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Beom JY, Low W, Park KS, Yoon TR, Lee CY, Song H. Surgical Resection of Neurogenic Heterotopic Ossification around Hip Joint in Stroke Patients: A Safety and Outcome Report. Hip Pelvis 2023; 35:268-276. [PMID: 38125274 PMCID: PMC10728050 DOI: 10.5371/hp.2023.35.4.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 12/23/2023] Open
Abstract
Purpose Resection remains the most reliable treatment for established heterotopic ossification, despite questions regarding its effectiveness due to the potential for complications. This study evaluated the clinical outcomes and complications of neurogenic heterotopic ossification (NHO) resection in stroke patients' ankylosed hips. Materials and Methods We retrospectively analyzed nine hip NHO resections performed on seven patients from 2010 to 2018. The pre- and postoperative range of motion of the operated hip were compared. Analysis of postoperative complications, including infection, recurrence, iatrogenic fracture, and neurovascular injury was performed. Results The mean operative time was 132.78±21.08 minutes, with a mean hemoglobin drop of 3.06±0.82 g/dL within the first postoperative week. The mean duration of postoperative follow-up was 52.08±28.72 months for all patients. Postoperative range of motion showed improvement from preoperative. Flexion and external rotation (mean, 58.89±30.60° and 16.67±18.03°, respectively) showed the greatest gain of motion of the operated hip joint. Postoperative infections resolved in two cases through surgical debridement, and one case required conversion to total hip arthroplasty due to instability. There were no recurrences, iatrogenic fractures, or neurovascular injuries. Conclusion Resection is a beneficial intervention for restoring the functional range of motion of the hip in order to improve the quality of life for patients with NHO and neurological disorders. We recommend performance of a minimal resection to achieve a targeted functional arc of motion in order to minimize the risk of postoperative complications.
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Affiliation(s)
- Jae-Young Beom
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - WengKong Low
- Orthopaedic and Traumatology Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Kyung-Soon Park
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Taek-Rim Yoon
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Chan Young Lee
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Hyeongmin Song
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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2
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Gueguen J, Girard D, Rival B, Fernandez J, Goriot ME, Banzet S. Spinal cord injury dysregulates fibro-adipogenic progenitors miRNAs signaling to promote neurogenic heterotopic ossifications. Commun Biol 2023; 6:932. [PMID: 37700159 PMCID: PMC10497574 DOI: 10.1038/s42003-023-05316-w] [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: 11/18/2022] [Accepted: 09/01/2023] [Indexed: 09/14/2023] Open
Abstract
Neurogenic heterotopic ossifications are intramuscular bone formations developing following central nervous system injury. The pathophysiology is poorly understood and current treatments for this debilitating condition remain unsatisfying. Here we explored the role of miRNAs in a clinically relevant mouse model that combines muscle and spinal cord injury, and in patients' cells. We found an osteo-suppressive miRNAs response in injured muscle that was hindered when the spinal cord injury was associated. In isolated fibro-adipogenic progenitors from damaged muscle (cells at the origin of ossification), spinal cord injury induced a downregulation of osteo-suppressive miRNAs while osteogenic markers were overexpressed. The overexpression of selected miRNAs in patient's fibro-adipogenic progenitors inhibited mineralization and osteo-chondrogenic markers in vitro. Altogether, we highlighted an osteo-suppressive mechanism involving multiple miRNAs in response to muscle injury that prevents osteogenic commitment which is ablated by the neurologic lesion in heterotopic ossification pathogenesis. This provides new research hypotheses for preventive treatments.
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Affiliation(s)
- Jules Gueguen
- Institut de Recherche Biomédicale des Armées, 92140, Clamart, France
- INSERM UMR-MD-1197, 92140, Clamart, France
| | - Dorothée Girard
- Institut de Recherche Biomédicale des Armées, 92140, Clamart, France
- INSERM UMR-MD-1197, 92140, Clamart, France
| | - Bastien Rival
- Institut de Recherche Biomédicale des Armées, 92140, Clamart, France
- INSERM UMR-MD-1197, 92140, Clamart, France
| | - Juliette Fernandez
- Institut de Recherche Biomédicale des Armées, 92140, Clamart, France
- INSERM UMR-MD-1197, 92140, Clamart, France
| | - Marie-Emmanuelle Goriot
- Institut de Recherche Biomédicale des Armées, 92140, Clamart, France
- INSERM UMR-MD-1197, 92140, Clamart, France
| | - Sébastien Banzet
- Institut de Recherche Biomédicale des Armées, 92140, Clamart, France.
- INSERM UMR-MD-1197, 92140, Clamart, France.
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3
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Follet L, Moke L, Ghijselings S, Wafa H, Vles G. Partial Femoral Diaphysectomy With Vastus Lateralis Interposition in a Paraplegic Patient With Severely Debilitating Hip Ankylosis: Low Risks and High Gains? Cureus 2023; 15:e35786. [PMID: 37025713 PMCID: PMC10072178 DOI: 10.7759/cureus.35786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 03/07/2023] Open
Abstract
We present the case of a 56-year-old male unable to sit because of an ankylosed right hip. This ankylosis originated from combined neurogenic heterotopic ossifications (NHO) and traumatic heterotopic ossifications (THO) as a result of a road traffic accident. Because of multiple ossifications, the proximity of neurovascular structures, and chronic pressure ulcers, a resection was deemed unsafe. We opted for a new articulation distal to the ossifications in unstained tissue. A partial femoral diaphysectomy was performed just distal of the lesser trochanter. and the vastus lateralis was rotated in the new articulation. Postoperatively, the patient was able to sit as his hip could flex again. A partial femoral diaphysectomy with vastus lateralis interposition flap appears to be a valid option in paraplegic patients with extensive heterotopic ossifications (HO) in close proximity to neurovascular structures with a low risk of complications and high gain in hip mobility.
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4
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Mohamed R, Iqbal A, Elawadi AA. Fifteen years’ experience of radiation therapy for resected advanced heterotopic ossification following motor vehicle accidents: outcome and side effects. J Egypt Natl Canc Inst 2022; 34:48. [DOI: 10.1186/s43046-022-00149-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 08/27/2022] [Indexed: 11/22/2022] Open
Abstract
Abstract
Background
Surgical resection is the primary treatment for advanced-stage heterotopic ossification (HO), with a high incidence of local recurrence reaching up to 50%. Postoperative radiotherapy (PORT) and indomethacin are commonly used prophylactic strategies following surgery. The study aims to assess the safety and effectiveness of PORT in advanced-stage HO patients having motor vehicle accidents (MVA).
Methods
Medical records of patients having HO following MVA between 2006 and 2021 were retrospectively reviewed. Thirty-nine patients with advanced disease (35 had hip HO and 4 had elbow HO) were included in the study.
Results
Excision of HO with joint preservation was performed for 82% of patients, while 18% had a joint replacement. Seven to 8 Gy radiation was given to all patients within 3 days postoperatively. A ninty seven percent of patients regained partially the movement range. The mean follow-up time was 74 months. Six patients had treatment failure, with only one having a recurrence of HO. The 8-year treatment failure-free rate (8-y TFFR) was 79.3±9%, and the 5-year HO failure-free rate (5y-HOFFR) was 97.2±3%. Acute side effects were experienced in 13% of patients but resolved without any consequences. Despite the relatively long follow-up time, we did not report any absolute infertility or secondary malignancies related to the radiation. The testicular mean calculated dose was 33±44 cGy, and the mean measured dose was 58±40 cGy. Of the 35 patients who received radiation to the pelvis, 26 were married, and all did not experience infertility post-treatment.
Conclusion
PORT proved an effective and safe treatment for advanced-stage HO disease. The treatment failure is mainly related to surgical difficulties due to advanced disease. Treatment using a 3-dimensional or intensity-modulated radiation therapy is not associated with serious side effects like second malignancy or absolute infertility.
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5
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Hwang CD, Pagani CA, Nunez JH, Cherief M, Qin Q, Gomez-Salazar M, Kadaikal B, Kang H, Chowdary AR, Patel N, James AW, Levi B. Contemporary perspectives on heterotopic ossification. JCI Insight 2022; 7:158996. [PMID: 35866484 PMCID: PMC9431693 DOI: 10.1172/jci.insight.158996] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Heterotopic ossification (HO) is the formation of ectopic bone that is primarily genetically driven (fibrodysplasia ossificans progressiva [FOP]) or acquired in the setting of trauma (tHO). HO has undergone intense investigation, especially over the last 50 years, as awareness has increased around improving clinical technologies and incidence, such as with ongoing wartime conflicts. Current treatments for tHO and FOP remain prophylactic and include NSAIDs and glucocorticoids, respectively, whereas other proposed therapeutic modalities exhibit prohibitive risk profiles. Contemporary studies have elucidated mechanisms behind tHO and FOP and have described new distinct niches independent of inflammation that regulate ectopic bone formation. These investigations have propagated a paradigm shift in the approach to treatment and management of a historically difficult surgical problem, with ongoing clinical trials and promising new targets.
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Affiliation(s)
- Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Chase A Pagani
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Johanna H Nunez
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Masnsen Cherief
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qizhi Qin
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Balram Kadaikal
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Heeseog Kang
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ashish R Chowdary
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron W James
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benjamin Levi
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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6
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Tseng HW, Kulina I, Girard D, Gueguen J, Vaquette C, Salga M, Fleming W, Jose B, Millard SM, Pettit AR, Schroder K, Thomas G, Wheeler L, Genêt F, Banzet S, Alexander KA, Lévesque JP. Interleukin-1 Is Overexpressed in Injured Muscles Following Spinal Cord Injury and Promotes Neurogenic Heterotopic Ossification. J Bone Miner Res 2022; 37:531-546. [PMID: 34841579 DOI: 10.1002/jbmr.4482] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 11/14/2021] [Accepted: 11/17/2021] [Indexed: 12/12/2022]
Abstract
Neurogenic heterotopic ossifications (NHOs) form in periarticular muscles after severe spinal cord (SCI) and traumatic brain injuries. The pathogenesis of NHO is poorly understood with no effective preventive treatment. The only curative treatment remains surgical resection of pathological NHOs. In a mouse model of SCI-induced NHO that involves a transection of the spinal cord combined with a muscle injury, a differential gene expression analysis revealed that genes involved in inflammation such as interleukin-1β (IL-1β) were overexpressed in muscles developing NHO. Using mice knocked-out for the gene encoding IL-1 receptor (IL1R1) and neutralizing antibodies for IL-1α and IL-1β, we show that IL-1 signaling contributes to NHO development after SCI in mice. Interestingly, other proteins involved in inflammation that were also overexpressed in muscles developing NHO, such as colony-stimulating factor-1, tumor necrosis factor, or C-C chemokine ligand-2, did not promote NHO development. Finally, using NHO biopsies from SCI and TBI patients, we show that IL-1β is expressed by CD68+ macrophages. IL-1α and IL-1β produced by activated human monocytes promote calcium mineralization and RUNX2 expression in fibro-adipogenic progenitors isolated from muscles surrounding NHOs. Altogether, these data suggest that interleukin-1 promotes NHO development in both humans and mice. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Hsu-Wen Tseng
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia
| | - Irina Kulina
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia
| | - Dorothée Girard
- Institut de Recherche Biomédicale des Armées (IRBA), Clamart, France.,INSERM UMR-MD 1197, Université de Paris-Saclay, Gif-sur-Yvette, France
| | - Jules Gueguen
- Institut de Recherche Biomédicale des Armées (IRBA), Clamart, France.,INSERM UMR-MD 1197, Université de Paris-Saclay, Gif-sur-Yvette, France
| | - Cedryck Vaquette
- School of Dentistry, The University of Queensland, Herston, Australia.,Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - Marjorie Salga
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia.,Unité Péri Opératoire du Handicap (UPOH), PMR Department, Versailles Saint-Quentin-en-Yvelines University (UVSQ); UFR Simone Veil - Santé, END: ICAP, INSERM U1179, Hôpital Raymond-Poincaré, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France.,Université de Versailles Saint-Quentin-en-Yvelines (UVSQ); UFR Simone Veil - Santé, END: ICAP, INSERM U1179, Montigny-le-Bretonneux, France
| | - Whitney Fleming
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia
| | - Beulah Jose
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia
| | - Susan M Millard
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia
| | - Allison R Pettit
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia
| | - Kate Schroder
- Institute for Molecular Bioscience, University of Queensland, Saint Lucia, Australia
| | - Gethin Thomas
- The University of Queensland Diamantina Institute, Translational Research Institute, Woolloongabba, Australia
| | - Lawrie Wheeler
- The University of Queensland Diamantina Institute, Translational Research Institute, Woolloongabba, Australia
| | - François Genêt
- Unité Péri Opératoire du Handicap (UPOH), PMR Department, Versailles Saint-Quentin-en-Yvelines University (UVSQ); UFR Simone Veil - Santé, END: ICAP, INSERM U1179, Hôpital Raymond-Poincaré, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France.,Université de Versailles Saint-Quentin-en-Yvelines (UVSQ); UFR Simone Veil - Santé, END: ICAP, INSERM U1179, Montigny-le-Bretonneux, France
| | - Sébastien Banzet
- Institut de Recherche Biomédicale des Armées (IRBA), Clamart, France.,INSERM UMR-MD 1197, Université de Paris-Saclay, Gif-sur-Yvette, France
| | - Kylie A Alexander
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia
| | - Jean-Pierre Lévesque
- Mater Research Institute - The University of Queensland, Woolloongabba, Australia
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7
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Carpentier VT, Salga M, Gatin L, Genêt F, Paquereau J. Early diagnosis of heterotopic ossification among patients admitted to a neurological Post-Intensive Care Rehabilitation Unit. Eur J Phys Rehabil Med 2021; 57:527-534. [PMID: 33448758 DOI: 10.23736/s1973-9087.21.06589-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Heterotopic ossification (HO) is defined as the formation of endochondral bone within soft tissue. Non-genetic forms, mainly corresponding to a consequence of bone, brain or spinal cord injury, are the most common. HO leads to important functional limitations and alteration of quality of life. To our knowledge, the time between brain, bone, or spinal cord injury and clinical suspicion of HO has never been studied. By admitting patients with severe neurological disorders, we hypothesized that the prevalence of HO in neurological post-intensive care rehabilitation units (PICRU) might be significant as these patients have recognized risk factors for HO. AIM This study aimed to investigate HO among patients admitted to a neurological PICRU with two objectives: 1) to describe the prevalence of HO in PICRU; 2) to assess the time between neurological disorder, clinical suspicion of HO and radiological diagnosis. DESIGN A monocentric retrospective cohort study. SETTING PICRU in our public university teaching hospital. This inpatient referral department is specifically dedicated to the early discharge from Intensive Care Units (ICU) of patients with severe neurological impairment who need rehabilitation. POPULATION We study all patients admitted between April 2016 and January 2019. One hundred twenty-five subjects were admitted for a rehabilitation program after neuro-trauma or stroke. We included all first-time stays in PICRU lasting 7 days or longer. METHODS Retrospective data extraction using administrative data from an electronic patient management program was done to select eligible subjects. Included subjects were then identified by a retrospective review of electronic inpatient medical records after patient discharge. Data of interest were collected from these same medical records. RESULTS Forty-four HO were diagnosed in 24 subjects (24/125; 19%), with a median number of 2 [1; 2] HO per subject. Neurological trauma was the main reason for admission to ICU (89/125; 71%) and half of patients had a traumatic brain injury (TBI) (67/125; 54%). The diagnosis of HO was made in PICRU in 75% of cases. Clinical suspicion of HO (autonomic dysfunction, local inflammatory signs, pain, or reduced joint range of motion) was made 6 [5; 7] weeks after admission to ICU. Radiological confirmation of clinical suspicion or fortuitous diagnosis by imaging (50% of the cases) occurred 8 [7; 12] weeks after admission to ICU. The median time of clinical suspicion or radiological diagnosis was 1 week after admission to PICRU. CONCLUSIONS HO is a sub-acute complication which develops in patients admitted to ICU for severe central nervous system disorders as clinical suspicion or radiological confirmation of diagnosis was made within the first week after admission in neurological PICRU (i.e. 6 to 8 weeks after ICU admission). CLINICAL REHABILITATION IMPACT As treatment for HO may at least partially improves rehabilitation and quality of life, we recommend a systematic screening in PICRU patients for HO by clinical examination supplemented by imaging in case of suspicion.
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Affiliation(s)
- Vincent T Carpentier
- Department of Physical Medicine and Rehabilitation, CIC-IT 1429, Raymond-Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France.,Faculty of Medicine, University of Paris, Paris, France.,Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France
| | - Marjorie Salga
- Department of Physical Medicine and Rehabilitation, CIC-IT 1429, Raymond-Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France.,Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France.,U1179 END-ICAP, Inserm, UFR Simone Veil - Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), Paris Saclay University, Montigny-le-Bretonneux, France
| | - Laure Gatin
- Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France.,U1179 END-ICAP, Inserm, UFR Simone Veil - Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), Paris Saclay University, Montigny-le-Bretonneux, France.,Department of Orthopedic Surgery, Raymond-Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France
| | - François Genêt
- Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France.,U1179 END-ICAP, Inserm, UFR Simone Veil - Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), Paris Saclay University, Montigny-le-Bretonneux, France
| | - Julie Paquereau
- Department of Physical Medicine and Rehabilitation, CIC-IT 1429, Raymond-Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France - .,Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France
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8
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Wong KR, Mychasiuk R, O'Brien TJ, Shultz SR, McDonald SJ, Brady RD. Neurological heterotopic ossification: novel mechanisms, prognostic biomarkers and prophylactic therapies. Bone Res 2020; 8:42. [PMID: 33298867 PMCID: PMC7725771 DOI: 10.1038/s41413-020-00119-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/20/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023] Open
Abstract
Neurological heterotopic ossification (NHO) is a debilitating condition where bone forms in soft tissue, such as muscle surrounding the hip and knee, following an injury to the brain or spinal cord. This abnormal formation of bone can result in nerve impingement, pain, contractures and impaired movement. Patients are often diagnosed with NHO after the bone tissue has completely mineralised, leaving invasive surgical resection the only remaining treatment option. Surgical resection of NHO creates potential for added complications, particularly in patients with concomitant injury to the central nervous system (CNS). Although recent work has begun to shed light on the physiological mechanisms involved in NHO, there remains a significant knowledge gap related to the prognostic biomarkers and prophylactic treatments which are necessary to prevent NHO and optimise patient outcomes. This article reviews the current understanding pertaining to NHO epidemiology, pathobiology, biomarkers and treatment options. In particular, we focus on how concomitant CNS injury may drive ectopic bone formation and discuss considerations for treating polytrauma patients with NHO. We conclude that understanding of the pathogenesis of NHO is rapidly advancing, and as such, there is the strong potential for future research to unearth methods capable of identifying patients likely to develop NHO, and targeted treatments to prevent its manifestation.
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Affiliation(s)
- Ker Rui Wong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Stuart J McDonald
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Physiology, Anatomy and Microbiology, School of Life Sciences, La Trobe University, Bundoora, VIC, Australia
| | - Rhys D Brady
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia. .,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.
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9
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Severe Heterotopic Ossification with Proximal Entrapment of the Ulnar Nerve following Primary Anterior Shoulder Dislocation. Case Rep Orthop 2020; 2020:8883758. [PMID: 33083076 PMCID: PMC7558775 DOI: 10.1155/2020/8883758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 09/15/2020] [Accepted: 09/24/2020] [Indexed: 11/30/2022] Open
Abstract
Heterotopic ossifications (HO) in the shoulder are rare. The effectiveness of conservative treatment is limited, and therefore, symptomatic cases are usually treated surgically. However, there are no guidelines for the surgical treatment of HO. Herein, we report the case of a 45-year-old man with severe HO and proximal entrapment of the ulnar nerve following primary anterior shoulder dislocation without concomitant injuries (e.g., fracture and rotator cuff tears). Surgical intervention was indicated, including resection of HO and neurolysis of the brachial plexus. Nine months after surgery, the patient presented with restored shoulder function, pain relief, and good patient satisfaction. The case shows that the ulnar nerve can also be impaired due to HO following shoulder dislocation.
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10
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Liu X, Kaminsky AJ, Hill DM, Velamuri SR. Heterotopic ossification: a preventable case of gossypiboma in spinal cord injury. J Wound Care 2020; 29:S30-S32. [PMID: 32160126 DOI: 10.12968/jowc.2020.29.sup3.s30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Heterotopic ossification is the formation of ectopic bone in soft tissues. It has three established aetiologies: genetic, traumatic and neurogenic. A gossypiboma is defined as a retained foreign body, such as a mass or sponge, usually after a surgical procedure. In this article, we present a unique, preventable case of a patient admitted for newly developed heterotopic ossification in the gluteus maximus muscle caused by a retained piece of foam from negative pressure wound therapy (NPWT). The heterotopic ossification lesion, together with the retained foreign body, was completely excised and reconstructed using a posterior thigh fasciocutaneous advancement flap. This is the first reported case of heterotopic ossification caused by a retained foreign body and may be helpful to better understanding of the aetiology of heterotopic ossification.
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Affiliation(s)
- Xiangxia Liu
- 1 Department of Plastic Surgery, University of Tennessee Health Science Center, Memphis, US.,2 Division of Plastic Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Alexander J Kaminsky
- 1 Department of Plastic Surgery, University of Tennessee Health Science Center, Memphis, US
| | - David M Hill
- 3 Firefighters Burn Center, Department of Pharmacy, Regional One Health, Memphis, US.,4 Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Memphis, US
| | - Sai R Velamuri
- 1 Department of Plastic Surgery, University of Tennessee Health Science Center, Memphis, US
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11
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de l'Escalopier N, Salga M, Gatin L, Genêt F, Denormandie P. Resection of heterotopic ossification around the hip after trauma. EFORT Open Rev 2019; 4:263-268. [PMID: 31210967 PMCID: PMC6549106 DOI: 10.1302/2058-5241.4.180098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Traumatic neurological lesions may lead to development of heterotopic ossification. These cases are classified as ‘neurogenic heterotopic ossifications’ (NHOs). The associated neurological lesions can be caused by cranial trauma or spinal cord injury and may sometimes include a local trauma. NHOs that form around the hip joints are of particular interest because they often cause the patient to avoid the sitting position or the resumption of walking. Whilst NHO can involve the knee, shoulder and elbow joints, hip-involving NHOs are more numerous, and sometimes develop in close contact with vascular or neurological structures. Multi-disciplinary clinical examination is fundamental to evaluate patients for surgical intervention and to define the objectives of the surgery. The best investigation to define an NHO mass is a computerized tomography (CT) scan. Resection is performed to liberate a fused joint to provide functionality, and this need not be exhaustive if it is not necessary to increase the range of motion. While recurrence does occur post-surgery, a partial resection does not pose a greater risk of recurrence and there are no adjuvant treatments available to reduce this risk. The greatest risks associated with NHO surgical resection are infection and haematoma; these risks are very high and must be considered when evaluating patients for surgery.
Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180098
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Affiliation(s)
- Nicolas de l'Escalopier
- Service de Chirurgie Orthopédique, Hôpital Raymond Poincaré, France.,Service de Chirurgie Orthopédique, Traumatologie et Chirurgie Réparatrice des Membres, Hôpital d'Instruction des Armées Percy, France
| | - Marjorie Salga
- Service de médecine physique et réadaptation, Hôpital Raymond Poincaré, France
| | - Laure Gatin
- Service de Chirurgie Orthopédique, Hôpital Raymond Poincaré, France
| | - François Genêt
- Service de médecine physique et réadaptation, Hôpital Raymond Poincaré, France
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Ali T, Mandurah RF, Ullah S. Polyarticular Neurogenic Heterotopic Ossification in a Spinal Cord Injury: A Case Report from Saudi Arabia. Cureus 2019; 11:e4019. [PMID: 31007977 PMCID: PMC6453613 DOI: 10.7759/cureus.4019] [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: 01/27/2019] [Accepted: 02/05/2019] [Indexed: 11/30/2022] Open
Abstract
A 33-year-old male victim of a motor vehicle accident, who presented with a T12 (thoracic 12 vertebra) burst fracture (ISNCSCI T11 AIS-A: International Standards for Neurological Classification of Spinal Cord Injury T11 ASIA Impairment Scale), was admitted to a rehabilitation hospital. A stage-II left ischial pressure ulcer was also reported. An X-ray of the pelvis revealed bilateral neurogenic heterotopic ossification (NHO) in both hips and knees, which was further confirmed by TC-99m methylene diphosphonate (MDP) bone scintigraphy. Interventions included indomethacin and conservative management. Surgery was not preferred, as NHO was still immature. Moreover, patient transfer and lower body dressing were unaffected by NHO. It is important to consider an early radiological screen in selected high-risk cases for NHO, to minimize the risk of associated complications.
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Affiliation(s)
- Taha Ali
- Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh, USA
| | - Rouaa F Mandurah
- Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh, SAU
| | - Sami Ullah
- Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh, SAU
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Genêt F, Denormandie P, Keenan MA. Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques. Ann Phys Rehabil Med 2018; 62:225-233. [PMID: 30290282 DOI: 10.1016/j.rehab.2018.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 09/09/2018] [Accepted: 09/09/2018] [Indexed: 12/26/2022]
Abstract
Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.
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Affiliation(s)
- F Genêt
- Service de médecine physique et de réadaptation, hôpital Raymond Poincaré, Assistance publique-Hôpitaux de Paris, CIC-IT 1429, 92380 Garches, France; End:icap" U1179 Inserm, service de université Versailles Saint Quentin en Yvelines, UFR des Sciences de la Santé-Simone Veil, 2, avenue de la source de bièvres, 78170 Montigny le Bretonneux, France.
| | - P Denormandie
- End:icap" U1179 Inserm, service de université Versailles Saint Quentin en Yvelines, UFR des Sciences de la Santé-Simone Veil, 2, avenue de la source de bièvres, 78170 Montigny le Bretonneux, France; Chirurgie orthopédique et traumatologique, hôpital Raymond Poincaré, Assistance publique-Hôpitaux de Paris, CIC-IT 1429, 92380 Garches, France
| | - M A Keenan
- Penn Neuro-Orthopaedics Service, University of Pennsylvania, Philadelphia, PA, USA
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Brady RD, Shultz SR, McDonald SJ, O'Brien TJ. Neurological heterotopic ossification: Current understanding and future directions. Bone 2018; 109:35-42. [PMID: 28526267 DOI: 10.1016/j.bone.2017.05.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 12/30/2022]
Abstract
Neurological heterotopic ossification (NHO) involves the formation of bone in soft tissue following a neurological condition, of which the most common are brain and spinal cord injuries. NHO often forms around the hip, knee and shoulder joints, causing severe pain and joint deformation which is associated with significant morbidity and reduced quality of life. The cellular and molecular events that initiate NHO have been the focus of an increasing number of human and animal studies over the past decade, with this work largely driven by the need to unearth potential therapeutic interventions to prevent the formation of NHO. This review provides an overview of the present understanding of NHO pathogenesis and pathobiology, current treatments, novel therapeutic targets, potential biomarkers and future directions.
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Affiliation(s)
- Rhys D Brady
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC, 3010, Australia.
| | - Sandy R Shultz
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC, 3010, Australia
| | - Stuart J McDonald
- Department of Physiology, Anatomy and Microbiology, La Trobe University, VIC, 3086, Australia
| | - Terence J O'Brien
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC, 3010, Australia
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Denormandie P, de l'Escalopier N, Gatin L, Grelier A, Genêt F. Resection of neurogenic heterotopic ossification (NHO) of the hip. Orthop Traumatol Surg Res 2018; 104:S121-S127. [PMID: 29174871 DOI: 10.1016/j.otsr.2017.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/21/2017] [Accepted: 04/13/2017] [Indexed: 02/02/2023]
Abstract
Neurogenic heterotopic ossification of the hip is secondary to neurologic lesions such as cranial trauma, stroke, medullary injury or cerebral anoxia. We shall not deal here with the other etiologies of heterotopic ossification. There are numerous locations within the hip, depending on etiology and relations with adjacent neurovascular structures are sometimes close. Preoperative work-up should include contrast-enhanced CT; scintigraphy is non-contributive. Indications for surgery are decided in a multidisciplinary team meeting, with a contract laying out expected functional gain. It is this contract that determines the extent of resection, without seeking complete resection, which would incur an increased risk of complications. The surgical approach and resection strategy depend on lesion location and any resulting neurovascular compression. The most common complications are infection and postoperative hematoma. No adjuvant treatments have demonstrated efficacy against recurrence.
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Affiliation(s)
- P Denormandie
- Service de chirurgie orthopédique, hôpital Raymond-Poincaré, 92380 Garches, France
| | - N de l'Escalopier
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'instruction des Armées-Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France.
| | - L Gatin
- Service de chirurgie orthopédique, hôpital Raymond-Poincaré, 92380 Garches, France
| | - A Grelier
- Service de médecine physique et réadaptation, hôpital Raymond-Poincaré, 92380 Garches, France
| | - F Genêt
- Service de médecine physique et réadaptation, hôpital Raymond-Poincaré, 92380 Garches, France
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Debaud C, Salga M, Begot L, Holy X, Chedik M, de l’Escalopier N, Torossian F, Levesque JP, Lataillade JJ, Le Bousse-Kerdilès MC, Genêt F. Peripheral denervation participates in heterotopic ossification in a spinal cord injury model. PLoS One 2017; 12:e0182454. [PMID: 28854256 PMCID: PMC5576715 DOI: 10.1371/journal.pone.0182454] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/18/2017] [Indexed: 12/26/2022] Open
Abstract
We previously reported the development of a new acquired neurogenic HO (NHO) mouse model, combining spinal cord transection (SCI) and chemical muscle injury. Pathological mechanisms responsible for ectopic osteogenesis after central neurological damage are still to be elucidated. In this study, we first hypothesized that peripheral nervous system (PNS) might convey pathological signals from injured spinal cord to muscles in NHO mouse model. Secondly, we sought to determine whether SCI could lead to intramuscular modifications of BMP2 signaling pathways. Twenty one C57Bl6 mice were included in this protocol. Bilateral cardiotoxin (CTX) injection in hamstring muscles was associated with a two-stage surgical procedure, combining thoracic SCI with unilateral peripheral denervation. Volumes of HO (Bone Volume, BV) were measured 28 days after surgery using micro-computed tomography imaging techniques and histological analyses were made to confirm intramuscular osteogenesis. Volume comparisons were conducted between right and left hind limb of each animal, using a Wilcoxon signed rank test. Quantitative polymerase chain reaction (qPCR) was performed to explore intra muscular expression of BMP2, Alk3 and Id1. Nineteen mice survive the complete SCI and peripheral denervation procedure. When CTX injections were done right after surgery (n = 7), bilateral HO were detected in all animals after 28 days. Micro-CT measurements showed significantly increased BV in denervated paws (1.47 mm3 +/- 0.5) compared to contralateral sides (0.56 mm3 +/-0.4), p = 0.03. When peripheral denervation and CTX injections were performed after sham SCI surgery (n = 6), bilateral HO were present in three mice at day 28. Quantitative PCR analyses showed no changes in intra muscular BMP2 expression after SCI as compared to control mice (shamSCI). Peripheral denervation can be reliably added to spinal cord transection in NHO mouse model. This new experimental design confirms that neuro inflammatory mechanisms induced by central or peripheral nervous system injury plays a key role in triggering ectopic osteogenesis.
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Affiliation(s)
- Charlotte Debaud
- Spine Division Orthopaedic Surgery Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
- University of Versailles Saint Quentin en Yvelines, U1179 INSERM, UFR des Sciences de la Santé – Simone Veil, Montigny-le-Bretonneux, France
- * E-mail:
| | - Marjorie Salga
- University of Versailles Saint Quentin en Yvelines, U1179 INSERM, UFR des Sciences de la Santé – Simone Veil, Montigny-le-Bretonneux, France
- Rehabilitation Service, Hôpital Raymond Poincaré, APHP, CIC-IT 1429, Garches, France
| | - Laurent Begot
- Institut de Recherche Biomédicale des Armées, Brétigny-sur-Orge, France
| | - Xavier Holy
- Institut de Recherche Biomédicale des Armées, Brétigny-sur-Orge, France
| | - Malha Chedik
- University of Versailles Saint Quentin en Yvelines, U1179 INSERM, UFR des Sciences de la Santé – Simone Veil, Montigny-le-Bretonneux, France
| | | | - Fréderic Torossian
- University of Paris-Sud, INSERM UMR-S/MD 1197, Hôpital Paul Brousse, APHP, Villejuif, France
| | - Jean-Pierre Levesque
- Blood and Bone Diseases Program, Mater Research Institute, University of Queensland, Woolloongabba and School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Jean-Jacques Lataillade
- University of Paris-Sud, Unité mixte Inserm/SSA 1197, IRBA/CTSA/HIA Percy, École du Val de Grâce, Clamart, France
| | | | - François Genêt
- University of Versailles Saint Quentin en Yvelines, U1179 INSERM, UFR des Sciences de la Santé – Simone Veil, Montigny-le-Bretonneux, France
- Rehabilitation Service, Hôpital Raymond Poincaré, APHP, CIC-IT 1429, Garches, France
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Two new risk factors for heterotopic ossification development after severe burns. PLoS One 2017; 12:e0182303. [PMID: 28777823 PMCID: PMC5544177 DOI: 10.1371/journal.pone.0182303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 07/16/2017] [Indexed: 11/19/2022] Open
Abstract
Objectives Life after severe burns is conditioned by the remaining sequelae. The pathophysiology and risk factors of Heterotopic Ossification (HO) after burns are still poorly understood. The aim of this study was to determine: 1) the incidence of HO after burns and 2) the risk factors associated with HO development, in a large retrospective study. Methods A case-control study of patients admitted to the burns intensive care unit of Percy Hospital, Paris, from the 1st January 2009 to the 31st December 2013 and then admitted to one of three centres specialised in the rehabilitation of patients with burns. Multivariate analysis was carried out to analyse the relationship between HO development and demographic and clinical data. Results 805 patients were included. 32 patients (4.0%) developed a total of 74 heterotopic ossifications, that is a little higher incidence than the incidence found in the literature. The epidemiological characteristics of the population studied was similar to the literature. HOs were mainly localized around the elbows, followed by the hips, shoulders and knees. Each case-patient was paired with 3 control-patients. There were significant associations between HO development and the length of stay in the burns intensive care unit, the extent and depth of the burns, the occurrence of pulmonary or cutaneous infections, use of curare and use of an air-fluidized bed. Conclusion In addition to recognized risk factors (duration of stay in the intensive care burns unit, extent and depth of burns, pulmonary and cutaneous infections), the use of curare and the use of a fluidized bed (with the duration of use) were significantly associated with HO formation.
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The traumatic bone: trauma-induced heterotopic ossification. Transl Res 2017; 186:95-111. [PMID: 28668522 PMCID: PMC6715128 DOI: 10.1016/j.trsl.2017.06.004] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/22/2017] [Accepted: 06/08/2017] [Indexed: 01/08/2023]
Abstract
Heterotopic ossification (HO) is a common occurrence after multiple forms of extensive trauma. These include arthroplasties, traumatic brain and spinal cord injuries, extensive burns in the civilian setting, and combat-related extremity injuries in the battlefield. Irrespective of the form of trauma, heterotopic bone is typically endochondral in structure and is laid down via a cartilaginous matrix. Once formed, the heterotopic bone typically needs to be excised surgically, which may result in wound healing complications, in addition to a risk of recurrence. Refinements of existing diagnostic modalities, like micro- and nano-CT are being adapted toward early intervention. Trauma-induced HO is a consequence of aberrant wound healing, systemic and local immune system activation, infections, extensive vascularization, and innervation. This intricate molecular crosstalk culminates in activation of stem cells that initiate heterotopic endochondral ossification. Development of animal models recapitulating the unique traumatic injuries has greatly facilitated the mechanistic understanding of trauma-induced HO. These same models also serve as powerful tools to test the efficacy of small molecules which specifically target the molecular pathways underlying ectopic ossification. This review summarizes the recent advances in the molecular understanding, diagnostic and treatment modalities in the field of trauma-induced HO.
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Gatin L, Genêt F, Dinh A, Denormandie P. Postoperative infections after excision of neurogenic heterotopic ossifications at the hip: Risk factors and causative organisms. Orthop Traumatol Surg Res 2017; 103:357-361. [PMID: 28215612 DOI: 10.1016/j.otsr.2017.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Neurogenic heterotopic ossification (NHO) is usually treated by surgical excision. Postoperative infection (POI) is a possible complication, whose epidemiology, causative organisms, and risk factors are poorly known. We therefore conducted a case-control study to (1) identify the risk factors for POI after surgical excision of NHO at the hip, (2) determine the frequency of POI, (3) and identify the causative organisms. HYPOTHESIS Risk factors for POI after NHO excision at the hip can be identified. MATERIAL AND METHODS In this retrospective case-control study, the BANKHO database for patients with NHO at our centre was used to identify risk factors by comparing patients with and without POI after NHO excision at the hip. To this end, odds ratios (ORs) with their 95% confidence intervals (95%CIs) were computed for each main criterion. Postoperative follow-up was at least 6 months. RESULTS Between 1993 and 2013, 411 hip NHO excisions were performed. Among them, 42 (10%) were followed by POI. The American Society of Anesthesiologists (ASA) score was I in 2/42 (5%) patients with vs. 74/369 (20%) patients without POI, II in 30/42 (71%) patients with vs. 258/369 (70%) patients without POI, and III in 10/42 (24%) patients with vs. 37/369 (10%) patients without POI (P<0.01). Mean age was 31±11 years (range, 17-79years) in the group with POI and 39±14 years (range, 15-77years) in the group without POI (P<0.01). The NHO was related to spinal cord injury in 26/42 (62%) patients with POI compared to 92/369 (25%) patients without POI (P<0.01). ORs indicated a significant risk increase in patients with an ASA score of III (2.84; 95%CI, 1.28-6.31), age younger than 30 years (1.85; 95%CI, 1.03-3.32), and spinal cord injury as the cause of NHO (4.89; 95%CI, 2.67-8.98). The predominant organisms were staphylococci (skin flora) in the patients with spinal cord injury and bacteria commonly found in intensive care units in the other patients. DISCUSSION A higher ASA score, younger age, and spinal cord injury as the cause of NHO at the hip are risk factors for POI. The proportion of patients with POI after hip NHO excision was 10%, in accordance with previous reports. POI was more common among patients with spinal cord injury (22% vs. 5% in the other patients). Neither changes in prophylactic antibiotic therapy regimens nor the institution of a detailed skin preparation protocol affected the frequency of POI. Skin pH alterations may deserve to be investigated with the goal of diminishing the risk of POI, most notably in spinal cord injury patients. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- L Gatin
- Service de chirurgie orthopédique et traumatologique, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380 Garches, France.
| | - F Genêt
- Service de médecine physique et réadaptation, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380 Garches, France
| | - A Dinh
- Unité de maladies infectieuses et tropicales, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380 Garches, France
| | - P Denormandie
- Service de chirurgie orthopédique et traumatologique, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380 Garches, France
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Agarwal S, Loder S, Cholok D, Li J, Breuler C, Drake J, Brownley C, Peterson J, Li S, Levi B. Surgical Excision of Heterotopic Ossification Leads to Re-Emergence of Mesenchymal Stem Cell Populations Responsible for Recurrence. Stem Cells Transl Med 2016; 6:799-806. [PMID: 28297577 PMCID: PMC5442786 DOI: 10.5966/sctm.2015-0365] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 08/29/2016] [Indexed: 01/04/2023] Open
Abstract
Trauma‐induced heterotopic ossification (HO) occurs after severe musculoskeletal injuries and burns, and presents a significant barrier to patient rehabilitation. Interestingly, the incidence of HO significantly increases with repeated operations and after resection of previous HO. Treatment of established heterotopic ossification is challenging because surgical excision is often incomplete, with evidence of persistent heterotopic bone. As a result, patients may continue to report the signs or symptoms of HO, including chronic pain, nonhealing wounds, and joint restriction. In this study, we designed a model of recurrent HO that occurs after surgical excision of mature HO in a mouse model of hind‐limb Achilles’ tendon transection with dorsal burn injury. We first demonstrated that key signaling mediators of HO, including bone morphogenetic protein signaling, are diminished in mature bone. However, upon surgical excision, we have noted upregulation of downstream mediators of osteogenic differentiation, including pSMAD 1/5. Additionally, surgical excision resulted in re‐emergence of a mesenchymal cell population marked by expression of platelet‐derived growth factor receptor‐α (PDGFRα) and present in the initial developing HO lesion but absent in mature HO. In the recurrent lesion, these PDGFRα+ mesenchymal cells are also highly proliferative, similar to the initial developing HO lesion. These findings indicate that surgical excision of HO results in recurrence through similar mesenchymal cell populations and signaling mechanisms that are present in the initial developing HO lesion. These results are consistent with findings in patients that new foci of ectopic bone can develop in excision sites and are likely related to de novo formation rather than extension of unresected bone. Stem Cells Translational Medicine2017;6:799–806
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Affiliation(s)
- Shailesh Agarwal
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shawn Loder
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - David Cholok
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - John Li
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Chris Breuler
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - James Drake
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Cameron Brownley
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joshua Peterson
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shuli Li
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Benjamin Levi
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Recurrence of heterotopic ossification after removal in patients with traumatic brain injury: A systematic review. Ann Phys Rehabil Med 2016; 59:263-9. [PMID: 27173174 DOI: 10.1016/j.rehab.2016.03.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 03/25/2016] [Accepted: 03/25/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE A systematic review of the literature to determine whether in patients with neurological heterotopic ossification (NHO) after traumatic brain injury, the extent of the neurological sequelae, the timing of surgery and the extent of the initial NHO affect the risk of NHO recurrence. DATA SOURCES We searched MEDLINE via PubMed and Cochrane library for articles published up to June 2015. Results were compared with epidemiological studies using data from the BANKHO database of 357 patients with central nervous system (CNS) lesions who underwent 539 interventions for troublesome HO. RESULTS A large number of studies were published in the 1980s and 1990s, most showing poor quality despite being performed by experienced surgical teams. Accordingly, results were contradictory and practices heterogeneous. Results with the BANKHO data showed troublesome NHO recurrence not associated with aetiology, sex, age at time of CNS lesion, multisite HO, or "early" surgery (before 6months). Equally, recurrence was not associated with neurological sequelae or disease extent around the joint. CONCLUSIONS The recurrence of NHO is not affected by delayed surgery, neurological sequelae or disease extent around the joint. Surgical excision of NHO should be performed as soon as comorbid factors are under control and the NHO is sufficiently constituted for excision.
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Isaacson BM, Potter BK, Bloebaum RD, Epperson RT, Kawaguchi BS, Swanson TM, Pasquina PF. Link Between Clinical Predictors of Heterotopic Ossification and Histological Analysis in Combat-Injured Service Members. J Bone Joint Surg Am 2016; 98:647-57. [PMID: 27098323 DOI: 10.2106/jbjs.15.00895] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a debilitating condition that occurs following traumatic injury and may restrict range of motion and delay rehabilitation. The timing and efficacy of surgical resection have varied widely, and there is a gap in knowledge between clinical predictors of HO recurrence and histological analysis. METHODS Thirty-three service members seen at Walter Reed National Military Medical Center for symptomatic HO were enrolled in an institutional review board-approved study. Participants took oxytetracycline on four scheduled days prior to HO resection to determine the mineral apposition rate (bone growth rate). RESULTS Detailed histological analyses included scanning electron microscopy with backscattered electron imaging and light microscopy. Data indicated that the mineral apposition rate of trauma-induced HO was approximately 1.7 μm/day at the time of operative intervention, which was 1.7 times higher than the rate in non-pathological human bone. The mineral apposition rate and postoperative alkaline phosphatase values were demonstrated to be positively and significantly related (ρ = 0.509, p = 0.026, n = 19). When the analysis was limited to patients with no more than a two-year period from injury to excision (thereby removing outliers who had a longer time period than their counterparts) and traumatic brain injury and nonsteroidal anti-inflammatory drugs (known correlates with HO development) were controlled for in the statistical analysis, the mineral apposition rate and recurrence severity were significantly related (ρ = -0.572, p = 0.041, n = 11). CONCLUSIONS Data demonstrated a link between benchtop research and bedside care, with the mineral apposition rate elevated in patients with HO and correlated with recurrence severity; however, a larger sample size and more clinical factors are needed to refine this model. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- B M Isaacson
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland The Center for Rehabilitation Sciences Research, Department of Physical Medicine & Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - B K Potter
- Departments of Orthopaedics (B.K.P.) and Rehabilitation (P.F.P.), Walter Reed National Military Medical Center, Bethesda, Maryland Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - R D Bloebaum
- Bone & Joint Research Laboratory, Department of Veterans Affairs, Salt Lake City, Utah Departments of Bioengineering and Biology, University of Utah, Salt Lake City, Utah
| | - R T Epperson
- Bone & Joint Research Laboratory, Department of Veterans Affairs, Salt Lake City, Utah
| | - B S Kawaguchi
- Bone & Joint Research Laboratory, Department of Veterans Affairs, Salt Lake City, Utah
| | - T M Swanson
- The Center for Rehabilitation Sciences Research, Department of Physical Medicine & Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - P F Pasquina
- The Center for Rehabilitation Sciences Research, Department of Physical Medicine & Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, Maryland Departments of Orthopaedics (B.K.P.) and Rehabilitation (P.F.P.), Walter Reed National Military Medical Center, Bethesda, Maryland
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