1
|
Wen L, Chen C, Deng Y, Chen G. Effectiveness of indomethacin in preventing Heterotopic Ossification: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 2024; 19:589. [PMID: 39342298 PMCID: PMC11437995 DOI: 10.1186/s13018-024-05086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 09/14/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND Heterotopic ossification (HO) is a frequent complication of joint trauma or surgery, commonly occurring after hip replacements, acetabular or other joint injuries, or surgeries. Indomethacin has long been used to prevent HO and is considered the first-line therapy. However, its effectiveness and necessity for HO prevention are still debated due to mixed evidence about its efficacy and potential side effects. METHODS Following PRISMA guidelines, this systematic review and meta-analysis evaluated randomized controlled trials using the PICO framework. Searches were conducted across PubMed, Embase, Cochrane Library, and Web of Science. Data were extracted and assessed based on the evidence levels of the selected articles. This study was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY). RESULTS This analysis included 665 patients, with 347 in the Indomethacin group and 318 in the No Indomethacin group. The outcomes analyzed-HO, Gastrointestinal Side Effects, and Bone Ununion-indicated that indomethacin effectively prevents HO. The meta-analysis revealed that the Indomethacin group experienced a significant reduction in the occurrence of grade I-II HO compared to the No Indomethacin group, but not for grade III-IV HO. Gastrointestinal side effects were notably higher in the Indomethacin group. The incidence of bone nonunion was higher in the Indomethacin group, although not statistically significant. CONCLUSIONS The meta-analysis suggests that indomethacin is effective in preventing HO, particularly for Brooker grade I-II, rather than Brooker grade III-IV. Special attention should be given to gastrointestinal complications when using indomethacin. Further prospective randomized controlled studies are required to confirm these findings.
Collapse
Affiliation(s)
- Lei Wen
- Department of Orthopedics and Trauma Surgery, Affiliated Hospital of Yunnan University, Kunming, 650032, China
| | - Changshun Chen
- Department of Orthopedics and Trauma Surgery, Affiliated Hospital of Yunnan University, Kunming, 650032, China
| | - Yongcheng Deng
- Department of Orthopedics and Trauma Surgery, Affiliated Hospital of Yunnan University, Kunming, 650032, China
| | - Ge Chen
- Department of Orthopedics and Trauma Surgery, Affiliated Hospital of Yunnan University, Kunming, 650032, China.
| |
Collapse
|
2
|
Migliorini F, Maffulli N. Prevention of heterotopic ossification in primary total hip arthroplasty: a bone in the dark. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04087-2. [PMID: 39320409 DOI: 10.1007/s00590-024-04087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2024] [Accepted: 08/25/2024] [Indexed: 09/26/2024]
Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
- Department of Life Sciences, Health, and Health Professions, Link Campus University, 00165, Rome, Italy.
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine and Psychology, University La Sapienza, 00185, Rome, Italy
- Faculty of Medicine, School of Pharmacy and Bioengineering, Keele University, Stoke on Trent, ST4 7QB, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK
| |
Collapse
|
3
|
Liu F, Zhao Y, Pei Y, Lian F, Lin H. Role of the NF-kB signalling pathway in heterotopic ossification: biological and therapeutic significance. Cell Commun Signal 2024; 22:159. [PMID: 38439078 PMCID: PMC10910758 DOI: 10.1186/s12964-024-01533-w] [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: 12/31/2023] [Accepted: 02/13/2024] [Indexed: 03/06/2024] Open
Abstract
Heterotopic ossification (HO) is a pathological process in which ectopic bone develops in soft tissues within the skeletal system. Endochondral ossification can be divided into the following types of acquired and inherited ossification: traumatic HO (tHO) and fibrodysplasia ossificans progressiva (FOP). Nuclear transcription factor kappa B (NF-κB) signalling is essential during HO. NF-κB signalling can drive initial inflammation through interactions with the NOD-like receptor protein 3 (NLRP3) inflammasome, Sirtuin 1 (SIRT1) and AMP-activated protein kinase (AMPK). In the chondrogenesis stage, NF-κB signalling can promote chondrogenesis through interactions with mechanistic target of rapamycin (mTOR), phosphatidylinositol-3-kinase (PI3K)/AKT (protein kinase B, PKB) and other molecules, including R-spondin 2 (Rspo2) and SRY-box 9 (Sox9). NF-κB expression can modulate osteoblast differentiation by upregulating secreted protein acidic and rich in cysteine (SPARC) and interacting with mTOR signalling, bone morphogenetic protein (BMP) signalling or integrin-mediated signalling under stretch stimulation in the final osteogenic stage. In FOP, mutated ACVR1-induced NF-κB signalling exacerbates inflammation in macrophages and can promote chondrogenesis and osteogenesis in mesenchymal stem cells (MSCs) through interactions with smad signalling and mTOR signalling. This review summarizes the molecular mechanism of NF-κB signalling during HO and highlights potential therapeutics for treating HO.
Collapse
Affiliation(s)
- Fangzhou Liu
- Department of Pathophysiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, China
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Yike Zhao
- Department of Pathophysiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, China
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Yiran Pei
- Department of Pathophysiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, China
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Fengyu Lian
- Department of Pathophysiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, China
- Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Hui Lin
- Department of Pathophysiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, China.
| |
Collapse
|
4
|
Dean RS, Hamama BA, Cavinatto L, Nho SJ, Chahla J, Hinckel BB. Chemoprophylaxis for heterotopic ossification following hip arthroscopy: A systematic review. J ISAKOS 2023; 8:484-489. [PMID: 37619960 DOI: 10.1016/j.jisako.2023.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/05/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Heterotopic ossification (HO) is a known complication diagnosed following hip arthroscopy. PURPOSE/HYPOTHESIS This study sought to review the current literature on chemoprophylaxis for HO following hip arthroscopy and to describe what agents and doses are being utilized. STUDY DESIGN Systematic Review. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines on the use of chemoprophylactic medications for HO prevention following hip arthroscopy. Mechanical and radiation prophylaxis were not included in the current analysis. RESULTS A total of 203 studies were identified, of which 15 were included with 6463 patients. There was one randomized control trial (RCT) and 4 additional comparative studies. The most commonly utilized chemoprophylactic agents were the following: naproxen (n = 8), celecoxib (n = 3), indomethacin (n = 3), aspirin (n = 1), etoricoxib (n = 1), and etodolac (n = 1), and non-specific non-steroidal anti-inflammatory drugs (NSAIDs) (n = 1). Naproxen was either given at a dose of 500 mg once or twice daily for 2-4 weeks. RCTs and additional comparative studies showed significant HO prevention using chemoprophylactic agents following hip arthroscopy. CONCLUSIONS HO is a known and common complication following hip arthroscopy. The current systematic review found significant heterogeneity across the literature with respect to specific chemoprophylactic agents and their dosing regimens aimed to reduce the incidence and severity of HO following hip arthroscopy. Additionally, this review demonstrates that most studies that utilize chemoprophylaxis use NSAIDs with successful reduction in the incidence of HO. LEVEL OF EVIDENCE Level IV Evidence.
Collapse
Affiliation(s)
| | - Britanny A Hamama
- Central Michigan University College of Medicine, Mount Pleasant, MI, 48073, USA
| | | | - Shane J Nho
- Midwest Orthopaedics at Rush, Chicago, IL, 48073, USA
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Chicago, IL, 48073, USA
| | | |
Collapse
|
5
|
Schneider J, Maffulli N, Eschweiler J, Bell A, Hildebrand F, Migliorini F. Efficacy of ibuprofen and indomethacin as prophylaxis of heterotopic ossification: a comparative study. Sci Rep 2023; 13:20210. [PMID: 37980449 PMCID: PMC10657366 DOI: 10.1038/s41598-023-47508-8] [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: 09/25/2022] [Accepted: 11/14/2023] [Indexed: 11/20/2023] Open
Abstract
The prophylactic action of non-steroidal anti-inflammatory drugs (NSAIDs) in heterotopic ossification (HO) was first described following analgesic therapy with indomethacin. Following that evidence, several compounds have been successfully used for prophylaxes of HO. Ibuprofen has been also proposed for the prevention of HO following THA. The present study compared the administration of ibuprofen for three weeks versus indomethacin as prophylaxis for HO following primary THA. In all THA procedures, pre- and post-operative protocols were conducted in a highly standardized fashion. The type of HO prophylaxis (indomethacin 100 mg/daily or ibuprofen 100 mg/daily) was chosen according to a chronological criterion: from 2017 to 2019 indomethacin was used, whereas from 2019 to 2022 ibuprofen was administered. In case of allergy or intolerance to NSAIDs, no prophylaxis was performed, and patients were included as a control group. All patients who underwent an anteroposterior radiography of the pelvis at a minimum of 12 months following THA were considered for inclusion. On admission, the age and sex of the patients were recorded. Moreover, the causes of osteoarthritis and the date of surgery were recorded. The grade of HO was assigned by a blinded assessor who was not involved in the clinical management of the patients. The modified Brooker Staging System was used to rate the efficacy of the interventions. Data from 1248 patients were collected. 62% (767 of 1248 patients) were women. The mean age was 67.0 ± 2.9 years. The mean follow-up was 21.1 ± 10.8 months. In the ibuprofen group, 73% of patients evidenced Brooker 0, 17% Brooker I, and 10% Brooker II. In the indomethacin group, 77% of patients evidenced Brooker 0, 16% Brooker I, 6% Brooker II. No patient in the ibuprofen and indomethacin group developed Brooker III or IV. In the control group, 64% of patients evidenced Brooker 0, 21% Brooker I, 3% Brooker II, and 12% Brooker III. No patient in the control group developed Brooker IV HO. Concluding, three weeks of administration of ibuprofen demonstrated similar efficacy to indomethacin in preventing HO following primary THA. The prophylaxis with ibuprofen or indomethacin was more effective in preventing HO compared to a control group who did not receive any pharmacological prophylaxis.
Collapse
Affiliation(s)
- Jens Schneider
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Nicola Maffulli
- Department of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
- Faculty of Medicine, School of Pharmacy and Bioengineering, Keele University, Stoke on Trent, ST4 7QB, UK
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK
| | - Jörg Eschweiler
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
| | - Andreas Bell
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Frank Hildebrand
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, 39100, Bolzano, Italy.
| |
Collapse
|
6
|
von Kroge S, Büyükyilmaz Z, Alimy AR, Hubert J, Citak M, Amling M, Beil FT, Ohlmeier M, Rolvien T. Do Clinical Parameters Reflect Local Bone Metabolism in Heterotopic Ossification After Septic or Aseptic THA? Clin Orthop Relat Res 2023; 481:2029-2041. [PMID: 37462509 PMCID: PMC10499090 DOI: 10.1097/corr.0000000000002758] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/06/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a common complication after THA. Although current research primarily focuses on treatment and prevention, little is known about the local bone metabolism of HO and clinical contributing factors. QUESTIONS/PURPOSES We aimed to assess bone remodeling processes in HO using histomorphometry, focusing on the effects of inflammation and prior NSAID treatment. Specifically, we asked: (1) Are HO specimens taken from patients with periprosthetic joint infection (PJI) more likely to exhibit active bone modeling and remodeling than specimens taken at the time of revision from patients without infection? (2) Do clinical or inflammatory serum and synovial parameters reflect the microstructure of and remodeling in both HO entities? (3) Is NSAID treatment before revision surgery associated with altered local bone mineralization or remodeling properties? METHODS Between June 2021 and May 2022, we screened 395 patients undergoing revision THA at two tertiary centers in Germany. Of those, we considered all patients with radiographic HO as potentially eligible. Based on that, 21% (83 of 395) were eligible; a further 43 were excluded because of an inability to remove the implant intraoperatively (16 patients), insufficient material (11), comorbidities with a major effect on bone metabolism (10), or bone-specific drugs (six), leaving 10% (40) for analysis in this retrospective, comparative study. HO specimens were collected during aseptic (25 patients: 18 male, seven female, mean age 70 ± 11 years, mean BMI 29 ± 4 kg/m 2 ) and septic (15 patients: 11 male, four female, mean age 69 ± 9 years, mean BMI 32 ± 9 kg/m 2 ) revision THA at a mean of 6 ± 7 years after primary implantation and a mean age of 70 ± 9 years at revision. Septic origin (PJI) was diagnosed based on the 2018 International Consensus Meeting criteria, through a preoperative assessment of serum and synovial parameters. To specify the local bone microstructure, ossification, and cellular bone turnover, we analyzed HO specimens using micro-CT and histomorphometry on undecalcified sections. Data were compared with those of controls, taken from femoral neck trabecular bone (10 patients: five female, five male, mean age 75 ± 6 years, mean BMI 28 ± 4 kg/m 2 ) and osteophytes (10 patients: five female, five male, mean age 70 ± 10 years, mean BMI 29 ± 7 kg/m 2 ). The time between primary implantation and revision (time in situ), HO severity based on the Brooker classification, and serum and synovial markers were correlated with HO microstructure and parameters of cellular bone turnover. In a subgroup of specimens of patients with NSAID treatment before revision, osteoid and bone turnover indices were evaluated and compared a matched cohort of specimens from patients without prior NSAID treatment. RESULTS Patients with aseptic and septic HO presented with a higher bone volume (BV/TV; aseptic: 0.41 ± 0.15, mean difference 0.20 [95% CI 0.07 to 0.32]; septic: 0.43 ± 0.15, mean difference 0.22 [95% CI 0.08 to 0.36]; femoral neck: 0.21 ± 0.04; both p < 0.001), lower bone mineral density (aseptic: 809 ± 66 mg HA/cm 3 , mean difference -91 mg HA/cm 3 [95% CI -144 to -38]; septic: 789 ± 44 mg HA/cm 3 , mean difference -111 mg HA/cm 3 [95% CI -169 to -53]; femoral neck: 899 ± 20 mg HA/cm 3 ; both p < 0.001), and ongoing bone modeling with endochondral ossification and a higher proportion of woven, immature bone (aseptic: 25% ± 17%, mean difference 25% [95% CI 9% to 41%]; septic: 37% ± 23%, mean difference 36% [95% CI 19% to 54%]; femoral neck: 0.4% ± 0.5%; both p < 0.001) compared with femoral neck specimens. Moreover, bone surfaces were characterized by increased osteoblast and osteoclast indices in both aseptic and septic HO, although a higher density of osteocytes was detected exclusively in septic HO (aseptic: 158 ± 56 1/mm 2 versus septic: 272 ± 48 1/mm 2 , mean difference 114 1/mm 2 [95% CI 65 to 162]; p < 0.001). Compared with osteophytes, microstructure and turnover indices were largely similar in HO. The Brooker class was not associated with any local bone metabolism parameters. The time in situ was negatively associated with bone turnover in aseptic HO specimens (osteoblast surface per bone surface: r = -0.46; p = 0.01; osteoclast surface per bone surface: r = -0.56; p = 0.003). Serum or synovial inflammatory markers were not correlated with local bone turnover in septic HO. Specimens of patients with NSAID treatment before revision surgery had a higher osteoid thickness (10.1 ± 2.1 µm versus 5.5 ± 2.6 µm, mean difference -4.7 µm [95% CI -7.4 to -2.0]; p = 0.001), but there was no difference in other osteoid, structural, or cellular parameters. CONCLUSION Aseptic and septic HO share phenotypic characteristics in terms of the sustained increase in bone metabolism, although differences in osteocyte and adipocyte numbers suggest distinct homeostatic mechanisms. These results suggest persistent bone modeling or remodeling, with osteoblast and osteoclast indices showing a moderate decline with the time in situ in aseptic HO. Future studies should use longitudinal study designs to correlate our findings with clinical outcomes (such as HO growth or recurrence). In addition, the molecular mechanisms of bone cell involvement during HO formation and growth should be further investigated, which may allow specific therapeutic and preventive interventions. CLINICAL RELEVANCE To our knowledge, our study is the first to systematically investigate histomorphometric bone metabolism parameters in patients with HO after THA, providing a clinical reference for evaluating modeling and remodeling activity. Routine clinical, serum, and synovial markers are not useful for inferring local bone metabolism.
Collapse
Affiliation(s)
- Simon von Kroge
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Assil-Ramin Alimy
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Hubert
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank Timo Beil
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Ohlmeier
- Department of Joint Surgery, Helios ENDO-Klinik, Hamburg, Germany
- Department of Orthopaedic and Trauma Surgery, UKM Marienhospital, Steinfurt, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
7
|
Wang Z, Mao Z, Yu M, Li H, Chen G, Wang Y, Yao Q. Role of aspirin in the prevention of heterotopic ossification following total hip replacement: a systematic review and meta-analysis. ANZ J Surg 2023; 93:1907-1916. [PMID: 37043691 DOI: 10.1111/ans.18447] [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: 12/06/2022] [Revised: 03/03/2023] [Accepted: 03/26/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND To systematically investigate if aspirin (ASA), used as venous thromboembolism (VTE) prophylaxis, plays a role in the prevention of heterotopic ossification (HO) following total hip arthroplasty (THA) and if ASA dosage impacted the rate of HO. METHODS Eligible studies published from January 2000 to July 2022 were identified from the computerized searching of PubMed, Scopus and Web of Science. HO was defined according to Brooker Classification. Pooled risk ratios (OR) and 95% confidence interval (CI) were estimated under a random-effect model. Additionally, combined HO incidences were compared according to ASA dosage (a regular dose of 325 bid vs. a low dose of 81 mg bid/162 mg qd). RESULTS Thirteen studies were included. ASA administered for VTE prophylaxis was significantly associated with a reduced risk of all-grade HO following THA (univariate, OR: 0.50, 95% CI: 0.34-0.74, P < 0.001; multivariate, OR: 0.60, 95% CI: 0.49-0.73, P < 0.001). Similar results could be observed for high-grade HO (univariate, OR: 0.57, 95% CI: 0.36-0.89, P = 0.015; multivariate, OR: 0.50, 95% CI: 0.27-0.92, P = 0.026). There was a non-significant trend towards a higher incidence of HO formation for low-dose ASA (31%, 95% CI: 29-34%), compared with regular-dose ASA (21%, 95% CI: 11-33%) (P = 0.069 under test of interaction). CONCLUSIONS ASA can be an effective option for HO prophylaxis. More well-designed trials with long-term follow-ups are encouraged to confirm the current findings and to investigate the effect of ASA dosage on HO reduction.
Collapse
Affiliation(s)
- Zhenwei Wang
- Department of Orthopedics, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Zimu Mao
- Department of Orthopedics, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Meng Yu
- Department of Orthopedics, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Hongchuan Li
- Department of Orthopedics, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Guoqiang Chen
- Department of Orthopedics, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Yang Wang
- Department of Orthopedics, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Qi Yao
- Department of Orthopedics, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| |
Collapse
|
8
|
Purcell KF, Lachiewicz PF. Heterotopic Ossification After Modern Total Hip Arthroplasty: Predisposing Factors, Prophylaxis, and Surgical Treatment. J Am Acad Orthop Surg 2023; 31:490-496. [PMID: 36972521 DOI: 10.5435/jaaos-d-22-01070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Indexed: 03/29/2023] Open
Abstract
Heterotopic ossification (HO) is a common radiographic finding and potentially serious complication after modern total hip arthroplasty. Although historically associated with the posterolateral approach, HO has been noted in 10% to 40% of patients having direct anterior or anterior-based muscle sparing approaches. The available data are uncertain whether robotic arm-assisted procedures are associated with this complication. Current prophylaxis for patients considered high risk of this complication includes postoperative, nonsteroidal, anti-inflammatory medication for several weeks or low-dose perioperative irradiation. The surgical treatment of symptomatic HO associated with severely restricted motion or ankylosis of the hip should be individualized but may include wide excision of bone, acetabular revision to prevent instability, and prophylaxis to prevent recurrence.
Collapse
Affiliation(s)
- Kevin F Purcell
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | | |
Collapse
|
9
|
Sun Z, Liu H, Hu Y, Luo G, Yuan Z, Tu B, Ruan H, Li J, Fan C. STING contributes to trauma-induced heterotopic ossification through NLRP3-dependent macrophage pyroptosis. Clin Immunol 2023; 250:109300. [PMID: 36963448 DOI: 10.1016/j.clim.2023.109300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/05/2023] [Accepted: 03/10/2023] [Indexed: 03/26/2023]
Abstract
Trauma-induced heterotopic ossification (HO) is featured by aberrant bone formation at extra-skeletal site. STING is a master adaptor protein linking cellular damage to immune responses, while its role in HO remains elusive. A murine burn/tenotomy model was used to mimic trauma-induced HO in vivo. We demonstrated elevated STING expression in macrophages in inflammatory stage after burn/tenotomy, and STING inhibition significantly alleviated HO formation. Activated NLRP3-dependent macrophage pyroptosis was also found in inflammatory stage after burn/tenotomy. Either STING or NLRP3 suppression reduced mature HO by weakening macrophage pyroptotic inflammation, while protective effects of STING were abolished by NLRP3 overexpression. Further, in vitro, we also found a prominent STING level in pyroptotic BMDMs. STING suppression relieved macrophage pyroptotic inflammation, while abolished by NLRP3 overexpression. Our results reveal that STING poses regulatory effects on trauma-induced HO formation, via modulating NLRP3-dependent macrophage pyroptosis. Targeting STING-NLRP3 axis represents an attractive approach for trauma-induced HO prevention.
Collapse
Affiliation(s)
- Ziyang Sun
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai 201306, PR China
| | - Hang Liu
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai 201306, PR China
| | - Yuehao Hu
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China
| | - Gang Luo
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai 201306, PR China
| | - Zhengqiang Yuan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai 201306, PR China
| | - Bing Tu
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai 201306, PR China
| | - Hongjiang Ruan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai 201306, PR China.
| | - Juehong Li
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai 201306, PR China.
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai 201306, PR China.
| |
Collapse
|
10
|
Wang SY, Jiang JH, Liu SY, Zhang J, Gao X, Liu H, Ke KX, Jiang Y, Liu L, He BC. Interleukin 6 promotes BMP9-induced osteoblastic differentiation through Stat3/mTORC1 in mouse embryonic fibroblasts. Aging (Albany NY) 2023; 15:718-733. [PMID: 36750182 PMCID: PMC9970304 DOI: 10.18632/aging.204504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/23/2023] [Indexed: 02/09/2023]
Abstract
Interleukin 6 (IL-6) plays a dual role in regulating bone metabolism, although the concrete mechanism is unclear. Bone morphogenetic protein 9 (BMP9) is one of the most potent osteogenic inducers, and a promising alternative for bone tissue engineering. The relationship between IL-6 and BMP9 in osteogenic differentiation remains to be elucidated, and the osteoblastic potential of BMP9 needs to be enhanced to overcome certain shortcomings of BMP9. In this study, we used real-time PCR, western blot, immunofluorescent stain, fetal limb culture and cranial defects repair model to explore the IL-6 role in BMP9-induced osteogenic differentiation in mouse embryonic fibroblasts (MEFs). We found that the rat serum level of IL-6 was increased in the dexamethasone-induced osteoporosis model, and IL-6 expression was detectable in several progenitor cells and MEFs. BMP9 upregulated IL-6 in MEFs, and the BMP9-induced osteoblastic markers were elevated by IL-6, but reduced by IL-6 knockdown. BMP9 and/or IL-6 both activated mTOR, and the IL-6 effect on BMP9-induced osteoblastic markers and bone formation were reduced greatly by mTOR inhibition. Raptor was up-regulated by IL-6 and/or BMP9 specifically, and the osteoblastic markers induced by IL-6 and/or BMP9 were reduced by Raptor knockdown. Meanwhile, Stat-3 was activated by IL-6 and/or BMP9, and the increase of Raptor or osteoblastic markers by IL-6 and/or BMP9 were reduced by Stat-3 inhibition. The Raptor promoter activity was regulated by p-Stat-3. Our finding suggested that IL-6 can promote the BMP9 osteoblastic potential, which may be mediated through activating Stat-3/mTORC1 pathway.
Collapse
Affiliation(s)
- Shi-Yu Wang
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Jin-Hai Jiang
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Si-Yuan Liu
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Jie Zhang
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Xiang Gao
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Hang Liu
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Kai-Xin Ke
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Yue Jiang
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Lu Liu
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| | - Bai-Cheng He
- Department of Pharmacology, School of Pharmacy, Chongqing Medical University, Chongqing 400016, China,Key Laboratory of Biochemistry and Molecular Pharmacology of Chongqing, Chongqing Medical University, Chongqing 400016, China
| |
Collapse
|
11
|
Pulik Ł, Mierzejewski B, Sibilska A, Grabowska I, Ciemerych MA, Łęgosz P, Brzóska E. The role of miRNA and lncRNA in heterotopic ossification pathogenesis. Stem Cell Res Ther 2022; 13:523. [PMID: 36522666 PMCID: PMC9753082 DOI: 10.1186/s13287-022-03213-3] [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] [Received: 05/18/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Heterotopic ossification (HO) is the formation of bone in non-osseous tissues, such as skeletal muscles. The HO could have a genetic or a non-genetic (acquired) background, that is, it could be caused by musculoskeletal trauma, such as burns, fractures, joint arthroplasty (traumatic HO), or cerebral or spinal insult (neurogenetic HO). HO formation is caused by the differentiation of stem or progenitor cells induced by local or systemic imbalances. The main factors described so far in HO induction are TGFβ1, BMPs, activin A, oncostatin M, substance P, neurotrophin-3, and WNT. In addition, dysregulation of noncoding RNAs, such as microRNA or long noncoding RNA, homeostasis may play an important role in the development of HO. For example, decreased expression of miRNA-630, which is responsible for the endothelial-mesenchymal transition, was observed in HO patients. The reduced level of miRNA-421 in patients with humeral fracture was shown to be associated with overexpression of BMP2 and a higher rate of HO occurrence. Down-regulation of miRNA-203 increased the expression of runt-related transcription factor 2 (RUNX2), a crucial regulator of osteoblast differentiation. Thus, understanding the various functions of noncoding RNAs can reveal potential targets for the prevention or treatment of HO.
Collapse
Affiliation(s)
- Łukasz Pulik
- Department of Orthopaedics and Traumatology, Medical University of Warsaw, Lindley 4 St, 02-005, Warsaw, Poland.
| | - Bartosz Mierzejewski
- Department of Cytology, Faculty of Biology, University of Warsaw, Miecznikowa 1 St, 02-096, Warsaw, Poland
| | - Aleksandra Sibilska
- Department of Orthopaedics and Traumatology, Medical University of Warsaw, Lindley 4 St, 02-005, Warsaw, Poland
| | - Iwona Grabowska
- Department of Cytology, Faculty of Biology, University of Warsaw, Miecznikowa 1 St, 02-096, Warsaw, Poland
| | - Maria Anna Ciemerych
- Department of Cytology, Faculty of Biology, University of Warsaw, Miecznikowa 1 St, 02-096, Warsaw, Poland
| | - Paweł Łęgosz
- Department of Orthopaedics and Traumatology, Medical University of Warsaw, Lindley 4 St, 02-005, Warsaw, Poland
| | - Edyta Brzóska
- Department of Cytology, Faculty of Biology, University of Warsaw, Miecznikowa 1 St, 02-096, Warsaw, Poland
| |
Collapse
|
12
|
Spreadborough PJ, Strong AL, Mares J, Levi B, Davis TA. Tourniquet use following blast-associated complex lower limb injury and traumatic amputation promotes end organ dysfunction and amplified heterotopic ossification formation. J Orthop Surg Res 2022; 17:422. [PMID: 36123728 PMCID: PMC9484189 DOI: 10.1186/s13018-022-03321-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic heterotopic ossification (tHO) is characterized by ectopic bone formation in extra-skeletal sites leading to impaired wound healing, entrapment of neurovascular structures, pain, and reduced range of motion. HO has become a signature pathology affecting wounded military personnel who have sustained blast-associated traumatic amputations during the recent conflicts in Iraq and Afghanistan and can compound recovery by causing difficulty with prosthesis limb wearing. Tourniquet use to control catastrophic limb hemorrhage prior to surgery has become almost ubiquitous during this time, with the recognition the prolonged use may risk an ischemia reperfusion injury and associated complications. While many factors influence the formation of tHO, the extended use of tourniquets to limit catastrophic hemorrhage during prolonged field care has not been explored. METHODS Utilizing an established pre-clinical model of blast-associated complex lower limb injury and traumatic amputation, we evaluated the effects of tourniquet use on tHO formation. Adult male rats were subjected to blast overpressure exposure, femur fracture, and soft tissue crush injury. Pneumatic tourniquet (250-300 mmHg) applied proximal to the injured limb for 150-min was compared to a control group without tourniquet, before a trans-femoral amputation was performed. Outcome measures were volume to tHO formation at 12 weeks and changes in proteomic and genomic markers of early tHO formation between groups. RESULTS At 12 weeks, volumetric analysis with microCT imaging revealed a 70% increase in total bone formation (p = 0.007) near the site of injury compared to rats with no tourniquet time in the setting of blast-injuries. Rats subjected to tourniquet usage had increased expression of danger-associated molecular patterns (DAMPs) and end organ damage as early as 6 h and as late as 7 days post injury. The expressions of pro-inflammatory cytokines and chemokines and osteochondrogenic genes using quantitative RT-PCR similarly revealed increased expression as early as 6 h post injury, and these genes along with hypoxia associated genes remained elevated for 7 days compared to no tourniquet use. CONCLUSION These findings suggest that tourniquet induced ischemia leads to significant increases in key transcription factors associated with early endochondral bone formation, systemic inflammatory and hypoxia, resulting in increased HO formation.
Collapse
Affiliation(s)
- Philip J. Spreadborough
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Amy L. Strong
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - John Mares
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Benjamin Levi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Thomas A. Davis
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| |
Collapse
|
13
|
Sun Z, Liu W, Liu H, Li J, Hu Y, Tu B, Wang W, Fan C. A new prognostic nomogram for heterotopic ossification formation after elbow trauma : the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction (STEHOP) model. Bone Joint J 2022; 104-B:963-971. [PMID: 35909382 DOI: 10.1302/0301-620x.104b8.bjj-2022-0206.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries. METHODS This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation. RESULTS Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes. CONCLUSION The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963-971.
Collapse
Affiliation(s)
- Ziyang Sun
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Weixuan Liu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Hang Liu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Juehong Li
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Yuehao Hu
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Tu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Cunyi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| |
Collapse
|
14
|
Migliorini F, Pintore A, Baroncini A, Pastor T, Hildebrand F, Maffulli N. Selective versus non-selective NSAIDs as prophylaxis for heterotopic ossification following hip arthroplasty: a meta-analysis. J Orthop Traumatol 2022; 23:30. [PMID: 35809109 PMCID: PMC9271145 DOI: 10.1186/s10195-022-00646-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background Some patients have demonstrated evidence of heterotopic ossification (HO) following total hip arthroplasty (THA). Selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) are used as prophylaxis for HO following THA. This meta-analysis compared selective versus non-selective NSAIDs as prophylaxis for HO following THA. Material and methods The present study was conducted according to the PRISMA 2020 guidelines. All the clinical investigations comparing selective versus non-selective NSAIDs as prophylaxis for HO following THA were accessed in February 2022. An assessment of the methodological quality and statistical analyses were performed through the risk of bias summary tool of the Review Manager 5.3 software (Cochrane Collaboration, Copenhagen). The modified Brooker staging system was used to rate the efficacies of the interventions. Results Data from 8 studies and 1526 patients were collected. 60.8% were female. No difference was found in the sample size, mean age, and percentage of females between the two groups at baseline. No statistically significant difference was found between selective and non-selective NSAIDs in term of efficacy. 72% (1078 of 1502) of the patients were classified as Brooker 0, 21% (322 of 1502) as Brooker I, 5% (80 of 1502) as Brooker II, 1% (16 of 1502) as Brooker III, and 0.1% (2 of 1502) as Brooker IV. Conclusion Selective and non-selective NSAIDs were equally effective when used as prophylaxis for HO following THA. Level of evidence Level III, systematic review and meta-analysis.
Collapse
Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Andrea Pintore
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
| | - Alice Baroncini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Torsten Pastor
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital of Lucerne, 6000, Lucerne, Switzerland
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, ST4 7QB, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, E1 4DG, London, England
| |
Collapse
|
15
|
Pathophysiology and Emerging Molecular Therapeutic Targets in Heterotopic Ossification. Int J Mol Sci 2022; 23:ijms23136983. [PMID: 35805978 PMCID: PMC9266941 DOI: 10.3390/ijms23136983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 12/23/2022] Open
Abstract
The term heterotopic ossification (HO) describes bone formation in tissues where bone is normally not present. Musculoskeletal trauma induces signalling events that in turn trigger cells, probably of mesenchymal origin, to differentiate into bone. The aetiology of HO includes extremely rare but severe, generalised and fatal monogenic forms of the disease; and as a common complex disorder in response to musculoskeletal, neurological or burn trauma. The resulting bone forms through a combination of endochondral and intramembranous ossification, depending on the aetiology, initiating stimulus and affected tissue. Given the heterogeneity of the disease, many cell types and biological pathways have been studied in efforts to find effective therapeutic strategies for the disorder. Cells of mesenchymal, haematopoietic and neuroectodermal lineages have all been implicated in the pathogenesis of HO, and the emerging dominant signalling pathways are thought to occur through the bone morphogenetic proteins (BMP), mammalian target of rapamycin (mTOR), and retinoic acid receptor pathways. Increased understanding of these disease mechanisms has resulted in the emergence of several novel investigational therapeutic avenues, including palovarotene and other retinoic acid receptor agonists and activin A inhibitors that target both canonical and non-canonical signalling downstream of the BMP type 1 receptor. In this article we aim to illustrate the key cellular and molecular mechanisms involved in the pathogenesis of HO and outline recent advances in emerging molecular therapies to treat and prevent HO that have had early success in the monogenic disease and are currently being explored in the common complex forms of HO.
Collapse
|
16
|
Willburger RE, Brinkhoff F, Nottenkämper J, Krapp J, Oberberg S. Heterotopic ossification after total hip arthroplasty: When is development completed? J Orthop Surg Res 2022; 17:147. [PMID: 35248082 PMCID: PMC8898402 DOI: 10.1186/s13018-022-02959-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Heterotopic ossifications (HO) are a common complication after total hip arthroplasty (THA). Nonsteroidal anti-inflammatory drugs have proven to reduce the occurrence of HO. It is still unclear when the formation of HO is finished. Aim of our study was to answer this question. Methods In a prospective study, the occurrence of periarticular HO was checked during the follow-up (FU) examinations. In total, 75 consecutive patients who underwent THA were included. To ensure a high follow-up rate, only patients with a life expectancy of at least 10 years were included. A medical ossification prophylaxis with mostly etoricoxib (90 mg once daily) was administered. Follow-up examinations were performed at 3 months, 1 year, 3, 5, and 10 years postoperatively. Each time, a clinical and radiological examination was carried out. The HO was graded according to Brooker’s method.
Results Low-grade HO classified by Brooker grade I and II occurred significantly more frequent than HO grade III. In patients with present HO, a possible increase in Brooker stage could further be observed within 3 years postoperatively. After 3 years, the formation of HO was completed in all patients. Conclusion Three years after THA, the formation of HO is complete. After more than 3 years postoperatively, if HO occurs or increases, other triggering causes such as new trauma, periarticular infection, or implant loosening should be considered.
Collapse
|
17
|
[Research progress of traumatic heterotopic ossification]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:386-394. [PMID: 35293183 PMCID: PMC8923934 DOI: 10.7507/1002-1892.202110078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To review and evaluate the research progress of traumatic heterotopic ossification (HO). METHODS The domestic and foreign related research literature on traumatic HO was widely consulted, and its etiology, pathogenesis, pathological progress, diagnosis, prevention, and treatment were summarized. RESULTS Traumatic HO is often caused by severe trauma such as joint operation, explosion injury, nerve injury, and burn. At present, it is widely believed that the occurrence of traumatic HO is closely related to inflammation and hypoxia. Oral non-steroidal anti-inflammatory drugs and surgery are the main methods to prevent and treat traumatic HO. CONCLUSION Nowadays, the pathogenesis of traumatic HO is still unclear, the efficiency of relevant prevention and treatment measures is low, and there is a lack of specific treatment method. In the future, it is necessary to further study the pathogenesis of traumatic HO and find specific prevention and treatment targets.
Collapse
|
18
|
Amar R, Thiry T, Salga M, Safa D, Chetrit A, Gatin L, Carlier RY. Comparison of magnetic resonance imaging and computed tomography for bone assessment of neurogenic heterotopic ossification of the hip: a preliminary study. J Orthop Surg Res 2021; 16:725. [PMID: 34930354 PMCID: PMC8686225 DOI: 10.1186/s13018-021-02869-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Neurogenic heterotopic ossification (NHO) is a frequent complication, often involving the hip. The functional impact may require surgical management and pre-surgical imaging assessment is necessary, usually by computed tomography (CT). We aimed to compare the performances of magnetic resonance imaging (MRI) and CT for bone assessment on pre-surgical imaging of the heterotopic ossifications and their features in NHO of the hip. Methods This single-center prospective preliminary study included all patients who underwent surgery for NHO with joint limitation from July 2019 to March 2020. All patients had a CT after biphasic iodinated solution injection and an MRI including T1-weighted, STIR and ZTE sequences. Standardized reports were completed for both exams for each patient, evaluating location, implantation and fragmentation of NHO, relation to the joint capsule and bone mineralization, then were compared. Results Seven patients from 32 to 70 years old (mean = 50.2 ± 17.2 years) were evaluated. NHO were bilateral in 2 patients, for a total of nine hips: six right hips and three left hips. Observed concordance rates between MRI and CT were, respectively, 94.4% for location, 100% for circumferential extension, 87.3% for implantation 88.9% for fragmentation, 77.8% for relation to the joint capsule and 66.7% for bone mineralization. It was 100% for femoral neck fracture and osteonecrosis of the femoral head. Conclusion This preliminary study suggests that pre-surgical MRI imaging should be considered as effective as CT for bone assessment of NHO and their features. Trial registration: ClinicalTrials.gov, NCT03832556. Registered February 6, 2019, https://clinicaltrials.gov/ct2/show/NCT03832556.
Collapse
Affiliation(s)
- Raphaël Amar
- Department of Radiology, Assistance Publique - Hôpitaux de Paris (AP-HP), DMU Start Imaging, Raymond Poincaré Teaching Hospital, Garches, France.
| | - Tristan Thiry
- Department of Radiology, Assistance Publique - Hôpitaux de Paris (AP-HP), DMU Start Imaging, Raymond Poincaré Teaching Hospital, Garches, France
| | - Marjorie Salga
- Department of Physical Medicine and Rehabilitation, Assistance Publique - Hôpitaux de Paris (AP-HP), Raymond Poincaré Teaching Hospital, CIC 1429, Garches, France.,UVSQ, INSERM U1179, END-ICAP, University of Paris-Saclay, Montigny-le-Bretonneux, France.,Group for Research in Neuro-Orthopedics From Garches (GRENOG), Garches, France
| | - Dominique Safa
- Department of Radiology, Assistance Publique - Hôpitaux de Paris (AP-HP), DMU Start Imaging, Raymond Poincaré Teaching Hospital, Garches, France
| | - Annaëlle Chetrit
- Department of Radiology, Assistance Publique - Hôpitaux de Paris (AP-HP), DMU Start Imaging, Raymond Poincaré Teaching Hospital, Garches, France
| | - Laure Gatin
- UVSQ, INSERM U1179, END-ICAP, University of Paris-Saclay, Montigny-le-Bretonneux, France.,Group for Research in Neuro-Orthopedics From Garches (GRENOG), Garches, France.,Department of Orthopaedic and Trauma Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Raymond Poincaré Teaching Hospital, Garches, France
| | - Robert-Yves Carlier
- Department of Radiology, Assistance Publique - Hôpitaux de Paris (AP-HP), DMU Start Imaging, Raymond Poincaré Teaching Hospital, Garches, France.,UVSQ, INSERM U1179, END-ICAP, University of Paris-Saclay, Montigny-le-Bretonneux, France
| |
Collapse
|
19
|
Macrophages in heterotopic ossification: from mechanisms to therapy. NPJ Regen Med 2021; 6:70. [PMID: 34702860 PMCID: PMC8548514 DOI: 10.1038/s41536-021-00178-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 09/30/2021] [Indexed: 01/04/2023] Open
Abstract
Heterotopic ossification (HO) is the formation of extraskeletal bone in non-osseous tissues. It is caused by an injury that stimulates abnormal tissue healing and regeneration, and inflammation is involved in this process. It is worth noting that macrophages are crucial mediators of inflammation. In this regard, abundant macrophages are recruited to the HO site and contribute to HO progression. Macrophages can acquire different functional phenotypes and promote mesenchymal stem cell (MSC) osteogenic differentiation, chondrogenic differentiation, and angiogenesis by expressing cytokines and other factors such as the transforming growth factor-β1 (TGF-β1), bone morphogenetic protein (BMP), activin A (Act A), oncostatin M (OSM), substance P (SP), neurotrophin-3 (NT-3), and vascular endothelial growth factor (VEGF). In addition, macrophages significantly contribute to the hypoxic microenvironment, which primarily drives HO progression. Thus, these have led to an interest in the role of macrophages in HO by exploring whether HO is a "butterfly effect" event. Heterogeneous macrophages are regarded as the "butterflies" that drive a sequence of events and ultimately promote HO. In this review, we discuss how the recruitment of macrophages contributes to HO progression. In particular, we review the molecular mechanisms through which macrophages participate in MSC osteogenic differentiation, angiogenesis, and the hypoxic microenvironment. Understanding the diverse role of macrophages may unveil potential targets for the prevention and treatment of HO.
Collapse
|
20
|
Burn-induced heterotopic ossification from incidence to therapy: key signaling pathways underlying ectopic bone formation. Cell Mol Biol Lett 2021; 26:34. [PMID: 34315404 PMCID: PMC8313878 DOI: 10.1186/s11658-021-00277-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/20/2021] [Indexed: 01/02/2023] Open
Abstract
Burn injury is one of the potential causes of heterotopic ossification (HO), which is a rare but debilitating condition. The incidence ranges from 3.5 to 5.6 depending on body area. Burns that cover a larger percentage of the total body surface area (TBSA), require skin graft surgeries, or necessitate pulmonary intensive care are well-researched risk factors for HO. Since burns initiate such complex pathophysiological processes with a variety of molecular signal changes, it is essential to focus on HO in the specific context of burn injury to define best practices for its treatment. There are numerous key players in the pathways of burn-induced HO, including neutrophils, monocytes, transforming growth factor-β1-expressing macrophages and the adaptive immune system. The increased inflammation associated with burn injuries is also associated with pathway activation. Neurological and calcium-related contributions are also known. Endothelial-to-mesenchymal transition (EMT) and vascularization are known to play key roles in burn-induced HO, with hypoxia-inducible factor-1 (HIF-1) and vascular endothelial growth factor (VEGF) as potential initiators. Currently, non-steroidal anti-inflammatory drugs (NSAIDs) and radiotherapy are effective prophylaxes for HO. Limited joint motion, ankylosis and intolerable pain caused by burn-induced HO can be effectively tackled via surgery. Effective biomarkers for monitoring burn-induced HO occurrence and bio-prophylactic and bio-therapeutic strategies should be actively developed in the future.
Collapse
|