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Galietta E, Gaiani L, Giannini C, Sambri A, Buwenge M, Macchia G, Deodato F, Cilla S, Strigari L, Arcelli A, Fiore M, Cammelli S, DE Paolis M, Morganti AG. Personalizing Prophylactic Radiotherapy for Hip Heterotopic Ossification: An AMSTAR-2 Compliant Review of Meta-analyses. In Vivo 2024; 38:1530-1536. [PMID: 38936917 PMCID: PMC11215626 DOI: 10.21873/invivo.13603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND/AIM Heterotopic ossification (HO) is a common complication following total hip arthroplasty. Various prophylactic treatments have been proposed, including radiotherapy (RT). This review summarizes the evidence from meta-analyses on the efficacy of RT in preventing hip HO. MATERIALS AND METHODS A literature search was conducted on PubMed. The quality of the meta-analyses was assessed using the AMSTAR-2 tool. RESULTS Seven meta-analyses were included. One meta-analysis reported a significant reduction in HO occurrence after RT compared to the control group. Comparing RT and non-steroidal anti-inflammatory drugs, one and two meta-analyses showed significantly greater efficacy of RT in preventing severe HO and better outcomes in patients receiving drugs, respectively. Regarding RT settings, the postoperative and preoperative RT were each supported by one meta-analysis. Furthermore, two meta-analyses showed an advantage of multi-fractionated RT over single fraction RT. The overall confidence rate of the meta-analyses was moderate, low, and critically low in one, three, and three meta-analyses, respectively. CONCLUSION RT is a confirmed prophylactic intervention for HO. However, the precise optimization of timing, dosage, and fractionation requires elucidation. Future research should focus on the development of predictive models through large-scale data collection and advanced analytics to refine individualized treatment strategies and assess RT comparative effectiveness with drugs.
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Affiliation(s)
- Erika Galietta
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-Bologna University, Bologna, Italy;
| | - Luca Gaiani
- U.O. Ortopedia e Traumatologia, AUSL Imola, Imola, Italy
| | | | - Andrea Sambri
- UOC Ortopedia e Traumatologia, IRCCS Azienda Ospedaliera Universitaria di Bologna, Bologna, Italy
| | - Milly Buwenge
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-Bologna University, Bologna, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Lidia Strigari
- Medical Physics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandra Arcelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Silvia Cammelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-Bologna University, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Massimiliano DE Paolis
- UOC Ortopedia e Traumatologia, IRCCS Azienda Ospedaliera Universitaria di Bologna, Bologna, Italy
| | - Alessio Giuseppe Morganti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-Bologna University, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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2
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Zhao P, Li R, Liu L, Wang X, Chen X, Guan J, Wu M. Clinical study of modified INFIX combined with sacroiliac joint screws for pelvic instable injuries. BMC Surg 2023; 23:350. [PMID: 37974146 PMCID: PMC10655463 DOI: 10.1186/s12893-023-02205-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/23/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE The INFIX technique is becoming one of the most commonly performed surgical procedures for anterior pelvic ring instability injuries. The purpose of this article is to compare the clinical outcomes of modified anterior subcutaneous internal fixation (M-INFIX) with conventional anterior subcutaneous internal fixation (C-INFIX) for anterior pelvic ring instability injuries. PATIENTS AND METHODS A retrospective analysis of 36 cases of unstable pelvic injuries treated operatively at our institution, 20 of which were treated with C-INFIX and 16 with M-INFIX. Data collected included age, gender, ISS score, fracture typing, operative time, operative bleeding, postoperative complications, fracture healing time, Matta score, Majeed score, and follow-up time. Statistical sub-folding of each variable between the two groups was performed. RESULTS There was no statistical difference between the C-INFIX and M-INFIX groups in terms of age, gender, ISS (Injury Severity Score), follow-up time, fracture typing, fracture healing time, and Majeed score (P > 0.05). the M-INFIX had a significantly lower incidence of postoperative complications than the C-INFIX group, especially in the incidence of Lateral femoral cutaneous nerve (LFCN) injury (P < 0.05). In contrast, the M-INFIX group had statistically higher operative time, intraoperative bleeding, and Matta score than the C-INFIX group (P < 0.05). CONCLUSION This study was based on a modified application of the surgical experience with C-INFIX and showed better clinical outcomes in terms of complication rates and quality of repositioning than the conventional surgical approach. These findings indicate that further analytical studies of this study would be valuable.
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Affiliation(s)
- Peishuai Zhao
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Renjie Li
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Leyu Liu
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Xiaopan Wang
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Xiaotian Chen
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Jianzhong Guan
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China.
| | - Min Wu
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China.
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Olivero M, Capurro B, Reis-Campos P, Aprato A, Ayeni O, Chawla A, Larrainzar Garijo R, Marín-Peña O. Low-dose prophylaxis protocol for heterotopic ossification after hip preservation surgery in a sport participants cohort. SICOT J 2023; 9:27. [PMID: 37668540 PMCID: PMC10478760 DOI: 10.1051/sicotj/2023024] [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] [Received: 04/17/2023] [Accepted: 07/30/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Heterotopic ossification (HO) is a well-known complication of arthroscopic and open surgical treatment of femoroacetabular impingement (FAI). Incidence of heterotopic ossification has been reported in the literature between 0% and 44% after hip arthroscopy and between 18.2% and 25% after anterior mini-open surgery. Currently, pharmacological prophylaxis with NSAIDs and selective COX-2 inhibitors are commonly used and their effectiveness is well documented in literature. HYPOTHESIS We hypothesized that the low-dose prophylaxis protocol with selective cox-2 inhibitors decreases the risk of heterotopic ossification in open or arthroscopic hip preservation surgery in athletes. METHODS This study is an analysis of prospectively gathered data on 98 sport participant patients who underwent arthroscopic or anterior mini-open treatment for FAI between April 2008 and April 2018. All the patients received postoperative oral prophylaxis with 60 mg etoricoxib once daily for two weeks. Post-operative X-rays were performed at 1, 3, and 12 months after surgery and reviewed by two orthopedic surgeons blinded to the type and side of surgery. HO were graded according to the Brooker classification. Descriptive statistics was used to analyze demographic data. Bivariate analysis was performed to analyze the association of HO with each of the following variables: type of surgery, physical activity, time of evolution of symptoms, age at surgery, and sex. Finally, a regression model analysis was performed to determine the presence of confounding effects between variables. RESULTS The study cohort was composed of 54 patients in the arthroscopic treatment group and 44 patients in the anterior mini-open group. HO was identified in 6 (13.6%) patients in the mini-open group. No HO was identified in the arthroscopic group. In the bivariate analysis, "type of surgery" was the only variable that showed a statistically significant association with HO (p = 0.007). CONCLUSION Results of this study suggest that anterior mini-open treatment was characterized by a higher risk of HO development compared to hip arthroscopy for femoroacetabular impingement treatment regardless of pharmacological prophylaxis. The treatment regimen of 60 mg etoricoxib daily for two weeks was an effective prophylaxis for HO formation in sport participant patients compared with data available in the literature.
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Affiliation(s)
- Matteo Olivero
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Centro Traumatológico Ortopédico, (CTO), University of Torino 10126 Torino Italy
| | - Bruno Capurro
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Department of Orthopaedic Surgery and Sport Traumatology, IMSKE Hospital 46024 Valencia Spain
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European Hip Preservation Associates, EHPA-ESSKA Section Europe
| | - Pedro Reis-Campos
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Orthopedic and Traumatology Department, Hospital Vila Franca de Xira 2600-009 Portugal
| | - Alessandro Aprato
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Centro Traumatológico Ortopédico, (CTO), University of Torino 10126 Torino Italy
| | - Olufemi Ayeni
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Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Center L8S 4S4 Hamilton Canada
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European Hip Preservation Associates, EHPA-ESSKA Section Europe
| | - Anuj Chawla
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Department of Orthopaedic Surgery, Tan Tock Seng Hospital PC 308433 Novena Singapore
| | - Ricardo Larrainzar Garijo
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Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Infanta Leonor 28031 Madrid Spain
| | - Oliver Marín-Peña
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Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Infanta Leonor 28031 Madrid Spain
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European Hip Preservation Associates, EHPA-ESSKA Section Europe
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Luo G, Sun Z, Liu H, Yuan Z, Wang W, Tu B, Li J, Fan C. Verteporfin attenuates trauma-induced heterotopic ossification of Achilles tendon by inhibiting osteogenesis and angiogenesis involving YAP/β-catenin signaling. FASEB J 2023; 37:e23057. [PMID: 37367700 DOI: 10.1096/fj.202300568r] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023]
Abstract
Heterotopic ossification occurs as a pathological ossification condition characterized by ectopic bone formation within soft tissues following trauma. Vascularization has long been established to fuel skeletal ossification during tissue development and regeneration. However, the feasibility of vascularization as a target of heterotopic ossification prevention remained to be further clarified. Here, we aimed to identify whether verteporfin as a widely used FDA-approved anti-vascularization drug could effectively inhibit trauma-induced heterotopic ossification formation. In the current study, we found that verteporfin not only dose dependently inhibited the angiogenic activity of human umbilical vein endothelial cells (HUVECs) but also the osteogenic differentiation of tendon stem cells (TDSCs). Moreover, YAP/β-catenin signaling axis was downregulated by the verteporfin. Application of lithium chloride, an agonist of β-catenin, recovered TDSCs osteogenesis and HUVECs angiogenesis that was inhibited by verteporfin. In vivo, verteporfin attenuated heterotopic ossification formation by decelerating osteogenesis and the vessels densely associated with osteoprogenitors formation, which could also be readily reversed by lithium chloride, as revealed by histological analysis and Micro-CT scan in a murine burn/tenotomy model. Collectively, this study confirmed the therapeutic effect of verteporfin on angiogenesis and osteogenesis in trauma-induced heterotopic ossification. Our study sheds light on the anti-vascularization strategy with verteporfin as a candidate treatment for heterotopic ossification prevention.
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Affiliation(s)
- Gang Luo
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Ziyang Sun
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Hang Liu
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Zhengqiang Yuan
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Bing Tu
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Juehong Li
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Cunyi Fan
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
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5
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Shapira J, Yelton MJ, Chen JW, Rosinsky PJ, Maldonado DR, Meghpara M, Lall AC, Domb BG. Efficacy of NSAIDs versus radiotherapy for heterotopic ossification prophylaxis following total hip arthroplasty in high-risk patients: a systematic review and meta-analysis. Hip Int 2022; 32:576-590. [PMID: 33736491 DOI: 10.1177/1120700021991115] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aims of this systematic review were: (1) to investigate the prophylactic effect of radiotherapy (RT) and NSAIDs in high-risk patients following total hip arthroplasty (THA); and (2) to compare the efficacy of non-selective and COX-II selective NSAIDs in preventing post-THA HO, utilising a meta-analysis of randomised control studies. METHODS The PubMed, Embase, and Cochrane Databases were searched for articles regarding HO following THA in March 2019. Studies were included if they contained data regarding HO incidence after THA or contained data regarding HO prophylaxis comparison of NSAIDs and/or RT in terms of dosage or duration. RESULTS 24 studies reported on populations that were not at high-risk for HO. These studies reported between 47.3% and 90.4% of their patient populations had no HO formation; between 2.8% and 52.7% had mild formation; and between 0.0% and 10.4% had severe formation. A total of 13 studies reported on populations at high-risk for HO. Studies analysing RT in high-risk patients reported between 28.6% and 97.4% of patients developed no HO formation; between 1.9% and 66.7% developed mild HO formation; and between 0.0% and 11.9% developed severe HO formation. Studies analysing NSAID treatment among high-risk populations reported between 76.6% and 88.9% had no HO formation; between 11.1% and 23.4% had mild HO formation, and between 0.0% and 1.8% had severe HO formation. 9 studies were identified as randomised control trials and subsequently used for meta-analysis. The relative risk for COX-II in developing any HO after THA was not significantly different compared to non-selective NSAIDs (RR 1.00; CI, 0.801-1.256; p = 0.489). CONCLUSIONS NSAIDs prophylaxis for HO may have better efficacy than RT in high-risk patients following THA. Non-selective and COX-II selective NSAIDs have comparable efficacy in preventing HO. Factors such as medical comorbidities and side-effect profile should dictate the prophylaxis recommendation.
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Affiliation(s)
- Jacob Shapira
- American Hip Institute Research Foundation, Chicago, IL, USA
| | | | - Jeffery W Chen
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | | | - Mitchell Meghpara
- American Hip Institute Research Foundation, Chicago, IL, USA.,AMITA Health St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, IL, USA.,AMITA Health St. Alexius Medical Center, Hoffman Estates, IL, USA.,American Hip Institute, Chicago, IL, USA
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, IL, USA.,AMITA Health St. Alexius Medical Center, Hoffman Estates, IL, USA.,American Hip Institute, Chicago, IL, USA
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Yeung P, Zarnett O, Lefaivre KA, Guy P. Risk Factors for the Development of Heterotopic Ossification Following Acetabular Fractures: A Systematic Review. JBJS Rev 2022; 10:01874474-202209000-00005. [PMID: 36137013 DOI: 10.2106/jbjs.rvw.20.00263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Heterotopic ossification (HO) following acetabular fractures is a common complication that may affect clinical outcomes. However, the effects of prophylactic treatment with nonsteroidal anti-inflammatory drugs or radiation therapy remain controversial. While several factors have been related to the development of HO, there is considerable uncertainty regarding their importance or effect size in the setting of acetabular surgery. Therefore, this systematic review aims to summarize the risk factors for HO following the operative fixation of acetabular fractures and clarify their interrelationships. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, MEDLINE, Embase, and CINAHL databases were searched from inception to February 2021. Studies that assessed factors related to HO development among patients with operatively repaired acetabular fractures were included. Outcomes were risk factors and their effect size (p values, odds ratios, and 95% confidence intervals). RESULTS Twenty-five studies and 1 conference abstract with a total of 3,940 patients were included. The following risk factors for HO were identified. Patient factors were increased body mass index, male sex, and increased age. Injury factors were intensive care unit (ICU) admission and length of stay, non-ICU hospitalization for >10 days, the need for mechanical ventilation for ≥2 days, abdominal and/or chest injuries, the number and type of associated fractures, traumatic brain injuries, T-type acetabular fractures, pelvic ring injuries, and hip dislocation. Care factors were a delay to surgery, extensile and posterior surgical approaches to the hip, trochanteric osteotomy, postoperative step-off of >3 mm, and a delay to prophylaxis following injury or surgery. Ethnicity, Injury Severity Score, cause of the fracture, femoral head injuries, degloving injuries, comminution, intra-articular debris, the type of bone void filler, gluteus minimus muscle preservation, prolonged operative time, and intraoperative patient position were not risk factors for developing HO. CONCLUSIONS HO following operative fixation of acetabular fractures is not uncommon, with severe-grade HO associated with substantial disability. Careful consideration of the risk factor effect sizes and interdependencies could aid physicians in identifying patients at risk for developing HO and guide their prophylactic management. The results of this study could establish a framework for future studies. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Phillip Yeung
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Oren Zarnett
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kelly A Lefaivre
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Guy
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, British Columbia, Canada
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Liu Q, Tang D, Zhu W, Chen Y. Patellar Tendon Reconstruction Using Autologous Hamstring Tendons for the Treatment of Extensive Patellar Tendon Ossification. Orthop Surg 2022; 14:3119-3124. [PMID: 36000539 PMCID: PMC9627062 DOI: 10.1111/os.13435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background Extensive patellar tendon ossification is very uncommon and requires surgical intervention when ossification significantly affects knee function. While various approaches and grafts are available for reconstructing ruptured patellar tendons, there is a paucity of literature regarding the management of joint ankylosis due to severely ossified patellar tendons. Case Presentation This is a case involving an extensively ossified patellar tendon after patellar and tibial tuberosity fracture fixation. Reconstruction of the patellar tendon was performed using ipsilateral semitendinosus and gracilis autografts. At the latest follow‐up of 12 months, the patient achieved knee flexion up to 120° with a slight extension lag and resumed daily activities. Conclusions Autograft hamstring reconstruction of the patellar tendon is suitable for extensive heterotopic ossification of the patellar tendon, resulting in significant improvement in postoperative knee function. Similar patients may be referred for this reconstruction technique.
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Affiliation(s)
- Qian Liu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Dezhou Tang
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Weihong Zhu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yueming Chen
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, China
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Palovarotene Can Attenuate Heterotopic Ossification Induced by Tendon Stem Cells by Downregulating the Synergistic Effects of Smad and NF-κB Signaling Pathway following Stimulation of the Inflammatory Microenvironment. Stem Cells Int 2022; 2022:1560943. [PMID: 35530413 PMCID: PMC9071930 DOI: 10.1155/2022/1560943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/07/2022] [Accepted: 04/12/2022] [Indexed: 11/18/2022] Open
Abstract
Heterotopic ossification (HO) is defined as the formation of bone tissues outside the bones, such as in the muscles. Currently, the mechanism of HO is still unclear. Tendon stem cells (TSCs) play important roles in the occurrence and development of HO. The inflammatory microenvironment dominated by macrophages also plays an important role in the course of HO. The commonly used clinical treatment methods, such as nonsteroidal anti-inflammatory drugs and radiotherapy, have relatively large side effects, and more efficient treatment methods are needed in clinical practice. Under physiological conditions, retinoic acid receptor (RAR) signal transduction pathway inhibits osteogenic progenitor cell aggregation and chondrocyte differentiation. We focus on palovarotene, a retinoic acid γ-receptor activator, showing an inhibitory effect on HO mice, but the specific mechanism is still unclear. This study was aimed at exploring the specific molecular mechanism of palovarotene by blocking osteogenic differentiation and HO formation of TSCs in vitro and in vivo in an inflammatory microenvironment. We constructed a coculture model of TCSs and polarized macrophages, as well as overexpression and knockdown models of the Smad signaling pathway of TCSs. In addition, a rat model of HO, which was constructed by Achilles tendon resection, was also established. These models explored the role of inflammatory microenvironment and Smad signaling pathways in the osteogenic differentiation of TSCs which lead to HO, as well as the reversal role played by palovarotene in this process. Our results suggest that, under the stimulation of inflammatory microenvironment and trauma, the injured site was in an inflammatory state, and macrophages were highly concentrated in the injured site. The expression of osteogenic and inflammation-related proteins, as well as Smad proteins, was upregulated. Osteogenic differentiation was performed in TCSs. We also found that TCSs activated Smad and NF-κB signaling pathways, which initiated the formation of HO. Palovarotene inhibited the aggregation of osteogenic progenitor cells and macrophages and attenuated HO by blocking Smad and NF-κB signaling pathways. Therefore, palovarotene may be a novel HO inhibitor, while other drugs or antibodies targeting Smad and NF-κB signaling pathways may also prevent or treat HO. The expressions of Smad5, Id1, P65, and other proteins may predict HO formation.
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Aprato A, Cambursano S, Artiaco S, Bevilacqua S, Catalani P, Massè A. Heterotopic ossification in primary total hip arthroplasty: risk factor analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1037-1041. [PMID: 35377072 PMCID: PMC10126050 DOI: 10.1007/s00590-022-03244-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/28/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Aim is to identify if age, sex, type of posterolateral approach (mini vs standard), surgical time and time from surgery to drainage removal were independent risk factors for heterotopic ossifications after total hip arthroplasty. MATERIALS AND METHODS Patients who underwent a THA with posterolateral approach during a 15 years period were included. The exclusion criteria were absence of X-rays follow-up or HO prophylaxis protocol adoption. The following data were collected: age, sex, type of approach (classical/minimal-invasive), surgical time, time from surgery to drainage removal. Two orthopedic surgeons independently reviewed the 2 years follow-up X-rays and classified the HO according to Brooker classification. Severe HO was defined if HO were classified as major than grade 2. Correlation between severe HO and risk factor has been tested with multivariable analysis. RESULTS About 1225 patients were included: mean age of 63.8 years, 504 were men. HO were found in 67.6%. Men showed higher severe HO rate than woman (44.1% vs 29.1%, p = 0.001). Patients older than 65 years showed higher severe HO rate (30.3% vs 39.9%, p = 0.002). Standard posterolateral approach was performed in 75.4% and severe HO rate was 32.8% versus 27.1% in those treated with the minimally invasive approach (p = 0.067). In 75.6% of cases surgery lasted less than 90 min and this group showed a severe HO rate in 29.1%, while patient with longer surgical time showed a rate of 35.7% (p = 0.033). In 47.4% of patients, the drainage was removed in the first post-operative day, in this group severe HO rate was significantly lower than the others: 24.8 versus 36.2% (p = 0.001). DISCUSSION Male sex, age older than 65 years, surgical time longer than 90 min and delayed drainage removal are risk factors for severe HO. Patients with one or more of those risk factors should be identified as good candidates for HO prophylaxis.
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Affiliation(s)
- Alessandro Aprato
- University of Turin, Viale 25 aprile 137 int 6, 10133, Turin, Italy.
| | | | - Stefano Artiaco
- University of Turin, Viale 25 aprile 137 int 6, 10133, Turin, Italy
| | | | - Paolo Catalani
- University of Turin, Viale 25 aprile 137 int 6, 10133, Turin, Italy
| | - Alessandro Massè
- University of Turin, Viale 25 aprile 137 int 6, 10133, Turin, Italy
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BUENO THIAGOSANCHEZPIRES, GODOY GABRIELPARISDE, FURUKAVA REBECABARROS, GAGGIOLI NICOLETAKAKURA, TAMAOKI MARCELJUNSUGAWARA, MATSUNAGA FABIOTERUO, BELLOTI JOÃOCARLOS. HETEROTOPIC OSSIFICATION IN ACETABULAR FRACTURES: SYSTEMATIC REVIEW AND META-ANALYSIS OF PROPHYLAXIS. ACTA ORTOPEDICA BRASILEIRA 2021; 29:331-340. [PMID: 34849100 PMCID: PMC8601386 DOI: 10.1590/1413-785220212906244689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
Objective: Heterotopic ossification is defined as the formation of trabecular bone in soft tissues. It is a common complication after surgical treatment of acetabular fractures. However, its prophylaxis and treatment are still controversial. The objective of this research is to evaluate the effectiveness of actions to prevent the development of heterotopic ossification after surgical correction of acetabular fractures. Methods: A systematic review was carried out with research in the databases PubMed/MEDLINE, Embase, LILACS and Cochrane until August 4, 2020, without restrictions on language and year of publication. Only randomized clinical studies carried out in humans without restrictions based on the dosage of treatments, use and duration of prophylaxis were included in this review. Results: Two studies compared the use of radiotherapy and indomethacin and three compared the use of indomethacin with a placebo or non-indomethacin group. The meta-analysis calculations did not indicate statistical differences between radiotherapy versus indomethacin (RR 1.45, IC 95% 0.97 to 2.17, p = 0,55) and indomethacin versus placebo or not indomethacin (RR 0.85, IC 95% 0.68 to 1.06, p = 0,59). Conclusion: There is insufficient evidence to affirm that the use of radiotherapy or indomethacin are effective to prevent the formation of heterotopic ossification after surgery for fractures of the acetabulum. In addition, the number of complications was higher in the indomethacin group when compared to placebo or no intervention. Level of Evidence I, Systematic Review.
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Henstenburg JM, Sherman M, Ilyas AM. Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis. J Hand Microsurg 2021; 13:189-195. [PMID: 34511838 DOI: 10.1055/s-0040-1721880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Introduction Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence Level III.
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Affiliation(s)
- Jeffrey M Henstenburg
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Matthew Sherman
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Asif M Ilyas
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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Georhakopoulos I, Kouloulias V, Kougiountzopoulou A, Platoni K, Antypas C, Liakouli Z, Nikoloudi S, Kelekis N, Moulopoulou LE, Zygogianni A. Radiation therapy for the prevention of heterotopic ossification: Efficacy and toxicity of single fraction radiotherapy. Orthop Rev (Pavia) 2020; 12:8577. [PMID: 32922703 PMCID: PMC7461644 DOI: 10.4081/or.2020.8577] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/01/2020] [Indexed: 01/05/2023] Open
Abstract
Numerous nonmalignant diseases can be treated with radiation therapy (RT). Among them, Heterotopic Ossification (HO) is a benign condition resulting from several causes that can be successfully managed with ionizing radiation. More often seen in the hip area after major surgical procedures, HO is of major concern as it can lead to functional disorders, pain and even to joint ankylosis. We retrospectively analyzed the outcome of therapeutic irradiation for the prevention of HO in 14 patients treated in our hospital between 2005 and 2011. All patients were irradiated with a dose ranging from 7 to10 Gy in a single fraction for prevention of HO after surgery. After a median follow up of 126 months (range 96 – 156 months) none of our patients developed HO. Impaired wound healing or other post surgery complications like trochanteric nonunion were not observed. A single fraction of RT seems to be a sufficient, cost effective and safe treatment regimen. In our study we report excellent results as none of our patients developed HO.
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Affiliation(s)
- Ioannis Georhakopoulos
- National and Kapodistrian University of Athens, Medical School, 2 Department of Radiology, Radiotherapy Unit, ATTIKON University Hospital, Athens
| | - Vasilios Kouloulias
- National and Kapodistrian University of Athens, Medical School, 2 Department of Radiology, Radiotherapy Unit, ATTIKON University Hospital, Athens
| | - Andromachi Kougiountzopoulou
- National and Kapodistrian University of Athens, Medical School, 2 Department of Radiology, Radiotherapy Unit, ATTIKON University Hospital, Athens
| | - Kalliopi Platoni
- National and Kapodistrian University of Athens, Medical School, 2 Department of Radiology, Radiotherapy Unit, ATTIKON University Hospital, Athens
| | - Christos Antypas
- National and Kapodistrian University of Athens, Medical School, 1 Department of Radiology, Radiotherapy Unit, Aretaieion University Hospital, Athens, Greece
| | - Zoi Liakouli
- National and Kapodistrian University of Athens, Medical School, 1 Department of Radiology, Radiotherapy Unit, Aretaieion University Hospital, Athens, Greece
| | - Stiliani Nikoloudi
- National and Kapodistrian University of Athens, Medical School, 1 Department of Radiology, Radiotherapy Unit, Aretaieion University Hospital, Athens, Greece
| | - Nikolaos Kelekis
- National and Kapodistrian University of Athens, Medical School, 2 Department of Radiology, Radiotherapy Unit, ATTIKON University Hospital, Athens
| | - Lia Evangelia Moulopoulou
- National and Kapodistrian University of Athens, Medical School, 1 Department of Radiology, Radiotherapy Unit, Aretaieion University Hospital, Athens, Greece
| | - Anna Zygogianni
- National and Kapodistrian University of Athens, Medical School, 1 Department of Radiology, Radiotherapy Unit, Aretaieion University Hospital, Athens, Greece
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Resection of hip heterotrophic ossification leads to resolution of autonomic nervous system dysfunction in a patient with spinal Charcot arthropathy: a case report. Spinal Cord Ser Cases 2020; 6:41. [PMID: 32404876 DOI: 10.1038/s41394-020-0286-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Patients with complete spinal cord injury (SCI) may develop concurrent sequalae that interact and share symptoms; thus, a careful approach to diagnosis and management of new symptoms is crucial. CASE PRESENTATION A patient with prior T4 complete SCI presented with progressive autonomic nervous system (ANS) dysfunction. The initial differential diagnosis included syringomyelia and lumbar Charcot arthropathy. He had comorbid heterotopic ossification (HO) of the left hip. Surprisingly, his autonomic symptoms resolved following resection of the HO. In hindsight, loss of motion through the hip caused by HO may have led to hinging through a previously asymptomatic lumbar Charcot joint, causing dysautonomia. DISCUSSION ANS dysfunction is a disabling sequela of complete SCI and has a broad differential diagnosis. Hip immobility may be an indirect and overlooked cause due to the mechanical relationship between the hip and the lumbar spine.
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Schwarze M, Merle C, Glanzmann P, Schiltenwolf M. [Omitted prophylaxis of heterotopic ossification]. DER ORTHOPADE 2020; 49:815-817. [PMID: 32372225 DOI: 10.1007/s00132-020-03919-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M Schwarze
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland.
| | - C Merle
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - P Glanzmann
- Gutachterkommission Bezirksärztekammer Nordbaden, Karlsruhe, Deutschland
| | - M Schiltenwolf
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
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Dow T, King JP, Wong IHB. The Reduction of Heterotopic Ossification Incidence After Hip Arthroscopy in Patients Treated With Selective Cyclooxygenase 2 Inhibitor (Celecoxib). Arthroscopy 2020; 36:453-461. [PMID: 31734042 DOI: 10.1016/j.arthro.2019.08.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effectiveness of celecoxib, a selective cyclooxygenase 2 inhibitor, in reducing heterotopic ossification (HO) after hip arthroscopic surgery and to evaluate celecoxib's impact on clinical outcomes. METHODS We performed a retrospective review of patients who received hip arthroscopy performed by the same surgeon between January 1, 2012, and December 31, 2016. Patients who had an allergy to sulfa drugs, had pre-existing HO or previous surgery on the operative side, or failed to complete radiographic follow-up at 6 months postoperatively were excluded. Patients in the treatment group received 400 mg of celecoxib postoperatively for 6 weeks, whereas the control group received no postoperative celecoxib. The incidence of HO was assessed using anteroposterior radiographs obtained at 6 months, 1 year, and 2 years postoperatively. Patients completed the International Hip Outcome Tool 33 survey, and the proportion of patients who met the minimal clinically important difference, substantial clinical benefit (SCB), and absolute SCB was calculated. RESULTS A total of 559 patients were identified. After application of the exclusion criteria, 454 patients were included in the study (211 in control group and 243 in treatment group). The overall incidence of HO was 20.3% (n = 92). The treatment group had a significantly lower incidence of HO at 6 months (P = .006), 1 year (P < .001), and 2 years (P = .008) postoperatively. At 2 years postoperatively, the treatment group had a significantly higher International Hip Outcome Tool 33 score on average: 64.2 versus 57.3 (P = .023). No significant difference in the proportion of patients reaching the minimal clinically important difference, SCB, or absolute SCB was found at any of the postoperative time points. CONCLUSION The findings of this study suggest that a prophylactic treatment regimen of 400 mg of celecoxib once daily for 6 weeks significantly reduces the incidence of HO formation after hip arthroscopic surgery; however, it did not impact clinical outcomes. LEVEL OF EVIDENCE Level III, retrospective, comparative case-control study.
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Affiliation(s)
- Todd Dow
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John-Paul King
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ivan Ho-Bun Wong
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
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Li F, Mao D, Pan X, Zhang X, Mi J, Rui Y. Celecoxib cannot inhibit the progression of initiated traumatic heterotopic ossification. J Shoulder Elbow Surg 2019; 28:2379-2385. [PMID: 31757369 DOI: 10.1016/j.jse.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND HYPOTHESIS Heterotopic ossification (HO) is a recognized sequela after trauma and arthroplasty. The purpose of this study was to evaluate the therapeutic effect of celecoxib on HO. We hypothesized that celecoxib may inhibit the progression of initiated HO. METHODS We performed a retrospective review of 37 patients who underwent elbow joint surgery between January 2014 and June 2018. Seventeen patients were prescribed orally administered celecoxib (200 mg/dose, twice daily) for 2 months after the diagnosis of HO, whereas the remaining 20 patients were administered celecoxib for 1 month starting immediately after surgery. HO progression was evaluated by plain radiographs. By use of an Achilles tendon puncture-induced HO mouse model, the curative effect of celecoxib was illustrated at different HO progression stages. The mice were assigned to 1 of 4 groups: sham group, vehicle group, group receiving celecoxib on day 1, and group receiving celecoxib in week 6. Achilles tendons were analyzed by micro-computed tomography and histochemistry after 12 weeks. RESULTS Celecoxib did not inhibit the progression of initiated HO in the patients in whom HO was diagnosed, whereas those who received celecoxib after surgery had lower morbidity. Achilles tendon puncture effectively induced typical HO in mice. The ectopic bone volume was significantly reduced in the day 1 celecoxib group compared with the vehicle group; however, the difference was not statistically significant in the week 6 celecoxib group. CONCLUSIONS Administration of celecoxib starting immediately after surgery can significantly inhibit the formation of HO. Once HO is visible on plain radiographs or micro-computed tomography, celecoxib cannot effectively attenuate further progression of HO in humans and mice.
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Affiliation(s)
- Fengfeng Li
- Department of Orthopedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Dong Mao
- Research Institute of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Xiaoyun Pan
- Research Institute of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Xin Zhang
- Research Institute of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Jingyi Mi
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Yongjun Rui
- Department of Orthopedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China.
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Use of Acellular Dermal Matrix to Prevent Recurrence of Radioulnar Heterotopic Ossification. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2257. [PMID: 31624673 PMCID: PMC6635193 DOI: 10.1097/gox.0000000000002257] [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: 11/18/2018] [Accepted: 03/18/2019] [Indexed: 11/26/2022]
Abstract
Radioulnar heterotopic ossification is a rare occurrence found in approximately 2% of all forearm injuries. Treatment is complicated by relatively high recurrence rates. Strategies to decrease recurrence have included the range of motion exercises and the interposition of inert or autogenous barriers. We report on the interposition of human acellular dermal matrix (ADM) for the treatment of distal radioulnar synostosis. We report a novel technique for the treatment of distal radioulnar heterotopic ossification. After resection, ADM in a cigar-shaped construct is interposed between the radius and ulna. Patients are followed clinically and radiographically. Two female patients were treated. Both patients had significant improvement in the range of motion in supination and pronation of the affected wrist postoperatively with an average follow-up of 36 months. There were no postoperative complications. Neither patient had recurrent disease. We describe the successful treatment of 2 patients with distal radioulnar heterotopic ossification with the use of human ADM. The ADM provides a barrier between the radius and ulna to prevent the recurrent formation of heterotopic ossification. ADM usage results in no donor site morbidity and is theoretically more resistant to infection when compared with nonbiologic barriers such as silicone and Integra. This technique is a simple, safe, and effective way to treat and prevent the recurrence of radioulnar heterotopic ossification.
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Heterotopic ossification: radiological and pathological review. Radiol Oncol 2019; 53:275-284. [PMID: 31553710 PMCID: PMC6765162 DOI: 10.2478/raon-2019-0039] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Heterotopic Ossification (HO) is a common condition referring to ectopic bone formation in soft tissues. It has two major etiologies, acquired (more common) and genetic. The acquired form is closely related to tissue trauma. The exact pathogenesis of this disease remains unclear; however, there is ongoing research in prophylactic and therapeutic treatments that is promising. Conclusions Due to HO potential to cause disability, it is so important to differentiate it from other causes in order to establish the best possible management.
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Yu S, Chen M, Fan C. Team Approach: Elbow Contracture Due to Heterotopic Ossification. JBJS Rev 2019; 5:01874474-201701000-00004. [PMID: 28135231 DOI: 10.2106/jbjs.rvw.16.00008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Shiyang Yu
- 1Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Radiation Prophylaxis for Hip Salvage Surgery in Cerebral Palsy: Can We Reduce the Incidence of Heterotopic Ossification? J Pediatr Orthop 2019; 39:e386-e391. [PMID: 30543561 DOI: 10.1097/bpo.0000000000001314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a well-recognized complication of proximal femoral resection (PFR) surgery in children with cerebral palsy (CP). Although single-dose radiation prophylaxis (SDRP) has been shown to be effective at lowering the rates of HO following adult total hip arthroplasty; there has been limited study examining the efficacy of SDRP for HO prevention in children with CP undergoing PFR. The purpose of this study was to assess the efficacy of SDRP in children with CP undergoing PFR. METHODS This retrospective case control series identified all patients from one tertiary children's hospital undergoing PFHR. Patients were dichotomized into (1) SDRP and (2) non-SDRP groups. In SDRP, radiation was delivered preoperatively at a dose of 7.5 Gy utilizing a 6 MV photon beam. The incidence of HO in the SDRP cohort was compared to historic data using binomial testing. The size of HO lesions was compared using Wilcoxon signed-rank test. McCarthy, Brooker, and Anatomic Classifications of HO were compared using repeated measures logistic regression. RESULTS Twenty-three patients (mean age, 15.5) and 35 hips (17 SDRP, 18 Non-SDRP) were included in the analysis. There were 17 females and 6 males in the cohort with the majority classified as GMFCS V, 21/23 (91%). HO was seen in 6 of the SDRP cohort (6/17, 35%) and 15 of the non-SDRP cohort (15/18, 83%) (P=0.015). The average size of HO at maturity was 282.7 mm in the SDRP cohort compared with 1221.5 mm in the Non-SDRP cohort (P=0.026). Radiation treatment was associated with a 938.9 mm decrease in HO size at maturity (P= 0.026). Multivariate repeated measures logistic regression analysis found that non-SDRP hips had 13 times higher odds of developing HO (P=0.015). There were no significant differences in infection rates between the 2 cohorts and there were no radiation-associated complications. CONCLUSIONS Short-term follow up demonstrates that SDRP is a safe and efficacious intervention in decreasing the incidence and size of HO in children with CP undergoing PFR. LEVELS OF EVIDENCE Level III-Case control cohort study.
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Abstract
Posttraumatic arthritis accounts for a notable share of secondary osteoarthritis about the hip joint. Compared with total hip arthroplasty for primary osteoarthritis or inflammatory arthritis, total hip arthroplasty for posttraumatic arthritis offers greater technical challenges because of bone deformities and retained implants. Careful preoperative evaluation is necessary to prepare the approach, hardware removal strategy, and implants necessary to address bone deficiencies. Although arthroplasty is a highly successful procedure for posttraumatic arthritis, the results are less favorable than surgery for primary osteoarthritis. It is associated with a higher incidence of intraoperative and postoperative complications, including periprosthetic fractures, infection, instability, and decreased survivorship.
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Heterotopic ossification after total elbow arthroplasty: a systematic review. J Shoulder Elbow Surg 2019; 28:587-595. [PMID: 30639172 DOI: 10.1016/j.jse.2018.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/24/2018] [Accepted: 10/05/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a known complication that can arise after total elbow arthroplasty (TEA). In most cases, it is asymptomatic; however, in some patients, it can limit range of motion and lead to poor outcomes. The objective of this review was to assess and report the incidence, risk factors, prophylaxis, and management of HO after TEA. METHODS A systematic search was conducted using MEDLINE, Embase, and PubMed to retrieve all relevant studies evaluating the occurrence of HO after TEA. The search was performed in duplicate, and a quality assessment of all included studies was performed. RESULTS A total of 1907 studies were retrieved, of which 45 were included involving 2256 TEA patients. HO was radiographically present in 10% of patients and was symptomatic in 3%. Fewer than 1% of patients went on to undergo surgical excision of HO, with outcomes after surgery reported as good or excellent as assessed by range of motion and the Mayo Elbow Performance Score. HO appears more likely to develop in patients undergoing TEA because of ankylosis, primary osteoarthritis, and distal humeral fractures. Surgical intervention is more likely to be required in patients in whom HO develops after TEA performed for ankylosis and post-traumatic osteoarthritis. CONCLUSION HO is an uncommon complication after TEA, with most patients in whom HO develops being asymptomatic and requiring no surgical management. Routine HO prophylaxis for TEA is not supported by the literature. The effectiveness of prophylaxis in high-risk patients is uncertain, and future studies are required to clarify its usefulness.
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Yin Y, Luo J, Zhang R, Li S, Jiao Z, Zhang Y, Hou Z. Anterior subcutaneous internal fixator (INFIX) versus plate fixation for pelvic anterior ring fracture. Sci Rep 2019; 9:2578. [PMID: 30796253 PMCID: PMC6385294 DOI: 10.1038/s41598-019-39068-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 01/16/2019] [Indexed: 01/13/2023] Open
Abstract
The aim of this study was to compare the clinical outcomes in patients with unstable anterior pelvic ring fractures after treatment with anterior subcutaneous internal fixator (INFIX) or plate fixation. We performed a retrospective study from August 2015 to October 2017. A consecutive series of 74 patients who underwent surgical treatment of their anterior pelvic ring (35 treated with INFIX and 39 treated with plates) were studied. Data collected included patients’ demographic data, injury severity score (ISS), AO/OTA classification, injury mechanism, time to surgery, procedure time, and blood loss. The quality of postoperative reduction were assessed by postoperative radiographs using the Tornetta and Matta method. Functional outcome was evaluated using Majeed scoring system. In the INFIX group, ten patients developed LFCN paralysis, one patient suffered from superficial infection. Three screw loosening cases and two wound infection cases occurred in the plate group. INFIX is relatively minimally invasive and time-saving than the reconstruction plate in the treatment of anterior pelvic ring fracture. However, plate fixation increases the rate of anatomic reduction of the pelvic anterior ring fracture. Plates also provide a higher functional outcome compared with INFIX. INFIX is especially suitable in patients with urological injury, which can also decrease the wound infection rate.
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Affiliation(s)
- Yingchao Yin
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P. R. China.,Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P. R. China
| | - Junhao Luo
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P. R. China.,Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P. R. China
| | - Ruipeng Zhang
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P. R. China.,Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P. R. China
| | - Shilun Li
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P. R. China.,Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P. R. China
| | - Zhenqing Jiao
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P. R. China.,Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P. R. China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P. R. China. .,Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P. R. China. .,Chinese Academy of Engineering, Beijing, 100088, P. R. China.
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P. R. China.,Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P. R. China
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Outcomes of Preoperative Versus Postoperative Radiation for Heterotopic Ossification Prevention in Children With Neuromuscular Hip Dysplasia Undergoing Proximal Femoral Resection. J Pediatr Orthop 2019; 39:e102-e107. [PMID: 29068805 PMCID: PMC5916744 DOI: 10.1097/bpo.0000000000001018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies exist to inform the extrapolated practice of irradiating children for heterotopic ossification (HO) prevention. We report the incidence of HO formation following prophylactic preoperative compared with postoperative radiation therapy (RT) in children with neuromuscular hip dysplasia (NHD) following proximal femoral resection (PFR). METHODS A retrospective, 2-institution chart review was performed. Eligibility was limited to patients with at least 1 year of follow-up. Evaluation included radiographic HO grading by a combined severity scale, assessment of synchronous symptoms of pain or decreased range of motion, and stratification by preoperative versus postoperative reception of RT. A control cohort included 4 nonirradiated hips with NHD after PFR. RESULTS Twenty-five hips in 20 children met eligibility criteria. Eleven hips were irradiated preoperatively and 14 postoperatively. Radiographic evidence of post-RT development of radiographic evidence of heterotopic ossification (rHO) was found in all 25 hips and earlier in patients irradiated preoperatively (median time to rHO was 4.0 vs. 15.7 mo, P=0.03, 95% confidence interval, 0.24-21.5). There was no statistically significant difference in the development of symptomatic HO (P=0.62) between the preoperative (45.5%) and postoperative (35.7%) groups, nor in HO grade (P=0.34). Seven (28%) of the 25 hips (5 preoperative and 2 postoperative) had documentation of rHO-free intervals after surgery, with an average duration of 5.6 months, while the remaining presented with rHO at first follow-up visit. All eligible control hips (100%) developed rHO and symptomatic heterotopic ossification. CONCLUSIONS Perioperative RT did not prevent the formation of HO in any child with NHD after PFR. Extrapolation of evidence of the efficacy of RT for HO prevention in ambulatory adults after traumatic hip injury to a population of children with central nervous system injury and NHD may be premature. Additional studies are needed to clarify optimal prevention of HO in this population. LEVEL OF EVIDENCE Level III-therapeutic retrospective comparative study.
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Cai L, Wang Z, Luo X, She W, Zhang H. Optimal strategies for the prevention of heterotopic ossification after total hip arthroplasty: A network meta-analysis. Int J Surg 2019; 62:74-85. [PMID: 30615954 DOI: 10.1016/j.ijsu.2018.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/06/2018] [Accepted: 12/20/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), selective NSAIDs, and radiation are widely used for the prevention of heterotopic ossification (HO) after total hip arthroplasty (THA). Previous studies have suggested that nonselective NSAIDs, selective NSAIDs and radiation can prevent HO after THA, though the results are conflicting. In this network meta-analysis, we aimed to comprehensively analyze the efficacy and safety of three strategies for preventing HO after THA compared to a placebo. PATIENTS AND METHODS Relevant studies about nonselective NSAIDs, selective NSAIDs, radiation and controls that were used to prevent HO after THA were collected. Data were extracted independently by two reviewers. Network meta-analysis was applied to assess treatment efficacy and safety. The surface under the cumulative ranking curve (SUCRA) method was used to assess which treatment was ranked the highest. The node-splitting method was used to calculate inconsistency. RESULTS Radiation was found to be the most efficient option for preventing overall incidence of HO and Brooker IV, I, II and III HO after THA. Selective NSAIDs were the safest option, and radiation was ranked second for preventing HO after THA, as the treatments were ranked taking discontinuation caused by nongastrointestinal side effects (DNGSE) and the incidence of complications into consideration. CONCLUSIONS A network meta-analysis concluded that radiation is the most efficacious method for preventing HO after THA.
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Affiliation(s)
- Liyang Cai
- Department of Orthopaedics, Gansu Provincial Hospital, 204 Donggangxi Road, 730000, Lanzhou, Gansu Province, China
| | - Zhan Wang
- Department of Orthopaedics, Gansu Provincial Hospital, 204 Donggangxi Road, 730000, Lanzhou, Gansu Province, China
| | - Xiangli Luo
- Department of Orthopaedics, Gansu Provincial Hospital, 204 Donggangxi Road, 730000, Lanzhou, Gansu Province, China
| | - Wei She
- Department of Orthopaedics, Gansu Provincial Hospital, 204 Donggangxi Road, 730000, Lanzhou, Gansu Province, China
| | - Hui Zhang
- Department of Orthopaedics, Gansu Provincial Hospital, 204 Donggangxi Road, 730000, Lanzhou, Gansu Province, China.
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Yin Y, Zhang R, Li S, Su K, Hou Z, Zhang Y. Complications Following Internal Fixator in the Treatment of Pelvic Fracture. Orthopedics 2019; 42:e7-e13. [PMID: 30403824 DOI: 10.3928/01477447-20181102-06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/19/2018] [Indexed: 02/03/2023]
Abstract
The aim of this systematic review was to investigate the incidence of complications of the internal fixator in the treatment of anterior pelvic ring injury. The literature was comprehensively searched from 1980 to January 2017 to identify potential studies. Six studies involving 272 cases of anterior pelvic ring injury treated with the internal fixator were included in this meta-analysis. The rates of wound infection, heterotopic ossification, nerve paresthesia, pain, and fracture dislocation were 5.7%, 35.1%, 28.2%, 3.7%, and 3.0%, respectively. This new technique should be prudently used to treat pelvic fractures. [Orthopedics. 2019; 42(1):e7-e13.].
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Logan NJ, Camman M, Williams G, Higgins CA. Demethylation of ITGAV accelerates osteogenic differentiation in a blast-induced heterotopic ossification in vitro cell culture model. Bone 2018; 117:149-160. [PMID: 30219480 PMCID: PMC6218666 DOI: 10.1016/j.bone.2018.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 12/22/2022]
Abstract
Trauma-induced heterotopic ossification is an intriguing phenomenon involving the inappropriate ossification of soft tissues within the body such as the muscle and ligaments. This inappropriate formation of bone is highly prevalent in those affected by blast injuries. Here, we developed a simplified cell culture model to evaluate the molecular events involved in heterotopic ossification onset that arise from the shock wave component of the disease. We exposed three subtypes of human mesenchymal cells in vitro to a single, high-energy shock wave and observed increased transcription in the osteogenic master regulators, Runx2 and Dlx5, and significantly accelerated cell mineralisation. Reduced representation bisulfite sequencing revealed that the shock wave altered methylation of gene promoters, leading to opposing changes in gene expression. Using a drug to target ITGAV, whose expression was perturbed by the shock wave, we found that we could abrogate the deposition of mineral in our model. These findings show how new therapeutics for the treatment of heterotopic ossification can be identified using cell culture models.
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Affiliation(s)
- Niall J Logan
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom,.
| | - Marie Camman
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom
| | - Greg Williams
- Farjo Hair Institute, London, W1G 7LH, United Kingdom.
| | - Claire A Higgins
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom,.
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Ng M, Brigati D, Wagner TC, Bigart K, Khlopas A, Sultan AA, Mont MA, Brooks P. Prophylactic Celecoxib Administration Is Associated With Decreased Incidence and Severity of Heterotopic Ossification After Hip Resurfacing by Direct Lateral Approach in Male Patients. Orthopedics 2018; 41:e807-e812. [PMID: 30222794 DOI: 10.3928/01477447-20180912-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/23/2018] [Indexed: 02/03/2023]
Abstract
Heterotopic ossification is a potential complication that may have a particularly higher association with hip resurfacing. The 2 current mainstays for heterotopic ossification treatment and prophylaxis are administration of nonsteroidal anti-inflammatory drugs and radiotherapy. Recent studies have determined that celecoxib is effective in heterotopic ossification prophylaxis after total hip arthroplasty. However, considering the reportedly higher incidence and severity of heterotopic ossification in these patients, relatively few studies have evaluated its role in hip resurfacing. Therefore, the authors assessed the incidence, severity, and risk factors of heterotopic ossification in patients who had hip resurfacing and did or did not receive celecoxib. Of the 198 patients, 83 received celecoxib and 115 did not. Radiographs were examined to grade heterotopic ossification using the Brooker classification system. The rate of heterotopic ossification differed between patients who did and patients who did not receive celecoxib prophylaxis (25% vs 65%, P<.001). Celecoxib was an independent predictor of decreased heterotopic ossification (odds ratio, 0.16; 95% confidence interval, 0.08-0.35). Celecoxib administration is associated with decreased incidence and severity of heterotopic ossification after hip resurfacing performed using the direct lateral approach in male patients. [Orthopedics. 2018; 41(6):e807-e812.].
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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
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Tao MJ, Probyn L, Drost L, Kreder H, Nousiainen M, Tsao M, Barnes E, Jenkinson R, Wan BA, Poon M, Chan S, Chow E. Efficacy of Prophylactic Radiotherapy in the Treatment of Heterotopic Ossification. Clin Oncol (R Coll Radiol) 2018; 30:393-395. [DOI: 10.1016/j.clon.2018.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 11/25/2022]
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Abstract
The hip is a common location for heterotopic ossification after surgical trauma, blunt trauma, or muscle injury. However, the region around the pubic rami is an unusual location for heterotopic bone formation. Here, we present a case of a young, active man in the Armed Forces Reserve with a large heterotopic bone involving the left inferior pubic ramus who underwent surgical excision through an unusual approach via the perineum. The patient had notable pain relief postoperatively and returned to his active duties 1 month after surgery without discomfort or functional limitation.
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The effect of late radiotherapy on the progression of heterotopic ossification following total hip arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1125-1131. [DOI: 10.1007/s00590-018-2185-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/15/2018] [Indexed: 10/17/2022]
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Ruo Redda MG, De Colle C, Bianco L, Ruggieri A, Nassisi D, Rossi A, Gino E, Airaldi C. Heterotopic ossifications: role of radiotherapy as prophylactic treatment. Radiol Med 2018; 123:463-468. [PMID: 29397526 DOI: 10.1007/s11547-018-0853-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 01/04/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heterotopic ossification (HO) is abnormal formation of lamellar bone in soft tissue; the most frequent causes are total hip arthroplasty and trauma. Severe cases can lead to ankilosis with important impact on quality of life. Surgery is the elective treatment, but, especially in high-risk patients, it is important to prevent the re-formation of HO and, in these cases, radiotherapy (RT) can play an important role. MATERIALS AND METHODS we retrospectively analyzed a mono-institutional casistic of 30 patients (31 sites) at high risk for HO development, treated with surgery and pre- or postoperative RT. The majority of patients received a single RT fraction of 7 Gy, median age was 62, with a prevalence of male and hip as most frequently involved site. Radiological studies and clinical examination were performed in all patients during the follow-up period to evaluate both treatment efficacy and acute or late toxicity. RESULTS With a median follow up of 67 months, 23 patients had a complete response (CR) with excellent results in term of joint mobility. Two patients with CR showed a relapse of HO in the same site 19 and 12 months after treatment, respectively. Seven patients (22,6%) had a partial response (PR) to RT. One patient who reached CR had a history of previous irradiation in the same site 16 years before. No acute or late reactions have been reported. CONCLUSION Our data confirm safety and efficacy of RT in preventing HO, especially in high-risk patients, preferring a single fraction of 7 Gy.
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Affiliation(s)
- Maria Grazia Ruo Redda
- Department of Oncology, Radiation Oncology, School of Medicine, Azienda Ospedaliera Ordine Mauriziano Umberto I, University of Turin, Turin, Italy
| | - Chiara De Colle
- Department of Oncology, Radiation Oncology, School of Medicine, Azienda Ospedaliera Ordine Mauriziano Umberto I, University of Turin, Turin, Italy
| | - Lavinia Bianco
- Department of Oncology, Radiation Oncology, School of Medicine, Azienda Ospedaliera Ordine Mauriziano Umberto I, University of Turin, Turin, Italy.
| | - Andrea Ruggieri
- Department of Oncology, Radiation Oncology, School of Medicine, Azienda Ospedaliera Ordine Mauriziano Umberto I, University of Turin, Turin, Italy
| | - Daniela Nassisi
- Department of Oncology, Radiation Oncology, School of Medicine, Azienda Ospedaliera Ordine Mauriziano Umberto I, University of Turin, Turin, Italy
| | - Annalisa Rossi
- Department of Oncology, Radiation Oncology, School of Medicine, Azienda Ospedaliera Ordine Mauriziano Umberto I, University of Turin, Turin, Italy
| | - Eva Gino
- Department of Oncology, Radiation Oncology, School of Medicine, Azienda Ospedaliera Ordine Mauriziano Umberto I, University of Turin, Turin, Italy
| | - Claudia Airaldi
- Department of Oncology, Radiation Oncology, School of Medicine, Azienda Ospedaliera Ordine Mauriziano Umberto I, University of Turin, Turin, Italy
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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.
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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
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Abstract
Post-traumatic radioulnar synostosis is a rare complication after forearm or elbow injury that can result in loss of motion and significant disability. Risk factors include aspects of the initial trauma and of the surgical treatment of that trauma. Surgical intervention for synostosis is the standard of care and is determined based on the location of the bony bridge. Surgical timing is recommended between 6 months and 2 years with recent advocacy for the 6- to 12-month period after radiographs demonstrate bony maturation but early enough to prevent further stiffness and contractures. For most types of synostosis, surgical resection with interposition graft is recommended. The types of materials used include synthetic, allograft, and vascularized and non-vascularized materials, but currently there is no consensus on which is the most preferable. Adjuvant therapy is not considered necessary for all cases but can be beneficial in patients with high risk factors such as recurrence or traumatic brain injury. Postoperative rehabilitation should be performed early to maintain range of motion.
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Affiliation(s)
- A Lee Osterman
- Department of Orthopaedic & Hand Surgery, Philadelphia Hand to Shoulder Center, Thomas Jefferson University, Philadelphia, PA
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Scott CEH, MacDonald D, Moran M, White TO, Patton JT, Keating JF. Cemented total hip arthroplasty following acetabular fracture. Bone Joint J 2017; 99-B:1399-1408. [PMID: 28963163 DOI: 10.1302/0301-620x.99b10.bjj-2016-1261.r2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 04/05/2017] [Indexed: 11/05/2022]
Abstract
AIMS To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture. PATIENTS AND METHODS Between 1992 and 2016, 49 patients (33 male) with mean age of 57 years (25 to 87) underwent cemented THA at a mean of 6.5 years (0.1 to 25) following acetabular fracture. A total of 38 had undergone surgical fixation and 11 had been treated non-operatively; 13 patients died at a mean of 10.2 years after THA (0.6 to 19). Patients were assessed pre-operatively, at one year and at final follow-up (mean 9.1 years, 0.5 to 23) using the Oxford Hip Score (OHS). Implant survivorship was assessed. An age and gender-matched cohort of THAs performed for non-traumatic osteoarthritis (OA) or avascular necrosis (AVN) (n = 98) were used to compare complications and patient-reported outcome measures (PROMs). RESULTS The mean time from fracture to THA was significantly shorter for patients with AVN (2.2 years) or protrusio (2.2 years) than those with post-traumatic OA (9.4 years) or infection (8.0 years) (p = 0.03). Nine contained and four uncontained defects were managed with autograft (n = 11), bulk allograft (n = 1), or trabecular metal augment (n = 1). Initial fracture management (open reduction and internal fixation or non-operative), timing of THA (>/< one year), and age (>/< 55 years) had no significant effect on OHS or ten-year survival. Six THAs were revised at mean of 12 years (5 to 23) with ten-year all-cause survival of 92% (95% confidence interval 80.8 to 100). THA complication rates (all complications, heterotopic ossification, leg length discrepancy > 10 mm) were significantly higher following acetabular fracture compared with atraumatic OA/AVN and OHSs were inferior: one-year OHS (35.7 versus 40.2, p = 0.026); and final follow-up OHS (33.6 versus 40.9, p = 0.008). CONCLUSION Cemented THA is a reasonable option for the sequelae of acetabular fracture. Higher complication rates and poorer PROMs, compared with patients undergoing THA for atraumatic causes, reflects the complex nature of these cases. Cite this article: Bone Joint J 2017;99-B:1399-1408.
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Affiliation(s)
- C E H Scott
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - D MacDonald
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - M Moran
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - T O White
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - J T Patton
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - J F Keating
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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Mercuri LG, Saltzman BM. Acquired heterotopic ossification of the temporomandibular joint. Int J Oral Maxillofac Surg 2017; 46:1562-1568. [PMID: 28711310 DOI: 10.1016/j.ijom.2017.06.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/07/2017] [Accepted: 06/21/2017] [Indexed: 01/14/2023]
Abstract
Although the risk factors and diagnosis of heterotopic ossification (HO) are discussed in the orthopedics literature, the etiology of HO, as well as its prevention and management, remain theoretical. Furthermore, there is a lack of information in the literature regarding HO in temporomandibular joint replacement (TMJR). This article provides a qualitative review of information relative to the etiology, diagnosis, and management of HO to inform and encourage further investigation in TMJR. The orthopedic HO literature considered for this qualitative review was drawn from a comprehensive examination of the subject published previously by one of the authors. Using the key words "heterotopic ossification" or "heterotopic bone", citations in the PubMed database from both the dental and oral and maxillofacial surgery literature were reviewed. Based on this, it appears that the etiology, diagnosis, imaging, laboratory testing, risk factors, prophylaxis, and non-surgical and surgical options available for the management of TMJR-related HO are similar to those for orthopedic HO, but further elucidation is required for TMJR. There is a lack of published information in the literature on TMJR. Therefore, using the literature from this review as a foundation, studies should be developed and reported so that alloplastic TMJ surgeons have evidence-based protocols that will lead to the early detection and potential prevention of HO.
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Affiliation(s)
- L G Mercuri
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA; TMJ Concepts, Ventura, California, USA.
| | - B M Saltzman
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Macheras GA, Lepetsos P, Leonidou A, Anastasopoulos PP, Galanakos SP, Tsiridis E. Results from the surgical resection of severe heterotopic ossification of the hip: a case series of 26 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:1097-1102. [PMID: 28589499 DOI: 10.1007/s00590-017-1980-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 05/16/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Surgical resection of heterotopic ossification (HO) around the hip joint is often challenging. The aim of this study is to evaluate the clinical and radiological outcomes following surgical resection of Brooker's type III and IV HO of the hip. METHODS We retrospectively reviewed clinical and radiological data, between November 2006 and January 2013, of all patients who underwent surgical resection of severe HO of the hip. Brooker's grading, range of motion and the Harris Hip Score before and after surgery were recorded in all cases. The combined radiation (700 cGy preoperatively) and indomethacin regimen was used to prevent heterotopic ossification recurrence. RESULTS Twenty-six patients (22 males and 4 females) were included in our study. Mean patient age was 47.38 years (range 24-72). The HO was graded as Brooker grade III in 3 patients (11.5%) and Brooker grade IV in 23 patients (88.5%). Mean time interval between HO development and resection was 40.8 months (range 13-156 months). All patients had CT scans prior to surgery. Mean follow-up was 31.4 months (range 24-40 months). There was no severe HO recurrence. Complications included one intraoperative injury of a femoral artery branch, one intraoperative femoral neck fracture treated with intramedullary nailing, one sciatic nerve injury and one superficial infection treated conservatively. CONCLUSIONS Surgical resection of severe HO of the hip along with preoperative radiation and indomethacin provides excellent results; however, the complication rate is relatively high. Careful evaluation of the preoperative CT scan and wide exposure are required in order to identify all the involved neurovascular structures.
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Affiliation(s)
- George A Macheras
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Nikis 2, Kifissia, 14561, Athens, Greece
| | - Panagiotis Lepetsos
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Nikis 2, Kifissia, 14561, Athens, Greece.
| | - Andreas Leonidou
- Third Academic Department of Orthopaedics and Trauma, Aristotle University Medical School, Ring Road, N. Efkarpia, 56403, Thessaloníki, Greece
| | | | - Spyridon P Galanakos
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Nikis 2, Kifissia, 14561, Athens, Greece
| | - Eleftherios Tsiridis
- Third Academic Department of Orthopaedics and Trauma, Aristotle University Medical School, Ring Road, N. Efkarpia, 56403, Thessaloníki, Greece
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Abstract
Heterotopic ossification (HO) presents a substantial barrier to rehabilitation for patients with severe burns or trauma. Although surgical excision is a mainstay of management for this condition, this is unable to address the chronic sequelae of HO, including chronic pain, joint contractures, nerve dysfunction, and open wounds. Current therapeutic modalities are aimed at excision and the prevention of recurrence using nonsteroidal antiinflammatory drugs (NSAIDs) or radiation therapy. Research is now focused on identifying alternative strategies to prevent the initial occurrence of HO through NSAIDs and novel inhibitors of the bone morphogenetic protein signaling pathway.
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Hoskins W, Bucknill A, Wong J, Britton E, Judson R, Gumm K, Santos R, Sheehy R, Griffin X. A prospective case series for a minimally invasive internal fixation device for anterior pelvic ring fractures. J Orthop Surg Res 2016; 11:135. [PMID: 27825365 PMCID: PMC5101701 DOI: 10.1186/s13018-016-0468-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/13/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND External fixation is commonly used as a means of definitive fixation of pelvic fractures. Pin site infection is common, with some cases of osteomyelitis and inpatient nursing can be challenging. The aim of this study is to report the outcomes and complications of an alternative minimally invasive technique, known as INFIX, utilising spinal pedicle screws inserted into the supra-acetabular bone and connected by a subcutaneous rod. METHODS A single-centre prospective case series was performed. The primary outcome measures were fracture stability and displacement at time of implant removal and intra- and post-operative complications. RESULTS Twenty-one patients were recruited, with 85.7 % of fractures being lateral compression type. Mean follow-up was 342 days. Mean application time was 51 min (range 44-65). Nineteen were removed electively, with mean time to removal 109 days. All cases were stable with no displacement. Two cases were removed emergently, one due to wound infection and the other due to lateral femoral cutaneous nerve neuropathic pain. Twelve patients sustained a lateral femoral cutaneous nerve palsy, with 20/42 nerves being affected. Improvement in all lateral femoral cutaneous nerve symptoms were reported with removal. Nine patients developed asymptomatic heterotopic ossification, and there were three deep infections and one symptomatic due to the bar. CONCLUSIONS Minimally invasive internal fixation with the INFIX for anterior pelvic ring fractures is an alternative to anterior external fixation. However, a higher rate of lateral femoral cutaneous nerve palsy is noted, and the implant is not well tolerated by all patients. Further studies are required to define fracture types and patients best suited to the technique and how LFCN complications may be minimised. TRIAL REGISTRATION ACTRN12616001421426 . Registered 12 October 2016. Retrospectively registered.
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Affiliation(s)
- Wayne Hoskins
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Grattan St, Parkville, VIC, 3052, Australia. .,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.
| | - Andrew Bucknill
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Grattan St, Parkville, VIC, 3052, Australia
| | - James Wong
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Grattan St, Parkville, VIC, 3052, Australia
| | - Edward Britton
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Grattan St, Parkville, VIC, 3052, Australia
| | - Rodney Judson
- Trauma Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kellie Gumm
- Trauma Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Roselyn Santos
- Trauma Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Rohan Sheehy
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Grattan St, Parkville, VIC, 3052, Australia
| | - Xavier Griffin
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK.,John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford, UK
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Sandilands SM, Raudenbush BL, Carreira DS, Cross BJ. Extra-articular hip impingement due to heterotopic ossification formation at the anterior inferior iliac spine following previous pelvic external fixation. BMJ Case Rep 2016; 2016:bcr-2015-213610. [PMID: 27637275 DOI: 10.1136/bcr-2015-213610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Femoroacetabular impingements (FAIs), specifically cam type and pincer type, continue to be accepted as causes of intra-articular hip pathology and sources of hip pain. Reports of other causes of hip impingement including extra-articular causes have surfaced recently. One structure of importance is the anterior inferior iliac spine (AIIS) due to its inconsistent bony morphology and the pull of the rectus femoris muscle putting it at risk for an avulsion fracture. Under certain circumstances, open surgical excision of exostosis formation after an avulsion fracture of the AIIS has been used. The case below represents a clinical scenario in which a medically unstable and multiply injured trauma patient had an external pelvic fixator placed as part of the treatment plan for an unstable pelvic injury. Following this pelvic external fixation treatment, the patient went on to develop clinically significant heterotopic bone formation at the AIIS pin site with extra-articular hip impingement syndrome.
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Affiliation(s)
- Scott M Sandilands
- Center for Advanced Orthopedics, Larkin Community Hospital, South Miami, Florida, USA
| | | | - Dominic S Carreira
- Department of Orthopedics, Broward Health Orthopedics and Sports Medicine, Nova Southeastern University, & Broward Health, Fort Lauderdale, Florida, USA
| | - Brian J Cross
- Department of Orthopedics, Nova Southeastern University & Broward Health, Fort Lauderdale, Florida, USA
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Yeung M, Jamshidi S, Horner N, Simunovic N, Karlsson J, Ayeni OR. Efficacy of Nonsteroidal Anti-inflammatory Drug Prophylaxis for Heterotrophic Ossification in Hip Arthroscopy: A Systematic Review. Arthroscopy 2016; 32:519-25. [PMID: 26432432 DOI: 10.1016/j.arthro.2015.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/15/2015] [Accepted: 08/06/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic review was to investigate the efficacy of nonsteroidal anti-inflammatory drug (NSAID) prophylaxis for preventing heterotopic ossification (HO) in the setting of hip arthroscopy. METHODS A systematic search was performed in duplicate for studies comparing the use of NSAID prophylaxis for HO in the setting of hip arthroscopy until March 2015. Study parameters--including sample size, incidence of HO, adverse effects, and level of symptoms--were obtained. Furthermore, the level of evidence of studies was collected and quality assessment was performed. The difference in incidence as well as pooled odds ratios were calculated and analyzed to compare no prophylaxis versus NSAID prophylaxis. RESULTS This systematic review identified 5 studies, consisting of 1,662 patients, investigating NSAID prophylaxis in hip arthroscopy. HO was diagnosed with the use of postoperative hip radiographs at follow-up, with 95% of cases classified using the Brooker classification. The incidence of HO was 13.4% without NSAID prophylaxis and 3.3% with NSAID prophylaxis. Pooled odds ratios from the prospective studies were 0.07 (95% confidence interval [CI], 0.02 to 0.28; P = .0002; I(2) = 0%), showing with statistical significance that NSAID prophylaxis decreased the incidence of HO. The retrospective data similarly showed pooled odds ratios of 0.03 (95% CI, 0.00 to 1.43); P = .08; I(2) = 84%), although it was not statistically significant. Most of the patients who experienced HO in both groups were not reported to be symptomatic. Adverse effects and compliance were not consistently reported. CONCLUSIONS The available orthopaedic literature suggests that the incidence of postoperative HO may be decreased with the use of NSAID prophylaxis in hip arthroscopy. However, the evidence is unclear regarding NSAID drug regimen choice, drug compliance, and adverse effects. LEVEL OF EVIDENCE Level III, systematic review of Level I, Level II, and Level III studies.
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Affiliation(s)
- Marco Yeung
- Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sahab Jamshidi
- Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nolan Horner
- Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sahlgrenska, University Hospital/Mölndal, Mölndal, Sweden
| | - Olufemi R Ayeni
- Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada.
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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.
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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
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Aljurayyan A, Tanzer D, Tanzer M. Acute revision hip arthroplasty: a previously unrecognized risk factor for heterotopic ossification. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:183-8. [PMID: 26724809 DOI: 10.1007/s00590-015-1733-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The aim of this retrospective review was to determine the incidence and severity of heterotrophic ossification (HO) following acute revision total hip arthroplasty (THA), and whether this represents a significant risk factor for HO that should be treated prophylactically. MATERIALS AND METHODS A total of seven patients (three men and four women) with a mean age of 55 years (39-70 years) who underwent a reoperation of their THA for any reason that required a hip arthrotomy within 3 weeks of their primary or revision THA were included, with a mean follow-up of 8.8 years (2-12 years). All patients were evaluated radiographically for any evidence of HO and clinically using the Harris Hip Score. RESULTS All seven hips (100 %) developed HO, with 71 % being severe (Brooker III and IV HO). One hip (14 %) developed Brooker IV HO, four hips (57 %) developed Brooker III HO, and two hips (29 %) developed Brooker II HO. The patient's range of motion varied, but was very limited in three patients. Three patients (42.8 %) were not satisfied with their surgery; one patient had Brooker IV HO, and two patients had Brooker III HO. CONCLUSION Acute reoperation after primary or revision THA is a significant risk factor for the development of extensive HO, which requires prophylactic treatment.
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Affiliation(s)
- Abdulaziz Aljurayyan
- Division of Orthopaedic Surgery, McGill University Health Centre, 1650 Cedar Avenue, B5.159, Montreal, QC, H3G 1A4, Canada.
| | - Dylan Tanzer
- Sackler Medical School, Tel Aviv University, Tel Aviv, Isreal
| | - Michael Tanzer
- Division of Orthopaedic Surgery, McGill University Health Centre, 1650 Cedar Avenue, B5.159, Montreal, QC, H3G 1A4, Canada.
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Milakovic M, Popovic M, Raman S, Tsao M, Lam H, Chow E. Radiotherapy for the prophylaxis of heterotopic ossification: A systematic review and meta-analysis of randomized controlled trials. Radiother Oncol 2015; 116:4-9. [PMID: 26163090 DOI: 10.1016/j.radonc.2015.05.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/04/2015] [Accepted: 05/08/2015] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Heterotopic ossification (HO) involves the formation of lamellar bone in nonosseous tissue. For HO, radiotherapy has been shown to be an effective prophylactic modality. OBJECTIVE To compare HO outcomes following radiotherapy and to investigate the comparative efficacy of preoperative versus postoperative radiotherapy. METHODS A systematic search was conducted on Ovid MEDLINE, EMBASE and Cochrane CENTRAL. Studies were included if they were randomized controlled trials (RCTs) that included patients who were prescribed prophylactic radiation for whom relevant HO progression outcomes were reported. RESULTS From a literature search of 528 articles, 12 RCTs were included. There was a statistically significant reduction in HO prevalence with multiple as opposed to single fraction radiotherapy (p=0.04), however there was no statistically significant difference when examining HO progression (p=0.34). There was no statistically significant difference in HO progression when comparing a biologically effective radiation dose (BED) of >2500cGy versus ⩽2500cGy (p=0.28). As well, no statistically significant difference existed in HO progression between postoperative versus preoperative radiation (p=0.43). CONCLUSION There was no difference between postoperative or preoperative radiotherapy in preventing HO progression. There seems to be no relationship between BED greater or less than 2500cGy and the efficacy of HO prophylaxis. Multiple fractions seem to be more effective than single fraction radiotherapy in preventing HO progression.
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Affiliation(s)
- Milica Milakovic
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Marko Popovic
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Srinivas Raman
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - May Tsao
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Henry Lam
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Edward Chow
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada.
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Ranganathan K, Loder S, Agarwal S, Wong VW, Forsberg J, Davis TA, Wang S, James AW, Levi B, Levi B. Heterotopic Ossification: Basic-Science Principles and Clinical Correlates. J Bone Joint Surg Am 2015; 97:1101-11. [PMID: 26135077 PMCID: PMC6948799 DOI: 10.2106/jbjs.n.01056] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Heterotopic ossification occurs most commonly after joint arthroplasty, spinal cord injury, traumatic brain injury, blast trauma, elbow and acetabular fractures, and thermal injury.➤ The conversion of progenitor cells to osteogenic precursor cells as a result of cell-mediated interactions with the local tissue environment is affected by oxygen tension, pH, availability of micronutrients, and mechanical stimuli, and leads to heterotopic ossification.➤ Radiation and certain nonsteroidal anti-inflammatory medications are important methods of prophylaxis against heterotopic ossification.➤ Well-planned surgical excision can improve patient outcomes regardless of the joint involved or the initial cause of injury.➤ Future therapeutic strategies are focused on targeted inhibition of local factors and signaling pathways that catalyze ectopic bone formation.
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Affiliation(s)
- Kavitha Ranganathan
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shawn Loder
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shailesh Agarwal
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Victor W. Wong
- Department of Surgery, Johns Hopkins School of Medicine, 4924 Campbell Boulevard, Baltimore, MD 21236
| | - Jonathan Forsberg
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Thomas A. Davis
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Stewart Wang
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Aaron W. James
- Department of Pathology & Laboratory Medicine, University of California at Los Angeles, DGSOM, 200 Medical Plaza, Los Angeles, CA 90095
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
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Rivera JC, Hsu JR, Noel SP, Wenke JC, Rathbone CR. Locally Delivered Nonsteroidal Antiinflammatory Drug: A Potential Option for Heterotopic Ossification Prevention. Clin Transl Sci 2015; 8:591-3. [PMID: 26074022 DOI: 10.1111/cts.12300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Oral nonsteroidal antiinflammatory drugs (NSAIDs) are prescribed for heterotopic ossification prophylaxis following at-risk injuries and procedures. We hypothesized that NSAIDs may be delivered locally in a wound for heterotopic ossification prophylaxis. In in vitro work, we cultured osteoblasts with three commercially available NSAIDs and then measured cell viability and DNA content. Indomethacin caused a 50% decrease in DNA at the lowest dose (0.0001 mM) and the most potent decrease in cell viability (<10% of control at 0.0005 mM). Ketorolac and ibuprofen required 10 times the dose to achieve a comparable decrease (<20% of control at 0.005 mM). In an animal study, 20 rats per treatment group received a full-thickness wound dressed with either saline-moistened gauze, saline-moistened chitosan sponge, or chitosan sponge loaded with indomethacin. After 28 days, we examined the tissue for healing. Wounds exposed to indomethacin loaded sponges demonstrated fewer inflammatory cells. All 20 rats in the indomethacin group had complete epithelial coverage at 28 days. Eighteen (90%) wounds in the saline-chitosan group and 11 (55%) wounds in the saline-gauze group were healed. Locally delivered NSAIDs may be useful for heterotopic ossification prophylaxis due to effects on osteoblast viability and lack of negative effects on wound healing.
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Affiliation(s)
- Jessica C Rivera
- US Army Institute of Surgical Research and San Antonio Military Medical Center Department of Orthopaedics and Rehabilitation, Joint Base San Antonio, Texas, USA
| | - Joseph R Hsu
- Carolinas Medical Center Department of Orthopaedics, Charlotte, North Carolina, USA
| | | | - Joseph C Wenke
- US Army Institute of Surgical Research, Joint Base San Antonio, Texas, USA
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Edwards DS, Barbur SAR, Bull AMJ, Stranks GJ. Posterior mini-incision total hip arthroplasty controls the extent of post-operative formation of heterotopic ossification. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1051-5. [PMID: 25953634 PMCID: PMC4512268 DOI: 10.1007/s00590-015-1646-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/16/2015] [Indexed: 01/17/2023]
Abstract
Heterotopic ossification (HO) is the formation of bone at extra-skeletal sites. Reported rates of HO after hip arthroplasty range from 8 to 90 %; however, it is only severe cases that cause problems clinically, such as joint stiffness. The effects of surgical-related controllable intra-operative risk factors for the formation of HO were investigated. Data examined included gender, age of patient, fat depth, length of operation, incision length, prosthetic fixation method, the use of pulsed lavage and canal brush, and component size and material. All cases were performed by the same surgeon using the posterior approach. A total of 510 cases of hip arthroplasty were included, with an overall rate of HO of 10.2 %. Longer-lasting operations resulted in higher grades of HO (p = 0.047). Incisions >10 cm resulted in more widespread HO formation (p = 0.021). No further correlations were seen between HO formation and fat depth, blood loss, instrumentation, fixation methods or prosthesis material. The mini-incision approach is comparable to the standard approach in the aetiology of HO formation, and whilst the rate of HO may not be controllable, a posterior mini-incision approach can limit its extent.
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Affiliation(s)
- D S Edwards
- Royal Centre for Defence Medicine, Birmingham, UK,
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50
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Pathogenesis and prevention strategies of heterotopic ossification in total hip arthroplasty: a narrative literature review and results of a survey in Germany. Arch Orthop Trauma Surg 2015; 135:481-9. [PMID: 25708028 DOI: 10.1007/s00402-015-2174-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Heterotopic ossification (HO) after THA can lead to pain, impaired range of motion and possibly revision surgery. This article summarizes current literature on the pathogenesis of HO in THA and trauma. Second, it presents the results of a survey on prophylactic concepts for HO in Germany. MATERIALS AND METHODS A narrative literature review was conducted by searching three databases (Pubmed, ScienceDirect, the Cochrane library) on the aetiology of HO. Between 2013 and 2014, a questionnaire was sent to 119 orthopaedic and trauma surgery departments in Germany. RESULTS The acquired form of HO seems to develop after tissue trauma, which induces a local inflammation. A change in tissue conditions, multiple signalling pathways and involvement of several different cell types seem to promote enchondral ossification and finally HO formation. The feed back rate of the survey was 67%. Eighty-seven percent of all departments currently administer NSAIDs with a mean time span of 3 weeks after surgery for oral prophylaxis. Prophylactic perioperative irradiation is performed in 64% of trauma/orthopaedic departments if the patient is at risk for HO with a mean dosage of 7 Gy. CONCLUSIONS Basic research detected new pathways and cell signalling mechanisms of HO pathogenesis, which could offer new treatment and prophylaxis options in the near future. So far, there is no uniform strategy for the clinical prophylaxis of HO in THA. Guidelines and new clinical trials need to be developed to further reduce HO rates in THA.
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