general population is difficult. Dominant multiple epiphyseal dysplasia type 1 accounts for approximately 70% of cases. Gene alterations of MATN3 are seen in roughly 20% of molecularly diagnosed cases and alterations of the three different COL9 genes account for another 10%.

Related Disorders

Symptoms of the following disorders can be similar to those of dominant multiple epiphyseal dysplasia. Comparisons may be useful for a differential diagnosis.

Skeletal dysplasias (osteochondrodysplasias) are a general term for a group of disorders characterized by abnormal growth or development or cartilage and bone. Some forms cause life-threatening complications shortly after birth, while others are only may or may not cause life-threatening complications. Some forms do not cause life-threatening complications early in life. Skeletal dysplasias can be associated with short-limbed short stature or with more proportional shortening of the trunk and limbs. Various additional abnormalities may be present depending upon the specific disorder. There are approximately 500 types of skeletal dysplasias with more than 300 causative genes.

Pseudoachondroplasia is a rare genetic disorder characterized by delayed growth, a waddling manner of walking (waddling gait), and joint disease, particularly in the large joints of the legs. Affected individuals may be shorter than normal (short stature) with shortened arms and legs (short-limbed dwarfism). Affected individuals may have loose ligaments and certain joints may be able to be stretched to greater degree than normal. Joint disease is progressive and can cause joint pain and degeneration of affected joints (osteoarthritis). Some individuals exhibit abnormal curvature of the spine (scoliosis). Pseudoachondroplasia is caused by a mutation in the same gene that causes dominant multiple epiphyseal dysplasia type 1 (allelic disorders). These disorders are part of a spectrum of disease involving the COMP gene. Pseudoachondroplasia is the severe end of the spectrum. Pseudoachondroplasia is inherited in an autosomal dominant manner. (For more information on this disorder, choose “pseudoachondroplasia” as your search term in the Rare Disease Database.)

Recessive multiple epiphyseal dysplasia (rMED) is a rare genetic disorder characterized by skeletal malformations (dysplasia) including those affecting bones of the hands, feet, and knees. Joint pain, particularly of the hips or knees, is also common and develops during childhood. Affected individuals may exhibit additional abnormalities such as mild sideways curvature of the spine (scoliosis). Certain malformations such as clubfoot can be present at birth (congenital). rMED is caused by mutations in the SLC26A2 gene. This gene is also known as the diastrophic dysplasia sulfate transport or DTDST gene. The term ‘recessive’ in the disorder’s name refers to the how the disorder is inherited (autosomal recessive inheritance). The disorder is also known as multiple epiphyseal dysplasia type 4. (For more information on this disorder, choose “recessive multiple epiphyseal dysplasia” as your search term in the Rare Disease Database.)

Legg-Calvé-Perthes disease (LCPD) is one of a group of disorders known as the osteochondroses. The Osteochondroses typically are characterized by degeneration (avascular necrosis) and subsequent regeneration of the growing end or ‘head’ of a long bone (epiphyses). In Legg-Calvé-Perthes disease, the growing end (epiphysis) of the upper portion (capital) of the thigh bone (femur) is affected. Researchers believe that an unexplained interruption of the blood supply (ischemia) to the capital femoral epiphysis results in degeneration (avascular necrosis) and deformity of the thigh bone in this area. Symptoms may include a limp with or without pain in the hip, knee, thigh, and/or groin; muscle spasms; delayed maturation of the femur (delayed bone age); mild short stature; and/or limited movements of the affected hip. The disease process seems to be self-limiting as new blood supplies are established (revascularization) and new healthy bone forms (reossifies) in the affected area. Most cases of Legg-Calvé-Perthes disease occur randomly for no apparent reason (sporadically). (For more information on this disorder, choose “Legg-Calvé-Perthes disease” as your search term in the Rare Disease Database.)

Meyer dysplasia is a rare condition that primarily affects the epiphyses of the thigh bone (femur) in young children. Meyer dysplasia may not cause any symptoms (asymptomatic), but can result in pain in both hips and cause young children to limp. Affected children may have limited range of motion in the hips and a waddling gait. In most cases, both hips are affected. The disorder usually begins during the second year of life and often resolves without treatment by the age of six. During this time the epiphyses continue to grow and unify. It is important to distinguish Meyer dysplasia from more serious causes of hip dysplasia. Many cases do not require treatment. In some cases, flattening of the epiphyses of the femur (femoral head) occurs and may possibly represent a mild form of multiple epiphyseal dysplasia.

Diagnosis

A diagnosis of dominant multiple epiphyseal dysplasia is based upon identification of characteristic symptoms, a detailed patient history, a thorough clinical evaluation and a variety of specialized tests. The disorder may be suspected in individuals with joint pain, particularly in the hips and knees, skeletal malformation of the hands, feet and knees, and scoliosis.

Clinical Testing and Workup
Basic x-rays (radiographs) can help to establish a diagnosis by revealing abnormal epiphyses and other characteristic skeletal findings.

Molecular genetic testing can support a diagnosis of multiple epiphyseal dysplasia. Molecular genetic testing can detect mutations in the specific genes known to cause the disorder, but it is only available as a diagnostic service at specialized laboratories.

Standard Therapies

Treatment
Treatment is directed toward the specific symptoms that are apparent in each individual. Treatment may require the coordinated efforts of a team of specialists. Pediatricians, specialists in diagnosing and treating skeletal disorders (orthopedists and orthopedic surgeons), rheumatologists, physical therapists and other healthcare professionals may need to systematically and comprehensively plan an affect child’s treatment. Genetic counseling may be of benefit for affected individuals and their families. Psychosocial support for the entire family is essential as well.

Standard physical therapy, which can improve joint motion and avoid muscle degeneration (atrophy), is beneficial. Physical therapy in a pool (hydrotherapy) can be beneficial for individuals with arthritis. Pain management can be challenging. Cautious use of pain (analgesic) medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended.

In some cases, surgery may be necessary to achieve better positioning and to increase the range of motion in certain joints. Surgery may be necessary to treat malformation of the hips and, in some cases, total hip replacement surgery (total hip arthroplasty) may be necessary. Surgical procedures may be recommended to treat abnormalities of the knee.

Investigational Therapies

A registry for skeletal dysplasias has been set up at the University of California Los Angeles. A registry is a special database that contains information about individuals with a specific disorder or group of conditions. The collection of data about rare disorders may enable researchers to increase the understanding of such disorders, expand the search for treatments, and accelerate clinical trials into specific treatment options. For more information, contact:

International Skeletal Dysplasia Registry
UCLA
615 Charles E. Young Drive, South RM 410
Los Angeles CA 90095-7358
Phone: 310-825-8998
Website: http://isdr.csmc.edu/

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Toll-free: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, in the main, contact:

www.centerwatch.com

For more information about clinical trials conducted in Europe, contact: https://www.clinicaltrialsregister.eu/

Resources

Please note that some of these organizations may provide information concerning certain conditions potentially associated with this disorder.

Supporting Organizations

European Skeletal Dysplasia Network
- Institute of Genetic Medicine
- Newcastle University
- Newcastle upon Tyne, NE1 3BZ United Kingdom
- Phone: 441612755642
- Email: info@esdn.org
- Website: http://www.esdn.org
Genetic and Rare Diseases (GARD) Information Center
- PO Box 8126
- Gaithersburg, MD 20898-8126
- Phone: (301) 251-4925
- Toll-free: (888) 205-2311
- Website: http://rarediseases.info.nih.gov/GARD/
Human Growth Foundation
- 997 Glen Cove Avenue
- Suite 5
- Glen Head, NY 11545
- Phone: (516) 671-4041
- Toll-free: (800) 451-6434
- Email: hgf1@hgfound.org
- Website: http://www.hgfound.org/
Restricted Growth Association
- PO Box 5137
- Yeovil, BA20 9FF United Kingdom
- Phone: (300) 111-1970
- Email: office@restrictedgrowth.co.uk
- Website: http://www.restrictedgrowth.co.uk

References

TEXTBOOKS
Mankin HJ, Mankin KP, eds. Multiple Epiphyseal Dysplasias. In: Rare Genetic Disorders that Affect the Skeleton. AuthorHouse, LLC, Bloomington, IN; 2013:88-95.

Jones KL, Jones MC, del Campo Casanelles, eds. Multiple Epiphyseal Dysplasia. In: Smith’s Recognizable Patterns of Human Malformation. 7th ed. Elsevier Saunders, Philadelphia, PA; 2013:494-495.

JOURNAL ARTICLES
Seo SG, Song HR, Kim HW, et al. Comparison of orthopaedic manifestations of multiple epiphyseal dysplasia caused by MATN3 versus COMP mutations: a case control study. BMC Musculoskelet Disord. 2014;15:84. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3984757/

Jackson GC, Mittaz-Cettrol L, Taylor JA, et al. Pseudoachondroplasia and multiple epiphyseal dysplasia: a 7-year comprehensive analysis of the know disease genes identify novel and recurrent mutations and provides an accurate assessment of their relative contribution. Hum Mutat. 2012;33:144-157. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3272220/

Kim OH, Park H, Seong MW, et al. Revisit of multiple epiphyseal: ethnic difference in genotypes and comparison of radiographic features linked to the COMP and MATN3 genes. Am J Med Genet A. 2011;155A:2669-2680. http://www.ncbi.nlm.nih.gov/pubmed/21965141

Warman ML, Cormier-Daire V, Hall C, et al. Nosology and classification of genetic skeletal disorders: 2010 revision. Am J Med Genet A. 2011;155:943-968. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3166781/

Dahlqvist J, Orlen H, Matsson H, et al. Multiple epiphyseal dysplasia. Acta Orthop. 2009;80:711-715. www.ncbi.nlm.nih.gov/pmc/articles/PMC2823319/

Nakashima E, Ikegawa S, Ohashi H, Kimizuka M, Nishimura G. Double-layered patella in multiple epiphyseal dysplasia is not exclusive to DTDST mutation. Am J Med Genet A. 2005;133A-106-107. http://www.ncbi.nlm.nih.gov/pubmed/15633184/

Jakkula E, Makitie O, Czarny-Ratajczak M, et al. Mutations in the known genes are not the major cause of MED; distinctive phenotypic entities among patients with no identified mutations. Eur J Hum Genet. 2005;13:292-301. http://www.ncbi.nlm.nih.gov/pubmed/15523498

Briggs MD, Chapman KL. Pseudoachondroplasia and multiple epiphyseal dysplasia: mutation review, molecular interactions, and genotype to phenotype correlations. Hum Mutat. 2002;19:465-478. http://www.ncbi.nlm.nih.gov/pubmed/11968079/

Czarny-Ratajczak M, Lohiniva J, Rogala P, et al. A mutation in COL9A1 causes multiple epiphyseal dysplasia: further evidence for locus heterogeneity. Am J Hum Genet. 2001;69:969-980. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1274373/

INTERNET
Briggs MD, Wright MJ, Mortier GR. Multiple Epiphyseal Dysplasia, Dominant. 2003 Jan 8 [Updated 2013 Jul 25]. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2015.Available from: http://www.ncbi.nlm.nih.gov/books/NBK1123/ Accessed March 3, 2015.

Le Merrer M. Multiple Epiphyseal Dysplasia. Orphanet Encyclopedia, November 2008. Available at: http://www.orpha.net/consor/cgi-bin/index.php Accessed March 3, 2015.

Ranade AS. McCarthy JJ. Multiple Epiphyseal Dysplasia. Emedicine Journal, August 2, 2013. Available at: http://emedicine.medscape.com/article/1259038-overview Accessed March 3, 2015.

Years Published

1987, 1990, 2001, 2015

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