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Stevens KN, Malone KJ. Posttraumatic Compressive Neuropathy of the Deep Motor Branch of the Ulnar Nerve Caused by Heterotopic Ossification. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:418-421. [PMID: 38817752 PMCID: PMC11133912 DOI: 10.1016/j.jhsg.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/25/2024] [Indexed: 06/01/2024] Open
Abstract
We report a case of posttraumatic compressive neuropathy of the deep motor branch of the ulnar nerve occurring in the setting of heterotopic ossification following a direct blow to the hypothenar eminence. Over several weeks, the patient developed ring and little finger claw deformities and atrophy of his first dorsal interosseous and adductor pollicis muscles with sparing of sensation. Electromyography and nerve conduction study localized the area of injury, and computed tomography confirmed the presence of heterotopic bone near the deep motor branch of the ulnar nerve. Intraoperatively, the deep motor branch of the ulnar nerve was under tension as it traversed volarly over the hook of hamate and heterotopic bone. Decompression of the deep motor branch of the ulnar nerve with resection of heterotopic bone and the hook of hamate was performed. Six months postoperatively, the patient demonstrated resolution of clawing and improving strength of his ulnar nerve innervated intrinsic muscles.
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Affiliation(s)
- Kali N. Stevens
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Kevin J. Malone
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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Heterotopic Ossification Complicating Traumatic Ulnar Nerve Palsy in a Child. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4089. [PMID: 35169522 PMCID: PMC8830818 DOI: 10.1097/gox.0000000000004089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022]
Abstract
Heterotopic ossification (HO) refers to the process of forming bony tissues in extra-skeletal sites such as muscles and soft tissues. This pathological process most commonly commences following trauma, surgery, and fractures. Rarely, HO can compress nearby neurovascular structures. To the best of our knowledge, however, no previous reports exist of HO serving as second-hit to partially injured ulnar nerve in the pediatric population. We present a case of a 6-year-old girl with complete high ulnar nerve palsy caused by medial epicondylar fracture followed by development of HO around the elbow. The patient was initially managed conservatively. Four months after the first visit, she presented with complete ulnar nerve palsy that was not evident on the initial presentation. Based on further investigations, she was taken to OR for release of the cubital tunnel and anterior transposition of ulnar nerve. On further follow-up, the patient regained sensory and motor functions of the ulnar nerve with minimum sequalae. Post-traumatic ulnar nerve injury is well described in the literature as resulting from initial trauma or as an iatrogenic injury following fracture reduction and fixation. HO in the pediatric age group is considerably rare, occurring after trauma and burn injuries. Surgical timing of HO release remains controversial. No previous reports of HO complicating traumatic ulnar nerve palsy in pediatric patients exist. In the current case report, partial ulnar nerve injury was initially due to medial epicondylar fracture, but it had progressed to full blown ulnar palsy secondary to superimposed HO. Early HO takedown combined with decompression of ulnar nerve are crucial to ensure complete nerve recovery.
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Khelil K, Znagui T, Khezami M, Achouri M, Hamdi M, Nouisri L. [Neurogenic paraosteopathy of the elbow: results of surgical arthrolysis (a retrospective study of 37 cases)]. Pan Afr Med J 2019; 34:131. [PMID: 33708300 PMCID: PMC7906558 DOI: 10.11604/pamj.2019.34.131.16685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 08/14/2019] [Indexed: 11/11/2022] Open
Abstract
Neurogenic paraosteoarthropathies are ectopic ossifications which develop near the joints. They are a process of neo-ectopic osteogenesis occurring after central or peripheral neurological lesions, in some types of comas (oxygen carbon intoxication, prolonged sedation) and following peripheral traumas including burns. They inolve almost exclusively the large proximal joints of the limbs. Elbow is the second area of involvment. The purpose of our study was to analyze the results of surgical arthrolysis in 37 patients with elbow stiffness due to neurogenic osteoarthropathy of the elbow. We conducted a retrospective study of 35 patients and 37 elbows over a 25-year period. Preoperative assessment included clinical and radiological examination. Since 2003 the patients had undergone systematic elbow arthroscopy. The gold standard surgical treatment was arthrolysis. All patients underwent functional rehabilitation protocol. Outcomes were analyzed after a mean 5-year follow-up period (6 months - 10 years). Neurogenic paraosteoarthropathy was caused by head injury with coma in 58.8% of cases. Preoperative assessment showed bending stiffness in the majority of cases (88%), severe or very severe in 64.7% of cases. Intraoperatively functional elbow range of motion from -30° to 130° was obtained in 61.7% of cases and in 41% of cases in the long term. Ulnar nerve liberation was satisfactory in 92% of cases. No postoperative instability of the elbow was reported. Two patients with definitive neurological lesions had osteoma recurrence. The results were equivalent regardless surgical delay. Surgical arthrolysis is an effective treatment for neurogenic osteomas of the elbow.
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Affiliation(s)
- Khaled Khelil
- Service de Chirurgie Orthopédique et Traumatologique, Hôpital Militaire Principal d'Instruction de Tunis, Tunisie
| | - Talel Znagui
- Service de Chirurgie Orthopédique et Traumatologique, Hôpital Militaire Principal d'Instruction de Tunis, Tunisie
| | - Mounira Khezami
- Service de Chirurgie Orthopédique et Traumatologique, Hôpital Militaire Principal d'Instruction de Tunis, Tunisie
| | - Mohamed Achouri
- Service de Chirurgie Orthopédique et Traumatologique, Hôpital Militaire Principal d'Instruction de Tunis, Tunisie
| | - Mounir Hamdi
- Service de Chirurgie Orthopédique et Traumatologique, Hôpital Militaire Principal d'Instruction de Tunis, Tunisie
| | - Lotfi Nouisri
- Service de Chirurgie Orthopédique et Traumatologique, Hôpital Militaire Principal d'Instruction de Tunis, Tunisie
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Sarman H, Isik C, Boz M, Boyraz I, Koc B, Turkoglu SA. IS RDW A PREDICTIVE PARAMETER FOR CUBITAL TUNNEL SYNDROME PATIENTS REQUIRING SURGERY? ACTA ORTOPEDICA BRASILEIRA 2016; 24:187-190. [PMID: 28243171 PMCID: PMC5035689 DOI: 10.1590/1413-785220162404156646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/23/2016] [Indexed: 12/05/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether haemogram parameters are predictive factors for both the severity of the disease and a decision in favor of surgical treatment in patients with an established diagnosis of cubital tunnel syndrome (CuTS) . METHODS The medical files of patients with a diagnosis of CuTS who were followed-up conservatively (n=92) or surgically treated (n=92) were retrospectively screened and the haemogram parameters were recorded . RESULTS The receiver operating characteristic (ROC) curve analysis revealed an area of 0.665 under the curve, with 76.3% sensitivity and 84.8% specificity at the cut-off of a red cell distribution width (RDW) level grater than 15.45%. RDW levels higher than 15.5%, electromyography (EMG) severity, and a clinical score higher than three were found to be independently associated with surgery . CONCLUSION An elevated RDW value was related to the severity of the electromyogram. RDW may, therefore, be a useful independent predictor for the decision to surgical treatment of CuTS. Level of Evidence III, Retrospective Study.
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Affiliation(s)
- Hakan Sarman
- . Abant Izzet Baysal University, School of Medicine, Department of Orthopaedics and Traumatology, Bolu, Turkey
| | - Cengiz Isik
- . Abant Izzet Baysal University, School of Medicine, Department of Orthopaedics and Traumatology, Bolu, Turkey
| | - Mehmet Boz
- . Abant Izzet Baysal University, School of Medicine, Department of Orthopaedics and Traumatology, Bolu, Turkey
| | - Ismail Boyraz
- . Abant Izzet Baysal University, School of Medicine, Department of Physical Medicine and Rehabilitation, Bolu, Turkey
| | - Bunyamin Koc
- . Abant Izzet Baysal University, School of Medicine, Department of Physical Medicine and Rehabilitation, Bolu, Turkey
| | - Sule Aydin Turkoglu
- . Abant Izzet Baysal University, School of Medicine, Department of Neurology, Bolu, Turkey
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Pavey GJ, Polfer EM, Nappo KE, Tintle SM, Forsberg JA, Potter BK. What Risk Factors Predict Recurrence of Heterotopic Ossification After Excision in Combat-related Amputations? Clin Orthop Relat Res 2015; 473:2814-24. [PMID: 25832006 PMCID: PMC4523520 DOI: 10.1007/s11999-015-4266-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is common after combat-related amputations and surgical excision remains the only definitive treatment for persistently symptomatic HO. There is no consensus in the literature regarding the timing of surgery, and recurrence frequency, reexcision, and complications have not been reported in large numbers of patients. QUESTIONS/PURPOSES (1) What are the rates of symptomatic recurrence resulting in reexcision and other complications resulting in reoperation in patients with HO? (2) Is either radiographic or symptomatic recurrence dependent on timing and type of initial surgery, the experience of the surgeon in performing the procedure, the severity of preexcision HO, the presence of concomitant neurologic injury, or the use of postoperative HO prophylaxis? METHODS Between March 2005 and March 2013 our institution treated 994 patients with 1377 combat-related major extremity amputations; of those, 172 amputations underwent subsequent excision of symptomatic HO. The mechanism of injury resulting in nearly all amputations (n = 168) was blast-related trauma. We reviewed medical records and radiographs to collect initial grade of HO, radiographic recurrence, complete compared with partial excision, concomitant neurologic injury, timing to initial surgery, surgeon experience, and use of postexcision prophylaxis with our primary study outcome being a return to the operating room (OR) for repeat excision of symptomatic HO. All 172 combat-related amputations were considered for this study irrespective of followup, which was noted to be robust, with 157 (91%) amputations having at least 6 months clinical followup by an orthopaedic surgeon or physiatrist (median, 20 months; range, 0-88 months). RESULTS Eleven of 172 patients (6.5%) underwent reexcision of HO, and 67 complications resulting in return to the OR occurred in 53 patients (31%) of patients. Multivariate analysis of our primary outcome measure showed more frequent symptomatic recurrences requiring reexcision when initial excision was performed as a partial excision (p = 0.03; odds ratio [OR], 5.0; 95% confidence interval [CI], 1.2-29.6) or when the initial excision was performed within 180 days of injury (p = 0.047; OR, 4.1; 95% CI, 1.02-16.6). There was no association between symptomatic recurrence and HO grade, central nervous system injury, experience of the attending surgeon, or postoperative prophylaxis. Radiographic recurrence was observed when partial excisions (eight of 30 [27%]) were done compared with complete excisions (five of 77 [7%]; p = 0.008). CONCLUSIONS HO is common after combat-related amputations, and patients undergoing surgical excision of HO for this indication often have complications that result in repeat surgical procedures. Partial excisions of immature lesions more often resulted in both symptomatic and radiographic recurrence. The likelihood of a patient undergoing reexcision can be minimized by performing a complete excision at least 180 days from injury to surgery with no evidence of a reduced risk of reexcision by waiting longer than 270 days. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Gabriel J. Pavey
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA
| | - Elizabeth M. Polfer
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Kyle E. Nappo
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA
| | - Scott M. Tintle
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Jonathan A. Forsberg
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Benjamin K. Potter
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
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Han KJ, Lee JH, Lee HD. Median nerve neuropathy associated with cubital heterotopic ossification. J Hand Surg Eur Vol 2015; 40:645-6. [PMID: 24436358 DOI: 10.1177/1753193413519936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- K J Han
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea
| | - J H Lee
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea
| | - H D Lee
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea
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Sciatic nerve compression by neurogenic heterotopic ossification: use of CT to determine surgical indications. Skeletal Radiol 2015; 44:233-40. [PMID: 25218150 DOI: 10.1007/s00256-014-2003-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/31/2014] [Accepted: 08/31/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the characteristics of neurogenic heterotopic ossification (NHO) based on clinical tests, electroneuromyography (ENMG) and CT in a database of patients with lesions of the central nervous system who required sciatic nerve neurolysis along with posterior hip NHO resection, and to determine the respective roles of ENMG and CT in the management of posterior hip NHOs in patients who are unable to communicate or express pain. METHODS The consistency of the ENMG results with clinical findings, CT results and macroscopic signs of lesions was retrospectively assessed after sciatic nerve neurolysis and ablation of 55 posterior hip NHOs. RESULTS Sciatic nerve neurolysis was necessary in 55 cases (47.4%; 55 out of 116). CT showed contact of the NHO with the nerve in all cases: 5 in contact with no deflection, 3 in contact with deflection, 21 moulded into a gutter and 26 entrapped in the NHO. There were clinical signs of sciatic nerve lesion in 21.8% of cases (12 out of 55). ENMG showed signs of sciatic nerve lesions in only 55.6% (10 out of 18), only 4 of whom presented with clinical signs of a nerve lesion. No significant relationship was found between clinical symptoms and ENMG findings of sciatic nerve compression (n = 13, p = 0.77). CONCLUSION Nerve compression by NHO is likely an underdiagnosed condition, particularly in patients who are unable to communicate. Diagnosis of sciatic compression by NHO should be based on regular clinical examinations and CT. ENMG is not sufficiently sensitive to be used alone for surgical decision-making.
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