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Estel K, Back DA, Scheuermann-Poley C, Willy C. Fulminant Heterotopic Ossification of the Lower Extremity After Gunshot Injury and Blunt Trauma: A Case Report. Mil Med 2024; 189:e1826-e1831. [PMID: 38651560 DOI: 10.1093/milmed/usae109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/22/2023] [Accepted: 03/04/2024] [Indexed: 04/25/2024] Open
Abstract
Traumatic heterotopic ossification (HO) of the lower extremity is relatively rare but is of major importance in clinical practice. They are defined as posttraumatic abnormal formations of bone within soft tissue outside of the skeletal system. This article describes the clinical case of a 31-year-old male patient who suffered 2 traumatic events within 12 months-a gunshot wound in the lumbar spine/gluteal region followed by a severe traumatic brain injury with intracranial hemorrhage in a traffic accident as a pedestrian. Clinically, the patient was bedridden because of complete stiffening of the lumbar spine, both hip joints, and the left knee joint. After preoperative diagnosis, 3 surgical ablations of the HO were performed on both the hip joints and the left knee joint. In addition, physiotherapeutic exercise, postoperative nonsteroidal anti-inflammatory drug administration (25 mg of indomethazine for 6 weeks, 3 times a day), and perioperative radiation with 7 Gy for each operation were advised. After 4 years of follow-up, the patient showed significant improvement. In HO treatment, prophylactic local radiotherapy (pre- and postoperative radiation with a local single dose of 7 Gy) and postoperative administration of nonsteroidal anti-inflammatory drugs are often recommended. For therapeutic purposes, surgical resection is still indicated for pronounced cases.
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Affiliation(s)
- Katharina Estel
- Department for Traumatology and Orthopedics, Bundeswehr Hospital Berlin, 10115, Berlin, Germany
| | - David Alexander Back
- Department for Traumatology and Orthopedics, Bundeswehr Hospital Berlin, 10115, Berlin, Germany
| | | | - Christian Willy
- Department for Traumatology and Orthopedics, Bundeswehr Hospital Berlin, 10115, Berlin, Germany
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Li D, Liu C, Wang H, Li Y, Wang Y, An S, Sun S. The Role of Neuromodulation and Potential Mechanism in Regulating Heterotopic Ossification. Neurochem Res 2024; 49:1628-1642. [PMID: 38416374 DOI: 10.1007/s11064-024-04118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/17/2024] [Accepted: 01/28/2024] [Indexed: 02/29/2024]
Abstract
Heterotopic ossification (HO) is a pathological process characterized by the aberrant formation of bone in muscles and soft tissues. It is commonly triggered by traumatic brain injury, spinal cord injury, and burns. Despite a wide range of evidence underscoring the significance of neurogenic signals in proper bone remodeling, a clear understanding of HO induced by nerve injury remains rudimentary. Recent studies suggest that injury to the nervous system can activate various signaling pathways, such as TGF-β, leading to neurogenic HO through the release of neurotrophins. These pathophysiological changes lay a robust groundwork for the prevention and treatment of HO. In this review, we collected evidence to elucidate the mechanisms underlying the pathogenesis of HO related to nerve injury, aiming to enhance our understanding of how neurological repair processes can culminate in HO.
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Affiliation(s)
- Dengju Li
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Shandong First Medical University, Jinan, Shandong, China
| | - Changxing Liu
- Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Haojue Wang
- Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Yunfeng Li
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yaqi Wang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Senbo An
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
- Shandong First Medical University, Jinan, Shandong, China.
| | - Shui Sun
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
- Shandong First Medical University, Jinan, Shandong, China.
- Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China.
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Mangiavacchi A, Morelli G, Reppe S, Saera-Vila A, Liu P, Eggerschwiler B, Zhang H, Bensaddek D, Casanova EA, Medina Gomez C, Prijatelj V, Della Valle F, Atinbayeva N, Izpisua Belmonte JC, Rivadeneira F, Cinelli P, Gautvik KM, Orlando V. LINE-1 RNA triggers matrix formation in bone cells via a PKR-mediated inflammatory response. EMBO J 2024:10.1038/s44318-024-00143-z. [PMID: 38951609 DOI: 10.1038/s44318-024-00143-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 05/16/2024] [Accepted: 05/23/2024] [Indexed: 07/03/2024] Open
Abstract
Transposable elements (TEs) are mobile genetic modules of viral derivation that have been co-opted to become modulators of mammalian gene expression. TEs are a major source of endogenous dsRNAs, signaling molecules able to coordinate inflammatory responses in various physiological processes. Here, we provide evidence for a positive involvement of TEs in inflammation-driven bone repair and mineralization. In newly fractured mice bone, we observed an early transient upregulation of repeats occurring concurrently with the initiation of the inflammatory stage. In human bone biopsies, analysis revealed a significant correlation between repeats expression, mechanical stress and bone mineral density. We investigated a potential link between LINE-1 (L1) expression and bone mineralization by delivering a synthetic L1 RNA to osteoporotic patient-derived mesenchymal stem cells and observed a dsRNA-triggered protein kinase (PKR)-mediated stress response that led to strongly increased mineralization. This response was associated with a strong and transient inflammation, accompanied by a global translation attenuation induced by eIF2α phosphorylation. We demonstrated that L1 transfection reshaped the secretory profile of osteoblasts, triggering a paracrine activity that stimulated the mineralization of recipient cells.
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Affiliation(s)
- Arianna Mangiavacchi
- King Abdullah University of Science and Technology (KAUST), Biological Environmental Science and Engineering Division, Thuwal, 23500-6900, Kingdom of Saudi Arabia.
| | - Gabriele Morelli
- King Abdullah University of Science and Technology (KAUST), Biological Environmental Science and Engineering Division, Thuwal, 23500-6900, Kingdom of Saudi Arabia
| | - Sjur Reppe
- Oslo University Hospital, Department of Medical Biochemistry, Oslo, Norway
- Lovisenberg Diaconal Hospital, Unger-Vetlesen Institute, Oslo, Norway
- Oslo University Hospital, Department of Plastic and Reconstructive Surgery, Oslo, Norway
| | | | - Peng Liu
- King Abdullah University of Science and Technology (KAUST), Biological Environmental Science and Engineering Division, Thuwal, 23500-6900, Kingdom of Saudi Arabia
| | - Benjamin Eggerschwiler
- Department of Trauma, University Hospital Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland
- Life Science Zurich Graduate School, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | - Huoming Zhang
- Core Labs, King Abdullah University of Science and Technology (KAUST), Thuwal, 23500-6900, Kingdom of Saudi Arabia
| | - Dalila Bensaddek
- Core Labs, King Abdullah University of Science and Technology (KAUST), Thuwal, 23500-6900, Kingdom of Saudi Arabia
| | - Elisa A Casanova
- Sequentia Biotech, Carrer Comte D'Urgell 240, Barcelona, 08036, Spain
| | | | - Vid Prijatelj
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Francesco Della Valle
- King Abdullah University of Science and Technology (KAUST), Biological Environmental Science and Engineering Division, Thuwal, 23500-6900, Kingdom of Saudi Arabia
- Altos Labs, San Diego, CA, USA
| | - Nazerke Atinbayeva
- King Abdullah University of Science and Technology (KAUST), Biological Environmental Science and Engineering Division, Thuwal, 23500-6900, Kingdom of Saudi Arabia
| | | | - Fernando Rivadeneira
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Paolo Cinelli
- Sequentia Biotech, Carrer Comte D'Urgell 240, Barcelona, 08036, Spain
- Center for Applied Biotechnology and Molecular Medicine, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | | | - Valerio Orlando
- King Abdullah University of Science and Technology (KAUST), Biological Environmental Science and Engineering Division, Thuwal, 23500-6900, Kingdom of Saudi Arabia.
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Zhou MW, Zhang PW, Zhang AL, Wei CH, Xu YD, Chen W, Fu ZB. Ilizarov technique for treating elbow stiffness caused by myositis ossificans: A case report. World J Clin Cases 2024; 12:3144-3150. [PMID: 38898861 PMCID: PMC11185390 DOI: 10.12998/wjcc.v12.i17.3144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/12/2024] [Accepted: 04/19/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Myositis ossificans (MO) is a rare disease involving the formation of bone outside the musculoskeletal system. While surgical intervention is the main treatment approach, preventing recurrence and standardized rehabilitation are also crucial. Here, we present a surgical strategy to prevent the recurrence of MO. CASE SUMMARY A 28-year-old female patient was admitted for the first time for a comminuted fracture of the left olecranon. However, incorrect postoperative rehabilitation resulted in the development of elbow joint stiffness with ectopic ossification, causing a loss of normal range of motion. The patient was diagnosed with MO based on physical examination, X-ray findings, and clinical presentation. We devised a surgical strategy to remove MO, followed by fixation with an Ilizarov frame, and implemented a scientifically reasonable rehabilitation plan. The surgery lasted for 3 h with an estimated blood loss of 45 mL. A drainage tube was placed after surgery, and fluid was aspirated through ultrasound-guided puncture. The patient experienced a significant reduction in joint stiffness after surgery. In the final follow-up at 9 mouths, there was evident improvement in the range of motion of the elbow joint, and no other symptoms were reported. CONCLUSION The Ilizarov frame is an advantageous surgical technique for facilitating rehabilitation after MO removal. It offers benefits such as passive recovery, individualized treatment, and prompt recovery.
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Affiliation(s)
- Ming-Wang Zhou
- Department of Orthopedics Medicine, Gansu Province Hospital of Chinese Medicine, Lanzhou 730050, Gansu Province, China
| | - Peng-Wei Zhang
- Gansu University of Chinese Medicine, Clinical College of Traditional Chinese Medicine, Lanzhou 730000, Gansu Province, China
| | - An-Le Zhang
- Gansu University of Chinese Medicine, Clinical College of Traditional Chinese Medicine, Lanzhou 730000, Gansu Province, China
| | - Chang-Hao Wei
- Department of Orthopedics Medicine, Gansu Province Hospital of Chinese Medicine, Lanzhou 730050, Gansu Province, China
| | - Yu-De Xu
- Department of Orthopedics Medicine, Gansu Province Hospital of Chinese Medicine, Lanzhou 730050, Gansu Province, China
| | - Wei Chen
- Department of Orthopedics Medicine, Gansu Province Hospital of Chinese Medicine, Lanzhou 730050, Gansu Province, China
| | - Zhi-Bin Fu
- Department of Orthopedics Medicine, Gansu Province Hospital of Chinese Medicine, Lanzhou 730050, Gansu Province, China
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Won P, Pickering TA, Schneider JC, Kowalske K, Ryan CM, Carrougher GJ, Stewart BT, Yenikomshian HA. Physical and psychosocial outcomes among burn-injured people with heterotopic ossification: A burn model system study. Burns 2024; 50:957-965. [PMID: 38267289 PMCID: PMC11055684 DOI: 10.1016/j.burns.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/10/2024] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
INTRODUCTION Heterotopic ossification (HO), or ectopic bone formation in soft tissue, is a not so rare and poorly understood debilitating sequela of burn injury. Individuals developing HO following burn injuries to their hands often experience reductions in mobility, significant contractures, and joint pain. This study identifies demographic characteristics of individuals who develop HO and compares their physical and psychosocial outcomes to the general burn population. METHODS Participant demographics, injury characteristics, and PROMIS-29 scores across three time points (discharge, six- and 12- months after injury) were extracted from the Burn Model System National Longitudinal Database representing participants from 2015-2022. Mixed-effects linear regression models were used to compare PROMIS scores across all three longitudinal measurements. Models were adjusted for age, sex, race/ethnicity, HO status, and burn size. RESULTS Of the 861 participants with data concerning HO, 33 were diagnosed with HO (3.8% of participants). Most participants with HO were male (n = 24, 73%) and had an average age of 40 + /- 13 years. Participants with HO had significantly larger burn size (49 +/-23% Total Body Surface Area (TBSA)) than those without HO (16 +/-17%). Participants with HO reported significantly worse physical function, depression, pain interference and social integration scores than those without HO. After adjusting for covariables, participants with HO continued to report statistically significantly worse physical function than those without HO. Although physical functioning was consistently lower, the two populations did not differ significantly among psychosocial outcome measures. CONCLUSIONS While HO can result in physical limitations, the translation to psychosocial impairments was not evident. Targeted treatment of HO with the goal of maximizing physical function should be a focus of their rehabilitation. LEVEL OF EVIDENCE 2b TYPE OF STUDY: Symptom Prevalence Study.
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Affiliation(s)
- Paul Won
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Trevor A Pickering
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA
| | - Colleen M Ryan
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Gretchen J Carrougher
- Department of Surgery, University of Washington, UW Medicine Regional Burn Center at Harborview Medical Center, Seattle, WA, USA
| | - Barclay T Stewart
- Department of Surgery, University of Washington, UW Medicine Regional Burn Center at Harborview Medical Center, Seattle, WA, USA
| | - Haig A Yenikomshian
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Epperson RT, Isaacson BM, Rothberg DL, Olsen RE, Kawaguchi B, Rasmussen RM, Dickerson M, Pasquina PF, Shero J, Williams DL. Determining Which Combinatorial Combat-Relevant Factors Contribute to Heterotopic Ossification Formation in an Ovine Model. Bioengineering (Basel) 2024; 11:350. [PMID: 38671772 PMCID: PMC11048030 DOI: 10.3390/bioengineering11040350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/20/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
Traumatic heterotopic ossification (HO) is frequently observed in Service Members following combat-related trauma. Estimates suggest that ~65% of wounded warriors who suffer limb loss or major extremity trauma will experience some type of HO formation. The development of HO delays rehabilitation and can prevent the use of a prosthetic. To date there are limited data to suggest a standard mechanism for preventing HO. This may be due to inadequate animal models not producing a similar bone structure as human HO. We recently showed that traumatic HO growth is possible in an ovine model. Within that study, we demonstrated that 65% of sheep developed a human-relevant hybrid traumatic HO bone structure after being exposed to a combination of seven combat-relevant factors. Although HO formed, we did not determine which traumatic factor contributed most. Therefore, in this study, we performed individual and various combinations of surgical/traumatic factors to determine their individual contribution to HO growth. Outcomes showed that the presence of mature biofilm stimulated a large region of bone growth, while bone trauma resulted in a localized bone response as indicated by jagged bone at the linea aspera. However, it was not until the combinatory factors were included that an HO structure similar to that of humans formed more readily in 60% of the sheep. In conclusion, data suggested that traumatic HO growth can develop following various traumatic factors, but a combination of known instigators yields higher frequency size and consistency of ectopic bone.
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Affiliation(s)
- Richard T. Epperson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA; (B.M.I.); (D.L.R.); (R.E.O.); (B.K.); (R.M.R.); (D.L.W.)
- Bone & Biofilm Research Laboratory, University of Utah, Salt Lake City, UT 84112, USA
| | - Brad M. Isaacson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA; (B.M.I.); (D.L.R.); (R.E.O.); (B.K.); (R.M.R.); (D.L.W.)
- The Center for Rehabilitation Sciences Research, Uniformed Services University, Bethesda, MD 20814, USA; (P.F.P.); (J.S.)
- The Geneva Foundation, Tacoma, WA 98402, USA
| | - David L. Rothberg
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA; (B.M.I.); (D.L.R.); (R.E.O.); (B.K.); (R.M.R.); (D.L.W.)
| | - Raymond E. Olsen
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA; (B.M.I.); (D.L.R.); (R.E.O.); (B.K.); (R.M.R.); (D.L.W.)
| | - Brooke Kawaguchi
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA; (B.M.I.); (D.L.R.); (R.E.O.); (B.K.); (R.M.R.); (D.L.W.)
- Bone & Biofilm Research Laboratory, University of Utah, Salt Lake City, UT 84112, USA
| | - Ryan M. Rasmussen
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA; (B.M.I.); (D.L.R.); (R.E.O.); (B.K.); (R.M.R.); (D.L.W.)
- Bone & Biofilm Research Laboratory, University of Utah, Salt Lake City, UT 84112, USA
| | - Mary Dickerson
- Office of Comparative Medicine, University of Utah, Salt Lake City, UT 84112, USA;
| | - Paul F. Pasquina
- The Center for Rehabilitation Sciences Research, Uniformed Services University, Bethesda, MD 20814, USA; (P.F.P.); (J.S.)
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20910, USA
| | - John Shero
- The Center for Rehabilitation Sciences Research, Uniformed Services University, Bethesda, MD 20814, USA; (P.F.P.); (J.S.)
- Extremity Trauma Center of Excellence, Joint Base San Antonio Fort Sam Houston, San Antonio, TX 78240, USA
| | - Dustin L. Williams
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84108, USA; (B.M.I.); (D.L.R.); (R.E.O.); (B.K.); (R.M.R.); (D.L.W.)
- Bone & Biofilm Research Laboratory, University of Utah, Salt Lake City, UT 84112, USA
- The Center for Rehabilitation Sciences Research, Uniformed Services University, Bethesda, MD 20814, USA; (P.F.P.); (J.S.)
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA
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Zampogna B, Laudisio A, Papalia GF, Vorini F, Zampoli A, Righini R, Fiore M, Vadalà G, Angeletti S, Ramella S, Papalia R. Heterotopic hip ossification resection: monocentric experiences of associated factors, outcomes, and complications. INTERNATIONAL ORTHOPAEDICS 2024; 48:699-704. [PMID: 37776348 DOI: 10.1007/s00264-023-05993-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/15/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE The exponential increase in total hip arthroplasty (THA) has led to acute and chronic surgery-related complications. Common chronic and local complications are represented by hip ossification (HO). The aim of our study was to assess the clinical and radiological correlates of patients undergoing surgical removal of heterotopic ossifications after THA and the possible association between HO and prosthetic joint infection. METHODS Data of 26 patients who underwent surgical removal of periprosthetic calcifications after THA from 2000 to 2022 were analyzed and compared with characteristics of 156 subjects without HO. RESULTS The preoperative radiographs of patients showed a high-grade Brooker, 3 or 4, later reduced to 1 or 2 in the postoperative radiographs. Ten (38.5%) patients underwent radiotherapy prophylaxis, administered as a single dose 24 h before surgery. In 19 (73%) patients, pharmacological prophylaxis with indomethacin was added in the 30 postoperative days. Only one patient who underwent radiotherapy had a recurrence, while new ossifications were found in three patients without prophylaxis (11.5%). Intraoperative cultures were performed for suspected periprosthetic infection in 8 study group patients. In logistic regression, the presence of HO was significantly and inversely associated with the ASA score (OR = 0.27, 95% CI = 0.09-0.82; P = 0.021) after adjusting. CONCLUSION Surgical HO removal in symptomatic patients with high-grade disease produces good clinical and radiographic results. Radiotherapy was a good perioperative and preventive strategy for recurrence, also associated with NSAIDs and COX-2 inhibitors.
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Affiliation(s)
- B Zampogna
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - A Laudisio
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy.
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy.
- Research Unit of Geriatrics, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy.
| | - G F Papalia
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - F Vorini
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - A Zampoli
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - R Righini
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - M Fiore
- Operative Research Unit of Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Radiation Oncology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - G Vadalà
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - S Angeletti
- Operative Research Unit of Clinical Laboratory Science, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128, Rome, Italy
- Research Unit of Clinical Laboratory Science, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21 - 00128, Rome, Italy
| | - S Ramella
- Operative Research Unit of Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Radiation Oncology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - R Papalia
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
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Kontokostopoulos AP, Gkiatas I, Vasileiadis GI, Flevas D, Tsirigkakis SE, Kosmas D, Kostas-Agnantis I, Pakos E, Gelalis I, Korompilias A. Heterotopic Ossification around the Elbow Revisited. Life (Basel) 2023; 13:2358. [PMID: 38137958 PMCID: PMC10744911 DOI: 10.3390/life13122358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 10/31/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Heterotopic ossification (HO) is the process of ectopic bone formation in the periarticular soft tissues and is usually formed in the elbow, hip and knee joint as a complication of trauma, burns, brain injury or surgical procedures. The development of HO around the elbow joint can cause a severe limitation of range of motion (ROM) and may affect daily activities of the patient. Treatment of ectopic bone formation around the elbow is a challenge for many surgeons. Non-operative treatment usually fails to restore the ROM of the elbow joint; thus, surgery is necessary to restore the function of the joint. In the past, many surgeons suggested that a delayed excision of HO, until maturation of the ectopic bone, is the best option in order to avoid any possible recurrence. However, many authors now suggest that this delay may lead to complications such as muscular atrophy and formation of soft tissue contractures that can cause a greater impairment of elbow function; thus, early excision is a better option and can better restore the elbow ROM. We performed a literature research of articles that investigated which is the best time of HO excision and we also evaluated if the tethering effect of HO can lead to a greater impairment of the elbow function. We found numerous studies suggesting that a limitation in ROM of the elbow can appear from the tethering of the ectopic bone formation and not only from primary HO. Concerning the HO excision, there were no significant differences between patients who underwent delayed and early excision, concerning the recurrence rate of HO around the elbow. Patients who underwent early excision had better restoration of elbow ROM; thus, early excision, combined with a rehabilitation program, is reported to be the best option for these patients.
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Affiliation(s)
- Aristeidis-Panagiotis Kontokostopoulos
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Ioannis Gkiatas
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - George I. Vasileiadis
- Department of Physical Medicine and Rehabilitation, School of Medicine, University Hospital of Ioannina, 451 10 Ioannina, Greece;
| | - Dimitrios Flevas
- Arthroscopy & Orthopaedic Surgery Department, Metropolitan Hospital, Neo Faliro, 185 47 Pireas, Greece;
| | - Spyridon E. Tsirigkakis
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Dimitrios Kosmas
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Ioannis Kostas-Agnantis
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Emilios Pakos
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Ioannis Gelalis
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Anastasios Korompilias
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
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9
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Beom JY, Low W, Park KS, Yoon TR, Lee CY, Song H. Surgical Resection of Neurogenic Heterotopic Ossification around Hip Joint in Stroke Patients: A Safety and Outcome Report. Hip Pelvis 2023; 35:268-276. [PMID: 38125274 PMCID: PMC10728050 DOI: 10.5371/hp.2023.35.4.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 12/23/2023] Open
Abstract
Purpose Resection remains the most reliable treatment for established heterotopic ossification, despite questions regarding its effectiveness due to the potential for complications. This study evaluated the clinical outcomes and complications of neurogenic heterotopic ossification (NHO) resection in stroke patients' ankylosed hips. Materials and Methods We retrospectively analyzed nine hip NHO resections performed on seven patients from 2010 to 2018. The pre- and postoperative range of motion of the operated hip were compared. Analysis of postoperative complications, including infection, recurrence, iatrogenic fracture, and neurovascular injury was performed. Results The mean operative time was 132.78±21.08 minutes, with a mean hemoglobin drop of 3.06±0.82 g/dL within the first postoperative week. The mean duration of postoperative follow-up was 52.08±28.72 months for all patients. Postoperative range of motion showed improvement from preoperative. Flexion and external rotation (mean, 58.89±30.60° and 16.67±18.03°, respectively) showed the greatest gain of motion of the operated hip joint. Postoperative infections resolved in two cases through surgical debridement, and one case required conversion to total hip arthroplasty due to instability. There were no recurrences, iatrogenic fractures, or neurovascular injuries. Conclusion Resection is a beneficial intervention for restoring the functional range of motion of the hip in order to improve the quality of life for patients with NHO and neurological disorders. We recommend performance of a minimal resection to achieve a targeted functional arc of motion in order to minimize the risk of postoperative complications.
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Affiliation(s)
- Jae-Young Beom
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - WengKong Low
- Orthopaedic and Traumatology Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Kyung-Soon Park
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Taek-Rim Yoon
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Chan Young Lee
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Hyeongmin Song
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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10
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Schneider J, Maffulli N, Eschweiler J, Bell A, Hildebrand F, Migliorini F. Efficacy of ibuprofen and indomethacin as prophylaxis of heterotopic ossification: a comparative study. Sci Rep 2023; 13:20210. [PMID: 37980449 PMCID: PMC10657366 DOI: 10.1038/s41598-023-47508-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/14/2023] [Indexed: 11/20/2023] Open
Abstract
The prophylactic action of non-steroidal anti-inflammatory drugs (NSAIDs) in heterotopic ossification (HO) was first described following analgesic therapy with indomethacin. Following that evidence, several compounds have been successfully used for prophylaxes of HO. Ibuprofen has been also proposed for the prevention of HO following THA. The present study compared the administration of ibuprofen for three weeks versus indomethacin as prophylaxis for HO following primary THA. In all THA procedures, pre- and post-operative protocols were conducted in a highly standardized fashion. The type of HO prophylaxis (indomethacin 100 mg/daily or ibuprofen 100 mg/daily) was chosen according to a chronological criterion: from 2017 to 2019 indomethacin was used, whereas from 2019 to 2022 ibuprofen was administered. In case of allergy or intolerance to NSAIDs, no prophylaxis was performed, and patients were included as a control group. All patients who underwent an anteroposterior radiography of the pelvis at a minimum of 12 months following THA were considered for inclusion. On admission, the age and sex of the patients were recorded. Moreover, the causes of osteoarthritis and the date of surgery were recorded. The grade of HO was assigned by a blinded assessor who was not involved in the clinical management of the patients. The modified Brooker Staging System was used to rate the efficacy of the interventions. Data from 1248 patients were collected. 62% (767 of 1248 patients) were women. The mean age was 67.0 ± 2.9 years. The mean follow-up was 21.1 ± 10.8 months. In the ibuprofen group, 73% of patients evidenced Brooker 0, 17% Brooker I, and 10% Brooker II. In the indomethacin group, 77% of patients evidenced Brooker 0, 16% Brooker I, 6% Brooker II. No patient in the ibuprofen and indomethacin group developed Brooker III or IV. In the control group, 64% of patients evidenced Brooker 0, 21% Brooker I, 3% Brooker II, and 12% Brooker III. No patient in the control group developed Brooker IV HO. Concluding, three weeks of administration of ibuprofen demonstrated similar efficacy to indomethacin in preventing HO following primary THA. The prophylaxis with ibuprofen or indomethacin was more effective in preventing HO compared to a control group who did not receive any pharmacological prophylaxis.
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Affiliation(s)
- Jens Schneider
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Nicola Maffulli
- Department of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
- Faculty of Medicine, School of Pharmacy and Bioengineering, Keele University, Stoke on Trent, ST4 7QB, UK
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK
| | - Jörg Eschweiler
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
| | - Andreas Bell
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Frank Hildebrand
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, 39100, Bolzano, Italy.
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11
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Badi HA, Tanzer M, Nooh A, Hall B, Hart A. A Short Course of Celecoxib Prevents Heterotopic Ossification Following Cementless Total Hip Arthroplasty. Life (Basel) 2023; 13:life13040944. [PMID: 37109473 PMCID: PMC10142707 DOI: 10.3390/life13040944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/19/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Heterotopic ossification (HO) is a common complication after total hip arthroplasty (THA) and can result in pain and loss of motion of the hip. This is the first study in the literature to determine if a short course of Celecoxib is effective in the prevention of HO in patients undergoing cementless THA. In this retrospective study of prospectively collected data, consecutive patients undergoing a primary cementless THA were reviewed at a 2-year follow-up. The Control group consisted of 104 hips that did not receive Celecoxib (Control group), while the 208 hips in the Celecoxib group received 100 mg twice daily for 10 days. Radiographs, patient-recorded outcome measures and range of motion (ROM) were evaluated. Overall, there was a significantly decreased incidence of HO in the Celecoxib group (18.7%) than in the Control group (31.7%) (p = 0.01). The odds that a patient developed HO using Celecoxib were 0.4965 times the odds that a patient developed HO without treatment. Clinically, the Celecoxib group demonstrated significantly greater improvement in their mean WOMAC stiffness (0.35 vs. 0.17, p = 0.02) and physical function scores (3.26 vs. 1.83, p = 0.03) compared to those in the Control group, but there was no difference in the ROM between the two groups. This study is the first to demonstrate that the lowest dose of Celecoxib for a short course of only 10 days is a simple and effective prophylactic treatment option that can significantly reduce the incidence of HO following cementless THA.
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Affiliation(s)
- Hamid Al Badi
- Jo Miller Orthopaedic Research Laboratory, Division of Orthopaedic Surgery, McGill University, Montreal, QC H3G 1A4, Canada
| | - Michael Tanzer
- Jo Miller Orthopaedic Research Laboratory, Division of Orthopaedic Surgery, McGill University, Montreal, QC H3G 1A4, Canada
| | - Anas Nooh
- Jo Miller Orthopaedic Research Laboratory, Division of Orthopaedic Surgery, McGill University, Montreal, QC H3G 1A4, Canada
| | - Brandon Hall
- Jo Miller Orthopaedic Research Laboratory, Division of Orthopaedic Surgery, McGill University, Montreal, QC H3G 1A4, Canada
| | - Adam Hart
- Jo Miller Orthopaedic Research Laboratory, Division of Orthopaedic Surgery, McGill University, Montreal, QC H3G 1A4, Canada
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12
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Idiopathic Spontaneous Occurrence of Heterotrophic Occurrence During Pregnancy. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202301000-00009. [PMID: 36701241 PMCID: PMC9851693 DOI: 10.5435/jaaosglobal-d-22-00204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/23/2022] [Indexed: 01/27/2023]
Abstract
Heterotopic ossification (HO) typically presents in the hip, knee, and elbow joints in the setting of trauma or postsurgical intervention. Less commonly, it may occur secondary to neurologic dysfunction or underlying genetic conditions, but idiopathic HO is rare. Most cases of HO are managed nonoperatively with surgical resection remaining a controversy due to high recurrence rates. We describe a case of idiopathic HO of the shoulder that occurred in the absence of trauma, neurologic dysfunction, or underlying genetic disorder that was treated with surgical excision.
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13
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Mohamed R, Iqbal A, Elawadi AA. Fifteen years’ experience of radiation therapy for resected advanced heterotopic ossification following motor vehicle accidents: outcome and side effects. J Egypt Natl Canc Inst 2022; 34:48. [DOI: 10.1186/s43046-022-00149-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 08/27/2022] [Indexed: 11/22/2022] Open
Abstract
Abstract
Background
Surgical resection is the primary treatment for advanced-stage heterotopic ossification (HO), with a high incidence of local recurrence reaching up to 50%. Postoperative radiotherapy (PORT) and indomethacin are commonly used prophylactic strategies following surgery. The study aims to assess the safety and effectiveness of PORT in advanced-stage HO patients having motor vehicle accidents (MVA).
Methods
Medical records of patients having HO following MVA between 2006 and 2021 were retrospectively reviewed. Thirty-nine patients with advanced disease (35 had hip HO and 4 had elbow HO) were included in the study.
Results
Excision of HO with joint preservation was performed for 82% of patients, while 18% had a joint replacement. Seven to 8 Gy radiation was given to all patients within 3 days postoperatively. A ninty seven percent of patients regained partially the movement range. The mean follow-up time was 74 months. Six patients had treatment failure, with only one having a recurrence of HO. The 8-year treatment failure-free rate (8-y TFFR) was 79.3±9%, and the 5-year HO failure-free rate (5y-HOFFR) was 97.2±3%. Acute side effects were experienced in 13% of patients but resolved without any consequences. Despite the relatively long follow-up time, we did not report any absolute infertility or secondary malignancies related to the radiation. The testicular mean calculated dose was 33±44 cGy, and the mean measured dose was 58±40 cGy. Of the 35 patients who received radiation to the pelvis, 26 were married, and all did not experience infertility post-treatment.
Conclusion
PORT proved an effective and safe treatment for advanced-stage HO disease. The treatment failure is mainly related to surgical difficulties due to advanced disease. Treatment using a 3-dimensional or intensity-modulated radiation therapy is not associated with serious side effects like second malignancy or absolute infertility.
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14
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Zorn D, Lombardo J, Poiset S, Gutman M, Cappelli L, Hurwitz M, Ankam N. Single-Dose Radiation Therapy Without Additional Surgery as a Treatment for Heterotopic Ossification Developing After Transfemoral Amputation. Am J Phys Med Rehabil 2022; 101:e158-e161. [PMID: 35930773 DOI: 10.1097/phm.0000000000002075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Heterotopic ossification is the development of mature lamellar bone in soft tissues. Heterotopic ossification can occur in up to 23% of patients after amputation. Heterotopic ossification is often painful, causing significant dysfunction. While radiotherapy is used to prevent heterotopic ossification before formation, there is a dearth of literature on using radiotherapy to treat existing heterotopic ossification. This case report describes the use of late radiotherapy for the management of existing heterotopic ossification that developed after a transfemoral amputation. A 61-yr-old woman with peripheral artery disease of her bilateral lower limbs status post stenting and ultimately left transfemoral amputation was diagnosed with symptomatic heterotopic ossification limiting her function. Another surgery was not felt to be warranted. She was not improving with medical therapy and was prescribed 800 cGy in one fraction. After treatment, she experienced significant relief in her pain, allowing her to resume physical therapy and use of her prosthesis. There are no other published examples of using radiation alone for treatment of heterotopic ossification formation after transfemoral amputation without surgical revision of the bone formation. Our case shows possible utility in single-dose radiation as a treatment to prevent progression of heterotopic ossification, especially when limiting functional progress.
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Affiliation(s)
- Devon Zorn
- From the Department of Rehabilitation Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (DZ, NA); and Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (JL, SP, MG, LC, MH)
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15
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Bahmad HF, Lopez O, Sutherland T, Vinas M, Ben-David K, Howard L, Poppiti R, Alghamdi S. Heterotopic mesenteric ossification: a report of two cases. J Pathol Transl Med 2022; 56:294-300. [PMID: 36128866 PMCID: PMC9510041 DOI: 10.4132/jptm.2022.07.23] [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: 06/24/2022] [Accepted: 07/23/2022] [Indexed: 11/17/2022] Open
Abstract
Heterotopic mesenteric ossification (HMO) is abnormal bone formation in tissues which usually do not undergo ossification. There are approximately 75 cases reported worldwide. We present two cases of HMO. The first case is that of a 39-year-old man who presented with abdominal pain and a computerized tomography scan of the abdomen and pelvis revealed an apple core lesion resulting in small bowel obstruction. The second case is that of a 36-year-old woman who presented 2 months after undergoing robotic gastric sleeve resection complaining of weakness and emesis. An esophagogram revealed kinking at the distal esophagus. Surgical resection was performed in both, yielding the diagnosis of HMO. There are various theories as to the pathophysiology of HMO, but no clearly defined mechanism has been established. Management should be conservative whenever possible to prevent further ossification with subsequent surgical intervention.
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Affiliation(s)
- Hisham F. Bahmad
- Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami Beach, FL,
USA
| | - Olga Lopez
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL,
USA
| | - Tyson Sutherland
- Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami Beach, FL,
USA
| | - Marisa Vinas
- Department of General Surgery, Mount Sinai Medical Center, Miami Beach, FL,
USA
| | - Kfir Ben-David
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL,
USA
- Department of General Surgery, Mount Sinai Medical Center, Miami Beach, FL,
USA
| | - Lydia Howard
- Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami Beach, FL,
USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL,
USA
| | - Robert Poppiti
- Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami Beach, FL,
USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL,
USA
| | - Sarah Alghamdi
- Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami Beach, FL,
USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL,
USA
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16
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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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17
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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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18
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IL-6 is involved in thoracic ossification of the ligamentum flavum. PLoS One 2022; 17:e0272357. [PMID: 35905126 PMCID: PMC9337630 DOI: 10.1371/journal.pone.0272357] [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: 05/24/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022] Open
Abstract
Thoracic ossification of the ligamentum flavum (TOLF) is a heterotopic ossification of spinal ligaments. TOLF is the major cause of thoracic spinal canal stenosis and myelopathy, and its underlying mechanisms are not clear. Bone formation is a complex developmental process involving the differentiation of mesenchymal stem cells to osteoblasts, and regulated by BMP2, RUNX2, Osterix (OSX), etc. In this study, we continue to further characterize properties of TOLF. Our immunohistochemistry experiments showed that expressions of osteoblastic factors such as BMP2 and RUNX2 increased in TOLF. According to flow cytometry analysis the proportion of S phase of cell cycle in primary TOLF cells was 9% higher than the control. Alizarin red staining and ALP staining observations were consistent with immunohistochemistry results. It was also observed that inflammatory cytokine IL-6 level dramatically increased in the culture supernatant of primary TOLF cells. We propose the hypothesis that IL-6 is involved in TOLF. To testify the hypothesis, we examined the effect of IL-6. Our results showed that IL-6 was able to activate expressions of osteoblastic factors such as BMP2, RUNX2, OSX, OCN and ALP, and that expressions of cell proliferation factors cyclin D1 and cyclin C increased in the presence of IL-6. Moreover, IL-6-induced BMP2 expression was inhibited by p38 inhibitor SB203580, indicating that IL-6 regulated the osteogenic BMP2 activation through p38 MAPK pathway. These data suggest that IL-6 is involved in TOLF.
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19
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Hwang CD, Pagani CA, Nunez JH, Cherief M, Qin Q, Gomez-Salazar M, Kadaikal B, Kang H, Chowdary AR, Patel N, James AW, Levi B. Contemporary perspectives on heterotopic ossification. JCI Insight 2022; 7:158996. [PMID: 35866484 PMCID: PMC9431693 DOI: 10.1172/jci.insight.158996] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Heterotopic ossification (HO) is the formation of ectopic bone that is primarily genetically driven (fibrodysplasia ossificans progressiva [FOP]) or acquired in the setting of trauma (tHO). HO has undergone intense investigation, especially over the last 50 years, as awareness has increased around improving clinical technologies and incidence, such as with ongoing wartime conflicts. Current treatments for tHO and FOP remain prophylactic and include NSAIDs and glucocorticoids, respectively, whereas other proposed therapeutic modalities exhibit prohibitive risk profiles. Contemporary studies have elucidated mechanisms behind tHO and FOP and have described new distinct niches independent of inflammation that regulate ectopic bone formation. These investigations have propagated a paradigm shift in the approach to treatment and management of a historically difficult surgical problem, with ongoing clinical trials and promising new targets.
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Affiliation(s)
- Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Chase A Pagani
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Johanna H Nunez
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Masnsen Cherief
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qizhi Qin
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Balram Kadaikal
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Heeseog Kang
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ashish R Chowdary
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron W James
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benjamin Levi
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Pathophysiology and Emerging Molecular Therapeutic Targets in Heterotopic Ossification. Int J Mol Sci 2022; 23:ijms23136983. [PMID: 35805978 PMCID: PMC9266941 DOI: 10.3390/ijms23136983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 12/23/2022] Open
Abstract
The term heterotopic ossification (HO) describes bone formation in tissues where bone is normally not present. Musculoskeletal trauma induces signalling events that in turn trigger cells, probably of mesenchymal origin, to differentiate into bone. The aetiology of HO includes extremely rare but severe, generalised and fatal monogenic forms of the disease; and as a common complex disorder in response to musculoskeletal, neurological or burn trauma. The resulting bone forms through a combination of endochondral and intramembranous ossification, depending on the aetiology, initiating stimulus and affected tissue. Given the heterogeneity of the disease, many cell types and biological pathways have been studied in efforts to find effective therapeutic strategies for the disorder. Cells of mesenchymal, haematopoietic and neuroectodermal lineages have all been implicated in the pathogenesis of HO, and the emerging dominant signalling pathways are thought to occur through the bone morphogenetic proteins (BMP), mammalian target of rapamycin (mTOR), and retinoic acid receptor pathways. Increased understanding of these disease mechanisms has resulted in the emergence of several novel investigational therapeutic avenues, including palovarotene and other retinoic acid receptor agonists and activin A inhibitors that target both canonical and non-canonical signalling downstream of the BMP type 1 receptor. In this article we aim to illustrate the key cellular and molecular mechanisms involved in the pathogenesis of HO and outline recent advances in emerging molecular therapies to treat and prevent HO that have had early success in the monogenic disease and are currently being explored in the common complex forms of HO.
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Bohner M, Maazouz Y, Ginebra MP, Habibovic P, Schoenecker JG, Seeherman H, van den Beucken JJ, Witte F. Sustained local ionic homeostatic imbalance caused by calcification modulates inflammation to trigger heterotopic ossification. Acta Biomater 2022; 145:1-24. [PMID: 35398267 DOI: 10.1016/j.actbio.2022.03.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
Abstract
Heterotopic ossification (HO) is a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues. Despite being a frequent complication of orthopedic and trauma surgery, brain and spinal injury, the etiology of HO is poorly understood. The aim of this study is to evaluate the hypothesis that a sustained local ionic homeostatic imbalance (SLIHI) created by mineral formation during tissue calcification modulates inflammation to trigger HO. This evaluation also considers the role SLIHI could play for the design of cell-free, drug-free osteoinductive bone graft substitutes. The evaluation contains five main sections. The first section defines relevant concepts in the context of HO and provides a summary of proposed causes of HO. The second section starts with a detailed analysis of the occurrence and involvement of calcification in HO. It is followed by an explanation of the causes of calcification and its consequences. This allows to speculate on the potential chemical modulators of inflammation and triggers of HO. The end of this second section is devoted to in vitro mineralization tests used to predict the ectopic potential of materials. The third section reviews the biological cascade of events occurring during pathological and material-induced HO, and attempts to propose a quantitative timeline of HO formation. The fourth section looks at potential ways to control HO formation, either acting on SLIHI or on inflammation. Chemical, physical, and drug-based approaches are considered. Finally, the evaluation finishes with a critical assessment of the definition of osteoinduction. STATEMENT OF SIGNIFICANCE: The ability to regenerate bone in a spatially controlled and reproducible manner is an essential prerequisite for the treatment of large bone defects. As such, understanding the mechanism leading to heterotopic ossification (HO), a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues, would be very useful. Unfortunately, the mechanism(s) behind HO is(are) poorly understood. The present study reviews the literature on HO and based on it, proposes that HO can be caused by a combination of inflammation and calcification. This mechanism helps to better understand current strategies to prevent and treat HO. It also shows new opportunities to improve the treatment of bone defects in orthopedic and dental procedures.
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Heterotopic Ossification in Patients with Burns: a Systematic Literature Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2022. [DOI: 10.1007/s40141-022-00356-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Wei Z, Guo S, Wang H, Zhao Y, Yan J, Zhang C, Zhong B. Comparative proteomic analysis identifies differentially expressed proteins and reveals potential mechanisms of traumatic heterotopic ossification progression. J Orthop Translat 2022; 34:42-59. [PMID: 35615641 PMCID: PMC9117278 DOI: 10.1016/j.jot.2022.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/10/2022] [Accepted: 04/20/2022] [Indexed: 01/09/2023] Open
Abstract
Background Traumatic Heterotopic Ossification (tHO) is one of complications of elbow fractures to the detriment of patients' rehabilitation, and the severity of tHO corresponds to the size of ectopic bone. It has yet to be elucidated which proteins and pathways underlying the progression of tHO, and biomarkers to predict the severity of tHO at early stage of the disease also need further investigation. Methods In this study, a new rat model with distinct volume of ectopic bone was established first. Then a data-independent acquisition proteomics approach was used to investigate injured site tissues sequentially obtained from these rats (2, 7, 14, and 28 days post-injury). Differentially expressed analysis, functional annotation and co-expression analysis and protein-protein interaction network were performed to explore the pathways and hub proteins in the tHO progression. Clinical samples from a nest case-control study were used to validate the selected proteins for predicting the severity of tHO. Results The Achilles Tenotomy (AT) induced significantly larger sizes of ectopic bone compared to Partial Achilles Tenotomy (PAT) in rat models. A total of 3547 quantifiable proteins were screened for differential expression analysis among the AT, PAT and control groups. The hierarchical clustering and expression pattern analysis revealed more apparent difference in the pathways such as oxidative phosphorylation, mitochondrial function, and sirtuin signaling between AT and PAT group at the early stage (2 dpi) of tHO. The co-expression analysis identified five hub proteins, UBA1, EIF3E, RPL17, RPL27, and RPS28. qPCR assay, immunoblot assay and immunohistochemistry assay verified that these proteins had higher expression level in the tissue samples of clinically relevant HO patients and clinically irrelevant HO patients than HO negative patients. Conclusion The new established animal model and proteome profile could serve as a solid foundation for the comprehensive investigation of the progression of traumatic heterotopic ossification. And the identified 5 proteins (UBA1, EIF3E, RPL17, RPL27, and RPS28) may serve as potential biomarkers to predict the severity of tHO. The translational potential of this article The proteins identified in this study may be the potential biomarkers and therapeutic targets for predicting and treating the tHO at early stage.
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Affiliation(s)
- Zhenyuan Wei
- Department of Orthopedic Surgery, And Shanghai Institute of Microsurgery on Extremities, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Shang Guo
- Department of Orthopedic Surgery, And Shanghai Institute of Microsurgery on Extremities, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Hongwei Wang
- Department of Medicine, the University of Chicago. Chicago, IL 60637, USA
| | - Yang Zhao
- Department of Orthopedic Surgery, And Shanghai Institute of Microsurgery on Extremities, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Jiren Yan
- Department of Orthopedic Surgery, And Shanghai Institute of Microsurgery on Extremities, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Chi Zhang
- Department of Orthopedic Surgery, And Shanghai Institute of Microsurgery on Extremities, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China,Corresponding author.
| | - Biao Zhong
- Department of Orthopedic Surgery, And Shanghai Institute of Microsurgery on Extremities, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China,Corresponding author.
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Benkhaled S, Gomes da Silveira Cauduro C, Alexiou J, Jayankura M, Van Gestel D. Heterotopic ossification and severe COVID-19 infection. QJM 2022; 115:201-203. [PMID: 35188216 DOI: 10.1093/qjmed/hcac055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/16/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- S Benkhaled
- Department of Radiation-Oncology, Institut Jules Bordet-Université Libre de Bruxelles, Rue Meylemeersch 90, 1070 Brussels, Belgium
| | - C Gomes da Silveira Cauduro
- Department of Radiation-Oncology, Institut Jules Bordet-Université Libre de Bruxelles, Rue Meylemeersch 90, 1070 Brussels, Belgium
| | - J Alexiou
- Department of Radiology, Institut Jules Bordet-Université Libre de Bruxelles, Rue Meylemeersch 90, 1070 Brussels, Belgium
| | - M Jayankura
- Department of Orthopedic Surgery, Erasme Hospital-Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium. Instead of the Rue Meylemeersh 90, 1070 Brussels, Belgium
| | - D Van Gestel
- Department of Radiation-Oncology, Institut Jules Bordet-Université Libre de Bruxelles, Rue Meylemeersch 90, 1070 Brussels, Belgium
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Haffer H, Müller M, Ascherl R, Perka C, Winkler T. Diclofenac for prophylaxis of heterotopic ossification after hip arthroplasty: a systematic review. Hip Int 2022; 32:144-151. [PMID: 33272062 DOI: 10.1177/1120700020978194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is defined as the formation of lamellar bone in extraskeletal soft tissues. HO can be a severe complication after hip arthroplasty but can possibly be prevented by postoperative treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or radiotherapy. Diclofenac is 1 of the most used drugs in HO prophylaxis because it is effective and long established. However, there is still no uniform therapy regimen in terms of duration, dose and side effect profile regarding the application of diclofenac in HO prevention. We have, therefore, conducted the first systematic review investigating diclofenac for HO prophylaxis after hip arthroplasty. The aim of this study is to assess the efficacy, dose and duration of diclofenac therapy in preventing HO after total hip arthroplasty (THA). METHODS According to the PRISMA Guidelines we performed a systematic literature search in EMBASE via Ovid, in MEDLINE via PubMed and in the Cochrane Library addressing all studies in English and German regarding the prophylaxis of HO with diclofenac after THA. We identified 731 potential studies and included 6 randomised controlled trials with 957 patients. RESULTS The studies were heterogeneous with regard to duration of therapy, dose, comparative group and follow-up period. The therapy duration ranged from 9 to 42 days, the applied diclofenac doses ranged from 75 mg to 150 mg daily. Patients treated with diclofenac showed a significant reduction in the total incidence of HO regarding to the Brooker Classification compared to placebo and no clinically relevant ossifications occured (Brooker III and IV). CONCLUSIONS Diclofenac is efficacious in the prevention of HO and can be used routinely after THA. The existing data indicates that a minimum dose of 75 mg diclofenac per day started on the first postoperative day for a minimum of 9 days is needed to prevent HO with an acceptable incidence of side effects, such as gastrointestinal symptoms.
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Affiliation(s)
- Henryk Haffer
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Germany
| | - Michael Müller
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Germany
| | - Rudolf Ascherl
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Germany
| | - Tobias Winkler
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Germany.,BIH Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Germany.,Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Germany
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Low-dose Preoperative Unshielded Radiation Is Effective in Heterotopic Ossification Prophylaxis and Does Not Affect Porous Fixation in Total Hip Arthroplasty at 2 Years Minimum Follow-up: A Radiographic Study. J Am Acad Orthop Surg 2022; 30:223-228. [PMID: 35133992 DOI: 10.5435/jaaos-d-21-00113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 12/21/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Heterotopic ossification (HO) is a frequent complication of total hip arthroplasty (THA). HO can cause pain, limitation of range of motion, and instability. Radiation therapy (RT) for HO prophylaxis is well established but may interfere with early porous ingrowth and pullout strength of implants, as suggested by two animal studies. Although shielding of the bone from irradiation may theoretically protect ingrowth, it has been found to reduce RT effectiveness. Despite the popularity of porous implants in THA, the frequency of HO, and use of RT in its prophylaxis, the effect of RT on porous implant fixation in THA has not been previously reported. At our institution, we use unshielded, single-dose, preoperative 700 to 800 centigrays RT for HO prophylaxis in high-risk patients. We hypothesize that this RT protocol is effective and the press-fit technique protects porous implants during early ingrowth; therefore, long-term implant fixation is not compromised. METHODS This was a retrospective study aiming to determine fixation of porous THA implants, healing of trochanteric osteotomies, and efficacy of HO prophylaxis with this RT protocol. RESULTS Thirty-nine patients with follow-up of 24 to 144 months (average 59.7 months) were included. All 26 porous-coated femoral implants (11 revisions and 15 primary) were well fixed. There were 33 porous-coated acetabular implants (18 revisions and 15 primary). Thirty (91%) were well fixed, and three revision implants (9%) demonstrated radiolucent lines in two zones, but patients were clinically asymptomatic. All nine trochanteric osteotomies healed uneventfully. RT provided effective HO prophylaxis in 33 of 39 hips (85%). CONCLUSIONS Single, low-dose, preoperative RT without shielding does not increase aseptic loosening of porous implants manufactured with plasma porous spray or nonunion of extended trochanteric osteotomies. This protocol provides effective HO prophylaxis in high-risk patients undergoing primary and revision THA.
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Xu Y, Huang M, He W, He C, Chen K, Hou J, Huang M, Jiao Y, Liu R, Zou N, Liu L, Li C. Heterotopic Ossification: Clinical Features, Basic Researches, and Mechanical Stimulations. Front Cell Dev Biol 2022; 10:770931. [PMID: 35145964 PMCID: PMC8824234 DOI: 10.3389/fcell.2022.770931] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 01/03/2022] [Indexed: 12/13/2022] Open
Abstract
Heterotopic ossification (HO) is defined as the occurrence of extraskeletal bone in soft tissue. Although this pathological osteogenesis process involves the participation of osteoblasts and osteoclasts during the formation of bone structures, it differs from normal physiological osteogenesis in many features. In this article, the primary characteristics of heterotopic ossification are reviewed from both clinical and basic research perspectives, with a special highlight on the influence of mechanics on heterotopic ossification, which serves an important role in the prophylaxis and treatment of HO.
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Affiliation(s)
- Yili Xu
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Mei Huang
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Wenzhen He
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Chen He
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Kaixuan Chen
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Jing Hou
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Min Huang
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Yurui Jiao
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Ran Liu
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Nanyu Zou
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Ling Liu
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China
| | - Changjun Li
- Department of Endocrinology, Endocrinology Research Center, The Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, China.,Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, China
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Ramot Y, Rousselle S, Steiner M, Lavie Y, Ezov N, Nyska A. Safety and Performance Evaluation of Su2ura Approximation, a New Suturing Device, in Pigs. Toxicol Pathol 2021; 50:211-217. [DOI: 10.1177/01926233211067960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
One of the challenging aspects of minimal invasive surgery (MIS) is intracorporal suturing, which can be significantly time-consuming. Therefore, there is a rising need for devices that can facilitate the suturing procedure in MIS. Su2ura Approximation Device (Su2ura Approximation) is a novel device developed to utilize the insertion of anchors threaded with stitches to allow a single action placement of a suture. The objective of this study was to evaluate the long-term safety and tissue approximation of Su2ura Approximation in comparison to Endo Stitch + Surgidac sutures in female domestic pigs. All incision sites were successfully closed by both methods. Firm consolidation within and around the incision site was noted in several animals in both treatment groups, which corresponded histopathologically to islands of ectopic cartilage or bone spicules within the fibrotic scar. These changes reflect heterotopic ossification that is commonly seen in the healing of abdominal operation sites in pigs. No other abnormal findings were observed throughout the study period. In conclusion, the use of Su2ura Approximation under the present experimental conditions revealed no safety concerns.
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Affiliation(s)
- Yuval Ramot
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Dermatology, Hadassah Medical Center, Jerusalem, Israel
| | | | | | | | - Nati Ezov
- Envigo CRS (Israel), Ness Ziona, Israel
| | - Abraham Nyska
- Toxicologic Pathology, Tel Aviv and Tel Aviv University, Tel Aviv, Israel
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Yim CR, Uhrich RM, Perez L. Treatment of Temporomandibular Joint Heterotopic Ossificans: A Novel Protocol With Multimodal Therapy Based on Literature Review and Presentation of a Unique Case Reportc. J Oral Maxillofac Surg 2021; 80:869-888. [PMID: 35032438 DOI: 10.1016/j.joms.2021.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this study was to create a treatment protocol for cases of heterotopic ossification (HO) of the temporomandibular joint (TMJ), particularly those refractory to current TMJ HO protocols. In addition, we demonstrate the success of this protocol on a unique case of recurrent HO that failed multiple TMJ HO protocols in the setting of an improvised explosive device (IED) blast in a wounded warrior. METHODS An electronic literature review was conducted via PubMed and Web of Science. Twenty-five studies were identified to provide supporting evidence for a proposed, up-to-date protocol for the treatment of refractory TMJ HO. The authors present a case report of a wounded warrior with HO ankylosis of bilateral TMJs in the setting of IED blast and demonstrate successful use of our surgical and pharmacotherapeutic protocol. RESULTS Based on the literature review, our proposed protocol consists of pharmacotherapy with celecoxib and etidronate, with weekly forced dilation (brisement) and home physical therapy with the TheraBite Jaw Motion Rehab System. Surgically, the TMJ should be treated with two-stage reconstruction using initial polymethyl methacrylate spacers and subsequent total joint reconstruction with custom prostheses, fat grafting, and 3-dimensional-navigated total resection of HO. This protocol was successfully utilized in our patient's refractory HO ankylosed TMJ secondary to IED blast, and the patient's maximal incisal opening was regained and has remained stable 2 years after surgery without recurrent HO. CONCLUSIONS Our method for treatment in this case deviated from the standard TMJ Concepts HO protocol in that it included multimodal pharmacotherapy with celecoxib and etidronate. Based on our literature review and experience, we advise that clinicians utilize our protocol for the management of all craniofacial HO cases, particularly in cases of recurrent HO that fail conventional therapies and/or involving high-order blast trauma.
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Affiliation(s)
- Changmin Richard Yim
- Attending Surgeon, Department Oral & Maxillofacial Surgery, Walter Reed National Military Medical Center.
| | - Ross M Uhrich
- Attending Surgeon, Department Oral & Maxillofacial Surgery, Walter Reed National Military Medical Center & Washington Navy Yard Branch Health Clinic
| | - Leonel Perez
- Program Director and Attending Surgeon, Department of Oral & Maxillofacial Surgery, Walter Reed National Military Medical Center
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Mansur H, Bisol RL, Maranho DA. Ossificação heterotópica após luxação pediátrica do cotovelo: Um relato de caso. Rev Bras Ortop 2021. [DOI: 10.1055/s-0041-1739403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ResumoA luxação do cotovelo é relativamente incomum em crianças, sendo que a maioria dos casos ocorre com fraturas associadas. A luxação isolada do cotovelo é relativamente rara, podendo implicar em uma maior probabilidade de lesões graves dos tecidos moles. Uma possível complicação é o desenvolvimento da ossificação heterotópica, que geralmente é assintomática, mas pode alterar o movimento articular. Descrevemos o caso de uma menina de 11 anos que sofreu luxação do cotovelo sem fraturas associadas, mas com ruptura parcial distal do músculo braquial. Após a redução fechada, a paciente desenvolveu ossificação heterotópica no terço distal anterior do úmero, com perda da amplitude do movimento articular do cotovelo. O tratamento cirúrgico, com excisão da ossificação heterotópica, por meio de uma abordagem lateral direta, proporcionou um excelente resultado. A ossificação heterotópica é uma possível complicação após luxação do cotovelo em crianças, sendo que a excisão cirúrgica mediante uma abordagem lateral é sempre uma opção de tratamento quando há limitação funcional. Antes de ser tomada a decisão cirúrgica, a maturação do processo de ossificação deve ser observada.
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Affiliation(s)
- Henrique Mansur
- Departamento de Ortopedia e Traumatologia, Hospital Santa Helena – Rede D'or e Hospital Regional do Gama, Distrito Federal, Brasil
| | - Roberto Luiz Bisol
- Departamento de Ortopedia e Traumatologia, Rede Santa, Brasília, DF, Brasil
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Peters N, Baltin CT, Barham M, Wevers A. An unusual finding: Heterotopic ossification located in the subcutis of the iliac region – A case report in the context of current literature. TRANSLATIONAL RESEARCH IN ANATOMY 2021. [DOI: 10.1016/j.tria.2021.100137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Schaver AL, Willey MC, Westermann RW. Incidence of Heterotopic Ossification with NSAID Prophylaxis Is Low After Open and Arthroscopic Hip Preservation Surgery. Arthrosc Sports Med Rehabil 2021; 3:e1309-e1314. [PMID: 34712968 PMCID: PMC8527257 DOI: 10.1016/j.asmr.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 06/07/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose We evaluate the incidence of heterotopic ossification (HO) development with nonsteroidal anti-inflammatory drug (NSAID) prophylaxis in patients after open and arthroscopic hip preservation surgery. Methods A retrospective review identified patients who underwent hip preservation surgery at a single institution within the past 3 years. Patients who underwent hip arthroscopy with or without periacetabular osteotomy (PAO) or femoral osteotomy (FO) were included. Those who did not receive 3-month postoperative radiographs were excluded. The incidence and Brooker classification (BC) of HO in patients taking Naproxen or another NSAID (meloxicam, celecoxib, indomethacin, or aspirin alone) was assessed using AP radiographs available from 3-, 6-, and 12-month follow-up appointments. Univariate analysis was conducted to compare numerical means and categorical data (significance level P = .05). Results A total of 328 hips (284 patients) were included. All patients received hip arthroscopy, while 71 patients (21.6%) received concurrent periacetabular osteotomy (PAO; n = 65) or femoral osteotomy (FO; n = 6). Overall, 276 hips (84.4%) received Naproxen for HO prophylaxis. In total, 5 of 328 hips (1.5%) developed HO (4, BC I; 1, BC III). The rate of HO development was significantly higher in males versus females (4 of 121 (3.31%) vs 1 of 207 (.48%), P = .0441). All 5 patients received arthroscopic cam resection and labral repair, and 1 patient also received PAO. Three patients in the Naproxen group (.91%) developed HO, which was not statistically different from those taking a different NSAID (.61%, P = .1797). Conclusion The incidence of HO development was low with NSAID prophylaxis after hip preservation surgery.
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Affiliation(s)
- Andrew L Schaver
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Michael C Willey
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Robert W Westermann
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
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Epperson RT, Isaacson BM, Rothberg DL, Olsen RE, Kawaguchi B, Maxwell JM, Dickerson M, Pasquina PF, Shero J, Williams DL. Developing a combat-relevant translatable large animal model of heterotopic ossification. Bone Rep 2021; 15:101127. [PMID: 34584904 PMCID: PMC8452791 DOI: 10.1016/j.bonr.2021.101127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/25/2021] [Accepted: 09/04/2021] [Indexed: 11/05/2022] Open
Abstract
Heterotopic ossification (HO) refers to ectopic bone formation, typically in residual limbs following trauma and injury. A review of injuries from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) indicated that approximately 70% of war wounds involved the musculoskeletal system, largely in part from the use of improvised explosive devices (IED) and rocket-propelled grenades (RPG). HO is reported to occur in approximately 63%–65% of wounded warriors from OIF and OEF. Symptomatic HO may delay rehabilitation regimens since it often requires modifications to prosthetic limb componentry and socket size. There is limited evidence indicating a mechanism for preventing HO. This may be due to inadequate models, which do not produce HO bone structure that is morphologically similar to HO samples obtained from wounded warfighters injured in theatre. We hypothesized that using a high-power blast of air (shockwave) and simulated battlefield trauma (i.e. bone damage, tourniquet, bacteria, negative pressure wound therapy) in a large animal model, HO would form and have similar morphology to ectopic bone observed in clinical samples. Initial radiographic and micro-computed tomography (CT) data demonstrated ectopic bone growth in sheep 24 weeks post-procedure. Advanced histological and backscatter electron (BSE) analyses showed that 5 out of 8 (63%) sheep produced HO with similar morphology to clinical samples. We conclude that not all ectopic bone observed by radiograph or micro-CT in animal models is HO. Advanced histological and BSE analyses may improve confirmation of HO presence and morphology, which we demonstrated can be produced in a large animal model.
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Affiliation(s)
- Richard T Epperson
- University of Utah, Bone & Biofilm Research Laboratory, Salt Lake City, UT, United States of America.,University of Utah, Department of Orthopaedics, Salt Lake City, UT, United States of America
| | - Brad M Isaacson
- University of Utah, Department of Orthopaedics, Salt Lake City, UT, United States of America.,The Geneva Foundation, Tacoma, WA, United States of America.,The Center for Rehabilitation Sciences Research, Uniformed Services University, Bethesda, MD, United States of America
| | - David L Rothberg
- University of Utah, Bone & Biofilm Research Laboratory, Salt Lake City, UT, United States of America.,University of Utah, Department of Orthopaedics, Salt Lake City, UT, United States of America
| | - Raymond E Olsen
- University of Utah, Department of Orthopaedics, Salt Lake City, UT, United States of America
| | - Brooke Kawaguchi
- University of Utah, Bone & Biofilm Research Laboratory, Salt Lake City, UT, United States of America.,University of Utah, Department of Orthopaedics, Salt Lake City, UT, United States of America
| | - John M Maxwell
- University of Utah, Bone & Biofilm Research Laboratory, Salt Lake City, UT, United States of America.,University of Utah, Department of Orthopaedics, Salt Lake City, UT, United States of America
| | - Mary Dickerson
- University of Utah, Office of Comparative Medicine, Salt Lake City, UT, United States of America
| | - Paul F Pasquina
- The Center for Rehabilitation Sciences Research, Uniformed Services University, Bethesda, MD, United States of America.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States of America
| | - John Shero
- The Center for Rehabilitation Sciences Research, Uniformed Services University, Bethesda, MD, United States of America.,Extremity Trauma Center of Excellence, Joint Base San Antonio Fort Sam Houston, San Antonio, TX, United States of America
| | - Dustin L Williams
- University of Utah, Bone & Biofilm Research Laboratory, Salt Lake City, UT, United States of America.,University of Utah, Department of Orthopaedics, Salt Lake City, UT, United States of America.,The Center for Rehabilitation Sciences Research, Uniformed Services University, Bethesda, MD, United States of America.,University of Utah, Department of Pathology, Salt Lake City, UT, United States of America.,University of Utah, Department of Bioengineering, Salt Lake City, UT, United States of America
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Neurogenic heterotopic ossification in the upper limb. HAND SURGERY & REHABILITATION 2021; 41S:S167-S174. [PMID: 34536583 DOI: 10.1016/j.hansur.2020.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/15/2020] [Accepted: 09/08/2020] [Indexed: 11/21/2022]
Abstract
Neurogenic heterotopic ossifications (NHOs) are periarticular ectopic ossifications that frequently develop after a central nervous system injury, most often a traumatic one. They limit range of motion and cause pain, interfering with limb positioning and function, whether active or passive. Highly described in the lower limbs, NHOs can also develop in the upper limb, with specific characteristics depending on their location. This article provides a summary of the diagnostic and therapeutic management of NHOs in the upper limb, based on the current literature.
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Jayamaraju D, Sarkar AS, Patra SK, Palanivelayutham SK, Rajasekaran S. A Surgical Protocol for Management of Post Traumatic Heterotopic Ossification of Elbow. Indian J Orthop 2021; 55:898-906. [PMID: 34194645 PMCID: PMC8192647 DOI: 10.1007/s43465-021-00381-x] [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: 07/22/2020] [Accepted: 02/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Open excision remains the gold standard of treatment for posttraumatic heterotopic ossification (HO) of the elbow. The purpose of this study is to evaluate the functional outcome of early surgical excision done by adhering to a proposed surgical protocol with exclusive posttraumatic HO of the elbow. METHODS A retrospective study was conducted with 31 patients (25 males and 6 females) with a mean follow-up of 40.5 ± 27.44 months. Excision was done according to our surgical protocol based on the location of HO, associated fractures, stability, need for ulnar nerve transposition, previous operative scar. Improvement in elbow function, Mayo elbow performance score (MEPS) preoperatively and at final follow-up was compared, and statistical analysis was done. RESULTS Mean flexion-extension arc, supination-pronation arc and MEPS improved by 74.68° ± 29.32°, 26.13° ± 32.93°, 30.48 ± 11.57, respectively. Flexion arc deteriorated by 10.81° ± 10.42° from intraoperative to final follow-up. Improvement at final follow-up was significant in all the cases (P < 0.05). 19 patients had limited HO, and 12 had global HO. Their mean flexion-extension arc increase was 77.63° ± 29.12° and 70° ± 30.3° respectively, and the final mean MEPS score was 96.05 ± 5.16 and 88.75 ± 11.51, respectively. Nine patients had no initial fracture (Group 1), 13 had some fracture (Group 2), nine had a fracture-dislocation of the elbow (Group 3). Their flexion-extension improvement, final MEPS were 88.33° ± 30.82°, 98.33 ± 5, (Group 1); 81.15° ± 16.73°, 92.31 ± 9.27 (Group 2) and 51.67° ± 31.32°, 89.44 ± 9.5 (Group 3), respectively. We had two complications (6.45%). CONCLUSION The surgical protocol described here enabled us to achieve good functional results and was in concordance with similar studies done previously. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00381-x.
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Affiliation(s)
| | - Aniruddha Sinha Sarkar
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals, Coimbatore, India
| | - Sudipta Kumar Patra
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals, Coimbatore, India
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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 PMCID: PMC8426039 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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Kusano T, Nakatani M, Ishiguro N, Ohno K, Yamamoto N, Morita M, Yamada H, Uezumi A, Tsuchida K. Desloratadine inhibits heterotopic ossification by suppression of BMP2-Smad1/5/8 signaling. J Orthop Res 2021; 39:1297-1304. [PMID: 32043642 DOI: 10.1002/jor.24625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 01/30/2020] [Indexed: 02/04/2023]
Abstract
Heterotopic ossification (HO) is a pathological condition in which ectopic bone forms within soft tissues such as skeletal muscle. Human platelet-derived growth factor receptor α positive (PDGFRα+) cells, which were proved to be the original cells of HO were incubated in osteogenic differentiation medium with Food and Drug Administration-approved compounds. Alkaline phosphatase activity was measured as a screening to inhibit osteogenic differentiation. For the compounds which inhibited osteogenic differentiation of PDGFRα+ cells, we examined dose dependency of its effect using alizarin red S staining and its cell toxicity using WST-8. In addition, regulation of bone morphogenetic proteins (BMP)-Smad signaling which is the major signal of osteogenic differentiation was investigated by Western blotting to elucidate the mechanism of osteogenesis inhibitory effect by the compound. In vivo experiment, complete transverse incision of Achilles tendons in mice was made and mice were fed the compound by mixing with drinking water after operation. Ten weeks after operation, we assessed and quantified HO by micro-computed tomography scan. Intriguingly, we discovered desloratadine inhibited osteogenic differentiation of PDGFRα+ cells using the drug repositioning method. Desloratadine inhibited osteogenic differentiation of the cells dose dependently without cell toxicity. Desloratadine suppressed phosphorylation of Smad1/5/8 induced by BMP2 in PDGFRα+ cells. In Achilles tenotomy mice model, desloratadine treatment significantly inhibited ectopic bone formation compared with control. In conclusion, we discovered desloratadine inhibited osteogenic differentiation using human PDGFRα+ cells and proved its efficacy using Achilles tenotomy ectopic bone formation model in vivo. Our study paved the way to inhibit HO in early clinical use because of its guaranteed safety.
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Affiliation(s)
- Taiki Kusano
- Department of Orthopaedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan.,Division for Therapies against Intractable Diseases, Institute for Comprehensive Medical Science, Fujita Health University, Toyoake, Japan.,Division of Neurological Diseases and Cancer, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Masashi Nakatani
- Division for Therapies against Intractable Diseases, Institute for Comprehensive Medical Science, Fujita Health University, Toyoake, Japan
| | - Naoki Ishiguro
- Department of Orthopaedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Kinji Ohno
- Division of Neurological Diseases and Cancer, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Naoki Yamamoto
- Center for Joint Research Facilities Support, Fujita Health University, Research Promotion and Support Headquarters, Toyoake, Japan
| | - Mitsuhiro Morita
- Department of Orthopaedic Surgery, Fujita Health University, Toyoake, Japan
| | - Harumoto Yamada
- Department of Orthopaedic Surgery, Fujita Health University, Toyoake, Japan
| | - Akiyoshi Uezumi
- Department of Geriatric Medicine, Tokyo Metropolitan Institute of Gerontology, Itabashi, Tokyo, Japan
| | - Kunihiro Tsuchida
- Division for Therapies against Intractable Diseases, Institute for Comprehensive Medical Science, Fujita Health University, Toyoake, Japan
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Olsen E, Endrizzi D, Stephenson M, Farraher S. Characteristic heterotopic ossification of the proximal humerus after total shoulder arthroplasty. Skeletal Radiol 2021; 50:973-979. [PMID: 33067642 DOI: 10.1007/s00256-020-03653-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE A bony spur in a characteristic location involving the proximal humerus is identified on post-operative radiographs in some patients with history of total shoulder arthroplasty. The spur is theorized to represent heterotopic ossification near the attachment site of the pectoralis major tendon on the proximal humerus which is partially detached and then reattached during total shoulder arthroplasty. In this study, we determine the morphology, incidence, demographic associations, and clinical impact of this finding. MATERIALS AND METHODS This is a single-center, retrospective study of 500 patients who underwent total shoulder arthroplasty (250 standard and 250 reverse technique) between 2012 and 2017. Pre- and post-operative shoulder radiographs were reviewed to identify and measure the characteristic spur; inter-observer agreement was evaluated between the two reviewers. Incidence, demographic associations, and clinical significance were then determined. RESULTS The study group included 268 men and 234 women with a mean age of 70 (42-89) years, and clinical follow-up of 25 (1-84) months. Characteristic heterotopic ossification was seen in 88 patients (17.6%) and was first noted radiographically at a mean (interquartile range) of 12.1 (11.5-12.8) months after surgery. Male sex (adjusted odds ratio (95% confidence interval), 3.00 (0.68-5.34), p < 0.001) was independently associated with heterotopic ossification. No significant relationships between heterotopic ossification and adverse clinical outcomes were observed. CONCLUSION Characteristic heterotopic ossification of the proximal humerus in patients status post total shoulder arthroplasty is a common imaging finding that is not associated with adverse clinical outcomes.
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Affiliation(s)
- Erik Olsen
- Department of Radiology, Maine Medical Center, Portland, ME, USA.
| | - Donald Endrizzi
- Department of Surgery, Division of Orthopedics, Maine Medical Center, Portland, ME, USA
| | | | - Steven Farraher
- Department of Radiology, Maine Medical Center, Portland, ME, USA
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[Midline laparotomy with rib shears]. Chirurg 2021; 92:729-731. [PMID: 33733709 DOI: 10.1007/s00104-021-01384-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 10/21/2022]
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Strategies to reduce re-ankylosis in temporomandibular joint ankylosis patients. Br J Oral Maxillofac Surg 2021; 59:820-825. [PMID: 34272105 DOI: 10.1016/j.bjoms.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/16/2021] [Indexed: 11/20/2022]
Abstract
The purpose of the study was to define a protocol for the prevention of re-ankylosis after surgical management of temporomandibular joint ankylosis (TMJA). The investigators designed a retrospective study on all TMJA patients treated with different treatment modalities from 2013 to 2019. The investigators observed that complete removal of the ankylotic mass particularly on the medial side; use of a piezoelectric scalpel for a clean and smooth osteotomy with copious irrigation to remove bone chips and slurry; less trauma to the local tissue; osteotomy design parallel and inferior osteotomy at the narrowest part, which mostly corresponds to the condylar neck; performance of a coronoidectomy (if mouth opening is <30mm), fat interposition; no intraoperative correction of any pre-existing chin deviation when treated with costochondral graft; patient motivation; and aggressive physiotherapy, and use of a vacuum drain are all important to prevent re-ankylosis, irrespective of the treatment modality. A total of 114 patients (n=152 joints), [bilateral (n=38), unilateral (n=76)] were evaluated retrospectively. Interpositional arthroplasty with fat was performed in n=43, CCG was used for reconstruction in n=30 and total joint replacement (TJR) was done in n=41 patients. Re-ankylosis was seen in n=3 (2.6%) patients (2 in CCG and 1 patient in interpositional arthroplasty). The follow-up ranged from 12-80 months. The results conclude that following the suggested best practice protocol is effective in reducing re-ankylosis.
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Migliorini F, Trivellas A, Eschweiler J, Driessen A, Tingart M, Maffulli N. NSAIDs for Prophylaxis for Heterotopic Ossification After Total Hip Arthroplasty: A Bayesian Network Meta-analysis. Calcif Tissue Int 2021; 108:196-206. [PMID: 33044630 PMCID: PMC7819944 DOI: 10.1007/s00223-020-00763-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023]
Abstract
Non-steroidal anti-inflammatory drugs (NSAID) have been recommended to prevent of heterotopic ossification (HO) after total hip arthroplasty (THA), but debates are still ongoing. The present Bayesian network meta-analysis of randomized clinical trials (RCTs) compared all available pathways of NSAID treatment as prophylaxis for HO after THA. The present Bayesian network meta-analysis was conducted according to The PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions guidelines. All randomized clinical trials comparing two or more interventions to prevent HO after THA were considered for analysis. HO was classified according to Brooker. The quality of the methodological assessment was performed through the risk of bias summary tool of the Review Manager Software 5.3 (The Cochrane Collaboration, Copenhagen). The network meta-analysis was performed through a STATA routine for Bayesian hierarchical random-effects model analysis, with log odd ratio (LOR) effect measure. Data from 26 studies (6396 THAs; 58% females) were collected. The mean follow-up was 10.50 ± 5.7 months. ANOVA showed good comparability among mean age and gender (P > 0.5). Celecoxib demonstrated the highest rate of Brooker class 0 (LOR 6.96), followed by diclofenac (LOR 6.94). Naproxen demonstrated the lowest rate of Brooker I HO (LOR 2.82), followed by celecoxib (LOR 3.52). Celecoxib demonstrated lowest rate of Brooker class II HO (LOR 1.66), class III (LOR), and class IV (LOR 0.25). The equation for global linearity detected no statistically significant inconsistency (P > 0.5) in all the comparisons. The present Bayesian network meta-analysis encourages the use of celecoxib as a prophylaxis for HO. These conclusions must be interpreted in light of the limitations of the present study. Future investigations are required to establish more definitely the role of celecoxib.Level of Evidence: I, Bayesian network analysis of RCTs.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelstr. 31, 52074, Aachen, Germany
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Jörg Eschweiler
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelstr. 31, 52074, Aachen, Germany
| | - Arne Driessen
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelstr. 31, 52074, Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelstr. 31, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.
- Barts and the London School of Medicine and Dentistry, Mile End Hospital, Centre for Sports and Exercise Medicine, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England.
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Freije SL, Kushdilian MV, Burney HN, Zang Y, Saito NG. A Retrospective Analysis of 287 Patients Undergoing Prophylactic Radiation Therapy for the Prevention of Heterotopic Ossification. Adv Radiat Oncol 2020; 6:100625. [PMID: 34195485 PMCID: PMC8233464 DOI: 10.1016/j.adro.2020.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/30/2020] [Accepted: 11/11/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose Heterotopic ossification (HO) is a potentially disabling disorder of ectopic bone formation secondary to orthopedic surgery or trauma. In this retrospective analysis we evaluated the outcomes of patients who received radiation therapy (RT) for HO prophylaxis. Methods and Materials A total of 287 patients who received RT for HO prophylaxis at a major trauma center from 2007 to 2018 were analyzed. Data collected included types of injury, surgery, time intervals between key events, development of postprophylaxis HO, and secondary malignancies. Associations between various factors and the risk of developing HO were analyzed. Kaplan-Meier analysis was used to estimate failure rates. Results The most common indication for RT was traumatic acetabular fracture (83.3%). Twelve patients (4.2%) developed postprophylaxis HO with a median time to failure of 8.6 months (2.8-24.5). Kaplan-Meier 1-, 2-, and 5-year failure rates were 3.7%, 4.4%, and 7.4%, respectively. Injury type and timing of RT were not associated with the risk of failure, but we observed a trend of increased risk of failure in patients with longer time between surgery and RT (odd ration [OR] 1.68, P = .056). Current or former smokers (51.7%) were less likely to fail (OR 0.10, P = .03). There was no incidence of in-field secondary malignancy. Conclusions There was no significant association between injury and fracture type, surgical approach, or timing of RT and development of HO, contrary to published reports of increased HO risk with certain surgical approaches and longer time intervals between injury and surgery, suggesting that prophylactic RT might play a role in mitigating these effects. Decreased risk of postprophylaxis HO among former or current smokers was unexpected. No secondary malignancy in the RT field was identified, although the median follow-up was only 17 months. Compared with published HO incidences (17%-39%) in patients who receive no prophylaxis after traumatic acetabular fractures, our results are highly suggestive of the efficacy of prophylactic RT.
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Affiliation(s)
- Samantha L Freije
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael V Kushdilian
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Heather N Burney
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yong Zang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Naoyuki G Saito
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
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A 2-Week Course of Naproxen for Heterotopic Ossification Prophylaxis Is Effective Following Hip Arthroscopy for Femoroacetabular Impingement. Arthrosc Sports Med Rehabil 2020; 2:e789-e794. [PMID: 33376993 PMCID: PMC7754608 DOI: 10.1016/j.asmr.2020.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 07/10/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose To evaluate the effectiveness of 2 weeks of naproxen prophylaxis for heterotopic ossification (HO) after primary hip arthroscopy for femoroacetabular impingement (FAI). Methods All consecutive hip arthroscopy cases by a single surgeon from January 1, 2015, to December 31, 2016, were retrospectively reviewed. Cases were included if they met the following criteria: (1) Primary hip arthroscopy, including femoral neck osteoplasty, for FAI; (2) naproxen prophylaxis for 2 weeks’ duration; and (3) radiographic follow-up at a minimum of 3 months postoperatively. Radiographic imaging for each patient was evaluated for the presence of HO, and independent radiology reports were used to confirm patients with HO. Maximal size of HO was measured and classified according to the Brooker criteria. Demographic and operative variables of the patients included in this study who received naproxen prophylaxis for 2 weeks were formally compared with a cohort of patients who received naproxen prophylaxis for 3 weeks in a previous randomized controlled trial. Results A total of 185 patients who received naproxen prophylaxis for 2 weeks were included in the study, 5 of whom developed HO (3%). A total of 48 patients who received naproxen prophylaxis for 3 weeks were included for comparison, 2 of whom developed HO (4%). There was no significant difference in the rate of HO formation between 2 weeks and 3 weeks of naproxen prophylaxis (P = .597). All 7 cases of HO were classified as Brooker class 1. Conclusions The observed rate of postoperative heterotopic ossification after 2 weeks of naproxen prophylaxis in this study was equivalent to that observed after 3 weeks’ prophylaxis in a previously published study. Two weeks of naproxen prophylaxis may be a sufficient treatment course for the prevention of heterotopic ossification after primary hip arthroscopy for FAI. Level of Evidence Level III – Retrospective Comparative Study.
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Kumar V, Asodiya FA, Singh VK, Gajera HP. Microscopic and spectroscopic characterization of an extraskeletal intranasal osteoma in a Gir cow. Microsc Res Tech 2020; 84:555-562. [PMID: 33037761 DOI: 10.1002/jemt.23613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/19/2020] [Accepted: 09/23/2020] [Indexed: 01/12/2023]
Abstract
This is probably the first report characterizing an extraskeletal intranasal osteoma in a Gir cow through scanning electron microscopy and various spectroscopic techniques. Nasal obstruction in a 10-year-old Gir cow is investigated in this study. Skull radiograph demonstrated 174.12 mm × 81.97 mm sized well-circumscribed radiodense mass within the left nasal passage. The intranasal mass was excised completely through a rhinotomy incision. Grossly, intranasal mass was nonhyperemic, rock-hard, and calcified, 174.12 mm × 81.97 mm in size, and 650 g of weight. Excised intranasal mass was investigated through histopathologic, scanning electron microscopic (SEM), energy-dispersive X-ray (EDX) spectroscopic, X-ray fluorescence (XRF) spectroscopic, microwave plasma-atomic energy spectroscopic (MPAES), and Fourier-transform infrared (FTIR) spectroscopic techniques. A native bone of age-matched Gir cow, collected from a cadaver, was taken as a control. Microscopically, structures similar to cortical bone randomly coexisted with trabecular bone were observed. The EDX analysis of the intranasal mass indicated mean Ca/P weight ratio of 1.88, close to Ca/P weight ratio of the control. The XRF analysis revealed the presence of Ca, P, Sr, S, Zn, Cu, Fe, and Ni in the intranasal mass. Additionally, Mn was noted by MPAES analysis. Hence, the XRF and MPAES analyses confirmed a similar elemental composition of the intranasal mass and control. FTIR spectroscopic study confirmed the presence of inorganic ν1, ν3 PO4 3- , OH- in addition to organic collagen amide A, amide B, amide I, amide II, and amide III chemical functional groups in the intranasal mass. These findings of the intranasal mass were consistent with an osteoma having similar elemental and molecular compositions with the native bone.
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Affiliation(s)
- Vineet Kumar
- Department of Veterinary Surgery and Radiology, College of Veterinary and Animal Sciences, Sardar Vallabhbhai Patel University of Agriculture and Technology, Meerut, India
| | - Foram A Asodiya
- Department of Veterinary Surgery and Radiology, College of Veterinary Science and Animal Husbandry, Junagadh Agricultural University, Junagadh, India
| | - Vivek K Singh
- Department of Veterinary Physiology and Biochemistry, College of Veterinary Science and Animal Husbandry, Junagadh Agricultural University, Junagadh, India
| | - Harsukh P Gajera
- Department of Biotechnology, Junagadh Agricultural University, Junagadh, India
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Strong AL, Spreadborough PJ, Pagani CA, Haskins RM, Dey D, Grimm PD, Kaneko K, Marini S, Huber AK, Hwang C, Westover K, Mishina Y, Bradley MJ, Levi B, Davis TA. Small molecule inhibition of non-canonical (TAK1-mediated) BMP signaling results in reduced chondrogenic ossification and heterotopic ossification in a rat model of blast-associated combat-related lower limb trauma. Bone 2020; 139:115517. [PMID: 32622875 PMCID: PMC7945876 DOI: 10.1016/j.bone.2020.115517] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
Heterotopic ossification (HO) is defined as ectopic bone formation around joints and in soft tissues following trauma, particularly blast-related extremity injuries, thermal injuries, central nerve injuries, or orthopaedic surgeries, leading to increased pain and diminished quality of life. Current treatment options include pharmacotherapy with non-steroidal anti-inflammatory drugs, radiotherapy, and surgical excision, but these treatments have limited efficacy and have associated complication profiles. In contrast, small molecule inhibitors have been shown to have higher specificity and less systemic cytotoxicity. Previous studies have shown that bone morphogenetic protein (BMP) signaling and downstream non-canonical (SMAD-independent) BMP signaling mediated induction of TGF-β activated kinase-1 (TAK1) contributes to HO. In the current study, small molecule inhibition of TAK1, NG-25, was evaluated for its efficacy in limiting ectopic bone formation following a rat blast-associated lower limb trauma and a murine burn tenotomy injury model. A significant decrease in total HO volume in the rat blast injury model was observed by microCT imaging with no systemic complications following NG-25 therapy. Furthermore, tissue-resident mesenchymal progenitor cells (MPCs) harvested from rats treated with NG-25 demonstrated decreased proliferation, limited osteogenic differentiation capacity, and reduced gene expression of Tac1, Col10a1, Ibsp, Smad3, and Sox2 (P < 0.05). Single cell RNA-sequencing of murine cells harvested from the injury site in a burn tenotomy injury model showed increased expression of these genes in MPCs during stages of chondrogenic differentiation. Additional in vitro cell cultures of murine tissue-resident MPCs and osteochondrogenic progenitors (OCPs) treated with NG-25 demonstrated reduced chondrogenic differentiation by 10.2-fold (P < 0.001) and 133.3-fold (P < 0.001), respectively, as well as associated reduction in chondrogenic gene expression. Induction of HO in Tak1 knockout mice demonstrated a 7.1-fold (P < 0.001) and 2.7-fold reduction (P < 0.001) in chondrogenic differentiation of murine MPCs and OCPs, respectively, with reduced chondrogenic gene expression. Together, our in vivo models and in vitro cell culture studies demonstrate the importance of TAK1 signaling in chondrogenic differentiation and HO formation and suggest that small molecule inhibition of TAK1 is a promising therapy to limit the formation and progression of HO.
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Affiliation(s)
- Amy L Strong
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Philip J Spreadborough
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; Academic Department of Military Surgery and Trauma, Royal Centre for Defense Medicine, Birmingham, United Kingdom
| | - Chase A Pagani
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Ryan M Haskins
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America
| | - Devaveena Dey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Patrick D Grimm
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Keiko Kaneko
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Simone Marini
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Amanda K Huber
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Charles Hwang
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Kenneth Westover
- Departments of Biochemistry and Radiation Oncology, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States of America
| | - Yuji Mishina
- Department of Biologic and Materials Science and Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, United States of America
| | - Matthew J Bradley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Benjamin Levi
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America.
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America.
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Can adjunctive perioperative radiation improve range of motion after total knee revision for arthrofibrosis? Knee 2020; 27:1426-1432. [PMID: 33010757 DOI: 10.1016/j.knee.2020.06.007] [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: 12/02/2019] [Revised: 03/13/2020] [Accepted: 06/22/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Total knee arthroplasty revision (TKRev) can be performed to treat chronic arthrofibrosis. Low-dose irradiation may decrease fibro-osseous proliferation of soft tissue; therefore, it may be effective at increasing range of motion (ROM) after TKRev. Our hypothesis is that low-dose radiation administered in the immediate postoperative period leads to increased ROM after TKRev for arthrofibrosis. METHODS A retrospective analysis was conducted from 2008-2015 on 26 patients who underwent TKRev for treating chronic arthrofibrosis. Fifteen patients (XRT group) received 800 cGy radiation within 48 hours after TKRev and 11 patients (CTL group) did not. Measurements of extension, flexion, and total arc of ROM were performed preoperatively and at one, six, and 12 months postoperatively. RESULTS ROM improved from 14.3° extension, 69.0° flexion, and 54.7° total ROM preoperatively, to 3.3° extension, 94.0° flexion, and 90.7° total ROM postoperatively in the XRT group. ROM improved from 18.6° extension, 85.9° flexion, and 67.3° total ROM preoperatively to 4.1° extension, 102.5° flexion, and 98.5° total ROM postoperatively in the CTL group. The 1-year overall improvement in extension (12.5°), flexion (21.4°), and total ROM (33.9°) vs preoperative ROM was significant for all measurements (p < 0.001). The 8.4° improvement in flexion (25.0° vs 16.6°, p = 0.10) in the XRT group vs the CTL group approached, but did not reach significance. CONCLUSIONS TKRev for arthrofibrosis showed significant improvement in extension, flexion, and total ROM at one year. The use of low dose irradiation showed promise with improved flexion, but the result did not reach statistical significance in this small sample of patients.
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Abstract
Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576-584.
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Affiliation(s)
- Ziyang Sun
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Weixuan Liu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Juehong Li
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Hu ZH, Chen W, Sun JN, Zhang Y, Zhang Y, Chen XY, Feng S. Radiotherapy for the prophylaxis of heterotopic ossification after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trails. Med Dosim 2020; 46:65-73. [PMID: 32928622 DOI: 10.1016/j.meddos.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 01/14/2023]
Abstract
Heterotopic ossification (HO) refers to the formation of lamellar bone in soft tissues and is a significant complication after total hip arthroplasty (THA). Radiotherapy has been proven as an effective prophylaxis especially for those patients with high risk of HO after THA. However the dose, timing, and frequency of radiation have yet to be determined. To compare HO progressions with different radiotherapy strategies and explore an optimal radiation option. We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trails (through December 1, 2019; no language restrictions) collecting patients who accepted prophylaxis radiation for whom HO progression outcomes were reported. Of 87 identified studies, 10 randomized controlled trails including 1203 patients and 1268 hips were taken to this analysis. Compared with the low biologically effective radiation dose group (biologically effective dose [BED] < 20 Gy), the medium biologically effective radiation dose group (20 Gy ≤ BED ≤ 24 Gy) had statistically significant difference on the prophylaxis of HO (p = 0.003). But for overall incidence of HO, there was no statistically significant difference between low BED group and high BED group (BED > 24, p = 0.21). There was statistically significant reduction in the prophylaxis of HO progression with multiple fractions as opposed to single fraction radiotherapy (p = 0.04). Hips with preoperative radiation were no more likely to observe HO progression than those with postoperative radiotherapy (p = 0.43). Radiotherapy with medium dose (20 Gy ≤ BED ≤ 24 Gy) after THA is an effective dose for preventing HO. In the prophylaxis of HO, multiple fractions seem to be more effective than single fraction radiation. Preoperative radiotherapy could prevent HO progression with the same efficacy postoperative.
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Affiliation(s)
- Zheng-Hao Hu
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, China
| | - Wang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, China
| | - Jian-Ning Sun
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, China
| | - Ye Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, China
| | - Yu Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, China
| | - Xiang-Yang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, China.
| | - Shuo Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, China.
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Pakos EE, Papadopoulos DV, Gelalis ID, Tsantes AG, Gkiatas I, Kosmas D, Tsekeris PG, Xenakis TA. Is prophylaxis for heterotopic ossification with radiation therapy after THR associated with early loosening or carcinogenesis? Hip Int 2020; 30:559-563. [PMID: 30990093 DOI: 10.1177/1120700019842724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Heterotopic ossification may develop after major hip surgeries, thus preventive strategies including radiation therapy and non steroid anti-inflammatory drugs are commonly employed. There are certain concerns regarding the effects of radiation therapy on implant loosening and carcinogenesis. Our study aims to evaluate whether radiation therapy results in implant loosening or radiation-induced tumours in the long term. PATIENTS AND METHODS This was a prospective study including 97 high-risk patients for heterotopic ossification who underwent total hip arthroplasty. Patients were divided into 2 groups and received either a combination of radiation therapy and indomethacin (Group A), or indomethacin alone (Group B). Evaluated outcomes included implant loosening or development of radiation-induced tumours during the follow-up period. RESULTS The follow-up period of the study was 10 years. Group A consisted of 50 patients, while Group B consisted of 47 patients. 3 patients died during the follow-up. There were 2 cases of implant loosening, 1 from each of the 2 groups at 9 and 10 years after surgery respectively; thus, no statistically significant difference regarding implant loosening was found (p < 0.05). During the follow-up period no cases of radiation-induced tumours were identified. CONCLUSION Our results are consistent with those of other studies supporting the safety of radiation therapy as a preventive strategy for heterotopic ossification following major surgeries in high risk patients. Further studies with even longer follow-up may be required to definitely exclude the possibility of adverse outcomes linked with radiation therapy.
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Affiliation(s)
- Emilios E Pakos
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | | | - Ioannis D Gelalis
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | - Andreas G Tsantes
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | - Ioannis Gkiatas
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | - Dimitrios Kosmas
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | - Pericles G Tsekeris
- Department of Radiation Oncology, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Theodoros A Xenakis
- Laboratory of Orthopedics and Biomechanics, University of Ioannina, School of Medicine, Ioannina, Greece
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Nieuwenhuizen CJ, van Veldhoven PLJ, van Oosterom RF. Rare case of a traumatic myositis ossificans in the tibialis anterior muscle. BMJ Case Rep 2020; 13:13/8/e233210. [PMID: 32816878 DOI: 10.1136/bcr-2019-233210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Athletes involved in contact sports can be diagnosed with traumatic myositis ossificans. Myositis ossificans is characterised by a benign ossifying lesion in soft tissue mass, most commonly preceded by a muscle contusion in the thigh. Despite the fact that it is often a self-limiting disease, treatment modalities are anti-inflammatory drugs, physiotherapy, shockwave therapy, radiation therapy or surgical resection. We report a 22-year-old competitive football player with severe ongoing pain in the lower leg after a direct trauma. An X-ray showed calcification between the tibia and fibula. An additional ultrasound confirmed the diagnosis: myositis ossificans of the tibialis anterior muscle. After treating him with anti-inflammatory drugs and physiotherapy, he was able to return to sports. Myositis ossificans of the lower leg is an uncommon, though if present, troublesome condition, occurring after a contusion.
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Affiliation(s)
| | | | - Robert F van Oosterom
- Sports Medicine, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
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