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Graves BR. The examination and treatment of soft tissue contracture of the elbow. J ISAKOS 2024; 9:98-102. [PMID: 37866511 DOI: 10.1016/j.jisako.2023.10.006] [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: 08/31/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Abstract
Treatment of the stiff elbow can be a challenging task. A thorough understanding of normal elbow anatomy and the potential causes of elbow contracture are essential for the development of effective treatment strategies. This chapter provides a review of key points for the treating surgeon including normal elbow anatomy, etiological factors that commonly contribute to elbow stiffness, physical examination and imaging of the stiff elbow, and treatment options for contracture correction.
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Affiliation(s)
- Benjamin R Graves
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, One Medical Plaza Blvd, 4th Floor Watlington Hall, Winston-Salem, NC 27104, USA.
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Leyder D, Döbele S, Konrads C, Histing T, Fischer CS, Ahrend MD, Ziegler P. Classification and Incidence of Heterotopic Ossifications in Relation to NSAID Prophylaxis after Elbow Trauma. J Clin Med 2024; 13:667. [PMID: 38337359 PMCID: PMC10856632 DOI: 10.3390/jcm13030667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Heterotopic ossification (HO) after elbow trauma can be responsible for significant motion restrictions. The study's primary aim was to develop a new X-ray-based classification for HO of the elbow. This retrospective study analyzed elbow injury radiographs from 138 patients aged 6-85 years (mean 45.9 ± 18) who underwent operative treatment. The new classification was applied at 6 weeks, 12 weeks, and 6 months postoperatively. The severity of HO was graded from 0 to 4 and localization was defined as r (radial), p (posterior), u (ulnar) or a (anterior) by two observers. The patients were categorized based on injury location and use of non-steroidal anti-inflammatory drugs (NSAIDs) for HO prophylaxis. The correlations between the generated data sets were analyzed using Chi-square tests (χ2) with a significance level of p < 0.05. The inter- and intraobserver reliability was assessed using Cohen's Kappa. In 50.7% of the evaluated X-rays, the formation of HO could be detected after 12 weeks, and in 60% after 6 months. The analysis showed a significant correlation between the injury's location and the HO's location after 12 weeks (p = 0.003). The use of an NSAID prophylaxis did not show a significant correlation with the severity of HO. The classification showed nearly perfect inter- (κ = 0.951, p < 0.001) and intrareliability (κ = 0.946, p < 0.001) according to the criteria of Landis and Koch. Based on the presented classification, the dimension and localization of HO in the X-ray image can be described in more detail compared to previously established classifications and, thus, can increase the comparability of results across studies.
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Affiliation(s)
- Diane Leyder
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tübingen, Eberhard Karls University of Tübingen, 72074 Tübingen, Germany
| | - Stefan Döbele
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tübingen, Eberhard Karls University of Tübingen, 72074 Tübingen, Germany
- Medical Faculty, University of Tübingen, 72074 Tübingen, Germany; (C.K.)
| | - Christian Konrads
- Medical Faculty, University of Tübingen, 72074 Tübingen, Germany; (C.K.)
- Department of Orthopaedics and Traumatology, Helios Hanseatic Hospital Stralsund, 18435 Stralsund, Germany
| | - Tina Histing
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tübingen, Eberhard Karls University of Tübingen, 72074 Tübingen, Germany
| | - Cornelius S. Fischer
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tübingen, Eberhard Karls University of Tübingen, 72074 Tübingen, Germany
| | - Marc-Daniel Ahrend
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tübingen, Eberhard Karls University of Tübingen, 72074 Tübingen, Germany
| | - Patrick Ziegler
- Medical Faculty, University of Tübingen, 72074 Tübingen, Germany; (C.K.)
- Department of Orthopaedics and Trauma Surgery, Klinik Gut, 7500 St. Moritz, Switzerland
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Ausk BJ, Tucker AN, Huber P, Firoozabadi R, Gross JM, Gross TS, Bain SD. A microCT-based platform to quantify drug targeting. Eur Radiol Exp 2023; 7:38. [PMID: 37532922 PMCID: PMC10397158 DOI: 10.1186/s41747-023-00355-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/12/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Heterotopic ossification (HO) is a frequent and debilitating complication of traumatic musculoskeletal injuries and orthopedic procedures. Prophylactic dosing of botulinum toxin type A (BTxA) holds potential as a novel treatment option if accurately distributed throughout soft-tissue volumes where protection is clinically desired. We developed a high-resolution, microcomputed tomography (microCT)-based imaging strategy to assess drug distribution and validated this platform by quantifying distribution achieved via a prototype delivery system versus a single-bolus injection. METHODS We injected an iodine-containing contrast agent (iodixanol 320 mg I/mL) into dissected rabbit musculature followed by microCT imaging and analysis. To contrast the performance of distributed versus bolus injections, a three-dimensional (3D) 64-cm3-printed soft-tissue holder was developed. A centered 2-cm3 volume of interest (VOI) was targeted with a single-bolus injection or an equal volume distributed injection delivered via a 3D-printed prototype. VOI drug coverage was quantified as a percentage of the VOI volume that was < 1.0 mm from the injected fluid. RESULTS The microCT-based approach enabled high-resolution quantification of injection distribution within soft tissue. The distributed dosing prototype provided significantly greater tissue coverage of the targeted VOI (72 ± 3%, mean ± standard deviation) when compared to an equal volume bolus dose (43 ± 5%, p = 0.031) while also enhancing the precision of injection targeting. CONCLUSIONS A microCT-based imaging technique precisely quantifies drug distribution within a soft-tissue VOI, providing a path to overcome a barrier for clinical translation of prophylactic inhibition of HO by BTxA. RELEVANCE STATEMENT This platform will facilitate rapid optimization of injection parameters for clinical devices used to effectively and safely inhibit the formation of heterotopic ossification. KEY POINTS • MicroCT provides high-resolution quantification of soft-tissue drug distribution. • Distributed dosing is required to maximize soft-tissue drug coverage. • Imaging platform will enable rapid screening of 3D-printed drug distribution prototypes.
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Affiliation(s)
| | - Adam N Tucker
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Philippe Huber
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | | | - Ted S Gross
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Steven D Bain
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
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Rezidivierende heterotope Ossifikation am Ellenbogengelenk nach inadäquatem Trauma. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00514-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Chen Y, Niu Z, Yin X, Li Y, Han Y, Chai M, Li D, Tao R, Guo L, Lei Y, Han Y. Treatment of Severe Postburn Contracture of the Elbow via Distraction With External Circular Frame in Pediatric Patient. Ann Plast Surg 2021; 87:253-259. [PMID: 34397514 DOI: 10.1097/sap.0000000000002960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although external circular frame (ECF) has been widely used for the correction of knee and ankle deformities, few studies reported the use of ECF for the treatment of severe postburn elbow contracture and stiffness (SPECS). The purpose of this retrospective study was to investigate the effectiveness and safety of the distraction using ECF in treating SPECS. METHODS After institutional review board approval, we implemented a retrospective single-center case series study composed of consecutive patients treated for SPECS at Chinese PLA General Hospital between January 2010 and January 2018. After scar release and skin grafting, distraction with ECF was performed for 4 to 6 weeks, and the frame was retained for 2 more weeks before removal. Four weeks of splinting and at least 1 year of rehabilitation were recommended. Patient demographics, active and passive range of motion (ROM) of the elbow at different time points (preoperative, postdistraction, and final follow-up), and complications were collected from the electronic medical record. The primary outcome was the long-term improvement of the ROM. Other outcomes included complications and recurrence. RESULTS The ECF was used to treat SPECS in 6 patients (3 males and 3 females, average age of 11.7 ± 2.6 years). Scar release and distraction with ECF significantly increased both active (from 3° preoperative to 38.7° postdistraction) and passive (from 3.5° preoperative to 48.3° postdistraction) ROM over an average distraction duration of 5.2 weeks. The long-term improvement of active and passive ROM was 38° ± 13.4° and 46° ± 14.7°, respectively, over a median follow-up of 4.1 years. Pin-tract infection occurred in 2 patients and were treated with local wound care and oral antibiotics. A tendon readhesion developed in 1 of the 6 patients because of noncompliance with splinting and physiotherapy, and was treated with revision surgery. CONCLUSIONS The 3C strategy (i.e., contracture release, coverage of the defect with skin grafting, and correction of articular angle with gradual distraction using the ECF) is able to increase the ROM with minor complications. We recommend distraction with ECF as part of the treatment arsenal, particularly for severe contractures in which 1-stage correction is unfeasible because of considerable soft tissue shortening.
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Affiliation(s)
- Youbai Chen
- From the Department of Plastic and Reconstructive Surgery, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
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Geyer S, Imhoff AB, Siebenlist S. Komplikationsmanagement – Ellenbogenarthrolyse. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-020-00371-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bachman DR, Fitzsimmons JS, O'Driscoll SW. Safety of Arthroscopic Versus Open or Combined Heterotopic Ossification Removal Around the Elbow. Arthroscopy 2020; 36:422-430. [PMID: 31870750 DOI: 10.1016/j.arthro.2019.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 08/29/2019] [Accepted: 09/02/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the complications of arthroscopic heterotopic ossification (HO) excision and compare them with those of open removal of HO or a combined open-arthroscopic approach. METHODS We performed a retrospective review of elbow HO removal cases performed by a single surgeon from 1997 to 2014. In all cases studied, the intention was to restore range of motion owing to the presence of HO causing functional impairment. The arthroscopic, open, and combined treatment groups were compared. RESULTS The study cohort consisted of 223 surgical procedures performed on 213 elbows in 211 patients. Fifty major complications occurred in 46 cases (21%): 17 hematomas (8%) treated by irrigation and debridement, 8 cases of HO requiring reoperation (4%), 7 deep infections (3%), 4 contractures (2%), 3 cases of delayed-onset ulnar neuritis (1%), 2 cases of distal humeral avascular necrosis (1%), 2 tendon ruptures (1%), 2 cases of instability requiring reconstruction (1%), 2 postoperative fractures (1%), 1 intraoperative fracture (<0.5%), 1 case of worsening of pre-existing neuropathic pain (<0.5%), and 1 permanent partial posterior interosseous nerve injury (<0.5%). Of these 46 cases, the major complications occurred in 6 of the 41 (15%) performed arthroscopically, in 36 of the 158 (23%) performed open and in 4 of the 21 (17%) with combined (i.e. open + arthroscopic) HO removal. Preventive strategies, introduced to prevent hematomas and delayed-onset ulnar neuritis, reduced the rate of major complications from 35% during the period from 1997 to 2005 to 10% during the period from 2006 to 2014 (P < .0001). Moreover, the rate of reoperations was reduced from 34% to 10% in the same periods (P < .0001). Minor complications occurred in 36 cases (16%), including 17 cases of transient nerve palsy, 9 cases of superficial infection or delayed wound healing, 6 cases of mild instability, and 4 cases of hematoma resolved by aspiration. CONCLUSIONS The use of arthroscopy-or a combination of arthroscopic and open techniques-to remove HO around the elbow by a surgeon skilled in both arthroscopic and open elbow surgery does not increase the risk of major complications or need for reoperation compared with traditional open surgery. Preventive strategies, such as avoiding raising skin flaps by using multiple separate incisions for open and prophylactic ulnar nerve decompression in arthroscopic cases, were developed during the study period. These strategies were monitored prospectively and found to be effective in preventing two-thirds of the major complications needing reoperation with both open and arthroscopic HO removal. LEVEL OF EVIDENCE Level III, retrospective comparative study of prospectively collected data.
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Affiliation(s)
- Daniel R Bachman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Shawn W O'Driscoll
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.
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Chen JY, Fu CW, Ho HY, Lu YC. Surgical treatment of postburn heterotopic ossification around the elbow: Three case reports. Medicine (Baltimore) 2019; 98:e14403. [PMID: 30732187 PMCID: PMC6380831 DOI: 10.1097/md.0000000000014403] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Heterotopic ossification (HO), which is defined as the formation of new bone in tissues that do not normally ossify, is an infrequent yet debilitating complication of burns. Herein, we report three patients who suffered from elbow HO after burn injury due to a dust explosion event. This is a case report that includes the most cases involved in a single mass casualty incident in the presented literature. PATIENT CONCERNS Case 1: A 28-year-old man presented with second-to-third degree 88% total body surface area (TBSA) burns after the explosion event. He complained of decreased progressive bilateral elbow range of motion (ROM) for 1.5 months after the burn injury.Case 2: A 28-year-old woman presented with second-to-third degree 50% TBSA burns and complained of decreased progressive bilateral elbow ROM with intolerable pain on elbow extension for 1 month after the burn injury.Case 3: A 22-year-old man presented with second-to-third degree 90% TBSA burns and complained of significantly decreased left elbow ROM with intolerable pain 5 months after the burn injury. DIAGNOSIS The follow-up radiograph of the symptomatic elbow of these three patients revealed heterotopic ossification formation. Three-dimensional reconstruction computed tomography performed preoperatively showed that HO mainly affected the humeroulnar joint. INTERVENTIONS We treated all three patients with surgical elbow HO resection and ulnar nerve transposition, followed by immediate passive ROM exercise since postoperative day 1 and continuous physical therapy. OUTCOMES In case 1, the documented ROM gain on the last follow-up (18.5 months after surgery) was 30° in the right elbow and 118° in the left elbow. In case 2, the follow-up time was 21 months and the documented ROM gain on the last follow-up was 120° in the right elbow and 90° in the left elbow. In case 3, the follow-up time was 20 months and the documented left elbow ROM gain on the last follow-up was 40°. LESSONS We discuss our experience of treating postburn HO and review the recent literature. The postburn HO treatment results of early surgical excision combined with immediate postoperative physical therapy were satisfactory.
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Suito M, Yuzuriha S, Iwasawa M, Yanagisawa D, Kinjo Y, Takashimizu I, Hoshino Y. Therapeutic strategies for elbow ankylosis due to heterotopic ossification in patients with severe burns. JPRAS Open 2018; 17:24-30. [PMID: 32158828 PMCID: PMC7061606 DOI: 10.1016/j.jpra.2018.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/31/2018] [Accepted: 06/20/2018] [Indexed: 11/25/2022] Open
Abstract
Background Heterotopic ossification (HO) occurs frequently in the elbow in burn patients, and extends beyond the anatomical structure. HO of the elbow can cause joint contracture and adversely affect activities of daily living.Currently, there is no effective prophylaxis for HO as the precise underlying mechanism remains unknown. Therefore, there is no choice but to treat HO after it has developed. To date, however, no effective standard treatment has been reported, and therefore treatment methods vary between different facilities. Surgical resection is widely accepted as the only therapeutic option once HO limits functional mobility of the elbow. Purposes Based on past reports, we examined our cases and recommend effective therapeutic strategies. We posed the following three questions: (1) Is the surgical intervention effective or detrimental for elbow ankylosis due to HO? (2) What is the best timing for the intervention? (3) What is the most effective postoperative rehabilitation plan? Methods We treated three patients with complete ankylosis of the elbow due to HO after severe burn injury using different protocols. Results Surgery was performed in two cases and rehabilitation therapy was commenced immediately from the first postoperative day. Both patients showed improvement in the active range of motion in their elbow joints. The other patient did not undergo surgery, and his elbows became fixed in the completely extension position. Conclusion Surgical resection is beneficial for elbow ankylosis due to HO after burn injury. Although the exact surgical timing is still controversial, we recommend that surgery should be performed as soon as possible after improving the skin condition around the elbow and confirming the maturation of HO on radiographs. Early rehabilitation and pain control are also important after surgery.
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Affiliation(s)
- Motomu Suito
- Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Nagano, Japan
| | - Shunsuke Yuzuriha
- Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Nagano, Japan
| | - Motonao Iwasawa
- Department of Plastic and Reconstructive Surgery, Nagano Red Cross Hospital, Wakasato, Nagano, Nagano, Japan
| | - Daisuke Yanagisawa
- Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Nagano, Japan
| | - Yuto Kinjo
- Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Nagano, Japan
| | - Ikkei Takashimizu
- Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Nagano, Japan
| | - Yuki Hoshino
- Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Nagano, Japan
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Appropriate excision time of heterotopic ossification in elbow caused by trauma. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:27-31. [PMID: 29290538 PMCID: PMC6136303 DOI: 10.1016/j.aott.2017.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/23/2017] [Accepted: 11/24/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the optimal timing for the resection of heterotopic ossification (HO) of the elbow. METHODS We retrospectively reviewed 42 patients who were treated operatively for heterotopic ossification of the elbow from March 2010 to December 2014 at our institution. The patients were divided into early (before 12 months) and late (after 12 months) excision groups. In the early excision group (17 patients), the average time from the initial injury to HO excision was 7.4 (3-11) months, and in the late excision group (25 patients), the average time was 33.5 (12-240) months. Every patient was evaluated by range of motion (ROM), the Mayo Elbow Performance Score (MEPS), postoperative complications and HO recurrence. RESULTS The preoperative mean ROM in the late excision group was greater than that of the early excision group, suggesting that the ROM is expected to increase even without surgery. Both early and late surgery increased ROM and MEPS, but early surgery improved ROM and MEPS more than late surgery did (p < .05). CONCLUSIONS Early excision of HO can provide better elbow function, as indicated by ROM and MEPS. Considering that there were no notable differences in postoperative ROM and MEPS, HO recurrence, or postoperative complications, we concluded that early excision is safe and that the time from an elbow injury to surgery may be shortened. LEVEL OF EVIDENCE Level III, therapeutic study.
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Malca N, Serror K, Mimoun M, Chatelain S, Kaplan J, Chaouat M, Marco O, Boccara D. Our 35 years' experience on postburn heterotopic ossification: A three-step treatment. ANN CHIR PLAST ESTH 2018; 63:316-322. [PMID: 29289387 DOI: 10.1016/j.anplas.2017.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/30/2017] [Indexed: 11/18/2022]
Abstract
Our retrospective study of burn patients presents a three-step treatment of heterotopic ossification: excision surgery, early rehabilitation, and analgesia. We included patients admitted to the department for treatment of postburn heterotopic ossification between January 1, 1979, and September 30, 2015. The mean age at the time of the burn was 43.3 years. Men accounted for the majority of burn patients who developed an osteoma (70.8%). The mean total skin area burned was 38.4%. No osteoma justifying surgery was found for any patient with a total burned skin area less than 19%. The burned zones were related to the osteoma development in 94.3% of cases. On average, the surgery took place 10.8 months after the burn. The osteotomy was accompanied by surgical treatment of a contracture in 37.1% of patients. Most of the osteomata were found at the elbows (30), followed by the shoulders (3), and finally the knees (2). Rehabilitation began on D0 after the surgery, except if a flap or a thin-skin graft was used. Regarding analgesia, opiates were prescribed systematically during the immediate postoperative period. Elbow range of motion on flexion improved by a mean of 84.1°. During the postoperative period, we found 2 recurrences of osteoma and 1 elbow hematoma in two separate patients. There were no postoperative infections or neurological sequelae. Our retrospective French study confirmed results found in the international literature. The three-step treatment - excision surgery, early rehabilitation, and antalgia - seems to be the best means of treating osteoma with satisfactory results. Surgery is indicated only in the case of functional impairment and not simply based on imaging.
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Affiliation(s)
- N Malca
- Department of plastic surgery, Burn center (centre de traitement des brûlés), hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - K Serror
- Department of plastic surgery, Burn center (centre de traitement des brûlés), hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - M Mimoun
- Department of plastic surgery, Burn center (centre de traitement des brûlés), hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - S Chatelain
- Department of plastic surgery, Burn center (centre de traitement des brûlés), hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - J Kaplan
- NewYork-Presbyterian hospital, Columbia university medical center, New York, USA
| | - M Chaouat
- Department of plastic surgery, Burn center (centre de traitement des brûlés), hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - O Marco
- Department of plastic surgery, Burn center (centre de traitement des brûlés), hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - D Boccara
- Department of plastic surgery, Burn center (centre de traitement des brûlés), hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
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Viveen J, Doornberg JN, Kodde IF, Goossens P, Koenraadt KLM, The B, Eygendaal D. Continuous passive motion and physical therapy (CPM) versus physical therapy (PT) versus delayed physical therapy (DPT) after surgical release for elbow contractures; a study protocol for a prospective randomized controlled trial. BMC Musculoskelet Disord 2017; 18:484. [PMID: 29166890 PMCID: PMC5700741 DOI: 10.1186/s12891-017-1854-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/15/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The elbow is prone to stiffness after trauma. To regain functional elbow motion several conservative- and surgical treatment options are available. Conservative treatment includes physical therapy, intra-articular injections with corticosteroids and a static progressive or dynamic splinting program. If conservative treatment fails, an operative release of the posttraumatic stiff elbow is often performed. The best Evidence-Based rehabilitation protocol for patients after an operative release is unknown to date and differs per surgeon, hospital and country. Options include early- or delayed motion supervised by a physical therapist, immediate continuous passive motion (CPM), (night) splinting and a static progressive or dynamic splinting program. METHODS/DESIGN The SET-Study (Stiff Elbow Trial) is a single-centre, prospective, randomized controlled trial. The primary objective of this study is to compare the active Range of Motion (ROM) (flexion arc and rotational arc) twelve months after surgery between three groups. The first group will receive in-hospital CPM in combination with early motion Physical Therapy (PT) supervised by a physical therapist, the second group will receive only in-hospital early motion PT supervised by a physical therapist and the third group will receive outpatient supervised PT from postoperative day seven till ten. Secondary outcome measures will be Patient Reported Outcome Measures (PROMs) including the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), the quick Disabilities of Arm, Shoulder and Hand (qDASH) score, Visual Analogue pain Scale in rest and activity (VAS), Pain Catastrophizing Scale (PCS), the Short Form (SF)-36, the Centre for Epidemiological Studies Depression Scale Revised (CESD-R) and the Work Rehabilitation Questionnaire (WORQ) for the upper limb. DISCUSSION A successful completion of this trial will provide evidence on the best rehabilitation protocol in order to (re)gain optimal motion after surgical release of the stiff elbow. TRIAL REGISTRATION The trial is registered at the Dutch Trial Register: NTR6067 , 31-8-2016.
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Affiliation(s)
- Jetske Viveen
- , Department of Orthopaedic Surgery, Amphia Hospital, PO box 90158, Molengracht 21, 4818, CK, Breda, The Netherlands.
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Flinders University, Bedford Park SA, Adelaide, 5042, Australia
| | - Izaak F Kodde
- Department of Orthopaedic Surgery, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam-Zuidoost, The Netherlands
| | - Pjotr Goossens
- , Department of Orthopaedic Surgery, Amphia Hospital, PO box 90158, Molengracht 21, 4818, CK, Breda, The Netherlands
| | - Koen L M Koenraadt
- , Foundation for Orthopaedic Research, Care & Education, Amphia Hospital, 4818 , CK, Breda, The Netherlands
| | - Bertram The
- , Department of Orthopaedic Surgery, Amphia Hospital, PO box 90158, Molengracht 21, 4818, CK, Breda, The Netherlands
| | - Denise Eygendaal
- , Department of Orthopaedic Surgery, Amphia Hospital, PO box 90158, Molengracht 21, 4818, CK, Breda, The Netherlands.,Department of Orthopaedic Surgery, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam-Zuidoost, The Netherlands
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Abstract
Burns and trauma cause superficial and deep soft tissue wounds that cannot heal to the preinjury state. Healing requires cell proliferation and differentiation into the injured tissue type, laying down extracellular matrix, often as collagens. Heterotopic ossification causes severe pain, nonhealing wounds, and restricted range of motion. Treatment includes radiation therapy, nonsteroidal anti-inflammatory drugs, bisphosphonates, and possibly surgical excision and prophylactic measures. Hypertrophic scars, nonosseous lesions caused by excessive collagen deposition, are often painful, functionally limiting, and aesthetically displeasing. Treatment includes CO2 laser application, steroid injections, and excision with skin grafting. This article reviews the management of these pathologic wounds.
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Affiliation(s)
- Shailesh Agarwal
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Burn/Wound and Regenerative Medicine Laboratory, University of Michigan, Ann Arbor, MI, USA
| | - Michael Sorkin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Burn/Wound and Regenerative Medicine Laboratory, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin Levi
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Burn/Wound and Regenerative Medicine Laboratory, University of Michigan, Ann Arbor, MI, USA.
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Abstract
Postburn contractures of the elbow are uncommon debilitating sequelae of severe burn injuries, which result from thermal injury to both deep and superficial tissues. When periarticular heterotopic bone forms in association with burn injuries, severe and rigid contractures may develop that prohibit basic functions of daily living and are often refractory to nonoperative intervention. Surgical intervention is aimed at releasing or excising all pathologic anatomy limiting elbow motion. In patients with proper indications, surgical intervention can result in substantial improvement in elbow motion, allowing patients to return to activities of daily living, employment, and recreational activities.
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Affiliation(s)
- Mary Claire Manske
- Hand and Microvascular Surgery, Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98102, USA.
| | - Douglas P Hanel
- Hand and Upper Extremity Surgery, Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98102, USA
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Abstract
Heterotopic ossification (HO) presents a substantial barrier to rehabilitation for patients with severe burns or trauma. Although surgical excision is a mainstay of management for this condition, this is unable to address the chronic sequelae of HO, including chronic pain, joint contractures, nerve dysfunction, and open wounds. Current therapeutic modalities are aimed at excision and the prevention of recurrence using nonsteroidal antiinflammatory drugs (NSAIDs) or radiation therapy. Research is now focused on identifying alternative strategies to prevent the initial occurrence of HO through NSAIDs and novel inhibitors of the bone morphogenetic protein signaling pathway.
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16
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Foster N, Kornhaber R, McGarry S, Wood FM, Edgar DW. Heterotopic Ossification in adults following a burn: A phenomenological analysis. Burns 2017; 43:1250-1262. [PMID: 28413106 DOI: 10.1016/j.burns.2017.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/05/2017] [Accepted: 03/08/2017] [Indexed: 11/30/2022]
Abstract
Heterotopic Ossification (HO) is a rare but severely debilitating complication after a burn. Despite there being literature of varying quality explaining the postulated pathological process, risk factors and treatment for HO, the individual experiences of adults diagnosed with HO following a burn, remains unreported. This study sought to explore and describe burn survivors' experiences of HO to gain a greater understanding of the clinical needs for this unique patient population. A phenomenological inquiry of five men and one woman selected through purposeful sampling collected in-depth interviews analysed using Colaizzi's method of data analysis. Five emergent themes: (1) Early signs and symptoms, (2) Impact on the rehabilitation journey, (3) The role of the health care professionals (4) Loss of independence and an increased reliance on others and, (5) Learning to live with it: uncertainty, hope and adaptation. Eleven cluster themes were identified, highlighting the meaning of each emergent theme. These findings describe the significant impact the unique symptomology of HO had on the physical and psychosocial functioning of participants throughout the rehabilitation journey. Central to engagement in rehabilitation, is the participants' desire for autonomy particularly in the domains of living independently and community re-integration.
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Affiliation(s)
- Nichola Foster
- Sir Charles Gairdner Hospital, Physiotherapy Department, Perth, Australia; The University of Norte Dame, School of Physiotherapy, Fremantle, Australia
| | - Rachel Kornhaber
- University of Tasmania, Faculty of Health, School of Health Sciences, Sydney Campus, Australia; National Burns Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Sarah McGarry
- Total Care burn Unit, Princess Margaret Hospital, Perth, Western Australia, Australia; School of Exercise and Health Sciences, Edith Cowan University, Perth, Australia; Burns Service Western Australia, Perth, Australia; Fiona Wood Foundation, Murdoch, Australia
| | - Fiona M Wood
- Total Care burn Unit, Princess Margaret Hospital, Perth, Western Australia, Australia; Burns Service Western Australia, Perth, Australia; Burn Injury Research Unit, School of Surgery, University of Western Australia, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Perth, Murdoch, Australia; Fiona Wood Foundation, Murdoch, Australia
| | - Dale W Edgar
- Burns Service Western Australia, Perth, Australia; Burn Injury Research Node, The University of Notre Dame Australia, Fremantle, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Perth, Murdoch, Australia; Fiona Wood Foundation, Murdoch, Australia.
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17
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Ranganathan K, Loder S, Agarwal S, Wong VW, Forsberg J, Davis TA, Wang S, James AW, Levi B, Levi B. Heterotopic Ossification: Basic-Science Principles and Clinical Correlates. J Bone Joint Surg Am 2015; 97:1101-11. [PMID: 26135077 PMCID: PMC6948799 DOI: 10.2106/jbjs.n.01056] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Heterotopic ossification occurs most commonly after joint arthroplasty, spinal cord injury, traumatic brain injury, blast trauma, elbow and acetabular fractures, and thermal injury.➤ The conversion of progenitor cells to osteogenic precursor cells as a result of cell-mediated interactions with the local tissue environment is affected by oxygen tension, pH, availability of micronutrients, and mechanical stimuli, and leads to heterotopic ossification.➤ Radiation and certain nonsteroidal anti-inflammatory medications are important methods of prophylaxis against heterotopic ossification.➤ Well-planned surgical excision can improve patient outcomes regardless of the joint involved or the initial cause of injury.➤ Future therapeutic strategies are focused on targeted inhibition of local factors and signaling pathways that catalyze ectopic bone formation.
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Affiliation(s)
- Kavitha Ranganathan
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shawn Loder
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shailesh Agarwal
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Victor W. Wong
- Department of Surgery, Johns Hopkins School of Medicine, 4924 Campbell Boulevard, Baltimore, MD 21236
| | - Jonathan Forsberg
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Thomas A. Davis
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Stewart Wang
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Aaron W. James
- Department of Pathology & Laboratory Medicine, University of California at Los Angeles, DGSOM, 200 Medical Plaza, Los Angeles, CA 90095
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
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19
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Veltman ES, Doornberg JN, Eygendaal D, van den Bekerom MPJ. Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients. Arch Orthop Trauma Surg 2015; 135:613-7. [PMID: 25764510 DOI: 10.1007/s00402-015-2199-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The elbow is prone to stiffness after trauma. To regain functional elbow motion, several conservative and surgical treatment options are available. Nonoperative treatment includes physical therapy, intra-articular injections with corticosteroids, and a static progressive or dynamic splinting program. The objective of this study was to perform a comprehensive review of the literature to evaluate the best current evidence for nonoperative treatment options for posttraumatic elbow stiffness. METHODS We performed a search of all studies on nonoperative treatment for elbow stiffness in human adults. All articles describing nonoperative treatment of elbow stiffness, written in the English, German, French or Dutch language, including human adult patients and with the functional outcome reported were included in this study. RESULTS Eight studies (including 232 patients) met our eligibility criteria and were included for data analysis and pooling. These studies included one randomized controlled trial and seven retrospective cohort studies. Static progressive splinting was evaluated in 160 patients. The average pre-splinting range of motion of all elbows was 72°, which improved by 36° after splinting to an average post-splinting arc of motion of 108°. Dynamic splinting was evaluated in 72 patients with an average pre-splinting range of motion of 63°. The average improvement was 37° to an average post-splinting arc of motion of 100°. CONCLUSIONS Both dynamic orthoses and static progressive splinting show good results for the treatment of elbow stiffness, regardless of etiology. The choice for one treatment over the other is based on the preference of the surgeon and patient. We recommend to continue nonoperative treatment with dynamic or static bracing for 12 months or until patients stop making progression in range of elbow motion.
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Affiliation(s)
- Ewout S Veltman
- Department of Orthopaedic Surgery, Spaarne hospital, Hoofddorp, The Netherlands,
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