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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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Lachiewicz PF, Skalla LA, Purcell KF. Surgical Treatment of Severe Heterotopic Ossification After Total Hip Arthroplasty Over the Last 25 Years: A Systematic Review of the Literature and a New Case Series. J Arthroplasty 2024:S0883-5403(24)00116-5. [PMID: 38360283 DOI: 10.1016/j.arth.2024.02.017] [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: 10/09/2023] [Revised: 02/03/2024] [Accepted: 02/07/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Severe heterotopic ossification (HO) (grades III and IV) after total hip arthroplasty (THA) over the last 25 years requiring excision is very uncommon. We performed a systematic review of the literature and reported a new case series with operative treatment after primary uncemented THA. METHODS A systematic review identified papers describing patients who had excision of HO after THA performed after 1988. Concepts of hip arthroplasty, HO, and surgical excision were searched in MEDLINE, Embase, and Scopus from database inception to November 2022. The inclusion criteria were articles that included specific patient data on the grade of HO, operative procedure, and prophylaxis. Studies were screened for inclusion by 2 independent reviewers. The extracted data included demographic data, the interval from index surgery to excision, clinical results, and complications. There was one surgeon who performed reoperation for ankylosis of primary THA in 3 men who had severe pain and hip deformity. RESULTS Data from 7 studies were included. There were 41 patients who had grade III or IV HO who had excision, and in 5 patients, revision of a component was also performed. Perioperative prophylaxis was irradiation alone in 10 patients, irradiation and indomethacin in 10 patients, and indomethacin alone in 21 patients. At a mean follow-up time of 14.8 months, the definition of the results was not uniform, and range of motion was improved, but relief of pain was inconsistent. There was one dislocation after resection without revision, one gastrointestinal complication, and 2 recurrences. Treatment of the 3 new patients, with wide excision of periarticular bone, selective exchange of components, and perioperative irradiation prophylaxis, was successful in improving pain, motion, and deformity. CONCLUSIONS There is insufficient good-quality data on the operative treatment of severe symptomatic HO after THA performed over the last 25 years. Prophylaxis with low-dose irradiation prevented a recurrence. Multicenter studies are needed to determine the optimum timing and prognosis for treatment.
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Affiliation(s)
- Paul F Lachiewicz
- Departments of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina; Duke University Medical Center Library and Archives, Durham, North Carolina
| | - Lesley A Skalla
- Departments of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina; Duke University Medical Center Library and Archives, Durham, North Carolina
| | - Kevin F Purcell
- Departments of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina; Duke University Medical Center Library and Archives, Durham, North Carolina
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Lucas SL, Gallagher BP, Mullinix KP, Brumback RJ, Cunningham BW. 3D-Printed Model in Preoperative Planning of Sciatic Nerve Decompression Because of Heterotopic Ossification: A Case Report. JBJS Case Connect 2024; 14:01709767-202403000-00033. [PMID: 38394316 DOI: 10.2106/jbjs.cc.23.00483] [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: 02/25/2024]
Abstract
CASE A 31-year-old patient presented with an encapsulated sciatic nerve secondary to extensive hip heterotopic ossification (HO), which prevented visualization of a safe osteotomy site to avoid nerve damage. The 3D-printed model demonstrated an easily identifiable osseous reference point along the inferior aspect of the heterotopic mass, allowing for a vertical osteotomy to be safely performed. CONCLUSION HO is associated with loss of normal anatomic topography. The current case report illustrates the use of a 3D-printed model to identify pertinent anatomic landmarks required for safe decompression of an encapsulated sciatic nerve within the anatomic region of the hip.
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Affiliation(s)
- Sarah L Lucas
- Georgetown University School of Medicine, Washington, District of Columbia
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Brian P Gallagher
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Kenneth P Mullinix
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Robert J Brumback
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Bryan W Cunningham
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
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Ausk BJ, Tucker AN, Huber P, Firoozabadi R, Gross JM, Gross TS, Bain SD. A microCT-based platform to quantify drug targeting. Eur Radiol Exp 2023; 7:38. [PMID: 37532922 PMCID: PMC10397158 DOI: 10.1186/s41747-023-00355-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/12/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Heterotopic ossification (HO) is a frequent and debilitating complication of traumatic musculoskeletal injuries and orthopedic procedures. Prophylactic dosing of botulinum toxin type A (BTxA) holds potential as a novel treatment option if accurately distributed throughout soft-tissue volumes where protection is clinically desired. We developed a high-resolution, microcomputed tomography (microCT)-based imaging strategy to assess drug distribution and validated this platform by quantifying distribution achieved via a prototype delivery system versus a single-bolus injection. METHODS We injected an iodine-containing contrast agent (iodixanol 320 mg I/mL) into dissected rabbit musculature followed by microCT imaging and analysis. To contrast the performance of distributed versus bolus injections, a three-dimensional (3D) 64-cm3-printed soft-tissue holder was developed. A centered 2-cm3 volume of interest (VOI) was targeted with a single-bolus injection or an equal volume distributed injection delivered via a 3D-printed prototype. VOI drug coverage was quantified as a percentage of the VOI volume that was < 1.0 mm from the injected fluid. RESULTS The microCT-based approach enabled high-resolution quantification of injection distribution within soft tissue. The distributed dosing prototype provided significantly greater tissue coverage of the targeted VOI (72 ± 3%, mean ± standard deviation) when compared to an equal volume bolus dose (43 ± 5%, p = 0.031) while also enhancing the precision of injection targeting. CONCLUSIONS A microCT-based imaging technique precisely quantifies drug distribution within a soft-tissue VOI, providing a path to overcome a barrier for clinical translation of prophylactic inhibition of HO by BTxA. RELEVANCE STATEMENT This platform will facilitate rapid optimization of injection parameters for clinical devices used to effectively and safely inhibit the formation of heterotopic ossification. KEY POINTS • MicroCT provides high-resolution quantification of soft-tissue drug distribution. • Distributed dosing is required to maximize soft-tissue drug coverage. • Imaging platform will enable rapid screening of 3D-printed drug distribution prototypes.
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Affiliation(s)
| | - Adam N Tucker
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Philippe Huber
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | | | - Ted S Gross
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Steven D Bain
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
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5
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Kent SE, Ryan SP. Heterotopic Ossification Remodeling After Acetabular Surgery: A Natural History Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00032. [PMID: 37535810 DOI: 10.2106/jbjs.cc.23.00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
CASE A 30-year-old woman presented with a transverse plus posterior wall acetabular fracture and underwent operative fixation through a Kocher-Langenbeck approach. Shared decision was made for no heterotopic ossification (HO) prophylaxis. The patient developed symptomatic HO and was scheduled for resection, which was delayed because of the pandemic. She returned with interval remodeling of HO and symptom resolution. No surgery was required. CONCLUSION HO is a common complication after acetabular injury. Resection is the treatment of choice for symptomatic HO. We are not aware of other reports of spontaneous remodeling of symptomatic HO such that it no longer required surgery.
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Affiliation(s)
- Suzanne E Kent
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
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Boissonneault A, O Hara N, Pogorzelski D, Marchand L, Higgins T, Gitajn L, Gage MJ, Natoli RM, Sharma I, Pierrie S, O'Toole RV, Sprague S, Slobogean G. The impact of heterotopic ossification prophylaxis after surgical fixation of acetabular fractures: national treatment patterns and related outcomes. Injury 2023; 54:S0020-1383(23)00197-3. [PMID: 37002119 PMCID: PMC10480339 DOI: 10.1016/j.injury.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 03/04/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a common complication after surgical fixation of acetabular fractures. Numerous strategies have been employed to prevent HO formation, but results are mixed and optimal treatment strategy remains controversial. The purpose of the study was to describe current national heterotopic ossification (HO) prophylaxis patterns among academic trauma centers, determine the association between prophylaxis type and radiographic HO, and identify if heterogeneity in treatment effects exist based on outcome risk strata. METHODS We used data from a subset of participants enrolled in the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. We included only patients with closed AO-type 62 acetabular fractures that were surgically treated via a posterior (Kocher-Langenbeck), combined anterior and posterior, or extensile exposure. PREPARE Clinical Trial Registration Number: NCT03523962 Patient population This cohort study was nested within the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. The PREPARE trial is a multicenter cluster-randomized crossover trial evaluating the effectiveness of two alcohol-based pre-operative antiseptic skin solutions. All PREPARE trial clinical centers that enrolled at least one patient with a closed AO-type 62 acetabular fracture were invited to participate in the nested study. RESULTS 277 patients from 20 level 1 and level 2 trauma centers in the U.S. and Canada were included in this study. 32 patients (12%) received indomethacin prophylaxis, 100 patients (36%) received XRT prophylaxis, and 145 patients (52%) received no prophylaxis. Administration of XRT was associated with a 68% reduction in the adjusted odds of overall HO (OR 0.32, 95% CI, 0.14 - 0.69, p = 0.005). The overall severe HO (Brooker classes III or IV) rate was 8% for the entire cohort; XRT reduced the rate of severe HO in high-risk patients only (p=0.03). CONCLUSION HO prophylaxis patterns after surgical fixation of acetabular fractures have changed dramatically over the last two decades. Most centers included in this study did not administer HO prophylaxis. XRT was associated with a marked reduction in the rate of overall HO and the rate of severe HO in high-risk patients. Randomized trials are needed to fully elucidate the potential benefit of XRT. PREPARE Clinical Trial Registration Number: NCT03523962.
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Affiliation(s)
- Adam Boissonneault
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA.
| | - Nathan O Hara
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
| | - David Pogorzelski
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lucas Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Thomas Higgins
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Section of Orthopaedic Trauma, Duke University, Durham, North Carolina
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ishani Sharma
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarah Pierrie
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
| | - Sheila Sprague
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gerard Slobogean
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
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7
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Joseph NM, Flanagan CD, Heimke IM, Cho E, Pothireddy S, Scarcella N, Vallier HA. Factors influencing functional outcomes following open reduction internal fixation of acetabular fractures. Injury 2021; 52:1396-1402. [PMID: 33228993 DOI: 10.1016/j.injury.2020.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/15/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recent large series of patient-reported outcomes after acetabulum fracture are limited, and potentially modifiable risk factors may be unidentified. The goal of this study was to describe patient and injury factors which negatively influence functional outcomes following operative management of acetabular fractures. METHODS 699 patients with acetabular fractures were treated with open reduction and internal fixation (ORIF). Musculoskeletal Function Assessment (MFA) questionnaire was completed after a minimum 12 months post-injury by 283 adults. MFA scores range from 1 to 100 and higher scores represent greater dysfunction. Factors were assessed for potential association with MFA scores, and univariate and multiple linear regression analyses were performed. RESULTS Survey respondents were more severely injured than non-respondents, with more chest injury (38% vs 22%, p<0.001) and higher Injury Severity Score (19.3 vs 16.8, p=0.003). Patients were 69% male with mean age 44.0 years. Approximately one-third were smokers (31%), while 14% had comorbid diabetes mellitus type II. The majority of injuries occurred during a motor vehicle collision (65%); low-energy mechanisms were rare (4.2%). The most common fracture pattern was isolated posterior wall (23%), followed by transverse/posterior wall (21%). Heterotopic ossification (HO) was noted in 22%: Brooker 1: 29.5%, 2: 23.0%, 3: 32.8%, and 4: 14.8%. Tobacco use (β = 18.4, p<0.001), obesity (β = 0.39, p=0.009), diabetes (β = 8.2, p=0.029), post-traumatic arthrosis (PTA) (β = 5.94 p=0.035), and increasing HO severity (β = 8.93, p<0.001) were independently associated with worse MFA scores. Tobacco use had the strongest association, followed by the severity of HO. CONCLUSION In a large series of patient-reported functional outcomes following fixation of acetabular fractures, tobacco use, obesity, comorbid diabetes, PTA, and HO were associated with worse MFA scores. Further study to mitigate HO should be considered. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Noah M Joseph
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Christopher D Flanagan
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Isabella M Heimke
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elizabeth Cho
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sahini Pothireddy
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Nicholas Scarcella
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Heather A Vallier
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
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A Rare Case of Extremely Severe Heterotopic Ossification after Primary Total Hip Arthroplasty due to Persistent Mild Periprosthetic Joint Infection. Case Rep Orthop 2021; 2021:8849929. [PMID: 34094609 PMCID: PMC8164530 DOI: 10.1155/2021/8849929] [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: 06/17/2020] [Revised: 02/18/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022] Open
Abstract
Periprosthetic joint infection (PJI) caused by coagulase-negative staphylococci (CNS) can be a mild, persisting infection. Although heterotopic ossification (HO) is common following total hip arthroplasty (THA), the etiology of severe HO remains unclear. Herein, we describe a rare case of extremely severe HO after a PJI associated with a Staphylococcus caprae infection in a 78-year-old male patient. The patient had poorly controlled diabetes mellitus with no diabetic complications. The patient had no previous history of hip surgery, hip injury, or systemic bacterial infection. Immediately after the initial THA, he developed intermittent low-grade fever (37°C), which persisted for 3 months; consequently, he also reported mild hip pain during walking. He experienced a gradual decrease in hip range of motion within 5 years after the surgery, with progressive gait impairment. Two revision surgeries were required for the successful treatment of this difficult case. The patient's hip function improved, and the PJI was controlled following the second revision surgery. Based on the clinical course, CNS-caused PJI may lead to severe HO. This possibility warrants verification from an accumulated number of cases.
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9
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Cole PA, Dugarte AJ, Talbot M, Routt MLC. Early resection of ectopic bone in patients with heterotopic ossification about the hip after trauma. Injury 2020; 51:705-710. [PMID: 32035630 DOI: 10.1016/j.injury.2020.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/18/2019] [Accepted: 01/19/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Heterotopic ossification (HO) is a common complication in patients who have sustained high-energy trauma to the hip region. Traditionally, resection is performed after ectopic bone maturation. We hypothesized that early HO resection in patients with hip ankylosis after trauma can be performed with little chance of recurrence. DESIGN Retrospective clinical cohort. SETTING Level I Trauma Center PATIENTS/PARTICIPANTS: 14 patients with resection of HO about the hip performed by the senior author during a six-year period. INTERVENTION Early resection of Brooker Class III or IV HO. MAIN OUTCOME MEASUREMENTS The original injuries, risk factors for HO, post-traumatic clinical course including the workup for HO, times from fixation to resection, surgical approach, and complications were recorded. Records were reviewed to document pre and postoperative hip motions. Pre and post-operative x-rays and CT scans were reviewed to classify the HO and localize the ectopic mass. RESULTS Mean injury to resection interval was 6.8-months. Nine of 14 (64%) patients were followed for a mean of 32.9-months post-resection. Indications for resection included pain, stiffness, and evolving sciatic nerve lesions. Risk factors were male gender, brain injury, and extended iliofemoral and Kocher-Langenbeck surgical approaches. Complications included gluteal vein laceration, draining wounds, and recurrence. Mean flexion-extension arc of motion was 18° (range = 0-70°) preoperatively, 100° (range = 85-125°) intra-operatively, and 94° (range = 20-110°) at final follow-up. HO recurred in nine patients; functionally significant in one. CONCLUSION Early resection of HO around the hip may be performed with little chance of symptomatic recurrence. LEVEL OF EVIDENCE This is a Level IV retrospective case series.
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Affiliation(s)
- Peter A Cole
- University of Minnesota, Regions Hospital, Department of Orthopaedic Surgery, St. Paul, MN, United States.
| | - Anthony J Dugarte
- University of Minnesota, Regions Hospital, Department of Orthopaedic Surgery, St. Paul, MN, United States
| | - Max Talbot
- Canadian Armed Forces, 1 Canadian Field Hospital, 147 Flanders Row, Garrison Petawawa, Onatrio, K8H 2X3, Canada
| | - Milton L Chip Routt
- Department of Orthopaedic Surgery, UT Health McGovern Medical School, Houston, TX, United States.
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Abstract
Acetabular fractures are encountered by radiologists in a wide spectrum of practice settings. The radiologist's value in the acute and long-term management of acetabular fractures is augmented by familiarity with systematic computed tomography-based algorithms that streamline and simplify Judet-Letournel fracture typing, together with an appreciation of the role of imaging in initial triage, operative decision making, postoperative assessment, prognostication, and evaluation of complications. The steep increase in incidence of acetabular fractures in the elderly over the past several decades places special emphasis on familiarity with geriatric fracture patterns.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Christina A LeBedis
- Department of Radiology, Boston University Medical Center, 715 Albany Street, Boston, MA 02118, USA
| | - Jason W Nascone
- Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201, USA
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11
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Wentworth KL, Masharani U, Hsiao EC. Therapeutic advances for blocking heterotopic ossification in fibrodysplasia ossificans progressiva. Br J Clin Pharmacol 2019; 85:1180-1187. [PMID: 30501012 DOI: 10.1111/bcp.13823] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 12/12/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease in which heterotopic bone forms in muscle and soft tissue, leading to joint dysfunction and significant disability. FOP is progressive and many patients are wheelchair-bound by the 3rd decade of life. FOP is caused by an activating mutation in the ACVR1 gene, which encodes the activin A Type 1 receptor. Aberrant signalling through this receptor leads to abnormal activation of the pSMAD 1/5/8 pathway and triggers the formation of bone outside of the skeleton. There is no curative therapy for FOP; however, exciting advances in novel therapies have developed recently. Here, we review the clinical and translational pharmacology of three drugs that are currently in clinical trials (palovarotene, REGN 2477 and rapamycin) as well as other emerging treatment strategies for FOP.
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Affiliation(s)
- Kelly L Wentworth
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Umesh Masharani
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA
| | - Edward C Hsiao
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
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12
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Kitayama K, Kawakami Y, Fukui T, Oe K, Kuroda R, Niikura T. Rescue of ankylosing hip following open reduction and internal fixation of acetabular fracture by surgical resection of heterotopic ossification: A case report. Int J Surg Case Rep 2018; 53:107-111. [PMID: 30391733 PMCID: PMC6216073 DOI: 10.1016/j.ijscr.2018.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 10/13/2018] [Indexed: 11/30/2022] Open
Abstract
Heterotopic ossification is a major complication after surgical treatment of acetabular fractures. Whether delayed or early surgical resection of heterotopic ossification is more effective remains controversial. Early surgical resection is not necessarily contraindication.
Introduction Heterotopic ossification is a major complication after surgical treatment of acetabular fractures. Heterotopic ossification generally involves the large joints, often limits the range of motion, and may cause ankylosis. Presentation of case This case report describes a 59-year-old man with severe heterotopic ossification who developed an acetabular fracture and resultant hip ankylosis, which was rescued by surgical resection of the heterotopic ossification. He had accompanying head injury and multiple other fractures, which were treated conservatively. Open reduction with internal fixation of the acetabular fracture was performed through the ilioinguinal and Kocher–Langenbeck combined approach. The patient unexpectedly returned to our hospital 7.5 months after the fracture surgery. We found that his left hip joint was completely ankylosed by severe heterotopic ossification. We performed surgical resection of the heterotopic ossification through a direct lateral approach 9.5 months after the initial surgery. At the final follow-up, 5.5 years after the heterotopic ossification resection surgery, the hip function including the range of motion was satisfactory. Radiographs showed no signs of recurrence, and he could walk with no support. Discussion The only effective treatment for established HO is surgical excision. Whether delayed or early surgical resection of heterotopic ossification is more effective remains controversial. Conclusion We considered that waiting for a long time before surgical resection of the heterotopic ossification would lead to more disability, and early resection of the heterotopic ossification was not a contraindication despite the fact that the uptake on the bone scan was still intense.
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Affiliation(s)
- Kazumichi Kitayama
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yohei Kawakami
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
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13
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Abstract
INTRODUCTION Posttraumatic heterotopic ossification (HO) of the hip frequently follows acetabular fracture and hip surgery and can become symptomatic, with significant pain and limited range of motion (ROM). Definitive treatment may require surgical excision, which can result in serious complications if not planned and executed appropriately. METHODS Surgical excision of posttraumatic hip HO requires appropriate indications, preoperative planning, and intraoperative guidance using fluoroscopy to maximize excision of HO and minimize complications. This video presents a case of severe posttraumatic hip HO, indications and technique of surgical excision using fluoroscopic guidance, postoperative protocol, and the patient's clinical follow-up. RESULTS Surgical excision along with appropriate postoperative HO prophylaxis and immediate mobilization resulted in significant improvement in hip ROM and return to activities of daily living without complications or recurrence. Intraoperative blood loss can be significant and should be appropriately planned for preoperatively. CONCLUSIONS Posttraumatic hip HO can cause significantly limited hip ROM and pain with resulting disability. Surgical excision of posttraumatic hip HO in a preserved hip joint can be successful in restoring hip ROM and function. Appropriate postoperative HO prophylaxis can prevent recurrence.
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14
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Yoon BH, Park IK, Sung YB. Ankylosing Neurogenic Myositis Ossificans of the Hip: A Case Series and Review of Literature. Hip Pelvis 2018; 30:86-91. [PMID: 29896457 PMCID: PMC5990535 DOI: 10.5371/hp.2018.30.2.86] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/25/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose Neurogenic myositis ossificans (NMO) in patients with traumatic spinal cord or brain injuries can cause severe joint ankylosis or compromise neurovascularture. The purpose of this study was to evaluate the clinical and radiological outcomes of and review considerations relevant to surgical resection of NMO of the hip joint. Materials and Methods Six patients (9 hips) underwent periarticular NMO resection between 2015 and 2017. The medical records of these patients were retrospectively reviewed. Preoperative computed tomography including angiography was performed to determine osteoma location and size. Improvement in hip motion allowing sitting was considered the sole indicator of a successful surgery. The anterior approach was used in all patients. The ranges of motion (ROM) before and after surgery were compared. Results The mean time from accident to surgery was 3.6 years. Average ROM improved from 24.3°(flexion and extension) to 98.5°(flexion and extension) after surgery, and improvement was maintained at the last follow-up. No commom complications (e.g., deep infection, severe hematoma, deep vein thrombosis) occurred in any patient. Improvement in ROM in one hip in which surgical resection was performed 10 years after the accident was not satisfactory owing to the pathologic changes in the joint. Conclusion Surgical excision of periarticular NMO of the hip joint can yield satisfactory results, provided that appropriate preoperative evaluation is performed. Early surgical intervention yields satisfactory results and may prevent the development of intra-articular pathology.
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Affiliation(s)
- Byung-Ho Yoon
- Department of Orthopaedic Surgery, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - In Keun Park
- Department of Orthopaedic Surgery, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yerl-Bo Sung
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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15
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Macheras GA, Lepetsos P, Leonidou A, Anastasopoulos PP, Galanakos SP, Tsiridis E. Results from the surgical resection of severe heterotopic ossification of the hip: a case series of 26 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:1097-1102. [PMID: 28589499 DOI: 10.1007/s00590-017-1980-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 05/16/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Surgical resection of heterotopic ossification (HO) around the hip joint is often challenging. The aim of this study is to evaluate the clinical and radiological outcomes following surgical resection of Brooker's type III and IV HO of the hip. METHODS We retrospectively reviewed clinical and radiological data, between November 2006 and January 2013, of all patients who underwent surgical resection of severe HO of the hip. Brooker's grading, range of motion and the Harris Hip Score before and after surgery were recorded in all cases. The combined radiation (700 cGy preoperatively) and indomethacin regimen was used to prevent heterotopic ossification recurrence. RESULTS Twenty-six patients (22 males and 4 females) were included in our study. Mean patient age was 47.38 years (range 24-72). The HO was graded as Brooker grade III in 3 patients (11.5%) and Brooker grade IV in 23 patients (88.5%). Mean time interval between HO development and resection was 40.8 months (range 13-156 months). All patients had CT scans prior to surgery. Mean follow-up was 31.4 months (range 24-40 months). There was no severe HO recurrence. Complications included one intraoperative injury of a femoral artery branch, one intraoperative femoral neck fracture treated with intramedullary nailing, one sciatic nerve injury and one superficial infection treated conservatively. CONCLUSIONS Surgical resection of severe HO of the hip along with preoperative radiation and indomethacin provides excellent results; however, the complication rate is relatively high. Careful evaluation of the preoperative CT scan and wide exposure are required in order to identify all the involved neurovascular structures.
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Affiliation(s)
- George A Macheras
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Nikis 2, Kifissia, 14561, Athens, Greece
| | - Panagiotis Lepetsos
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Nikis 2, Kifissia, 14561, Athens, Greece.
| | - Andreas Leonidou
- Third Academic Department of Orthopaedics and Trauma, Aristotle University Medical School, Ring Road, N. Efkarpia, 56403, Thessaloníki, Greece
| | | | - Spyridon P Galanakos
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Nikis 2, Kifissia, 14561, Athens, Greece
| | - Eleftherios Tsiridis
- Third Academic Department of Orthopaedics and Trauma, Aristotle University Medical School, Ring Road, N. Efkarpia, 56403, Thessaloníki, Greece
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16
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Abstract
Heterotopic ossification (HO) is a common complication of the surgical treatment of acetabular fractures. HO is the formation of trabecular bone in soft tissues where bone does not usually occur. Over the last decade, many risk factors have been identified for HO after surgical fixation of acetabular fractures; however, prophylaxis and treatment of this condition are controversial. Potential preventive measures range from NSAIDs to external beam irradiation, but recent studies have questioned the utility of these measures. The Brooker classification system, which has been correlated with patient function and outcomes, is most commonly used to describe HO severity. Advances will assist in the diagnosis, prevention, and management of HO as well as the assessment of risk factors that could affect outcomes.
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17
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Abstract
Better understanding of the biology of heterotopic ossification (HO) formation will lead to treatment and prevention modalities that can be directed specifically at the cellular level. Early identification of HO precursor cells and target genes may provide prognostic value that guides individualized prophylactic treatment. Better understanding of molecular signaling and proteomics variability will allow surgeons to individualize preemptive treatment to suppress inflammation and formation of HO. Careful surgical technique to avoid muscle damage is important. Damaged muscle should be debrided as a prophylactic measure. Hemostasis and avoidance of a postoperative hematoma may decrease the chance of formation of HO.
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Affiliation(s)
- William R Barfield
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street-Suite 708, Charleston, SC 29425, USA
| | - Robert E Holmes
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street-Suite 708, Charleston, SC 29425, USA
| | - Langdon A Hartsock
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street-Suite 708, Charleston, SC 29425, USA.
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18
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Elhassan Y, Abdelhaq A, Piggott RP, Osman M, McElwain JP, Leonard M. Heterotopic Ossification following acetabular fixation: Incidence and risk factors: 10-year experience of a tertiary centre. Injury 2016; 47:1332-6. [PMID: 26997132 DOI: 10.1016/j.injury.2016.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 02/15/2016] [Accepted: 03/04/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Heterotopic Ossification (HO) is a well-recognized complication following acetabular fracture fixation and its presence is prognostic for suboptimal clinical outcome. There are many controversies pertaining to its aetiology, including surgical approach, associated injuries and the use of HO prophylaxis. Long term data from high volume centres is necessary to address these issues. AIM To determine the incidence of HO post open reduction and internal fixation (ORIF) of acetabular fractures and to examine the associated risk and prognostic factors. METHOD We studied a cohort of 369 consecutive acetabular fractures that underwent ORIF at our institution over a 10 year period. Data was analyzed using univariate and multivariate logistic regression. RESULTS The existence of HO was evident in 65 patients (17.62%), of these 39 (60.0%) were Class I, 16 (24.6%) were Class II, 8 (12.3%) were Class III, and 2 (3.1%) were Class IV according to Brooker Classification. We found a significant association between admission to an Intensive Care Unit (ICU) (P-value=0.039), chest injury (P-value=0.013), multiple fractures (P-value=0.005), and the time lapse between injury and operation (P-value=0.025), and some statistical significance with surgical approach, ipsilateral fractures, open fractures, tibial and patellar fractures. Age over 30 years as the only prognostic factor for severe HO. Prophylaxis with Indomethacin did not appear to confer any benefit in our patient group. CONCLUSION The risk factors for developing HO following acetabular fracture fixation are multifactorial and include admission to ICU, associated chest injuries, multiple fractures and delay between injury and surgery. Surgical approach, ipsilateral fractures and tibia and patellar fractures may also play a role. Age over thirty years was the only prognostic factor for developing severe HO.
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Affiliation(s)
- Yahya Elhassan
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| | - Ady Abdelhaq
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| | - Robert P Piggott
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| | - Mugtaba Osman
- Department of Psychiatry, University College Dublin, Ireland.
| | - John P McElwain
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
| | - Mike Leonard
- National Centre for Pelvic & Acetabular Surgery, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital, Dublin 24, Ireland.
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Ranganathan K, Loder S, Agarwal S, Wong VW, Forsberg J, Davis TA, Wang S, James AW, Levi B, Levi B. Heterotopic Ossification: Basic-Science Principles and Clinical Correlates. J Bone Joint Surg Am 2015; 97:1101-11. [PMID: 26135077 PMCID: PMC6948799 DOI: 10.2106/jbjs.n.01056] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Heterotopic ossification occurs most commonly after joint arthroplasty, spinal cord injury, traumatic brain injury, blast trauma, elbow and acetabular fractures, and thermal injury.➤ The conversion of progenitor cells to osteogenic precursor cells as a result of cell-mediated interactions with the local tissue environment is affected by oxygen tension, pH, availability of micronutrients, and mechanical stimuli, and leads to heterotopic ossification.➤ Radiation and certain nonsteroidal anti-inflammatory medications are important methods of prophylaxis against heterotopic ossification.➤ Well-planned surgical excision can improve patient outcomes regardless of the joint involved or the initial cause of injury.➤ Future therapeutic strategies are focused on targeted inhibition of local factors and signaling pathways that catalyze ectopic bone formation.
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Affiliation(s)
- Kavitha Ranganathan
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shawn Loder
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shailesh Agarwal
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Victor W. Wong
- Department of Surgery, Johns Hopkins School of Medicine, 4924 Campbell Boulevard, Baltimore, MD 21236
| | - Jonathan Forsberg
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Thomas A. Davis
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Stewart Wang
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Aaron W. James
- Department of Pathology & Laboratory Medicine, University of California at Los Angeles, DGSOM, 200 Medical Plaza, Los Angeles, CA 90095
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
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