1
|
Karimi M, Mousavi SA. "Heterotopic abdominal wall ossification: A case report" information. Int J Surg Case Rep 2024; 117:109469. [PMID: 38460290 PMCID: PMC10943427 DOI: 10.1016/j.ijscr.2024.109469] [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: 01/20/2024] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/11/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Heterotopic ossification is forming a new bone in tissues that do not normally ossify. HO was first reported in 1901 by Askanazy and Lubarsh in a case report study. The range of HO is wide from minute foci to large clinically significant ossification. The incidence of HO in abdominal scars is extremely low. CASE PRESENTATION We present an 84-year-old man referred to our hospital after an unsuccessful elective colostomy reversal in a local hospital. The colostomy was made for fecal diversion after sigmoidectomy due to treatment of sigmoid volvulus about three months ago. The patient had a past medical history of hypertension for 8 years under treatment of amiloride. CLINICAL DISCUSSION In general appearance, the patient was not ill or toxic. Vital signs were normal. Postoperatively Patient did not defecate. In his physical examination was not found abdominal tenderness or rebound tenderness. The patient underwent laparotomy which revealed significant retroperitoneal adhesion and colostomy was reversed. Accidentally was found a dense structure with bone-like consistency in the abdominal wall close to the scar was resected. The specimen Pathologic examination showed metaplastic bone deposition with mature bone trabeculae and heterotopic ossification was confirmed. CONCLUSION We report a rare case of HO that was identified at the abdominal wall. Heterotopic ossification can lead to serious complications. However, in symptomatic patients, surgical excision is an acceptable treatment, unlike in asymptomatic patients.
Collapse
Affiliation(s)
- Mohadeseh Karimi
- Department of Pathology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.
| | - Seyed Abdollah Mousavi
- Department of Pathology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| |
Collapse
|
2
|
Kent SE, Ryan SP. Heterotopic Ossification Remodeling After Acetabular Surgery: A Natural History Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00032. [PMID: 37535810 DOI: 10.2106/jbjs.cc.23.00055] [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: 08/05/2023]
Abstract
CASE A 30-year-old woman presented with a transverse plus posterior wall acetabular fracture and underwent operative fixation through a Kocher-Langenbeck approach. Shared decision was made for no heterotopic ossification (HO) prophylaxis. The patient developed symptomatic HO and was scheduled for resection, which was delayed because of the pandemic. She returned with interval remodeling of HO and symptom resolution. No surgery was required. CONCLUSION HO is a common complication after acetabular injury. Resection is the treatment of choice for symptomatic HO. We are not aware of other reports of spontaneous remodeling of symptomatic HO such that it no longer required surgery.
Collapse
Affiliation(s)
- Suzanne E Kent
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | | |
Collapse
|
3
|
Abstract
Heterotopic ossification (HO) refers to benign ectopic bone formation in soft tissue and is common following trauma surgery. HO bone can restrict movement and progress into ankylosis that may necessitate surgical intervention. This article discusses the current literature on the pathophysiology, prophylaxis, treatment, and epidemiology of postoperative HO following orthopedic trauma.
Collapse
Affiliation(s)
- Jad Lawand
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA.
| | - Zachary Loeffelholz
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Bilal Khurshid
- Texas College of Osteopathic Medicine, Fort Worth, Texas, USA
| | - Eric Barcak
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
| |
Collapse
|
4
|
Zorn D, Lombardo J, Poiset S, Gutman M, Cappelli L, Hurwitz M, Ankam N. Single-Dose Radiation Therapy Without Additional Surgery as a Treatment for Heterotopic Ossification Developing After Transfemoral Amputation. Am J Phys Med Rehabil 2022; 101:e158-e161. [PMID: 35930773 DOI: 10.1097/phm.0000000000002075] [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
ABSTRACT Heterotopic ossification is the development of mature lamellar bone in soft tissues. Heterotopic ossification can occur in up to 23% of patients after amputation. Heterotopic ossification is often painful, causing significant dysfunction. While radiotherapy is used to prevent heterotopic ossification before formation, there is a dearth of literature on using radiotherapy to treat existing heterotopic ossification. This case report describes the use of late radiotherapy for the management of existing heterotopic ossification that developed after a transfemoral amputation. A 61-yr-old woman with peripheral artery disease of her bilateral lower limbs status post stenting and ultimately left transfemoral amputation was diagnosed with symptomatic heterotopic ossification limiting her function. Another surgery was not felt to be warranted. She was not improving with medical therapy and was prescribed 800 cGy in one fraction. After treatment, she experienced significant relief in her pain, allowing her to resume physical therapy and use of her prosthesis. There are no other published examples of using radiation alone for treatment of heterotopic ossification formation after transfemoral amputation without surgical revision of the bone formation. Our case shows possible utility in single-dose radiation as a treatment to prevent progression of heterotopic ossification, especially when limiting functional progress.
Collapse
Affiliation(s)
- Devon Zorn
- From the Department of Rehabilitation Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (DZ, NA); and Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (JL, SP, MG, LC, MH)
| | | | | | | | | | | | | |
Collapse
|
5
|
Heterotopic ossification prophylaxis after acetabular fracture fixation using a posterior approach: a retrospective study at a level 1 trauma center. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
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
|
7
|
Hwang CD, Pagani CA, Nunez JH, Cherief M, Qin Q, Gomez-Salazar M, Kadaikal B, Kang H, Chowdary AR, Patel N, James AW, Levi B. Contemporary perspectives on heterotopic ossification. JCI Insight 2022; 7:158996. [PMID: 35866484 PMCID: PMC9431693 DOI: 10.1172/jci.insight.158996] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Heterotopic ossification (HO) is the formation of ectopic bone that is primarily genetically driven (fibrodysplasia ossificans progressiva [FOP]) or acquired in the setting of trauma (tHO). HO has undergone intense investigation, especially over the last 50 years, as awareness has increased around improving clinical technologies and incidence, such as with ongoing wartime conflicts. Current treatments for tHO and FOP remain prophylactic and include NSAIDs and glucocorticoids, respectively, whereas other proposed therapeutic modalities exhibit prohibitive risk profiles. Contemporary studies have elucidated mechanisms behind tHO and FOP and have described new distinct niches independent of inflammation that regulate ectopic bone formation. These investigations have propagated a paradigm shift in the approach to treatment and management of a historically difficult surgical problem, with ongoing clinical trials and promising new targets.
Collapse
Affiliation(s)
- Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Chase A Pagani
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Johanna H Nunez
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Masnsen Cherief
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qizhi Qin
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Balram Kadaikal
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Heeseog Kang
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ashish R Chowdary
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron W James
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benjamin Levi
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
8
|
Lateral Pterygoid Muscle Ossification After Intraoral Condylectomy. J Craniofac Surg 2022; 33:2122-2127. [PMID: 35765131 DOI: 10.1097/scs.0000000000008666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/03/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Lateral pterygoid muscle ossification has not been reported in condylectomy patients. This study aimed to explore the incidence, risk factors, and imaging characteristics of 38 cases with lateral pterygoid muscle ossification among 54 patients after condylectomy via intraoral approach. METHODS This retrospective study included 54 patients following simultaneous orthognathic surgery and condylectomy with coronoid process resection via intraoral approach. The authors evaluated the preoperative, 1 week, 6 months, and 1 year or more postoperative computed tomographic (CT) scans for the presence of lateral pterygoid muscle ossification and its characteristics. Sex, age at the time of surgery, disease course, affected side, preoperative alkaline phosphatase, pathology diagnosis, the height of the removed condyle, condylar shape, operator, preoperative temporomandibular joint movement, and clinical symptoms were assessed as risk factors for ossification. RESULTS No incidence of lateral pterygoid muscle ossification was found on preoperative CT images. Various small-size osseous masses were observed in the lateral pterygoid muscles on postoperative 6 months CT images in 38/54 patients (70.37%) after condylectomy. But no apparent enlargement of the osseous masses was found. No patients complained of clinical discomfort or functional disorder during the follow-up period (23.11 ± 13.16 months). No significant risk factors for ossification were found. CONCLUSIONS Lateral pterygoid muscle ossification is relatively common in patients after condylectomy via intraoral approach. However, its enlargement is self-limited and remains stable 6 months after surgery. it has no adverse effects on the temporomandibular joint functional movement.
Collapse
|
9
|
Evaluation and Management of Posterior Wall Acetabulum Fractures. J Am Acad Orthop Surg 2021; 29:e1057-e1067. [PMID: 34323866 DOI: 10.5435/jaaos-d-20-01301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 02/01/2023] Open
Abstract
Posterior wall acetabulum fractures typically result from high-energy mechanisms and can be associated with various orthopaedic and nonorthopaedic injuries. They range from isolated simple patterns to multifragmentary with or without marginal impaction. Determination of hip stability, which can depend on fragment location, size, and displacement, directs management. Although important in the assessment of posterior wall fractures, CT is unreliable when used to determine stability. The dynamic fluoroscopic examination under anesthesia (EUA) is the benchmark in assessment of hip stability, and fractures deemed stable by EUA have good radiographic and functional outcomes. In fractures that meet surgical criteria, accurate joint reduction guides outcomes. Joint débridement, identification and elevation of impaction, and adjunctive fixation of posterosuperior and peripheral rim fragments along with standard buttress plate fixation are critical. Complications of the fracture and surgical fixation include sciatic nerve injury, posttraumatic osteoarthritis, osteonecrosis of the femoral head, and heterotopic ossification. Although accuracy of joint reduction is paramount for successful results, other factors out of the surgeon's control such as comminution, femoral head lesions, and dislocation contribute to poor outcomes. Even with anatomic restoration of the joint surface, good clinical outcomes are not guaranteed and residual functional deficits can be expected.
Collapse
|
10
|
Chan PYW, Chan PSH. Synostosis of the interphalangeal joint: an uncommon cause of post-fracture digital stiffness. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2021; 8:93-97. [PMID: 34179296 PMCID: PMC8205094 DOI: 10.1080/23320885.2021.1935966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Loss of motion and stiffness after fracture of the digits are most commonly a result of soft tissue contracture and adhesions. However, stiffness can also have a bony etiology. We present a case of synostosis of the thumb interphalangeal joint after non-operative treatment of a closed fracture.
Collapse
|
11
|
Joseph NM, Flanagan CD, Heimke IM, Cho E, Pothireddy S, Scarcella N, Vallier HA. Factors influencing functional outcomes following open reduction internal fixation of acetabular fractures. Injury 2021; 52:1396-1402. [PMID: 33228993 DOI: 10.1016/j.injury.2020.11.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/15/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recent large series of patient-reported outcomes after acetabulum fracture are limited, and potentially modifiable risk factors may be unidentified. The goal of this study was to describe patient and injury factors which negatively influence functional outcomes following operative management of acetabular fractures. METHODS 699 patients with acetabular fractures were treated with open reduction and internal fixation (ORIF). Musculoskeletal Function Assessment (MFA) questionnaire was completed after a minimum 12 months post-injury by 283 adults. MFA scores range from 1 to 100 and higher scores represent greater dysfunction. Factors were assessed for potential association with MFA scores, and univariate and multiple linear regression analyses were performed. RESULTS Survey respondents were more severely injured than non-respondents, with more chest injury (38% vs 22%, p<0.001) and higher Injury Severity Score (19.3 vs 16.8, p=0.003). Patients were 69% male with mean age 44.0 years. Approximately one-third were smokers (31%), while 14% had comorbid diabetes mellitus type II. The majority of injuries occurred during a motor vehicle collision (65%); low-energy mechanisms were rare (4.2%). The most common fracture pattern was isolated posterior wall (23%), followed by transverse/posterior wall (21%). Heterotopic ossification (HO) was noted in 22%: Brooker 1: 29.5%, 2: 23.0%, 3: 32.8%, and 4: 14.8%. Tobacco use (β = 18.4, p<0.001), obesity (β = 0.39, p=0.009), diabetes (β = 8.2, p=0.029), post-traumatic arthrosis (PTA) (β = 5.94 p=0.035), and increasing HO severity (β = 8.93, p<0.001) were independently associated with worse MFA scores. Tobacco use had the strongest association, followed by the severity of HO. CONCLUSION In a large series of patient-reported functional outcomes following fixation of acetabular fractures, tobacco use, obesity, comorbid diabetes, PTA, and HO were associated with worse MFA scores. Further study to mitigate HO should be considered. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Noah M Joseph
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Christopher D Flanagan
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Isabella M Heimke
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elizabeth Cho
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sahini Pothireddy
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Nicholas Scarcella
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Heather A Vallier
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
| |
Collapse
|
12
|
Di Martino A, Coppola MAR, Bordini B, Stefanini N, Geraci G, Pilla F, Traina F, Faldini C. Clinical and radiological outcomes of total hip arthroplasty in patients affected by Paget's disease: a combined registry and single-institution retrospective observational study. J Orthop Traumatol 2021; 22:13. [PMID: 33733386 PMCID: PMC7969678 DOI: 10.1186/s10195-021-00574-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) in patients with Paget's disease can be associated with technical difficulties related to deformities and altered mechanical bone properties, and hypervascularity leads to significative intra-operative bleeding. The purpose of this registry and single-institution study was to investigate overall survival and causes of failure of THA in pagetic patients, together with an analysis of the clinical and radiological complications. MATERIAL AND METHODS Registry-based survival and complication analysis, type of fixation, intra- and post-operative complications, clinical (pharmacological history, blood transfusions, Harris hip score [HHS]) and radiographic (cup orientation, stem axial alignment, osteolysis around the cup and the stem and heterotopic ossification [HO]) data were reviewed. RESULTS In total, 66 patients (27 males and 39 females, mean age at surgery 71.1 years for males and 74.8 years for female) from the registry study presented a 10-year survival of 89.5%. In the institutional study, involving 26 patients (14 males and 12 females, 69 years average) and 29 THAs, hip function improved significantly. Average cup orientation was 40.5°, while varus stem alignment was 13.8%. In total, 52% of hips had heterotopic ossifications. Peri-acetabular osteolysis was in 13.8% of implants and in 45% of hips was found around the stem. Allogenic and autologous blood transfusion rate were 68.2% and 31.8%, respectively, with an average transfusion of 2 units of blood (range 1-6 units). HHS improved by an average of 34 points, with excellent result in 64.3% of patients. Two implants failed, one due to traumatic ceramic head fracture 64 months after surgery, and one due to mobilization of the cup on the second post-operative day. CONCLUSION THA surgery in Paget's patients is a safe procedure, and implant survival is only partly affected by bone remodelling and choice of fixation. The post-operative functional outcome is largely similar to that of other patients. Bleeding-related complications are the main complications; a careful pharmacological strategy should be recommended to decrease the risk of transfusions and of HO development. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Alberto Di Martino
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy.
| | | | - Barbara Bordini
- Laboratorio Di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano, 1/10, 40136, Bologna, Italy
| | - Niccolò Stefanini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Geraci
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Federico Pilla
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Francesco Traina
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
- Orthopaedic-Traumatology and Prosthetic Surgery and Revisions of Hip and Knee Implants, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
- University of Messina, Messina, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| |
Collapse
|
13
|
Freije SL, Kushdilian MV, Burney HN, Zang Y, Saito NG. A Retrospective Analysis of 287 Patients Undergoing Prophylactic Radiation Therapy for the Prevention of Heterotopic Ossification. Adv Radiat Oncol 2020; 6:100625. [PMID: 34195485 PMCID: PMC8233464 DOI: 10.1016/j.adro.2020.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/30/2020] [Accepted: 11/11/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose Heterotopic ossification (HO) is a potentially disabling disorder of ectopic bone formation secondary to orthopedic surgery or trauma. In this retrospective analysis we evaluated the outcomes of patients who received radiation therapy (RT) for HO prophylaxis. Methods and Materials A total of 287 patients who received RT for HO prophylaxis at a major trauma center from 2007 to 2018 were analyzed. Data collected included types of injury, surgery, time intervals between key events, development of postprophylaxis HO, and secondary malignancies. Associations between various factors and the risk of developing HO were analyzed. Kaplan-Meier analysis was used to estimate failure rates. Results The most common indication for RT was traumatic acetabular fracture (83.3%). Twelve patients (4.2%) developed postprophylaxis HO with a median time to failure of 8.6 months (2.8-24.5). Kaplan-Meier 1-, 2-, and 5-year failure rates were 3.7%, 4.4%, and 7.4%, respectively. Injury type and timing of RT were not associated with the risk of failure, but we observed a trend of increased risk of failure in patients with longer time between surgery and RT (odd ration [OR] 1.68, P = .056). Current or former smokers (51.7%) were less likely to fail (OR 0.10, P = .03). There was no incidence of in-field secondary malignancy. Conclusions There was no significant association between injury and fracture type, surgical approach, or timing of RT and development of HO, contrary to published reports of increased HO risk with certain surgical approaches and longer time intervals between injury and surgery, suggesting that prophylactic RT might play a role in mitigating these effects. Decreased risk of postprophylaxis HO among former or current smokers was unexpected. No secondary malignancy in the RT field was identified, although the median follow-up was only 17 months. Compared with published HO incidences (17%-39%) in patients who receive no prophylaxis after traumatic acetabular fractures, our results are highly suggestive of the efficacy of prophylactic RT.
Collapse
Affiliation(s)
- Samantha L Freije
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael V Kushdilian
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Heather N Burney
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yong Zang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Naoyuki G Saito
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
14
|
Do Indomethacin or Radiation for Heterotopic Ossification Prophylaxis Increase the Rates of Infection or Wound Complications After Acetabular Fracture Surgery? J Orthop Trauma 2020; 34:455-461. [PMID: 32815831 DOI: 10.1097/bot.0000000000001775] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the rates of infection and wound complications in patients undergoing operative fixation (ORIF) of acetabular fractures receiving heterotopic ossification (HO) prophylaxis using indomethacin or external beam radiation therapy (XRT) versus no prophylaxis. DESIGN Retrospective cohort. SETTING Level I trauma center. PATIENTS We reviewed 473 patients undergoing ORIF of acetabular fractures through posterior, combined, or extensile surgical approaches from 2012 to 2017, with a median follow-up of 13 months (0.5-77 months). MAIN OUTCOME MEASUREMENT Rates of infection and wound complications were stratified according to their HO prophylaxis method into three groups as indomethacin, XRT, and no prophylaxis. RESULTS Overall, 167 patients (35.3%) received indomethacin, 104 patients (22.0%) received postoperative XRT, and 202 patients (42.7%) received no prophylactic treatment. There was no difference between the 3 groups for the risk of surgical site infection (P = 0.280). The XRT group had a significantly increased risk of noninfectious wound complications (20.2%) compared with the indomethacin group (6.6%, P = 0.002) and the no prophylaxis group (5.0%, P < 0.0001). Multivariate analysis revealed XRT remained a significant risk factor for noninfectious wound complications compared with no prophylaxis (odds ratio 5.39; 95% confidence interval 2.37-12.22; P < 0.0001). CONCLUSIONS Although there is no difference between XRT, indomethacin, and no HO prophylaxis for the risk of surgical site infection, the use of XRT results in more than 5 times increased risk of noninfectious wound complications compared with no prophylaxis. This increased risk should be considered when contemplating XRT for HO prophylaxis in acetabular fracture patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
15
|
Extensive Circumferential Heterotopic Ossification Discovered at the Base of a Loop Ileostomy. Case Rep Surg 2019; 2019:4036716. [PMID: 31886007 PMCID: PMC6914893 DOI: 10.1155/2019/4036716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/17/2019] [Accepted: 11/21/2019] [Indexed: 11/18/2022] Open
Abstract
Heterotopic ossification is a rare phenomenon defined by the formation of bone within nonossifying soft tissues. A rare variant of heterotopic ossification is heterotopic mesenteric ossification (HMO), in which there is involvement of the mesentery and surrounding intra-abdominal structures. There are only four previously reported cases of HMO involving an ileostomy. We present a case of HMO affecting an ileostomy which was discovered during elective stoma reversal in a 52-year-old male who required fecal diversion following perineal necrotizing fasciitis.
Collapse
|
16
|
Rosteius T, Rausch V, Pätzholz S, Lotzien S, Baecker H, Schildhauer TA, Geßmann J. Incidence and risk factors for heterotopic ossification following periprosthetic joint infection of the hip. Arch Orthop Trauma Surg 2019; 139:1307-1314. [PMID: 31187256 DOI: 10.1007/s00402-019-03215-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Heterotopic ossifications (HOs) commonly occur following total hip arthroplasty. Data regarding the appearance of HO after periprosthetic joint infection (PJI) of the hip are rare. Therefore, the aim of this study was to analyze the incidence and potential risk factors for the development of HO in patients with PJI of the hip. MATERIALS AND METHODS We performed a single-center, retrospective study including patients treated with a two- or multistage operation and patients undergoing salvage procedure in cases of PJI of the hip with a minimum follow-up of 6 months. A total of 150 patients were included in the analysis. The Brooker-scale was used to classify HO. Patients were divided in three groups: (1) No HO, (2) HO Brooker type 1-4, and (3) high-grade HO (HO Brooker type 3 and 4). In each group, we checked possible risk factors for the development of HO for statistical significance. RESULTS Patients included in our study had a mean age of 70.4 ± 12.1 years. Of all patients, 75 were women (50%). HOs could be found in 70 patients (46.7%). Twenty-seven patients showed HO Brooker type 1, 23 type 2, 15 type 3 and 5 type 4. Male gender [odds ratio (OR) 2.14; p = 0.022], smoking (OR 5.75; p = 0.025) were significant risk factors for HO. A chronic infection (OR 3.54; p = 0.029) and a higher number of procedures (p = 0.009) were significant risk factors for the development of high-grade HO. CONCLUSIONS HOs often occur following surgical care of PJI. Male gender, smoking, a chronic infection and high number of operations are risk factors for developing HO after PJI.
Collapse
Affiliation(s)
- Thomas Rosteius
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
| | - Valentin Rausch
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Simon Pätzholz
- Department of Radiological Diagnostics, Interventional Radiology and Nuclear Medicine, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Sebastian Lotzien
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Hinnerk Baecker
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Jan Geßmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| |
Collapse
|
17
|
Softer Tissue Issues in Orthopaedic Trauma. J Orthop Trauma 2019; 33 Suppl 6:S30-S33. [PMID: 31083146 DOI: 10.1097/bot.0000000000001471] [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] [Indexed: 02/02/2023]
Abstract
There are number of significant issues outside of the bone and/or fracture that are important to consider in the treatment of orthopaedic trauma. Joint contractures, heterotopic bone formation, managing a traumatized soft-tissue envelope or substantial soft-tissue defects represent a few of these important issues. This article reviews these issues, including the best available evidence on how to manage them.
Collapse
|
18
|
Łęgosz P, Drela K, Pulik Ł, Sarzyńska S, Małdyk P. Challenges of heterotopic ossification-Molecular background and current treatment strategies. Clin Exp Pharmacol Physiol 2018; 45:1229-1235. [DOI: 10.1111/1440-1681.13025] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Paweł Łęgosz
- Department of Orthopaedics and Traumatology; 1st Faculty of Medicine; Medical University of Warsaw; Warsaw Poland
| | - Katarzyna Drela
- NeuroRepair Department; Mossakowski Medical Research Centre; Polish Academy of Sciences; Warsaw Poland
| | - Łukasz Pulik
- Department of Orthopaedics and Traumatology; 1st Faculty of Medicine; Medical University of Warsaw; Warsaw Poland
| | - Sylwia Sarzyńska
- Department of Orthopaedics and Traumatology; 1st Faculty of Medicine; Medical University of Warsaw; Warsaw Poland
| | - Paweł Małdyk
- Department of Orthopaedics and Traumatology; 1st Faculty of Medicine; Medical University of Warsaw; Warsaw Poland
| |
Collapse
|
19
|
|
20
|
Hoyt BW, Pavey GJ, Potter BK, Forsberg JA. Heterotopic ossification and lessons learned from fifteen years at war: A review of therapy, novel research, and future directions for military and civilian orthopaedic trauma. Bone 2018; 109:3-11. [PMID: 29462673 DOI: 10.1016/j.bone.2018.02.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 12/19/2022]
Abstract
Heterotopic ossification, the formation of bone in soft tissues, is a common complication of the high-energy extremity trauma sustained in modern armed conflict. In the past 15years, military treatment facilities and aligned laboratories have been in a unique position to study and treat this process due to the high volume of patients with these injuries secondary to blast trauma. The devastating nature of these wounds has limited traditional therapeutic options, necessitating alternative solutions to prophylaxis and initial treatment producing substantial advances in modeling, prophylaxis, detection, and therapy. Specific developments include establishment of an animal model that reproduces the systemic and local tissue injury of blast injuries, the use of molecular assays and predictive modeling in clinical decision making, advances in early detection including Raman spectroscopy, and investigation of prophylactic and therapeutic pharmacotherapy targeting the molecular pathways of aberrant bone formation. In this review article, we will present the literature to date, ongoing studies, and future directions for investigation of heterotopic ossification, with a focus on military-specific research.
Collapse
Affiliation(s)
- Benjamin W Hoyt
- Orthopaedics, USU-Walter Reed Department of Surgery Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Gabriel J Pavey
- Orthopaedics, USU-Walter Reed Department of Surgery Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Benjamin K Potter
- Orthopaedics, USU-Walter Reed Department of Surgery Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Jonathan A Forsberg
- Orthopaedics, USU-Walter Reed Department of Surgery Walter Reed National Military Medical Center, Bethesda, MD, United States..
| |
Collapse
|
21
|
Cholok D, Chung MT, Ranganathan K, Ucer S, Day D, Davis TA, Mishina Y, Levi B. Heterotopic ossification and the elucidation of pathologic differentiation. Bone 2018; 109:12-21. [PMID: 28987285 PMCID: PMC6585944 DOI: 10.1016/j.bone.2017.09.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/27/2017] [Accepted: 09/27/2017] [Indexed: 01/23/2023]
Abstract
Tissue regeneration following acute or persistent inflammation can manifest a spectrum of phenotypes ranging from the adaptive to the pathologic. Heterotopic Ossification (HO), the endochondral formation of bone within soft-tissue structures following severe injury serves as a prominent example of pathologic differentiation; and remains a persistent clinical issue incurring significant patient morbidity and expense to adequately diagnose and treat. The pathogenesis of HO provides an intriguing opportunity to better characterize the cellular and cell-signaling contributors to aberrant differentiation. Indeed, recent work has continued to resolve the unique cellular lineages, and causative pathways responsible for ectopic bone development yielding promising avenues for the development of novel therapeutic strategies shown to be successful in analogous animal models of HO development. This review details advances in the understanding of HO in the context of inciting inflammation, and explains how these advances inform the current standards of diagnosis and treatment.
Collapse
Affiliation(s)
- David Cholok
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael T Chung
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kavitha Ranganathan
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Serra Ucer
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Devaveena Day
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, USA
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, USA; Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Yuji Mishina
- School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
| |
Collapse
|
22
|
Arzeno A, Wang T, Huddleston JI. Abundant heterotopic bone formation following use of rhBMP-2 in the treatment of acetabular bone defects during revision hip arthroplasty. Arthroplast Today 2018; 4:162-168. [PMID: 29896546 PMCID: PMC5994604 DOI: 10.1016/j.artd.2017.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 12/12/2017] [Accepted: 12/13/2017] [Indexed: 01/28/2023] Open
Abstract
Revision hip arthroplasty in the setting of periacetabular bone loss presents a significant challenge, as options for restoring bone loss are limited. Recombinant human bone morphogenetic protein-2 may offer a solution by promoting bone growth to restore bone stock before implant reimplantation. Here we present a case of a patient with a periprosthetic acetabulum fracture, resulting in pelvic discontinuity as the result of significant periacetabular bone loss. Using a staged approach, periacetabular bone stock was nearly entirely reconstituted using recombinant BMPs and allograft, which resulted in stable fixation, but with abundant heterotopic bone formation. Recombinant BMP-2 offers a useful tool for restoring bone stock in complex hip arthroplasty revision cases with periacetabular bone loss; however, caution must be used as overabundant bone growth as heterotopic ossification may result.
Collapse
Affiliation(s)
- Alexander Arzeno
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Tim Wang
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
23
|
Cheng L, Long HT, Sun BH, Zhao SS, Zhu Y. The efficacy of a multimodal analgesia protocol in preventing heterotopic ossification after acetabular fractures surgery. Int J Clin Pharm 2017; 39:826-830. [PMID: 28500436 DOI: 10.1007/s11096-017-0476-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 04/28/2017] [Indexed: 11/30/2022]
Abstract
Background Heterotopic ossification (HO) after joint surgery is always a disturbing problem for patients and surgeons. Prophylaxis is the most effective therapy. Objective To assess the efficacy and safety of a multimodal analgesia protocol that included parecoxib and celecoxib in preventing HO after acetabular fracture surgery. Setting Selecting patients from trauma registry of our hospital. Method We identified 259 patients who had acetabular fracture surgery between January 2008 and December 2014. Hundredsixty-three patients received parecoxib and celecoxib (Group A) and 96 patients received no prophylaxis (Group B). The presence of HO was assessed according to the classification of Brooker et al. at the 12 month postoperative visit. Main outcome measure The differences in HO incidence and severity between the two groups. Results 49 patients (30.0%) developed HO in the Group A and 44(45.8%) in Group B. The difference in total HO incidence between the two groups was significant (P = 0.011 < 0.05, χ2 = 6.530, OR 0.508, 95% CI (0.301-0.857). Severe HO (Brooker grade III or IV) developed in 15 patients (9.2%) in Group A and 17 patients (17.7%) in Group B. Brooker grade I + II was 34(20.9%) and 27(28.1%) in each group. The difference in the severity of HO between the two Groups was significant (P = 0.008 < 0.05). Conclusion A short-term administration of parecoxib and celecoxib aids in the prevention of HO after acetabular fractures surgery.
Collapse
Affiliation(s)
- Liang Cheng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Hai-Tao Long
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Bu-Hua Sun
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Shu-Shan Zhao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Yong Zhu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
| |
Collapse
|
24
|
Abstract
Heterotopic ossification (HO) is a common complication of the surgical treatment of acetabular fractures. HO is the formation of trabecular bone in soft tissues where bone does not usually occur. Over the last decade, many risk factors have been identified for HO after surgical fixation of acetabular fractures; however, prophylaxis and treatment of this condition are controversial. Potential preventive measures range from NSAIDs to external beam irradiation, but recent studies have questioned the utility of these measures. The Brooker classification system, which has been correlated with patient function and outcomes, is most commonly used to describe HO severity. Advances will assist in the diagnosis, prevention, and management of HO as well as the assessment of risk factors that could affect outcomes.
Collapse
|
25
|
Subedi N, Heire P, Parmer V, Beardmore S, Oh C, Jepson F, Ali SI. Multimodality imaging review of the post-amputation stump pain. Br J Radiol 2016; 89:20160572. [PMID: 27579849 DOI: 10.1259/bjr.20160572] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Limb amputation is one of the oldest known surgical procedures performed for a variety of indications. Little surgical technical improvements have been made since the first procedure, but perioperative and post-operative refinements have occurred over time. Post-amputation pain (PAP) of the stump is a common complication but is an extremely challenging condition to treat. Imaging allows early diagnosis of the underlying cause so that timely intervention is possible to minimize physical disability with its possible psychological and socioeconomic implications. A multidisciplinary approach should be taken involving the rehabilitation medicine team, surgeon, prosthetist, occupational therapist and social workers. Conventional radiographs demonstrate the osseous origin of PAP while high-resolution ultrasound is preferred to assess soft-tissue abnormalities. These are often the first-line investigations. MRI remains as a problem-solving tool when clinical and imaging findings are equivocal. This article aimed to raise a clear understanding of common pathologies expected in the assessment of PAP. A selection of multimodality images from our Specialist Mobility and Rehabilitation Unit are presented so that radiologists are aware of and recognize the spectrum of pathological conditions involving the amputation stump. These include but are not limited to aggressive bone spurs, heterotopic ossification, soft-tissue inflammation (stump bursitis), collection, nervosas, osteomyelitis etc. The role of the radiologist in reaching the diagnosis early is vital so that appropriate treatment can be instituted to limit long-term disability. The panel of authors hopes this article helps readers identify the spectrum of pathological conditions involving the post-amputation stump by recognizing the imaging features of the abnormalities in different imaging modalities.
Collapse
Affiliation(s)
- Nawaraj Subedi
- 1 Department of Radiology, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - Priam Heire
- 1 Department of Radiology, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - Vinay Parmer
- 1 Department of Radiology, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - Simon Beardmore
- 1 Department of Radiology, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - Chooi Oh
- 1 Department of Radiology, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - Fergus Jepson
- 2 Specialist Mobility and Rehabilitation Centre, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Syed I Ali
- 1 Department of Radiology, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| |
Collapse
|
26
|
Elhassan Y, Abdelhaq A, Piggott RP, Osman M, McElwain JP, Leonard M. Heterotopic Ossification following acetabular fixation: Incidence and risk factors: 10-year experience of a tertiary centre. Injury 2016; 47:1332-6. [PMID: 26997132 DOI: 10.1016/j.injury.2016.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 02/15/2016] [Accepted: 03/04/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Heterotopic Ossification (HO) is a well-recognized complication following acetabular fracture fixation and its presence is prognostic for suboptimal clinical outcome. There are many controversies pertaining to its aetiology, including surgical approach, associated injuries and the use of HO prophylaxis. Long term data from high volume centres is necessary to address these issues. AIM To determine the incidence of HO post open reduction and internal fixation (ORIF) of acetabular fractures and to examine the associated risk and prognostic factors. METHOD We studied a cohort of 369 consecutive acetabular fractures that underwent ORIF at our institution over a 10 year period. Data was analyzed using univariate and multivariate logistic regression. RESULTS The existence of HO was evident in 65 patients (17.62%), of these 39 (60.0%) were Class I, 16 (24.6%) were Class II, 8 (12.3%) were Class III, and 2 (3.1%) were Class IV according to Brooker Classification. We found a significant association between admission to an Intensive Care Unit (ICU) (P-value=0.039), chest injury (P-value=0.013), multiple fractures (P-value=0.005), and the time lapse between injury and operation (P-value=0.025), and some statistical significance with surgical approach, ipsilateral fractures, open fractures, tibial and patellar fractures. Age over 30 years as the only prognostic factor for severe HO. Prophylaxis with Indomethacin did not appear to confer any benefit in our patient group. CONCLUSION The risk factors for developing HO following acetabular fracture fixation are multifactorial and include admission to ICU, associated chest injuries, multiple fractures and delay between injury and surgery. Surgical approach, ipsilateral fractures and tibia and patellar fractures may also play a role. Age over thirty years was the only prognostic factor for developing severe HO.
Collapse
Affiliation(s)
- Yahya Elhassan
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| | - Ady Abdelhaq
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| | - Robert P Piggott
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| | - Mugtaba Osman
- Department of Psychiatry, University College Dublin, Ireland.
| | - John P McElwain
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| | - Mike Leonard
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| |
Collapse
|
27
|
Davis JA, Roper B, Munz JW, Achor TS, Galpin M, Choo AM, Gary JL. Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture? Clin Orthop Relat Res 2016; 474:1430-5. [PMID: 26497882 PMCID: PMC4868158 DOI: 10.1007/s11999-015-4609-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Controversy regarding heterotopic ossification (HO) prophylaxis exists after Kocher-Langenbeck for treatment of acetabular fracture. Prophylaxis options include antiinflammatory oral medications, single-dose radiation therapy, and débridement of gluteus minimus muscle. Prior literature has suggested single-dose radiation therapy as the best prophylaxis to prevent HO formation. However, recent reports have emerged of radiation-induced sarcoma after radiotherapy for HO prophylaxis, which has led many surgeons to reconsider the risks and benefits of single-dose radiation therapy. We set out to determine if radiotherapy, in addition to standard débridement of gluteus minimus muscle, affected postoperative HO formation after a Kocher-Langenbeck approach for acetabular fracture. QUESTIONS/PURPOSES (1) After the Kocher-Langenbeck approach and gluteus minimus débridement, is single-dose radiotherapy associated with a decreased risk of HO? (2) Does addition of single-dose radiotherapy prolong length of stay after a Kocher-Langenbeck approach and gluteus minimus débridement as compared with patients without radiotherapy? METHODS After institutional review board approval, all adult patients treated for acetabular fracture by a single surgeon with a Kocher-Langenbeck approach between August 2011 and October 2014 were identified (n = 60). Débridement of gluteus minimus muscle caudal to the superior gluteal bundle was standard in all patients. Radiotherapy was given with a single dose of 700 cGy within 72 hours of surgery from August 2011 until April 2013. Patients treated subsequently did not receive radiotherapy. Patients treated with indomethacin (n = 1) and with fewer than 10 weeks followup were excluded (n = 12) because several studies suggest that most HO that develops is visible by that point in time. Our study group totaled 46 patients with 24 in the radiotherapy and débridement group and 22 in the débridement group. Charts were reviewed to determine length of stay. Attending orthopaedic trauma surgeons who were blinded to the patient's treatment group graded all followup radiographs according to the Brooker system, and Classes III and IV HO were considered clinically important Fisher's exact test was used to analyze clinically significant differences HO between the two groups. Length of stay was compared using a t-test. RESULTS Single-dose radiotherapy is associated with a decreased risk of clinically important (Brooker III-IV) HO after a Kocher-Langenbeck approach and gluteus minimus débridement (radiotherapy: one of 24 [4%], no radiotherapy: seven of 22 [32%], relative risk: 0.131 [95% confidence interval {CI}, 0.018-0.981], p = 0.020). Addition of single-dose radiotherapy did not result in increased length of stay (radiotherapy: 12 ± 7.0 days; no radiotherapy: 11 ± 7.2 days; mean difference: 1.0 [95% CI, -3.2 to 5.2] days, p = 0.635). CONCLUSIONS Single-dose radiation in combination with gluteus minimus débridement decreases the risk of clinically important HO compared with gluteus minimus débridement alone after a Kocher-Langenbeck approach for acetabular fracture. No differences in length of stay were seen. Surgeons who chose not to use radiotherapy as a result of concern for future sarcoma may see higher rates of clinically significant HO after a Kocher-Langenbeck approach for acetabular fracture fixation. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Jason A. Davis
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Brennan Roper
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - John W. Munz
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Timothy S. Achor
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Matthew Galpin
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Andrew M. Choo
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Joshua L. Gary
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA ,grid.267308.80000000092062401University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 1700, Houston, TX 77030 USA
| |
Collapse
|
28
|
Do Surrogates of Injury Severity Influence the Occurrence of Heterotopic Ossification in Fractures of the Acetabulum? J Orthop Trauma 2016; 30:213-6. [PMID: 26606599 DOI: 10.1097/bot.0000000000000490] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the relationship between injury severity surrogates and other patient factors with the development and severity of heterotopic ossification (HO) following open reduction internal fixation of acetabular fractures treated with a posterior approach. DESIGN Retrospective review. SETTING Academic level 1 trauma center. PARTICIPANTS Two hundred forty-one patients who were treated through a posterior approach with a minimum of 6-month radiographic follow-up were identified from an acetabular fracture database. INTERVENTION None. MAIN OUTCOME MEASURES The occurrence and severity (Brooker Grade III/IV) of HO 6 months postsurgery. RESULTS Length of stay (LOS) in the intensive care unit (ICU), non-ICU LOS >10 days, and HO prophylaxis with external radiation beam therapy (XRT) were significantly associated with the development of HO in a multivariate model [ICU LOS: 1-2 days, odds ratio (OR) = 4.33, 95% confidence interval (CI): 1.03-18.25; 3-6 days, OR = 4.1, 95% CI, 1.27-13.27; >6 days, OR = 11.7, 95% CI, 3.24-42.22; non-ICU LOS >10 days (vs. 0-6 days): OR = 7.6, 95% CI, 2.6-22.25; XRT HO prophylaxis: OR = 0.29, 95% CI, 0.10-0.85]. Other variables evaluated in multivariate modeling not significantly associated with development and severity of HO included age, gender, mechanism of injury, injury severity score, presence of neurologic injury, Letournel fracture type, occurrence of hip dislocation, interval from injury to surgery, operative time, and estimated blood loss. CONCLUSIONS Surrogates of injury severity, including days in the ICU and non-ICU hospital LOS >10 days, were associated with the development of HO in our cohort of acetabular fracture patients. Prophylaxis with XRT was significantly protective against the development of HO, and the ability to provide prophylaxis is very likely related to the severity of injury. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
29
|
Wang CG, Li YM, Zhang HF, Li H, Li ZJ. Anterior approach versus posterior approach for Pipkin I and II femoral head fractures: A systemic review and meta-analysis. Int J Surg 2016; 27:176-181. [PMID: 26854958 DOI: 10.1016/j.ijsu.2016.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/30/2015] [Accepted: 02/02/2016] [Indexed: 02/08/2023]
Abstract
PURPOSE We performed a meta-analysis, pooling the results from controlled clinical trials to compare the efficiency of anterior and posterior surgical approaches to Pipkin I and II fractures of the femoral head. METHODS Potential academic articles were identified from the Cochrane Library, Medline (1966-2015.5), PubMed (1966-2015.5), Embase (1980-2015.5) and ScienceDirect (1966-2015.5) databases. Gray studies were identified from the references of the included literature. Pooling of the data was performed and analyzed by RevMan software, version 5.1. RESULTS Five case-control trials (CCTs) met the inclusion criteria. There were significant differences in the incidence of heterotopic ossification (HO) between the approaches, but no significant differences were found between the two groups regarding functional outcomes of the hip, general postoperative complications, osteonecrosis of the femoral head or post-traumatic arthritis. CONCLUSION The present meta-analysis indicated that the posterior approach decreased the risk of heterotopic ossification compared with the anterior approach for the treatment of Pipkin I and II femoral head fractures. No other complications were related to anterior and posterior approaches. Future high-quality randomized, controlled trials (RCTs) are needed to determine the optimal surgical approach and to predict other postoperative complications. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Chen-Guang Wang
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, People's Republic of China
| | - Yao-Min Li
- Department of Rehabilitation, Tianjin Hospital, Tianjin 300211, People's Republic of China
| | - Hua-Feng Zhang
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, People's Republic of China
| | - Hui Li
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, People's Republic of China
| | - Zhi-Jun Li
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, People's Republic of China.
| |
Collapse
|
30
|
Boffeli TJ, Thompson JC, Waverly BJ, Pfannenstein RR, Mahoney KJ. Incidence and Clinical Significance of Heterotopic Ossification After Partial Ray Resection. J Foot Ankle Surg 2016; 55:714-9. [PMID: 26922732 DOI: 10.1053/j.jfas.2016.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Indexed: 02/03/2023]
Abstract
Heterotopic bone growth is a common finding after partial foot amputation that can predispose to recurrent wounds, osteomyelitis, and reamputation. Heterotopic ossification is the formation of excessive mature lamellar bone in the soft tissues adjacent to bone that is exacerbated by trauma or surgical intervention. The relevance of heterotopic ossification is dependent on its anatomic location. Its occurrence as a sequela of partial foot amputation can lead to prominence on the plantar aspect of the foot that can predispose the patient to recurrent neuropathic ulceration or preclude appropriate wound healing. Reulceration puts the high-risk patient who has already undergone local amputation at greater risk of recurrent infection and further amputation. The present study aimed to assess the incidence and risk factors for heterotopic ossification to further evaluate its role in partial foot amputation. A retrospective analysis of 72 consecutive patients who had undergone partial metatarsal resection was performed, with 90% of the cohort having peripheral neuropathy and 88% diabetes mellitus. Our findings revealed a heterotopic ossification incidence of 75% diagnosed radiographically. The initial onset of heterotopic ossification was not appreciated >10 weeks postoperatively. Ten patients (18.5%) exhibited heterotopic ossification-associated ulceration. The incidence of heterotopic ossification was 30% less in patients with peripheral vascular disease. These results indicate that heterotopic ossification is a common sequela of partial ray resection in an already high-risk patient population. The perioperative use of pharmacologic or radiation prophylaxis in an attempt to minimize amputation-related morbidity should be considered.
Collapse
Affiliation(s)
- Troy J Boffeli
- Director, Foot and Ankle Surgical Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN
| | - Jonathan C Thompson
- Attending Physician, Orthopedic Center at Mayo Clinic Health System, Eau Claire, WI
| | - Brett J Waverly
- Foot and Ankle Surgery Resident, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN.
| | - Ryan R Pfannenstein
- Attending Physician, Foot and Ankle Surgical Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN
| | - Kevin J Mahoney
- Foot and Ankle Surgery Resident, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN
| |
Collapse
|
31
|
Scheinfeld MH, Dym AA, Spektor M, Avery LL, Dym RJ, Amanatullah DF. Acetabular fractures: what radiologists should know and how 3D CT can aid classification. Radiographics 2016; 35:555-77. [PMID: 25763739 DOI: 10.1148/rg.352140098] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Correct recognition, description, and classification of acetabular fractures is essential for efficient patient triage and treatment. Acetabular fractures may result from high-energy trauma or low-energy trauma in the elderly. The most widely used acetabular fracture classification system among radiologists and orthopedic surgeons is the system of Judet and Letournel, which includes five elementary (or elemental) and five associated fractures. The elementary fractures are anterior wall, posterior wall, anterior column, posterior column, and transverse. The associated fractures are all combinations or partial combinations of the elementary fractures and include transverse with posterior wall, T-shaped, associated both column, anterior column or wall with posterior hemitransverse, and posterior column with posterior wall. The most unique fracture is the associated both column fracture, which completely dissociates the acetabular articular surface from the sciatic buttress. Accurate categorization of acetabular fractures is challenging because of the complex three-dimensional (3D) anatomy of the pelvis, the rarity of certain acetabular fracture variants, and confusing nomenclature. Comparing a 3D image of the fractured acetabulum with a standard diagram containing the 10 Judet and Letournel categories of acetabular fracture and using a flowchart algorithm are effective ways of arriving at the correct fracture classification. Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Meir H Scheinfeld
- From the Division of Emergency Radiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210 St, Bronx, NY 10467 (M.H.S., R.J.D.); Albert Einstein College of Medicine, Bronx, NY (A.A.D.); Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Conn (M.S.); Division of Emergency Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (L.L.A.); and Department of Orthopedic Surgery, Stanford University, Palo Alto, Calif (D.F.A.)
| | | | | | | | | | | |
Collapse
|
32
|
Furukava RB, Lenza M, Matsunaga FT, Tamaoki MJ, Matsumoto MH, Belloti JC. Interventions for preventing heterotopic bone formation after surgery for acetabular fractures. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd009262.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rebeca B Furukava
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; Rua Borges Lagoa, 783 - 5th Floor São Paulo São Paulo Brazil 04038-032
| | - Mário Lenza
- Hospital Israelita Albert Einstein; Orthopaedic and Trauma Department; Av. Albert Einstein, 627/701 São Paulo São Paulo Brazil CEP 05651-901
| | - Fabio T Matsunaga
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; Rua Borges Lagoa, 783 - 5th Floor São Paulo São Paulo Brazil 04038-032
| | - Marcel Jun Tamaoki
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; Rua Borges Lagoa, 783 - 5th Floor São Paulo São Paulo Brazil 04038-032
| | - Marcelo Hide Matsumoto
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; Rua Borges Lagoa, 783 - 5th Floor São Paulo São Paulo Brazil 04038-032
| | - João Carlos Belloti
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; Rua Borges Lagoa, 783 - 5th Floor São Paulo São Paulo Brazil 04038-032
| |
Collapse
|
33
|
Abstract
Successful management of the mangled extremity is difficult; however, recent advancements are changing the outcomes of these difficult cases. Multiple centers are working on new bionic limbs with real-time feedback and better performance parameters. Research progress, particularly in the military sector, has aided in our understanding of heterotopic ossification after devastating limb injuries. This progress has also allowed a better treatment program for the residual limb in surgery and postsurgery. It is an exciting time in the management and rehabilitation of amputated limbs, as both biologic and technological advancements are enabling better patient satisfaction. This article looks at some of these discoveries and how they are changing the treatment of the residual limb.
Collapse
|
34
|
Munshi N, Abbas A, Gulamhussein MA, Mehboob G, Qureshi RA. Functional outcome of the surgical management of acute acetabular fractures. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
35
|
Slone HS, Walton ZJ, Daly CA, Chapin RW, Barfield WR, Leddy LR, Hartsock LA. The impact of race on the development of severe heterotopic ossification following acetabular fracture surgery. Injury 2015; 46:1069-73. [PMID: 25744171 DOI: 10.1016/j.injury.2015.01.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/23/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the association between race on severe heterotopic ossification (HO) following acetabular fracture surgery. DESIGN Retrospective case control study. SETTING Level I university trauma centre. METHODS Two hundred and fifty-three patients who were surgically treated for acetabular fractures were retrospectively evaluated. Postoperative radiographs were evaluated for HO by a blinded musculoskeletal radiologist, and classified based on a modified Brooker classification. RESULTS Of the 253 patients that met inclusion and exclusion criteria, 175 (69%) were male and 78 (31%) were female. One hundred and fifty-four (61%) patients were Caucasian, and 99 (39%) were African American (AA). Fifty-five (21%) patients developed severe HO. Of those who developed severe HO, 25 were Caucasian (45%), 30 were African American (55%). Forty-one patients (75%) with severe HO were male, and 14 (25%) were female. No statistical differences (p>0.05) were found between groups in terms of age, days to surgery, GCS at presentation, surgical approach, perioperative HO prophylaxis, or AO/OTA fracture classification. The patient population was then stratified by race, gender, and race/gender. AA were more likely than Caucasians to develop severe HO (odds ratio [OR], 2.24; confidence interval [CI], 1.22-4.11). When gender was considered independent of race, no statistical differences (p>0.05) were observed (OR, 1.40; CI, 0.71-2.75). AA males were much more likely to develop severe HO when compared to Caucasian females (OR, 4.4; CI, 1.38-14.06). CONCLUSION Race is associated with different rates of severe HO formation following acetabular fracture surgery. AA patients are significantly more likely to develop severe HO following acetabular fracture surgery when compared to Caucasian patients.
Collapse
Affiliation(s)
- Harris S Slone
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, United States.
| | - Zeke J Walton
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Charles A Daly
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, United States
| | - Russell W Chapin
- Department of Radiology, Medical University of South Carolina, Charleston, SC, United States
| | - William R Barfield
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Lee R Leddy
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Langdon A Hartsock
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, United States
| |
Collapse
|
36
|
Kim JJ, Kim JW, Oh HK. The submuscular sliding plate technique for acetabular posterior wall fractures extending to the acetabular roof. Orthop Traumatol Surg Res 2014; 100:967-70. [PMID: 25453921 DOI: 10.1016/j.otsr.2014.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 07/31/2014] [Accepted: 09/09/2014] [Indexed: 02/02/2023]
Abstract
There is extension of the Kocher-Langenbeck approach using trochanteric osteotomy for posterior wall fracture extending to acetabular roof, but it exposes to complications such as nonunion, breakage, and heterotopic ossification. The current study introduces a submuscular sliding plate technique. We retrospectively analyzed 13 patients treated with this technique. It is based on conventional method for posterior wall fracture. After reduction of roof fragment with direct visualization, a pre-contoured plate was passed through a submuscular tunnel under the gluteus medius and minimus. A small split incision was performed on the muscles, and screws were inserted with a triple trocar complex safely under fluoroscopic imaging. All patients had fracture union without complications. X-rays results showed anatomical reduction in 10 cases and imperfect reduction in 3 cases. Our results were satisfactory, particularly without heterotopic ossifications despite no prophylactic regimen of NSAID was applied and no neurological complications, so we believe that this technique is a good option for posterior wall fractures extending to the acetabular roof.
Collapse
Affiliation(s)
- J J Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, South Korea
| | - J W Kim
- Department of Orthopedic Surgery, Haeundae Paik Hospital, Inje University, 875, Haeun-daero, Haeundae-gu, Busan 612-862, South Korea.
| | - H K Oh
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 875, 2240 Daehwa-dong, Ilsanseo-gu, Goyang 411-706, South Korea
| |
Collapse
|
37
|
Perosky JE, Peterson JR, Eboda ON, Morris MD, Wang SC, Levi B, Kozloff KM. Early detection of heterotopic ossification using near-infrared optical imaging reveals dynamic turnover and progression of mineralization following Achilles tenotomy and burn injury. J Orthop Res 2014; 32:1416-23. [PMID: 25087685 PMCID: PMC4408934 DOI: 10.1002/jor.22697] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 06/24/2014] [Indexed: 02/04/2023]
Abstract
Heterotopic ossification (HO) is the abnormal formation of bone in soft tissue. Current diagnostics have low sensitivity or specificity to incremental progression of mineralization, especially at early time points. Without accurate and reliable early diagnosis and intervention, HO progression often results in incapacitating conditions of limited range of motion, nerve entrapment, and pain. We hypothesized that non-invasive near-infrared (NIR) optical imaging can detect HO at early time points and monitor heterotopic bone turnover longitudinally. C57BL6 mice received an Achilles tenotomy on their left hind limb in combination with a dorsal burn or sham procedure. A calcium-chelating tetracycline derivative (IRDye 680RD BoneTag) was injected bi-weekly and imaged via NIR to measure accumulative fluorescence for 11 wk and compared to in vivo microCT images. Percent retention of fluorescence was calculated longitudinally to assess temporal bone resorption. NIR detected HO as early as five days and revealed a temporal response in HO formation and turnover. MicroCT could not detect HO until 5 wk. Confocal microscopy confirmed fluorophore localization to areas of HO. These findings demonstrate the ability of a near-infrared optical imaging strategy to accurately and reliably detect and monitor HO in a murine model.
Collapse
Affiliation(s)
| | | | | | | | | | - Benjamin Levi
- Department of Plastic Surgery, University of Michigan
| | | |
Collapse
|
38
|
Burnet NG, Nasr P, Yip G, Scaife JE, House T, Thomas SJ, Harris F, Owen PJ, Hull P. Prophylactic radiotherapy against heterotopic ossification following internal fixation of acetabular fractures: a comparative estimate of risk. Br J Radiol 2014; 87:20140398. [PMID: 25089852 DOI: 10.1259/bjr.20140398] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Radiotherapy (RT) is effective in preventing heterotopic ossification (HO) around acetabular fractures requiring surgical reconstruction. We audited outcomes and estimated risks from RT prophylaxis, and alternatives of indometacin or no prophylaxis. METHODS 34 patients underwent reconstruction of acetabular fractures through a posterior approach, followed by a 8-Gy single fraction. The mean age was 44 years. The mean time from surgery to RT was 1.1 days. The major RT risk is radiation-induced fatal cancer. The International Commission on Radiological Protection (ICRP) method was used to estimate risk, and compared with a method (Trott and Kemprad) specifically for estimating RT risk for benign disease. These were compared with risks associated with indometacin and no prophylaxis. RESULTS 28 patients (82%) developed no HO; 6 developed Brooker Class I; and none developed Class II-IV HO. The ICRP method suggests a risk of fatal cancer in the range of 1 in 1000 to 1 in 10,000; the Trott and Kemprad method suggests 1 in 3000. For younger patients, this may rise to 1 in 2000; and for elderly patients, it may fall to 1 in 6000. The risk of death from gastric bleeding or perforation from indometacin is 1 in 180 to 1 in 900 in older patients. Without prophylaxis risk of death from reoperation to remove HO is 1 in 4000 to 1 in 30,000. CONCLUSION These results are encouraging, consistent with much larger series and endorse our multidisciplinary management. Risk estimates can be used in discussion with patients. ADVANCES IN KNOWLEDGE The risk from RT prophylaxis is small, it is safer than indometacin and substantially overlaps with the range for no prophylaxis.
Collapse
Affiliation(s)
- N G Burnet
- 1 Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
|
40
|
Risk of radiation-induced malignancy with heterotopic ossification prophylaxis: a case-control analysis. Int J Radiat Oncol Biol Phys 2014; 89:584-9. [PMID: 24803038 DOI: 10.1016/j.ijrobp.2014.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 02/28/2014] [Accepted: 03/06/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE To determine the risk of radiation-induced malignancy after prophylactic treatment for heterotopic ossification (HO). METHODS AND MATERIALS A matched case-control study was conducted within a population-based cohort of 3489 patients treated either for acetabular fractures with acetabular open reduction internal fixation or who underwent total hip arthroplasty from 1990 to 2009. Record-linkage techniques identified patients who were diagnosed with a malignancy from our state health registry. Patients with a prior history of malignancy were excluded from the cohort. For each documented case of cancer, 2 controls were selected by stratified random sampling from the cohort that did not develop a malignancy. Matching factors were sex, age at time of hip treatment, and duration of follow-up. RESULTS A total of 243 patients were diagnosed with a malignancy after hip treatment. Five patients were excluded owing to inadequate follow-up time in the corresponding control cohort. A cohort of 238 cases (control, 476 patients) was included. Mean follow-up was 10 years, 12 years in the control group. In the cancer cohort, 4% of patients had radiation therapy (RT), compared with 7% in the control group. Of the 9 patients diagnosed with cancer after RT, none occurred within the field. The mean latency period was 5.9 years in the patients who received RT and 6.6 years in the patients who did not. Median (range) age at time of cancer diagnosis in patients who received RT was 62 (43-75) years, compared with 70 (32-92) years in the non-RT patients. An ad hoc analysis was subsequently performed in all 2749 patients who were not matched and found neither an increased incidence of malignancy nor a difference in distribution of type of malignancy. CONCLUSION We were unable to demonstrate an increased risk of malignancy in patients who were treated with RT for HO prophylaxis compared with those who were not.
Collapse
|
41
|
Posttraumatic heterotopic ossification around the hip. CURRENT ORTHOPAEDIC PRACTICE 2014. [DOI: 10.1097/bco.0000000000000109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
42
|
Zhang Y, Xie Y, Xu S, Zhang C. Massive heterotopic ossification associated with late deficits in posterior wall of acetabulum after failed acetabular fracture operation. BMC Musculoskelet Disord 2013; 14:368. [PMID: 24369897 PMCID: PMC3877962 DOI: 10.1186/1471-2474-14-368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 12/17/2013] [Indexed: 11/10/2022] Open
Abstract
Background Heterotopic ossification is a common postoperative complication of acetabular fracture. However, functionally significant heterotopic ossification with associated late bone defects in the posterior wall of the acetabulum is rare and challenging to treat. When heterotopic ossification is a late complication of failed acetabular fracture operation, it is disabling and may only be treated by THA. THA is highly susceptible to premature failure in young and active patients and may require numerous revisions. Case presentation This article describes a 40-year-old man with massive heterotopic ossification associated with late bone defects in the posterior wall of the acetabulum after a failed acetabular fracture operation. The primary fracture type was a 62-A2.3 fracture according to the AO/OTA Classification.Surgical excision and anatomical reconstruction of the acetabular wall using heterotopic ossific bone were performed 10 months after the fracture repair. Postoperatively, indomethacin was administered for prophylaxis against recurrence of heterotopic ossification, and hip range of motion was progressively increased. At 5 years and 6 months follow-up, the patient’s pain was relieved and hip function had recovered. Though radiography and CT showed minimal subchondral cysts and mild joint-space narrowing, there was no evidence of graft resorption, progressive posttraumatic osteoarthritis or necrosis of the femoral head. Conclusion To the authors’ knowledge, this is the first case of such a challenging condition. Although it is an extremely rare case, it provides an attractive option for avoiding THA, as the long-term follow-up shows a satisfactory outcome.
Collapse
Affiliation(s)
| | - Yang Xie
- Department of orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai 200433, China.
| | | | | |
Collapse
|
43
|
Arkader A, Rethlefsen SA, Kay RM. Heterotopic Ossification Excision Improves Kinetic and Kinematic Gait Parameters as Demonstrated by Computerized Motion Analysis: A Case Report. JBJS Case Connect 2013; 3:e109. [PMID: 29252272 DOI: 10.2106/jbjs.cc.m.00038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Alexandre Arkader
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Boulevard, M.S. 69, Los Angeles, CA 90027.
| | | | | |
Collapse
|
44
|
Ploumis A, Belbasis L, Ntzani E, Tsekeris P, Xenakis T. Radiotherapy for prevention of heterotopic ossification of the elbow: a systematic review of the literature. J Shoulder Elbow Surg 2013; 22:1580-8. [PMID: 24138821 DOI: 10.1016/j.jse.2013.07.045] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 07/02/2013] [Accepted: 07/16/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification is a pathological process characterized by abnormal formation of bone in nonskeletal tissue. Radiotherapy for heterotopic ossification of the elbow is questionable because of possible adverse effects. METHODS A systematic review of the literature was conducted in MEDLINE, Scopus, ISI Web of Science, National Institute for Health and Clinical Excellence, National Guideline Clearinghouse, System for Information on Grey Literature in Europe, ClinicalTrials.gov, Cochrane Central Register of Clinical Trials, and Cochrane Database of Systematic Reviews up to April 2012. All published articles assessing interventions including radiotherapy for prevention of heterotopic ossification in the elbow of adult patients were considered. Information was recorded by the first two authors, and disagreements in interpretation were resolved by consensus. RESULTS In total, 27 studies using radiotherapy for elbow heterotopic ossification were identified (1 randomized clinical trial, 1 case-control study, and 25 case reports and case series) in the literature. Most of them used a single dose of 7.0 Gy. The randomized clinical trial was stopped early because of severe adverse effects (pseudarthrosis) caused by radiation. The case-control study showed that radiotherapy did not effectively prevent recurrence of heterotopic ossification. The case reports and case series mentioned only sparse adverse events. CONCLUSION The use of radiation therapy for prevention of heterotopic ossification of the elbow is supported by weak evidence.
Collapse
Affiliation(s)
- Avraam Ploumis
- Department of Orthopaedics and Rehabilitation, University of Ioannina Medical School, Ioannina, Greece.
| | | | | | | | | |
Collapse
|
45
|
Bishop JA, Cross WW, Krieg JC, Chip Routt ML. Antegrade femoral nailing in acetabular fractures requiring a Kocher-Langenbeck approach. Orthopedics 2013; 36:e1159-64. [PMID: 24025007 DOI: 10.3928/01477447-20130821-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ipsilateral displaced acetabular and femoral shaft fractures represent a dilemma for orthopedic surgeons because antegrade femoral nailing may complicate a Kocher-Langenbeck acetabular exposure. The goals of this study were to review the results of ipsilateral femoral and acetabular fractures treated with antegrade femoral nailing and a Kocher-Langenbeck approach and to evaluate the assertion that this treatment strategy is associated with increased morbidity. This was a retrospective cohort study at a regional Level I trauma center. Sixteen patients with a femoral fracture treated with antegrade nailing and an ipsilateral acetabular fracture treated with a Kocher-Langenbeck approach were identified. One patient died as a result of his injuries, and 2 were not available for long-term follow-up. One had a deep infection requiring irrigation, debridement, and intraveonous antibiotics. One patient developed a hematoma requiring irrigation and debridement. At final follow-up, 2 patients had no heterotopic ossification about the hip, 4 had Brooker class I heterotopic ossification, 3 had Brooker class II heterotopic ossification, 2 had Brooker class III heterotopic ossification, and 2 patients had Brooker class IV heterotopic ossification requiring excision. Ipsilateral femoral and acetabular fractures represent a rare and severe injury constellation. Antegrade nailing of the femur with ipsilateral Kocher-Langenbeck exposure for fixation of the acetabulum was not associated with excessive rates of wound-healing complications, but the incidence of heterotopic ossification was increased.
Collapse
|
46
|
Heterotopic ossification rates after acetabular fracture surgery are unchanged without indomethacin prophylaxis. Clin Orthop Relat Res 2013; 471:2776-82. [PMID: 23440617 PMCID: PMC3734400 DOI: 10.1007/s11999-013-2871-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND We previously found no reduction in heterotopic ossification (HO) rates after acetabular surgery with indomethacin compared with a placebo. We subsequently abandoned routine indomethacin therapy after acetabular surgery but questioned whether the incidence had changed using a posterior approach. QUESTIONS/PURPOSES We therefore determined (1) the incidence of HO after acetabular fracture surgery through a posterior approach; (2) the incidence of symptoms attributable to HO; and (3) the rate of reoperation for HO. METHODS We retrospectively reviewed the records of all 423 patients with acetabular fractures following our clinical protocol change; of these, 120 were treated with a Kocher-Langenbeck approach and included. The presence of radiographic HO was documented a minimum of 10 weeks postoperatively using the classification of Brooker et al. Symptoms and reoperations were recorded. RESULTS The overall incidence of radiographic HO was 47% (56 of 120 patients): 26% Class I-II 13% Class III, and 8% Class IV. Overall, 15% of patients developed symptoms; 3.3% underwent reoperations for excision of HO. There were no major differences between the incidence of moderate and severe HO in this study when compared with the indomethacin and placebo groups from the prior study. CONCLUSIONS Our incidence of moderate and severe HO has not changed since discontinuing indomethacin. These findings support our institutional decision to abandon routine indomethacin prophylaxis after acetabular surgery. We recommend improved surgical techniques to limit damage to the abductors and improved risk stratification of patients when considering treatment options for HO prophylaxis.
Collapse
|
47
|
Daniilidis K, Vogt B, Raschke MJ. Symptomatic heterotopic ossification: seven years after patella fracture. Musculoskelet Surg 2013; 97:169-171. [PMID: 21779765 DOI: 10.1007/s12306-011-0160-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Accepted: 07/06/2011] [Indexed: 05/31/2023]
Abstract
We describe a case of heterotopic ossification (HO) of the lateral patella becoming symptomatic after 7 years following horizontal patella fracture. The patient presented peripatellar pain in full knee flexion and kneeling position. We resected the ossification, and the patient was immediately relieved from pain and was mobilised under full weight bearing with no limitation of knee flexion. The patient was able to return to his previous level of daily activities with no further episodes of pain. To our knowledge, this is the first case of heterotopic peripatellar ossification becoming symptomatic 7 years after a patellar fracture to be reported in the literature.
Collapse
|
48
|
Mourad WF, Packianathan S, Shourbaji RA, Jennelle R, Yang CC, Mobit P, Zhang Z, Khan MA, Graves M, Russell G, Vijayakumar S. The influence of pregnancy on heterotopic ossification post-displaced acetabular fractures surgical repair. J Orthop Res 2013; 31:944-8. [PMID: 23335247 DOI: 10.1002/jor.22309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 12/12/2012] [Indexed: 02/04/2023]
Abstract
Pregnancy is associated with maternal bone mineral density loss and modulation of calcium metabolism. We hypothesized that pregnancy may decrease the risk of heterotopic ossification (HO) after trauma. This is a single-institution, University of Mississippi Medical Center, retrospective study investigating the effect of pregnancy on the incidence HO after surgical repair (SR) of displaced acetabular fractures. Between January 1998 and 2010, 257 non-pregnant women (Group A) and 16 pregnant women (Group B) were identified. All the non-pregnant women received radiation therapy (RT) ± indomethacin. None of the pregnant women in group B received any prophylaxis. After a median follow-up of 6.6 years the incidence of HO in all patients was 27% (75/273). In Group A, non-pregnant, women who received RT ± indomethacin, 29% developed HO; HO risk was 0.4. In Group B, 16 pregnant patients, only one developed HO (6%); HO risk was 0.06. Thus, the risk of HO appears to be nearly six-fold higher in non-pregnant women despite prophylactic RT ± indomethacin. Our data suggest that pregnancy may be associated with a reduced risk of HO after SR of displaced acetabular fractures. Further analysis with a larger pregnant patient sample is necessary to confirm this finding.
Collapse
Affiliation(s)
- Waleed F Mourad
- Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, Mississippi, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Brunnekreef JJ, Hoogervorst P, Ploegmakers MJ, Rijnen WH, Schreurs BW. Is etoricoxib effective in preventing heterotopic ossification after primary total hip arthroplasty? INTERNATIONAL ORTHOPAEDICS 2013; 37:583-7. [PMID: 23359100 DOI: 10.1007/s00264-013-1781-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 01/06/2013] [Indexed: 01/01/2023]
Abstract
PURPOSE Heterotopic ossification is a common complication after total hip arthroplasty. Non-steroidal anti-inflammatory drugs (NSAIDs) are known to prevent heterotopic ossifications effectively, however gastrointestinal complaints are reported frequently. In this study, we investigated whether etoricoxib, a selective cyclo-oxygenase-2 (COX-2) inhibitor that produces fewer gastrointestinal side effects, is an effective alternative for the prevention of heterotopic ossification. METHODS We investigated the effectiveness of oral etoricoxib 90 mg for seven days in a prospective two-stage study design for phase-2 clinical trials in a small sample of patients (n = 42). A cemented primary total hip arthroplasty was implanted for osteoarthritis. Six months after surgery, heterotopic ossification was determined on anteroposterior pelvic radiographs using the Brooker classification. RESULTS No heterotopic ossification was found in 62 % of the patients that took etoricoxib; 31 % of the patients had Brooker grade 1 and 7 % Brooker grade 2 ossification. CONCLUSIONS Etoricoxib seems effective in preventing heterotopic ossification after total hip arthroplasty. This finding further supports the use of COX-2 inhibitors for the prevention of heterotopic ossification following total hip arthroplasty.
Collapse
Affiliation(s)
- Jaap J Brunnekreef
- Department of Orthopaedics, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | | | | | | | | |
Collapse
|
50
|
Chémaly O, Hebert-Davies J, Rouleau DM, Benoit B, Laflamme GY. Heterotopic ossification following total hip replacement for acetabular fractures. Bone Joint J 2013; 95-B:95-100. [DOI: 10.1302/0301-620x.95b1.29721] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO. The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome. Cite this article: Bone Joint J 2013;95-B:95–100.
Collapse
Affiliation(s)
- O. Chémaly
- Hôpital du Sacré Cœur de Montréal, University
of Montreal, 5400 Gouin Ouest, Local C-2095, Montréal, Québec
H4J 1C5, Canada
| | - J. Hebert-Davies
- Hôpital du Sacré Cœur de Montréal, University
of Montreal, 5400 Gouin Ouest, Local C-2095, Montréal, Québec
H4J 1C5, Canada
| | - D. M. Rouleau
- Hôpital du Sacré Cœur de Montréal, University
of Montreal, 5400 Gouin Ouest, Local C-2095, Montréal, Québec
H4J 1C5, Canada
| | - B. Benoit
- Hôpital du Sacré Cœur de Montréal, University
of Montreal, 5400 Gouin Ouest, Local C-2095, Montréal, Québec
H4J 1C5, Canada
| | - G. Y. Laflamme
- Hôpital du Sacré Cœur de Montréal, University
of Montreal, 5400 Gouin Ouest, Local C-2095, Montréal, Québec
H4J 1C5, Canada
| |
Collapse
|