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Chen C, Song C, Liu B, Wang Y, Jia J, Pang K, Wang Y, Wang P. Activation of BMP4/SMAD pathway by HIF-1α in hypoxic environment promotes osteogenic differentiation of BMSCs and leads to ectopic bone formation. Tissue Cell 2024; 88:102376. [PMID: 38608407 DOI: 10.1016/j.tice.2024.102376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/15/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Heterotopic ossification (HO), also known as ossifying myositis, is a condition that produces abnormal bone and cartilage tissue in the soft tissues. Hypoxia inducible factor lα (HIF-lα) regulates the expression of various genes, which is closely related to the promotion of bone formation, and Drosophila mothers against decapentaplegic protein (SMAD) mediates the signal transduction in the Bone morphogenetic protein (BMP) signaling pathway, which affects the function of osteoblasts and osteoclasts, and thus plays a key role in the regulation of bone remodeling. We aimed to investigate the mechanism by which HIF-1α induces osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs) in a hypoxic environment. METHODS A cellular hypoxia model was constructed to verify the expression of HIF-1α, while alizarin red staining was performed to observe the osteogenic differentiation ability of bone marrow mesenchymal stem cells (BMSCs). Alizarin red staining was used to analyze the late mineralization ability of the cells. Western blot analysis was performed to analyze the expression levels of osteogenesis-related factors OCN, OPN proteins as well as the pathway proteins BMP4, p-Smad1/5/8, and Smad1. We also constructed a rat model of ectopic bone formation, observed ectopic ossification by X-ray, and verified the success of the rat model by ELISA of HIF-1α. HE staining was used to observe the matrix and trabecular structure of bone, and Masson staining was used to observe the collagen and trabecular structure of bone. Immunohistochemistry analyzed the expression of OCN and OPN in ectopic bone tissues, and WB analyzed the expression of pathway proteins BMP4, p-Smad1/5/8 and Smad1 in ectopic bone tissues to verify the signaling pathway of ectopic bone formation. RESULTS Our results indicate that hypoxic environment upregulates HIF-1a expression and activates BMP4/SMAD signaling pathway. This led to an increase in ALP content and enhanced expression of the osteogenesis-related factors OCN and OPN, resulting in enhanced osteogenic differentiation of BMSCs. The results of our in vivo experiments showed that rats inoculated with BMSCs overexpressing HIF-1α showed bony structures in tendon tissues, enhanced expression of the bone signaling pathways BMP4 and p-Smad1/5/8, and enhanced expression levels of the osteogenic-related factors OCN and OPN, resulting in the formation of ectopic bone. CONCLUSIONS These data further suggest a novel mechanistic view that hypoxic bone marrow BMSCs activate the BMP4/SMAD pathway by up-regulating the expression level of HIF-1α, thereby promoting the secretion of osteogenic factors leading to ectopic bone formation.
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Affiliation(s)
- Cong Chen
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai 264200, China
| | - Chunhao Song
- Department of Medical Imaging, Weihai Wendeng District People Hospital, Weihai 264200, China
| | - Bo Liu
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai 264200, China
| | - Yitao Wang
- Department of Laboratory, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai 264200, China
| | - Jun Jia
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai 264200, China
| | - Kai Pang
- Department of Operations Management, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai 264200, China
| | - Yuanhao Wang
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai 264200, China
| | - Peng Wang
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai 264200, China.
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Okuda R, Hirakawa A, Komura S, Terabayashi N, Matsumoto K, Akiyama H. Heterotopic ossification of the elbow exacerbated by revision surgery for ipsilateral proximal humeral fracture: A case report. J Orthop Sci 2024; 29:370-373. [PMID: 35351322 DOI: 10.1016/j.jos.2022.03.001] [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: 11/15/2021] [Revised: 01/26/2022] [Accepted: 03/02/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Ryota Okuda
- Department of Orthopaedic Surgery, Gifu University School of Medicine, Gifu, Japan
| | - Akihiro Hirakawa
- Department of Orthopaedic Surgery, Gifu University School of Medicine, Gifu, Japan.
| | - Shingo Komura
- Department of Orthopaedic Surgery, Gifu University School of Medicine, Gifu, Japan
| | - Nobuo Terabayashi
- Department of Orthopaedic Surgery, Gifu University School of Medicine, Gifu, Japan
| | - Kazu Matsumoto
- Department of Orthopaedic Surgery, Gifu University School of Medicine, Gifu, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University School of Medicine, Gifu, Japan
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Jean S, Godleski M. Anterior Elbow Heterotopic Ossification in Patient With Pemphigus Vulgaris: An Unheard Complication of a Rare Condition. J Burn Care Res 2023; 44:214-217. [PMID: 36309901 DOI: 10.1093/jbcr/irac162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Indexed: 01/11/2023]
Abstract
Pemphigus vulgaris is a potentially fatal disease within the epidermis with rare noncutaneous manifestations. Heterotopic ossification has not been previously described as one of the inherent complications of this skin pathology. A 44-year-old man presented with severe pemphigus vulgaris involving 80 to 90% of his body surface area. He had an extended time to wound closure of 5 months, as well as two additional months bed bound due to related infectious and respiratory complications. He progressively developed a worsening range of motion at his bilateral elbows. X-ray demonstrated bilateral anterior elbow heterotopic ossification. Passive and active range of motion exercises were initiated early in the course of his treatment and only yielded a small positive effect. Thus, screening for heterotopic ossification may be warranted when a significant joint range of motion is lost in cases of autoimmune cutaneous disease, and even more in the presence of severe open wounds with delayed wound closure.
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Affiliation(s)
- Stephanie Jean
- Department of Physical Medicine and Rehabilitation, Université de Montréal, Institut de réadaptation Gingras-Lindsay-de-Montréal, Montreal, QC, Canada
| | - Matthew Godleski
- Department of Physical Medicine and Rehabilitation, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Non-Oncological Radiotherapy: A Review of Modern Approaches. J Pers Med 2022; 12:jpm12101677. [PMID: 36294816 PMCID: PMC9605240 DOI: 10.3390/jpm12101677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022] Open
Abstract
Despite being usually delivered in oncological patients, radiotherapy can be used as a successful treatment for several non-malignant disorders. Even though this use of radiotherapy has been scarcely investigated since the 1950s, more recent interest has actually shed the light on this approach. Thus, the aim of this narrative review is to analyze the applications of non-oncological radiotherapy in different disorders. Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used. This review contains a narrative report and a critical discussion of non-oncological radiotherapy approaches. In conclusion, non-oncological radiotherapy is a safe and efficacious approach to treat several disorders that needs to be further investigated and used in clinical practice.
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Progressive brachial plexopathy secondary to heterotopic ossification formation after shoulder trauma: a case report. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-term outcomes of open arthrolysis combined with radial head arthroplasty for post-traumatic elbow stiffness: results are durable over 8 years. J Shoulder Elbow Surg 2022; 31:509-521. [PMID: 34808353 DOI: 10.1016/j.jse.2021.10.028] [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: 08/08/2021] [Revised: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Post-trauma elbow stiffness (PTES) is a common complication after elbow trauma that causes severe upper limb disability. Open elbow arthrolysis (OEA) with radial head arthroplasty (RHA) is an effective method to treat PTES with rotation limitation, or persistent pain/instability after radial head resection. However, no long-term results have been reported for this technique. This study aimed to show the clinical and radiographic outcomes of OEA with RHA over 8 years and compare its efficacy at 3 years (short-term). METHODS Patients with PTES treated by OEA with RHA between September 2010 and December 2012 were retrospectively reviewed. Seventeen patients were followed up over 8 years (range, 100-106 months). A bipolar prosthesis of RHA was performed during OEA. Preoperative, 3-year, and 8-year elbow and forearm motion, upper limb function, radiographic outcomes, and complications were recorded. RESULTS Clinically important improvements in elbow motion and forearm rotation were obtained, from 34° and 58° preoperatively, to 109° and 135° at 3 years, which were maintained over 8 years, to 113° (P = .262) and 134° (P = .489). The Mayo Elbow Performance Index had clinically important increases from the preoperative level of 58 to 94 points at 3 years, and was maintained over 8 years (95 points, P = .422), with 100% reporting excellent to good outcomes. Pain and nerve symptoms were also improved. Complications consisted of new-onset ulnar nerve symptoms in 1 patient, nonclinically significant heterotopic ossification recurrence in 3, humeroulnar arthritis exacerbation in 4, and periprosthetic lucency in 8. CONCLUSIONS OEA with RHA yielded satisfactory short-term outcomes for PTES at 3 years, with substantial improvements in elbow mobility and function, and the results were durable over the long term (8 years).
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Geller JS, Allegra PR, Seldon CS, Spieler BO, Cohen LL, Barnhill SW, Huntley SR, De La Zerda A, Samuels S, Wang L, Isrow D, Wolfson AH, Yechieli RL. Primary Versus Secondary Radiotherapy for Heterotopic Ossification Prevention About the Elbow. J Orthop Trauma 2022; 36:e56-e61. [PMID: 34050084 DOI: 10.1097/bot.0000000000002188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow. DESIGN Retrospective chart review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Two hundred and twenty-nine patients who received prophylactic radiotherapy (XRT) over a 15-year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow-up after XRT. Fifty-four patients were ultimately included. INTERVENTION All patients were treated with a single dose of 7 Gy. Ninety-eight percentage of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery. MAIN OUTCOMES MEASUREMENTS The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint. RESULTS Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT and 11.1% required surgery to resect the heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT and 5.5% required resection surgery. No secondary malignancies were identified. CONCLUSIONS Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow-up is required to better characterize populations at high risk for development of HO and secondary malignancy. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph S Geller
- University of Miami Miller School of Medicine, Miami, FL; and
| | | | - Crystal S Seldon
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL
| | - Benjamin O Spieler
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL
| | - Lara L Cohen
- University of Miami Miller School of Medicine, Miami, FL; and
| | | | | | - Alberto De La Zerda
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL
| | - Stuart Samuels
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL
| | - Lora Wang
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL
| | - Derek Isrow
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron H Wolfson
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL
| | - Raphael L Yechieli
- Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL
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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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Henstenburg JM, Sherman M, Ilyas AM. Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis. J Hand Microsurg 2021; 13:189-195. [PMID: 34511838 DOI: 10.1055/s-0040-1721880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Introduction Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence Level III.
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Affiliation(s)
- Jeffrey M Henstenburg
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Matthew Sherman
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Asif M Ilyas
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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Sun Z, Li J, Luo G, Liu W, He Y, Wang F, Qian Y, Fan C. Pharmacological activation of SIRT1 by metformin prevented trauma-induced heterotopic ossification through inhibiting macrophage mediated inflammation. Eur J Pharmacol 2021; 909:174386. [PMID: 34332919 DOI: 10.1016/j.ejphar.2021.174386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/24/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
Trauma-induced heterotopic ossification (HO) is the aberrant extra-skeletal bone formation that severely incapacitates patient's daily life. Inflammation is the first stage of this progression, becoming an appealing target of early therapeutic intervention. Metformin, a widely used antidiabetic drug, also poses the therapeutic potential to modulate various inflammatory-related diseases. Therefore, this study aimed to investigate the preventive effect of metformin on trauma-induced HO progression, and unveil the underlying molecular mechanisms. A murine burn/tenotomy model was established to mimic trauma-induced HO in vivo. The anti-inflammation and anti-ossification effects of metformin were evaluated by histological staining and micro-CT. The inhibitory effects of metformin on macrophages activation in vitro were examined by ELISA and qRT-PCR. The underlying molecular mechanisms were further explored by immunofluorescence staining and western-blotting in vivo. Increased macrophages infiltration and inflammatory responses were found at early stage during HO progression. However, metformin dose-dependently attenuated the macrophage-mediated inflammatory responses both in vivo and vitro, which might account for the inhibitory effect of metformin on chondrogenesis and HO formation after trauma. Furthermore, elevated SIRT1 expression and decreased NF-κB p65 acetylation were found in the beneficial effects of metformin. Moreover, similar preventive effects were also found in SRT1720 HCI, a specific SIRT1 activator, while were remarkably reversed after the administration of EX527 (a specific SIRT1 inhibitor) with metformin. Taken together, our results provide a novel evidence that metformin can effectively attenuate trauma-induced HO by mitigating macrophage inflammatory responses through inhibiting NF-κB signaling via SIRT1-dependent mechanisms, which favors future therapeutic investigations for trauma-related disease.
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Affiliation(s)
- Ziyang Sun
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, 201306, PR China
| | - Juehong Li
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, 201306, PR China
| | - Gang Luo
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, 201306, PR China
| | - Weixuan Liu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, 201306, PR China
| | - Yunwei He
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, 201306, PR China
| | - Feiyan Wang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, 201306, PR China
| | - Yun Qian
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, 201306, PR China.
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, PR China; Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, 201306, PR China.
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Alexander KA, Tseng HW, Salga M, Genêt F, Levesque JP. When the Nervous System Turns Skeletal Muscles into Bones: How to Solve the Conundrum of Neurogenic Heterotopic Ossification. Curr Osteoporos Rep 2020; 18:666-676. [PMID: 33085000 DOI: 10.1007/s11914-020-00636-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Neurogenic heterotopic ossification (NHO) is the abnormal formation of extra-skeletal bones in periarticular muscles after damage to the central nervous system (CNS) such as spinal cord injury (SCI), traumatic brain injury (TBI), stroke, or cerebral anoxia. The purpose of this review is to summarize recent developments in the understanding of NHO pathophysiology and pathogenesis. Recent animal models of NHO and recent findings investigating the communication between CNS injury, tissue inflammation, and upcoming NHO therapeutics are discussed. RECENT FINDINGS Animal models of NHO following TBI or SCI have shown that NHO requires the combined effects of a severe CNS injury and soft tissue damage, in particular muscular inflammation and the infiltration of macrophages into damaged muscles plays a key role. In the context of a CNS injury, the inflammatory response to soft tissue damage is exaggerated and persistent with excessive signaling via substance P-, oncostatin M-, and TGF-β1-mediated pathways. This review provides an overview of the known animal models and mechanisms of NHO and current therapeutic interventions for NHO patients. While some of the inflammatory mechanisms leading to NHO are common with other forms of traumatic and genetic heterotopic ossifications (HO), NHOs uniquely involve systemic changes in response to CNS injury. Future research into these CNS-mediated mechanisms is likely to reveal new targetable pathways to prevent NHO development in patients.
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Affiliation(s)
- Kylie A Alexander
- Mater Research Institute, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, Queensland, 4102, Australia
| | - Hsu-Wen Tseng
- Mater Research Institute, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, Queensland, 4102, Australia
| | - Marjorie Salga
- Department of Physical Medicine and Rehabilitation, CIC 1429, Raymond Poincaré Hospital, APHP, Garches, France
- END:ICAP U1179 INSERM, University of Versailles Saint Quentin en Yvelines, UFR Simone Veil-Santé, Montigny le Bretonneux, France
| | - François Genêt
- Department of Physical Medicine and Rehabilitation, CIC 1429, Raymond Poincaré Hospital, APHP, Garches, France
- END:ICAP U1179 INSERM, University of Versailles Saint Quentin en Yvelines, UFR Simone Veil-Santé, Montigny le Bretonneux, France
| | - Jean-Pierre Levesque
- Mater Research Institute, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, Queensland, 4102, Australia.
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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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Treatment methods for post-traumatic elbow stiffness caused by heterotopic ossification. J Shoulder Elbow Surg 2020; 29:1380-1386. [PMID: 32553438 DOI: 10.1016/j.jse.2020.02.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/13/2020] [Accepted: 02/20/2020] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Heterotopic ossification (HO) is a common complication of surgically treated elbow fractures that can inhibit range of motion and impair quality of life. Although there are many treatment methods for HO, there is a lack of consensus as to the best option. We hypothesized that contracture release combined with Botox injection would lead to improved functional outcome scores when compared with current treatment methods. METHODS A retrospective review was conducted of patients who presented to a single surgeon with HO secondary to elbow fracture between 2005 and 2018. A total of 59 patients were identified who met inclusion criteria. Data were classified into 3 groups: contracture release (control - CR), Botox injection with CR (Botox + CR), and radiation therapy with CR (CR + RT). Range of motion measurements were obtained, including flexion, extension, pronation, and supination. RESULTS A total of 30 patients (30 of 59, 50.8%) received CR, 6 (6 of 59, 9.2%) were treated with CR + RT, and 23 (23 of 59, 40.0%) had CR + Botox. There was a significant difference between pre- and postoperative arc of motion for both CR + RT (P < .01) and CR + Botox (P < .01). In addition, there was a significant difference in pre- and postoperative extension for patients who received intraoperative Botox injections (P < .05). There was no significant difference between pre- and postoperative motion nor extension in the CR group. CONCLUSION Intraoperative Botox injection with CR is an effective method in the treatment of post-traumatic elbow stiffness caused by HO.
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Wang S, Tian J, Wang J, Liu S, Ke L, Shang C, Yang J, Wang L. Identification of the Biomarkers and Pathological Process of Heterotopic Ossification: Weighted Gene Co-Expression Network Analysis. Front Endocrinol (Lausanne) 2020; 11:581768. [PMID: 33391181 PMCID: PMC7774600 DOI: 10.3389/fendo.2020.581768] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/12/2020] [Indexed: 12/19/2022] Open
Abstract
Heterotopic ossification (HO) is the formation of abnormal mature lamellar bone in extra-skeletal sites, including soft tissues and joints, which result in high rates of disability. The understanding of the mechanism of HO is insufficient. The aim of this study was to explore biomarkers and pathological processes in HO+ samples. The gene expression profile GSE94683 was downloaded from the Gene Expression Omnibus database. Sixteen samples from nine HO- and seven HO+ subjects were analyzed. After data preprocessing, 3,529 genes were obtained for weighted gene co-expression network analysis. Highly correlated genes were divided into 13 modules. Finally, the cyan and purple modules were selected for further study. Gene ontology functional annotation and Kyoto Encyclopedia of Genes and Genomes pathway enrichment indicated that the cyan module was enriched in a variety of components, including protein binding, membrane, nucleoplasm, cytosol, poly(A) RNA binding, biosynthesis of antibiotics, carbon metabolism, endocytosis, citrate cycle, and metabolic pathways. In addition, the purple module was enriched in cytosol, mitochondrion, protein binding, structural constituent of ribosome, rRNA processing, oxidative phosphorylation, ribosome, and non-alcoholic fatty liver disease. Finally, 10 hub genes in the cyan module [actin related protein 3 (ACTR3), ADP ribosylation factor 4 (ARF4), progesterone receptor membrane component 1 (PGRMC1), ribosomal protein S23 (RPS23), mannose-6-phosphate receptor (M6PR), WD repeat domain 12 (WDR12), synaptosome associated protein 23 (SNAP23), actin related protein 2 (ACTR2), siah E3 ubiquitin protein ligase 1 (SIAH1), and glomulin (GLMN)] and 2 hub genes in the purple module [proteasome 20S subunit alpha 3 (PSMA3) and ribosomal protein S27 like (RPS27L)] were identified. Hub genes were validated through quantitative real-time polymerase chain reaction. In summary, 12 hub genes were identified in two modules that were associated with HO. These hub genes could provide new biomarkers, therapeutic ideas, and targets in HO.
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What Range of Motion and Functional Results Can Be Expected After Open Arthrolysis with Hinged External Fixation For Severe Posttraumatic Elbow Stiffness? Clin Orthop Relat Res 2019; 477:2319-2328. [PMID: 31107330 PMCID: PMC6999955 DOI: 10.1097/corr.0000000000000726] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The elbow is more susceptible to loss of motion after trauma than any other joint. Open arthrolysis often is performed for posttraumatic elbow stiffness if the stiffness does not improve with nonsurgical treatment, but the midterm results of this procedure and factors that may limit recovery have not been widely studied. QUESTIONS/PURPOSES We reviewed patients who had undergone open arthrolysis with hinged external fixator for severe posttraumatic elbow stiffness (ROM ≤ 60°) with a minimum of 5 years followup to (1) analyze ROM gains; (2) assess functional improvement with the Mayo Elbow Performance Index (MEPI) and DASH, quality of life with the SF-36, pain with VAS, and ulnar nerve function with the Amadio rating scale and Dellon classification; and (3) identify complications and risk factors that might hinder mid-term elbow motion recovery after this procedure. METHODS Between March 2011 and December 2012, we generally offered patients with elbow stiffness an open arthrolysis procedure when function did not improve with 6 months of nonoperative therapy, and no contraindications such as immature heterotopic ossification or complete destruction of articular cartilage were present. During that time, 161 patients underwent open arthrolysis for posttraumatic elbow stiffness at our institution; 49 of them satisfied the study inclusion criteria (adults with elbow ROM ≤ 60° as a result of trauma) and exclusion criteria (stiffness caused by burns or central nervous system injuries, causative trauma associated with nonunion or malunion of the elbow, severe articular damage that would have necessitated joint arthroplasty, or prior elbow release). In general, a combined medial-lateral approach to the elbow was performed to address the soft tissue tethers and any blocks to elbow motion, and a hinged external fixator was applied for 6 weeks to maintain elbow stability and improve the efficacy of postoperative rehabilitation. These patients were evaluated retrospectively at a mean followup period of 69 months (range, 62-83 months), and demographics, disease characteristics, arthrolysis details, pre- and postoutcome measures as noted, and complications were recorded via an electronic database. Multivariate regression analysis was performed to identify factors associated with ROM recovery. RESULTS At final followup, total ROM increased from a preoperative mean of 27 ± 20° to a postoperative mean of 131 ± 11° (mean difference, 104°; 95% CI, 98°-111°; p < 0.001), and 98% (48 of 49) of patients achieved a functional ROM of 30° to 130°. Improvements were also found in functional scores (MEPI: 54 ± 12 to 95 ± 7, mean difference, 41 points; DASH: 48 ± 17 to 8 ± 8, mean difference, 40 points; both p < 0.001), life quality (physical SF-36: 46 ± 11 to 81 ± 12, mean difference, 35 points; mental SF-36: 43 ± 14 to 80 ± 9, mean difference, 37 points; both p < .001), pain (VAS: 2.5 ± 2.4 to 0.4 ± 0.8; mean difference, 2.0 points; p < 0.001), and ulnar nerve function (Amadio score: 7.8 ± 1.9 to 8.4 ± 0.8; mean difference, 0.6 points; p = 0.004). A total of 18% (nine of 49 patients) developed complications, including new-onset or exacerbated nerve symptoms (four patients), recurrent heterotopic ossification (two patients), and pin-related infections (three patients). No patients underwent subsequent surgery for any of the above complications. Lastly, the medium-term ROM was divided into ROM ≤ 120° (n = 9) and ROM > 120° (n = 40). After controlling for potential confounding variables such as duration of stiffness and tobacco use, we found that tobacco use was the only independent risk factor examined (odds ratio, 9; 95% CI, 2-47; p = 0.009) associated with recovery of ROM. CONCLUSIONS Satisfactory medium-term results were found for open arthrolysis with hinged external fixation with our protocol in patients who had severe posttraumatic elbow stiffness. Appropriate and sufficient releases of tethered soft tissues and correction of any blocks that affect elbow motion intraoperatively, a dedicated team approach, and an aggressive and systematic postoperative rehabilitation program are the core steps for this procedure. Additionally, the importance of preoperative discontinuation of tobacco use should be emphasized. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Yu S, Chen M, Fan C. Team Approach: Elbow Contracture Due to Heterotopic Ossification. JBJS Rev 2019; 5:01874474-201701000-00004. [PMID: 28135231 DOI: 10.2106/jbjs.rvw.16.00008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Shiyang Yu
- 1Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Meyers C, Lisiecki J, Miller S, Levin A, Fayad L, Ding C, Sono T, McCarthy E, Levi B, James AW. Heterotopic Ossification: A Comprehensive Review. JBMR Plus 2019; 3:e10172. [PMID: 31044187 PMCID: PMC6478587 DOI: 10.1002/jbm4.10172] [Citation(s) in RCA: 245] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 12/31/2018] [Accepted: 01/13/2019] [Indexed: 12/17/2022] Open
Abstract
Heterotopic ossification (HO) is a diverse pathologic process, defined as the formation of extraskeletal bone in muscle and soft tissues. HO can be conceptualized as a tissue repair process gone awry and is a common complication of trauma and surgery. This comprehensive review seeks to synthesize the clinical, pathoetiologic, and basic biologic features of HO, including nongenetic and genetic forms. First, the clinical features, radiographic appearance, histopathologic diagnosis, and current methods of treatment are discussed. Next, current concepts regarding the mechanistic bases for HO are discussed, including the putative cell types responsible for HO formation, the inflammatory milieu and other prerequisite “niche” factors for HO initiation and propagation, and currently available animal models for the study of HO of this common and potentially devastating condition. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Carolyn Meyers
- Department of Pathology Johns Hopkins University Baltimore MD USA
| | | | - Sarah Miller
- Department of Pathology Johns Hopkins University Baltimore MD USA
| | - Adam Levin
- Department of Orthopaedic Surgery Johns Hopkins University Baltimore MD USA
| | - Laura Fayad
- Department of Radiology Johns Hopkins University Baltimore MD USA
| | - Catherine Ding
- UCLA and Orthopaedic Hospital Department of Orthopaedic Surgery and the Orthopaedic Hospital Research Center Los Angeles CA USA
| | - Takashi Sono
- Department of Pathology Johns Hopkins University Baltimore MD USA
| | - Edward McCarthy
- Department of Pathology Johns Hopkins University Baltimore MD USA
| | - Benjamin Levi
- Department of Surgery University of Michigan Ann Arbor MI USA
| | - Aaron W James
- Department of Pathology Johns Hopkins University Baltimore MD USA.,UCLA and Orthopaedic Hospital Department of Orthopaedic Surgery and the Orthopaedic Hospital Research Center Los Angeles CA USA
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Abstract
Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.The following presentation reviews the recent literature on pathomechanisms and treatment alternatives. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062.
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Affiliation(s)
- Lars Adolfsson
- Department of Orthopaedics, University Hospital of Linköping, Sweden
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19
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Abstract
Around one third of humeral fractures and 2–6% of all fractures occur to the distal part of the humerus. There is a bimodal distribution differentiating between young male patients with high-energy and elderly female patients with low-energy trauma related to osteoporosis. The AO classification and Dubberley subclassification are used in daily routine. Most fractures are diagnosed on radiographs. For further evaluation, three-dimensional computed tomography is recommended, especially for comminuted or complex fractures. Owing to the long immobilization and resultant poor functional outcome, conservative treatment is followed for inoperable patients. The operative approach and osteosynthesis depend on the fracture pattern. In A1 avulsion fractures, open reduction and screw fixation are recommended. In A2/A3 fractures, a triceps-sparing approach following a 90° double-plate construction (radial dorsal/ulnar lateral) with locking plates is favored. Partial articular B1/B2 fractures are exposed via a medial or lateral approach using unilateral locking plates to stabilize the medial/lateral column. Coronal shear fractures (B3) are classified after Dubberley and are treated via an extended Kocher approach and headless compression screws in anteroposterior direction. If there is a further posterior comminution or a lateral column fragment, stabilization is needed for the lateral/medial column with a precontoured locking plate. In solely articular fracture patterns, a dorsal approach with either a 90° or 180° double-plate construction is advised. If a reconstruction is not possible owing to fracture complexity or bone quality, total elbow arthroplasty is a viable option. However, lifelong limitation in weight-bearing up to 5 kg, limited longevity, and the potential for complicated revision surgery should be considered.
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21
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Wound breakdown reconstructed by reverse lateral arm flap after excision of heterotopic ossification of the elbow following severe burn injury: A case report. BURNS OPEN 2017. [DOI: 10.1016/j.burnso.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Sandeep KN, Suresh G, Gopisankar B, Abhishek N, Sujiv A. Does Excision of Heterotopic Ossification of the Elbow Result in Satisfactory Patient-Rated Outcomes? Malays Orthop J 2017; 11:35-40. [PMID: 28435572 PMCID: PMC5393112 DOI: 10.5704/moj.1703.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Treatment of heterotopic ossification (HO) of the elbow is challenging and fraught with complications. Patients who sustain direct trauma to the elbow joint, the central nervous system, and thermal burns are at increased risk for development of HO. There is a paucity of studies and reports on patient’s self-evaluation after the excision of the heterotopic ossification. Materials and Methods This retrospective study assessed outcomes after excision of heterotopic ossification around the elbow in a cohort of ten patients operated from 2012 to 2015. The outcome assessment was done by the Mayo Elbow Performance index (MEPI) and the American Shoulder and Elbow Surgeons-Elbow score (ASES-E scores). Results The mean follow-up was 18.11 months after the operation. The Mayo Elbow Performance Score was excellent in two elbows, good in six and fair in two. The mean gain in flexion-extension arc after excision of HO was 80 degrees. All of the patients had residual flexion deformity postoperatively. Eight of the nine patients were able to do activities requiring flexion at final follow-up. Conclusion Excision of HO around the elbow is associated with satisfactory patient-rated outcomes in spite of failure to regain full range of motion.
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Affiliation(s)
- K N Sandeep
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - G Suresh
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - B Gopisankar
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - N Abhishek
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - A Sujiv
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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Restoring independency with an osteochondral graft of the navicular for coronoid process reconstruction. Arch Orthop Trauma Surg 2017; 137:225-232. [PMID: 28083637 DOI: 10.1007/s00402-016-2623-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The coronoid is a crucial element for elbow stability. In case of posttraumatic instability or reduced range of motion, a complex reconstruction might be necessary. CASE We present the case of a polytraumatized patient with complex upper extremity injury and initial poor outcome. Subluxation after initial surgery was treated by sublime tubercle reconstruction with a corticocancellous iliac crest graft. Due to massive ossification, the elbow remained stiff and the paraplegic patient was unable to use a manually propelled wheelchair. After arthrolysis, the unstable elbow was treated with an osteocartilaginous graft from the navicular of the foot as well as ulnar and radial collateral ligamentoplasties. At the time of follow-up, the patient had a stable joint and was able to independently perform activities of daily living. CONCLUSION An autologous navicular graft seems to be an excellent option for our paraplegic patient as the shape matches the sublime tubercle of the ulna.
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Agarwal S, Loder SJ, Sorkin M, Li S, Shrestha S, Zhao B, Mishina Y, James AW, Levi B. Analysis of Bone-Cartilage-Stromal Progenitor Populations in Trauma Induced and Genetic Models of Heterotopic Ossification. Stem Cells 2016; 34:1692-701. [PMID: 27068890 DOI: 10.1002/stem.2376] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 03/14/2016] [Indexed: 11/09/2022]
Abstract
Heterotopic ossification (HO), the formation of extra-skeletal bone in soft tissues, is a pathologic process occurring after substantial burns or trauma, or in patients with type I bone morphogenetic protein (BMP) receptor hyperactivating mutations. Identifying the cells responsible for de novo bone formation during adulthood is of critical importance for therapeutic and regenerative purposes. Using a model of trauma-induced HO with hind limb Achilles' tenotomy and dorsal burn injury and a genetic nontrauma HO model (Nfatc1-Cre/caAcvr1(fl/wt) ), we demonstrate enrichment of previously defined bone-cartilage-stromal progenitor cells (BCSP: AlphaV+/CD105+/Tie2-/CD45-/Thy1-/6C3-) at the site of HO formation when compared with marrow isolated from the ipsilateral hind limb, or from tissue of the contralateral, uninjured hind limb. Upon transplantation into tenotomy sites soon after injury, BCSPs isolated from neonatal mice or developing HO incorporate into the developing lesion in cartilage and bone and express chondrogenic and osteogenic transcription factors. Additionally, BCSPs isolated from developing HO similarly incorporate into new HO lesions upon transplantation. Finally, adventitial cells, but not pericytes, appear to play a supportive role in HO formation. Our findings indicate that BCSPs contribute to de novo bone formation during adulthood and may hold substantial regenerative potential. Stem Cells 2016;34:1692-1701.
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Affiliation(s)
- Shailesh Agarwal
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shawn J Loder
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Sorkin
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shuli Li
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Swati Shrestha
- Department of Pathology & Laboratory Medicine and Orthopaedic Hospital Research Center, University of California, Los Angeles
| | - Bin Zhao
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Yuji Mishina
- School of Dentistry, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron W James
- Department of Pathology & Laboratory Medicine and Orthopaedic Hospital Research Center, University of California, Los Angeles
| | - Benjamin Levi
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Jentzsch T, Zimmermann SM, Nicholls F, Cinelli P, Simmen HP, Werner CML. Echinomycin did not affect the safety of fracture healing: an experimental pilot study on a murine femur fracture model. Patient Saf Surg 2016; 10:7. [PMID: 26884813 PMCID: PMC4754826 DOI: 10.1186/s13037-016-0094-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/02/2016] [Indexed: 11/25/2022] Open
Abstract
Background There is a need for effective drugs in the prevention and treatment of heterotopic ossifications (HO) after fractures. Echinomycin has been shown to prevent formation of HO in an animal model. However, before it may be considered as an option against HO, it needs to be studied whether it prevents fracture healing similar to non-steroidal anti-inflammatory drugs (NSAIDS). Therefore, the hypothesis was that echinomycin prevents fracture healing and callus formation. Methods In an experimental murine pilot study, standard blunt femur fractures were induced and retrograde intramedullary compression fixation of the femur was performed. The treatment group (n = 8) received echinomycin (0.3 mg/kg body weight) and the control group (n = 8) did not receive echinomycin. The fractures and implant positions were verified by conventional X-rays immediately postoperatively. As the primary outcome variable, fracture healing (osseous consolidation) was evaluated by conventional X-rays and micro-computed tomography (CT) scans after ten weeks and graded as healed, partial or complete pseudarthrosis. The secondary outcome, callus formation, was graded semi-quantitatively from 0 (mostly absent) to 3 (maximum). Results Fracture healing was present in all living cases after ten weeks concerning the treatment group. Partial pseudarthrosis was seen in two cases, one in the treatment and another one in the control group. Complete pseudarthrosis was seen in one case of the control group after an open fracture. Callus formation was similar in both groups with a mean grade of 1.5 within each group. Two cases of the treatment group died. Conclusion As a novel finding, echinomycin did not inhibit fracture healing or callus formation in this in vivo murine standard femur fracture model pilot study. Further studies involving a larger number of cases, quantitative assessment with CT scans and histopathological analysis are needed before generalizing the results of this pilot study.
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Affiliation(s)
- Thorsten Jentzsch
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Stefan M Zimmermann
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Flora Nicholls
- Central Biological Laboratory, University Hospital Zurich, Ramistrasse 100, Zurich, 8091 Switzerland
| | - Paolo Cinelli
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Hans-Peter Simmen
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Clément M L Werner
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
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Jennings JD, Hahn A, Rehman S, Haydel C. Management of Adult Elbow Fracture Dislocations. Orthop Clin North Am 2016; 47:97-113. [PMID: 26614925 DOI: 10.1016/j.ocl.2015.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.
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Affiliation(s)
- John D Jennings
- Department of Orthopedic Surgery and Sports Medicine, Temple University Hospital, 3501 North Broad Street, Philadelphia, PA 19140, USA.
| | - Alexander Hahn
- Department of Orthopedic Surgery and Sports Medicine, Temple University School of Medicine, 3501 N. Broad St, Philadelphia, PA 19102, USA
| | - Saqib Rehman
- Department of Orthopedic Surgery and Sports Medicine, Temple University Hospital, 3501 North Broad Street, Philadelphia, PA 19140, USA
| | - Christopher Haydel
- Department of Orthopedic Surgery and Sports Medicine, Temple University Hospital, 3501 North Broad Street, Philadelphia, PA 19140, USA
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Heterotopic Ossification following Tissue Transfer for Combat-Casualty Complex Periarticular Injuries. Plast Reconstr Surg 2015; 136:808e-814e. [DOI: 10.1097/prs.0000000000001796] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Ranganathan K, Loder S, Agarwal S, Wong VW, Forsberg J, Davis TA, Wang S, James AW, Levi B, Levi B. Heterotopic Ossification: Basic-Science Principles and Clinical Correlates. J Bone Joint Surg Am 2015; 97:1101-11. [PMID: 26135077 PMCID: PMC6948799 DOI: 10.2106/jbjs.n.01056] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Heterotopic ossification occurs most commonly after joint arthroplasty, spinal cord injury, traumatic brain injury, blast trauma, elbow and acetabular fractures, and thermal injury.➤ The conversion of progenitor cells to osteogenic precursor cells as a result of cell-mediated interactions with the local tissue environment is affected by oxygen tension, pH, availability of micronutrients, and mechanical stimuli, and leads to heterotopic ossification.➤ Radiation and certain nonsteroidal anti-inflammatory medications are important methods of prophylaxis against heterotopic ossification.➤ Well-planned surgical excision can improve patient outcomes regardless of the joint involved or the initial cause of injury.➤ Future therapeutic strategies are focused on targeted inhibition of local factors and signaling pathways that catalyze ectopic bone formation.
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Affiliation(s)
- Kavitha Ranganathan
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shawn Loder
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shailesh Agarwal
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Victor W. Wong
- Department of Surgery, Johns Hopkins School of Medicine, 4924 Campbell Boulevard, Baltimore, MD 21236
| | - Jonathan Forsberg
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Thomas A. Davis
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Stewart Wang
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Aaron W. James
- Department of Pathology & Laboratory Medicine, University of California at Los Angeles, DGSOM, 200 Medical Plaza, Los Angeles, CA 90095
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
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Abstract
Compared with arthroscopic release, open release is more commonly used for the treatment of stiff elbow. Flexion is recovered by releasing posterior tethering soft-tissue structures and by removing anterior impingement between the coronoid and/or radial head and the distal humerus. Extension is improved by releasing anterior soft-tissue tethers and by removing impingement between the olecranon tip and the olecranon fossa. Open elbow release is most commonly performed via ligament-sparing approaches. Ulnar nerve identification and transposition is recommended in the presence of nerve dysfunction or when correction of significant loss of elbow flexion is anticipated. Long-term improvement in flexion and extension can be expected with proper patient selection. Less predictable results are obtained in adolescent patients and in those with underlying traumatic brain injury.
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