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Ausk BJ, Tucker AN, Huber P, Firoozabadi R, Gross JM, Gross TS, Bain SD. A microCT-based platform to quantify drug targeting. Eur Radiol Exp 2023; 7:38. [PMID: 37532922 PMCID: PMC10397158 DOI: 10.1186/s41747-023-00355-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/12/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Heterotopic ossification (HO) is a frequent and debilitating complication of traumatic musculoskeletal injuries and orthopedic procedures. Prophylactic dosing of botulinum toxin type A (BTxA) holds potential as a novel treatment option if accurately distributed throughout soft-tissue volumes where protection is clinically desired. We developed a high-resolution, microcomputed tomography (microCT)-based imaging strategy to assess drug distribution and validated this platform by quantifying distribution achieved via a prototype delivery system versus a single-bolus injection. METHODS We injected an iodine-containing contrast agent (iodixanol 320 mg I/mL) into dissected rabbit musculature followed by microCT imaging and analysis. To contrast the performance of distributed versus bolus injections, a three-dimensional (3D) 64-cm3-printed soft-tissue holder was developed. A centered 2-cm3 volume of interest (VOI) was targeted with a single-bolus injection or an equal volume distributed injection delivered via a 3D-printed prototype. VOI drug coverage was quantified as a percentage of the VOI volume that was < 1.0 mm from the injected fluid. RESULTS The microCT-based approach enabled high-resolution quantification of injection distribution within soft tissue. The distributed dosing prototype provided significantly greater tissue coverage of the targeted VOI (72 ± 3%, mean ± standard deviation) when compared to an equal volume bolus dose (43 ± 5%, p = 0.031) while also enhancing the precision of injection targeting. CONCLUSIONS A microCT-based imaging technique precisely quantifies drug distribution within a soft-tissue VOI, providing a path to overcome a barrier for clinical translation of prophylactic inhibition of HO by BTxA. RELEVANCE STATEMENT This platform will facilitate rapid optimization of injection parameters for clinical devices used to effectively and safely inhibit the formation of heterotopic ossification. KEY POINTS • MicroCT provides high-resolution quantification of soft-tissue drug distribution. • Distributed dosing is required to maximize soft-tissue drug coverage. • Imaging platform will enable rapid screening of 3D-printed drug distribution prototypes.
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Affiliation(s)
| | - Adam N Tucker
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Philippe Huber
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | | | - Ted S Gross
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
| | - Steven D Bain
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
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Abstract
Heterotopic ossification (HO) refers to benign ectopic bone formation in soft tissue and is common following trauma surgery. HO bone can restrict movement and progress into ankylosis that may necessitate surgical intervention. This article discusses the current literature on the pathophysiology, prophylaxis, treatment, and epidemiology of postoperative HO following orthopedic trauma.
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Affiliation(s)
- Jad Lawand
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA.
| | - Zachary Loeffelholz
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Bilal Khurshid
- Texas College of Osteopathic Medicine, Fort Worth, Texas, USA
| | - Eric Barcak
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
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3
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Stengel D, Mutschler W, Dubs L, Kirschner S, Renkawitz T. [Interpretation of systematic review articles and meta-analyses : Clinical trials in trauma surgery and orthopedics]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:897-908. [PMID: 36166082 DOI: 10.1007/s00113-022-01244-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 06/16/2023]
Abstract
Clinical trials must be planned and interpreted in the context of current best clinical and scientific evidence, undoubtedly provided by systematic reviews and meta-analyses, especially Cochrane Reviews. While many clinicians feel overwhelmed by this complex data source, few visualElements (e.g., the traffic light system of the Cochrane risk of bias [RoB‑2] tool, forest plots, etc.), together with indices such as the I2 heterogeneity statistic, allow for a quick appraisal of all critical and necessary qualitative and quantitative information. The effectiveness of different treatment options can indirectly be assessed by methodological advancements like network meta-analyses.Point estimates of percentages are insufficient to describe the utility and value of a proposed novel intervention, which, in orthopedic and trauma surgery, often represents a step innovation. 95% confidence intervals and the so-called fragility index are helpful in determining the ultimate patient benefit.
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Affiliation(s)
- Dirk Stengel
- Forschung - Ressort Medizin, BG Kliniken - Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117, Berlin, Deutschland.
| | - Wolf Mutschler
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum der Universität München, Nußbaumstr. 20, 80336, München, Deutschland
| | - Luzi Dubs
- FMH für Orthopädische Chirurgie, Rychenbergstr. 155, 8400, Winterthur, Schweiz
| | - Stephan Kirschner
- Klinik für Orthopädie, St. Vincentius-Kliniken gAG, Steinhäuserstr. 18, 76135, Karlsruhe, Deutschland
| | - Tobias Renkawitz
- Orthopädie, Unfallchirurgie und Paraplegiologie, Orthopädische Universitätsklinik Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Deutschland
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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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Danya F, Marco B, Valentino C, Mario M, Antonio Pompilio G. Case Report: Unusual Heterotopic Ossification of the Hindfoot. Front Surg 2022; 9:917560. [PMID: 35747430 PMCID: PMC9209653 DOI: 10.3389/fsurg.2022.917560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
Heterotopic ossification (HO) is a pathologic condition in which aberrant lamellar bone deposits in soft tissues, outside of the normal skeleton. Pathogenesis is still unclear, but different risk factors are known. Here we report a case of a 14 year-old girl presenting with pain in the medial calcaneal region and evidence of a rapidly growing, firm and solid neoformation. The lesion was diagnosed 6 years earlier, but it was consistently smaller and asymptomatic so that the patient did not undergo any follow up. The patient had no previous trauma or surgery, no other risk factors for HO and did not show any clinically evident HO in other districts. Xray and CT showed a heterogeneous bony lesion in the context of soft tissues, isolated from the calcaneus. After complete excision, histological analysis confirmed the diagnosis of HO. In conclusion, lone non congenital HO can occur regardless of known risk factors. Small HO lesion may also enter a proliferative phase without evidence of triggering events. More studies are required to better understand etiopathogenesis of HO in these clinical settings.
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Affiliation(s)
- Falcioni Danya
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
- Correspondence: Danya Falcioni
| | - Baldini Marco
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Coppa Valentino
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marinelli Mario
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Gigante Antonio Pompilio
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Ancona, Italy
- Clinic of Adult and Paediatric Orthopedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
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Neurogenic heterotopic ossification in the upper limb. HAND SURGERY & REHABILITATION 2021; 41S:S167-S174. [PMID: 34536583 DOI: 10.1016/j.hansur.2020.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/15/2020] [Accepted: 09/08/2020] [Indexed: 11/21/2022]
Abstract
Neurogenic heterotopic ossifications (NHOs) are periarticular ectopic ossifications that frequently develop after a central nervous system injury, most often a traumatic one. They limit range of motion and cause pain, interfering with limb positioning and function, whether active or passive. Highly described in the lower limbs, NHOs can also develop in the upper limb, with specific characteristics depending on their location. This article provides a summary of the diagnostic and therapeutic management of NHOs in the upper limb, based on the current literature.
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McDonald SJ, Sharkey JM, Sun M, Kaukas LM, Shultz SR, Turner RJ, Leonard AV, Brady RD, Corrigan F. Beyond the Brain: Peripheral Interactions after Traumatic Brain Injury. J Neurotrauma 2021; 37:770-781. [PMID: 32041478 DOI: 10.1089/neu.2019.6885] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability, and there are currently no pharmacological treatments known to improve patient outcomes. Unquestionably, contributing toward a lack of effective treatments is the highly complex and heterogenous nature of TBI. In this review, we highlight the recent surge of research that has demonstrated various central interactions with the periphery as a potential major contributor toward this heterogeneity and, in particular, the breadth of research from Australia. We describe the growing evidence of how extracranial factors, such as polytrauma and infection, can significantly alter TBI neuropathology. In addition, we highlight how dysregulation of the autonomic nervous system and the systemic inflammatory response induced by TBI can have profound pathophysiological effects on peripheral organs, such as the heart, lung, gastrointestinal tract, liver, kidney, spleen, and bone. Collectively, this review firmly establishes TBI as a systemic condition. Further, the central and peripheral interactions that can occur after TBI must be further explored and accounted for in the ongoing search for effective treatments.
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Affiliation(s)
- Stuart J McDonald
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, Victoria, Australia
| | - Jessica M Sharkey
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Mujun Sun
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Lola M Kaukas
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sandy R Shultz
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Renee J Turner
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Anna V Leonard
- Discipline of Anatomy and Pathology, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rhys D Brady
- Department Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Frances Corrigan
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Mulpur P, Maryada V, Joseph V, Guravareddy A. The role of 3-D printed models in planning and resection of heterotopic ossification around the elbow: A case series. JOURNAL OF ORTHOPAEDICS AND SPINE 2021. [DOI: 10.4103/joasp.joasp_41_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Anthonissen J, Steffen CT, Alessandri B, Baranowski A, Rommens PM, Victor J, Hofmann A. Traumatic brain injury enhances the formation of heterotopic ossification around the hip: an animal model study. Arch Orthop Trauma Surg 2020; 140:1029-1035. [PMID: 31834481 DOI: 10.1007/s00402-019-03326-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The incidence of heterotopic ossification (HO) is at its highest when trauma of the hip or pelvis concurs with traumatic brain injury (TBI). The pathogenic mechanisms underlying the neurogenic enhancement of the formation of HO remain, however, poorly understood. Hence, the goal of the present study was to develop a novel small animal model that combines hip and brain trauma that can prove the enhancement of HO around the hip after TBI. MATERIALS AND METHODS Forty male Wistar rats were divided into four groups, to undergo hip surgery alone (group 1), hip surgery + moderate TBI (group 2), hip surgery + severe TBI (group 3) and only severe TBI (group 4). The femoral canal was reamed up to 2 mm and a muscle lesion was made to simulate hip surgery. An established controlled cortical impact model was used to create a TBI. Twelve weeks after surgery, the hip with the proximal half of the femur and the pelvic bone was removed and subjected to micro-computed tomography (µCT) analysis. A quantitative analysis using a modified Brooker score as well as a quantitative analysis using a bone-to-tissue ratio was used. RESULTS No HO could be found in all the ten animals that did not undergo hip surgery (group 4). In the animals that did undergo surgery to the hip, no HO was found in only one animal (group 1). All the other animals developed HO. In this study, significantly more HO was found in animals that underwent an additional severe TBI. CONCLUSION The newly developed rat model, with a combined hip and brain trauma, showed an enhancement of the HO formation around the hip after severe TBI.
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Affiliation(s)
- Joris Anthonissen
- Department of Orthopaedics and Trauma Surgery, University Hospital Mainz, Langenbeckstraße 1, 55131, Mainz, Germany. .,Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Clara Theressa Steffen
- Department of Orthopaedics and Trauma Surgery, University Hospital Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Beat Alessandri
- Institute for Neurosurgical Pathophysiology, University Hospital Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Andreas Baranowski
- Department of Orthopaedics and Trauma Surgery, University Hospital Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Pol Maria Rommens
- Department of Orthopaedics and Trauma Surgery, University Hospital Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Jan Victor
- Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Alexander Hofmann
- Department of Orthopaedics and Trauma Surgery, University Hospital Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
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Brady RD, Zhao MZ, Wong KR, Casilla-Espinosa PM, Yamakawa GR, Wortman RC, Sun M, Grills BL, Mychasiuk R, O'Brien TJ, Agoston DV, Lee PVS, McDonald SJ, Robinson DL, Shultz SR. A novel rat model of heterotopic ossification after polytrauma with traumatic brain injury. Bone 2020; 133:115263. [PMID: 32032779 DOI: 10.1016/j.bone.2020.115263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 01/08/2023]
Abstract
Neurological heterotopic ossification (NHO) is characterized by abnormal bone growth in soft tissue and joints in response to injury to the central nervous system. The ectopic bone frequently causes pain, restricts mobility, and decreases the quality of life for those affected. NHO commonly develops in severe traumatic brain injury (TBI) patients, particularly in the presence of concomitant musculoskeletal injuries (i.e. polytrauma). There are currently no animal models that accurately mimic these combinations of injuries, which has limited our understanding of NHO pathobiology, as well as the development of biomarkers and treatments, in TBI patients. In order to address this shortcoming, here we present a novel rat model that combines TBI, femoral fracture, and muscle crush injury. Young adult male Sprague Dawley rats were randomly assigned into three different injury groups: triple sham-injury, peripheral injury only (i.e., sham-TBI + fracture + muscle injury) or triple injury (i.e., TBI + fracture + muscle injury). Evidence of ectopic bone in the injured hind-limb, as confirmed by micro-computed tomography (μCT), was found at 6-weeks post-injury in 70% of triple injury rats, 20% of peripheral injury rats, and 0% of the sham-injured controls. Furthermore, the triple injury rats had higher ectopic bone severity scores than the sham-injured group. This novel model will provide a platform for future studies to identify underlying mechanisms, biomarkers, and develop evidence based pharmacological treatments to combat this debilitating long-term complication of TBI and polytrauma.
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Affiliation(s)
- 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.
| | - Michael Z Zhao
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Ker R Wong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Pablo M Casilla-Espinosa
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Glenn R Yamakawa
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Ryan C Wortman
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Mujun Sun
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Brian L Grills
- Department of Physiology, Anatomy, and Microbiology, La Trobe University, Bundoora, 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
| | - Denes V Agoston
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University, Bethesda, MD, USA
| | - Peter V S Lee
- Department of Biomedical Engineering, The University of Melbourne, Parkville, VIC, Australia
| | - Stuart J McDonald
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Dale L Robinson
- Department of Biomedical Engineering, 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
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Cole PA, Dugarte AJ, Talbot M, Routt MLC. Early resection of ectopic bone in patients with heterotopic ossification about the hip after trauma. Injury 2020; 51:705-710. [PMID: 32035630 DOI: 10.1016/j.injury.2020.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/18/2019] [Accepted: 01/19/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Heterotopic ossification (HO) is a common complication in patients who have sustained high-energy trauma to the hip region. Traditionally, resection is performed after ectopic bone maturation. We hypothesized that early HO resection in patients with hip ankylosis after trauma can be performed with little chance of recurrence. DESIGN Retrospective clinical cohort. SETTING Level I Trauma Center PATIENTS/PARTICIPANTS: 14 patients with resection of HO about the hip performed by the senior author during a six-year period. INTERVENTION Early resection of Brooker Class III or IV HO. MAIN OUTCOME MEASUREMENTS The original injuries, risk factors for HO, post-traumatic clinical course including the workup for HO, times from fixation to resection, surgical approach, and complications were recorded. Records were reviewed to document pre and postoperative hip motions. Pre and post-operative x-rays and CT scans were reviewed to classify the HO and localize the ectopic mass. RESULTS Mean injury to resection interval was 6.8-months. Nine of 14 (64%) patients were followed for a mean of 32.9-months post-resection. Indications for resection included pain, stiffness, and evolving sciatic nerve lesions. Risk factors were male gender, brain injury, and extended iliofemoral and Kocher-Langenbeck surgical approaches. Complications included gluteal vein laceration, draining wounds, and recurrence. Mean flexion-extension arc of motion was 18° (range = 0-70°) preoperatively, 100° (range = 85-125°) intra-operatively, and 94° (range = 20-110°) at final follow-up. HO recurred in nine patients; functionally significant in one. CONCLUSION Early resection of HO around the hip may be performed with little chance of symptomatic recurrence. LEVEL OF EVIDENCE This is a Level IV retrospective case series.
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Affiliation(s)
- Peter A Cole
- University of Minnesota, Regions Hospital, Department of Orthopaedic Surgery, St. Paul, MN, United States.
| | - Anthony J Dugarte
- University of Minnesota, Regions Hospital, Department of Orthopaedic Surgery, St. Paul, MN, United States
| | - Max Talbot
- Canadian Armed Forces, 1 Canadian Field Hospital, 147 Flanders Row, Garrison Petawawa, Onatrio, K8H 2X3, Canada
| | - Milton L Chip Routt
- Department of Orthopaedic Surgery, UT Health McGovern Medical School, Houston, TX, United States.
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Becker CA, Kussmaul AC, Suero EM, Regauer M, Woiczinski M, Braun C, Flatz W, Pieske O, Kammerlander C, Boecker W, Greiner A. Tape suture for stabilization of incomplete posterior pelvic ring fractures-biomechanical analysis of a new minimally invasive treatment for incomplete lateral compression pelvic ring fractures. J Orthop Surg Res 2019; 14:465. [PMID: 31881914 PMCID: PMC6935107 DOI: 10.1186/s13018-019-1509-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/05/2019] [Indexed: 12/13/2022] Open
Abstract
Background Incomplete lateral compression fractures (including AO Type B2.1) are among the most common pelvic ring injuries. Although the treatment of choice remains controversial, sacroiliac (SI) screws are commonly used for the operative treatment of incomplete lateral compression fractures of the pelvic ring. However, the disadvantages of SI screws include the risk of nerve root or blood vessel injury. Recently, tape sutures have been found useful as stabilizing material for the treatment of injuries of the syndesmosis, the rotator cuff and knee ligaments. In this current study, we aimed to test the biomechanical feasibility of tape sutures to stabilize the pelvis in the setting of AO Type B2.1 injury. Methods Six human cadaveric pelvises underwent cyclic loading to compare the biomechanical stability of different osteosynthesis methods in a B2.1 fracture model. The methods tested in this experiment were a FiberTape® suture and the currently established SI screw. A 3D ultrasound tracking system was used to measure fracture fragment motion. Linear regression was used to model displacement and stiffness at the posterior and anterior pelvic ring. Results At the posterior fracture site, the FiberTape® demonstrated similar displacement (2.2 ± 0.8 mm) and stiffness (52.2 ± 18.0 N/mm) compared to the sacroiliac screw (displacement 2.1 ± 0.6 mm, P > 0.999; stiffness 50.8 ± 13.0 N/mm, P > 0.999). Considering the anterior fracture site, the FiberTape® again demonstrated similar displacement (3.8 ± 1.3 mm) and stiffness (29.5 ± 9.0 N/mm) compared to the sacroiliac screw (displacement 2.9 ± 0.8 mm, P = 0.2196; stiffness 37.5 ± 11.5 N/mm, P = 0.0711). Conclusion The newly presented osteosynthesis, the FiberTape®, shows promising results for the stabilization of the posterior pelvic ring in AO Type B2.1 lateral compression fractures compared to a sacroiliac screw osteosynthesis based on its minimal-invasiveness and the statistically similar biomechanical properties.
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Affiliation(s)
| | - Adrian Cavalcanti Kussmaul
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Eduardo Manuel Suero
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Markus Regauer
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Matthias Woiczinski
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
| | - Christian Braun
- Department of Legal and Forensic Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Wilhelm Flatz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Pieske
- Department of Trauma Surgery, Evangelic Hospital Oldenburg, Oldenburg, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Boecker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Axel Greiner
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany.
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Zielinski E, Chiang BJL, Satpathy J. The role of preoperative vascular imaging and embolisation for the surgical resection of bilateral hip heterotopic ossification. BMJ Case Rep 2019; 12:12/8/e230964. [PMID: 31383688 DOI: 10.1136/bcr-2019-230964] [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: 11/03/2022] Open
Abstract
The surgical excision of heterotopic ossification can provide improved function for patients; however, complications can include damage to nearby vessels and nerves, blood loss and recurrence. In the preoperative planning for excision, our case report describes the combination of CT angiography, preoperative embolisation of involved vascular structures and the use of intraoperative vascular surgery for dissection around key structures to aid in the reduction of morbidity in these patients.
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Affiliation(s)
- Elizabeth Zielinski
- Department of Orthopaedics, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Jibanananda Satpathy
- Department of Orthopaedics, Virginia Commonwealth University, Richmond, Virginia, USA
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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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15
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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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16
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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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17
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O'Callaghan PK, Carter E, Walton Z, Chapin R, Bruner E. Heterotopic Ossification Formation Following a Simple Concussion: A Case Report. JBJS Case Connect 2018; 8:e26. [PMID: 29742529 DOI: 10.2106/jbjs.cc.17.00158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
CASE A 19-year-old woman presented with a 3-month history of an enlarging lesion on the proximal aspect of the femur. After imaging studies and a biopsy had been performed, the mass was determined to represent heterotopic ossification (HO). The only known risk factor was a history of concussion. The mass was resected and, as of the 12-month follow-up, had not recurred. CONCLUSION HO is a potentially serious complication of ossification in soft tissues that can develop secondary to several disease states; it commonly occurs following traumatic brain injury. To our knowledge, this is the only case report that describes HO associated with a concussion and no other risk factors.
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Affiliation(s)
- Patrick K O'Callaghan
- Departments of Orthopaedics (P.K.O'C. and Z.W.), Radiology (R.C.), and Pathology and Laboratory Medicine (E.B.), Medical University of South Carolina (E.C.), Charleston, South Carolina
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18
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Eisenstein N, Stapley S, Grover L. Post-Traumatic Heterotopic Ossification: An Old Problem in Need of New Solutions. J Orthop Res 2018; 36:1061-1068. [PMID: 29193256 DOI: 10.1002/jor.23808] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 11/12/2017] [Indexed: 02/04/2023]
Abstract
Heterotopic ossification (HO) is the formation of pathological bone in ectopic sites and it can have serious consequences for functional outcomes. For many years, its main clinical relevance was as a rare complication of elective joint arthroplasty or CNS injury and a number of prophylaxes were developed to mitigate against it in these settings. As a consequence of changes in patterns of wounding and survival in conflicts since the turn of the century, post-traumatic HO has become much more common and case severity has increased. It represents one of the main barriers to rehabilitation in a large cohort of combat-injured patients. However, extant prophylaxes have not been shown to be effective or appropriate in this patient cohort. In addition, the lack of reliable early detection or means of predicting which patients will develop HO is another barrier to effective prevention. This review examines the current state of understanding of post-traumatic HO including the historical context, epidemiology, pathophysiology, clinical issues, currently prophylaxis and detection, management, and potential future approaches. Our aims are to highlight the current lack of effective means of early detection and prevention of HO after major trauma and to stimulate research into novel solutions to this challenging problem. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1061-1068, 2018.
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Affiliation(s)
- Neil Eisenstein
- Royal Centre for Defence Medicine, Birmingham Research Park, ICT Centre, Vincent Drive, Birmingham, B15 2SQ, United Kingdom.,School of Chemical Engineering, University of Birmingham, Edgbaston, B15 2TT, United Kingdom
| | - Sarah Stapley
- Royal Centre for Defence Medicine, Birmingham Research Park, ICT Centre, Vincent Drive, Birmingham, B15 2SQ, United Kingdom.,School of Chemical Engineering, University of Birmingham, Edgbaston, B15 2TT, United Kingdom
| | - Liam Grover
- School of Chemical Engineering, University of Birmingham, Edgbaston, B15 2TT, United Kingdom
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19
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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: 50] [Impact Index Per Article: 8.3] [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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20
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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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21
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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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22
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Management of Medical Complications During the Rehabilitation of Moderate-Severe Traumatic Brain Injury. Phys Med Rehabil Clin N Am 2017; 28:259-270. [DOI: 10.1016/j.pmr.2016.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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23
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Reznik JE, Biros E, Lamont AC, Sacher Y, Kibrik O, Milanese S, Gordon S, Galea MP. A preliminary investigation on the effect of extracorporeal shock wave therapy as a treatment for neurogenic heterotopic ossification following traumatic brain injury. Part I: Effects on pain. Brain Inj 2017; 31:526-532. [PMID: 28340308 DOI: 10.1080/02699052.2017.1283059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Neurogenic heterotopic ossification (NHO) is a complication of a neurological injury following traumatic brain injury (TBI) and may be present around major synovial joints. It is often accompanied by severe pain, which may lead to limitation in activities of daily living. Currently, a common intervention for NHO is surgery, which has been reported to carry many additional risks. This study was designed to assess the effect of extracorporeal shock wave therapy (ESWT) on pain in patients with TBI with chronic NHO. METHODS A series of single-case studies (n = 11) was undertaken with patients who had TBI and chronic NHO at the hip or knee. Each patient received four applications of high-energy EWST delivered to the affected joint over 8 weeks. Two-weekly follow-up assessments were carried out, and final assessments were made 3 and 6 months post-intervention. Pain was measured using the Faces Rating Scale, and X-rays were taken at baseline and 6-months post-intervention to physiologically measure the size of the NHO. RESULTS The application of high-energy ESWT was associated with significant overall reduction of pain in patients with TBI and NHO (Tau-0.412, 95% confidence interval -0.672 to -0.159, p = 0.002). CONCLUSIONS ESWT is a novel non-invasive intervention for reducing pain resulting from NHO in patients with TBI.
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Affiliation(s)
- J E Reznik
- a College of Healthcare Science and Division of Tropical Health and Medicine
| | - E Biros
- b Queensland Research Centre for Peripheral Vascular Disease
| | - A C Lamont
- c College of Medicine and Dentistry, James Cook University , Townsville , QLD , Australia.,d Department of Radiology , The Townsville Hospital , Townsville , QLD , Australia
| | | | - O Kibrik
- f Loewenstein Rehabilitation Center, Sackler Faculty of Medicine , Tel Aviv University , Raanana , Israel
| | - S Milanese
- g Discipline of Physiotherapy , University of South Australia , Adelaide , SA , Australia
| | - S Gordon
- h College of Healthcare Science, James Cook University , Townsville , QLD , Australia.,i School of Health Sciences, Flinders University , Bedford Park , SA , Australia
| | - M P Galea
- j Department of Medicine, Royal Melbourne Hospital , The University of Melbourne , Melbourne , VIC , Australia.,k James Cook University , Townsville , QLD , Australia
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24
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Reznik JE, Biros E, Sacher Y, Kibrik O, Milanese S, Gordon S, Galea MP. A preliminary investigation on the effect of extracorporeal shock wave therapy as a treatment for neurogenic heterotopic ossification following traumatic brain injury. Part II: Effects on function. Brain Inj 2017; 31:533-541. [PMID: 28340312 DOI: 10.1080/02699052.2017.1283060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Neurogenic heterotopic ossification (NHO) occurs as a complication of traumatic brain injury (TBI). Management of clinically significant NHO remains variable. Complications of mature NHO include limitation of mobility. The effect of the extracorporeal shock wave therapy (ESWT) on range of motion at hip and knee, and function in patients with TBI with chronic NHO was investigated. METHODS A series of single-case studies applying ESWT to chronic NHO at the hip or knee of 11 patients with TBI were undertaken at a rehabilitation hospital. Participants received four applications of high-energy EWST delivered to the affected hip or knee over a period of 8 weeks. Two-weekly follow- up assessments were carried out; final assessments were made 3 and 6 months post-intervention. Range of motion (ROM) and Functional Reach (FR) or Modified Functional Reach (MFR) were measured. RESULTS Application of high-energy ESWT was associated with significant improvement in ROM (flexion) of the NHO-affected knee (Tau = 0.833, 95% CI 0.391-1.276, p = 0.002) and significant improvement of FR (Overall Tau 0.486, 95% CI 0.141-0.832, p = 0.006); no significant improvement in hip ROM or MFR. CONCLUSIONS ESWT may improve mobility and balance of patients with TBI who have chronic NHO.
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Affiliation(s)
- J E Reznik
- a College of Healthcare Science and Division of Tropical Health and Medicine
| | - E Biros
- b Queensland Research Centre for Peripheral Vascular Disease , James Cook University , Townsville , QLD , Australia
| | | | - O Kibrik
- d Loewenstein Rehabilitation Center, Sackler Faculty of Medicine , Tel Aviv University , Raanana , Israel
| | - S Milanese
- e Discipline of Physiotherapy , University of South Australia , Adelaide , SA , Australia
| | - S Gordon
- f College of Healthcare Science, James Cook University , Townsville , QLD , Australia.,g School of Health Sciences, Flinders University , Bedford Park , SA , Australia
| | - M P Galea
- h Department of Medicine, Royal Melbourne Hospital , The University of Melbourne , Melbourne , VIC , Australia.,i College of Healthcare Science and Division of Tropical Health and Medicine, James Cook University , Townsville , QLD , Australia
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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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26
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Chen S, Liu J, Cai J, Zheng W, Li Z, Chen W, Fan C. Results and outcome predictors after open release of complete ankylosis of the elbow caused by heterotopic ossification. INTERNATIONAL ORTHOPAEDICS 2017; 41:1627-1632. [DOI: 10.1007/s00264-016-3395-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/27/2016] [Indexed: 10/20/2022]
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27
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Law-Ye B, Hangard C, Felter A, Safa D, Denormandie P, Genet F, Carlier RY. Pre-surgical CT-assessment of neurogenic myositis ossificans of the hip and risk factors of recurrence: a series of 101 consecutive patients. BMC Musculoskelet Disord 2016; 17:433. [PMID: 27756329 PMCID: PMC5070170 DOI: 10.1186/s12891-016-1294-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/11/2016] [Indexed: 12/02/2022] Open
Abstract
Background Neurogenic Myositis Ossificans (NMO) is a rare disabling pathology characterized by peri-articular heterotopic ossifications following severe peripheral or central nervous system injuries. It results in ankylosis and vessels or nerves compressions. Our study aimed to describe the pre-operative findings of patients with NMO of the hip using biphasic computerized tomography (CT). Methods Between 2006 and 2012, we retrospectively analyzed 101 consecutive patients with hip NMO. We analyzed all CTs and surgical reports following a standardized grid depicting the osteoma and its relations with joint capsule, vessels and nerves and bone mineralization. We studied surgical complications and recurrence during follow-up. Chi2-test and Fischer’s test were performed to compare qualitative values with respectively normal and non-normal distribution. Quantitative values were analyzed with a one factor analysis of variance (ANOVA) test. Agreement between pre-surgical CT and surgical observations was evaluated with Cohen’s kappa test. Results Correlation between pre-operative CT and surgical findings was excellent regarding relationships with vessels (0,82) and was good concerning relationships with sciatic nerves (0.62) and with joint capsule (0.68). Close contact or disruption of joint capsule (p = 0.005), joint space narrowing (p = 0.007) and bone demineralization (p < 0.001) were correlated with NMO recurrence. Conclusions Biphasic enhanced-CT allows pre-operative assessment of NMO with good correlation to surgical observations and helps prevent surgical complications.
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Affiliation(s)
- Bruno Law-Ye
- APHP, Neuroradiology Department, Pitié-Salpêtrière Hospital, Paris, France.,Pierre and Marie Curie Faculty of Medicine, Sorbonne Universités, Paris, France
| | - Chloé Hangard
- APHP, Radiology Department, Neuro-musculoskeletal Pole, Raymond Poincaré Hospital, 92380, Garches, France.,Versailles University, Paris-Saclay UMR 1179, End: icap, Saint-Quentin-en-Yvelines, France
| | - Adrien Felter
- APHP, Radiology Department, Neuro-musculoskeletal Pole, Raymond Poincaré Hospital, 92380, Garches, France.,Versailles University, Paris-Saclay UMR 1179, End: icap, Saint-Quentin-en-Yvelines, France
| | - Dominique Safa
- APHP, Radiology Department, Neuro-musculoskeletal Pole, Raymond Poincaré Hospital, 92380, Garches, France
| | - Philippe Denormandie
- APHP, Orthopedic surgery Department, Neuro-orthopedic Unit, Neuro-musculoskeletal Pole, Raymond Poincaré Hospital, 92380, Garches, France
| | - François Genet
- Versailles University, Paris-Saclay UMR 1179, End: icap, Saint-Quentin-en-Yvelines, France.,APHP, Rehabilitation Department and Pole, Raymond Poincaré Hospital, 92380, Garches, France
| | - Robert-Yves Carlier
- APHP, Radiology Department, Neuro-musculoskeletal Pole, Raymond Poincaré Hospital, 92380, Garches, France. .,Versailles University, Paris-Saclay UMR 1179, End: icap, Saint-Quentin-en-Yvelines, France. .,CIC 1429, Raymond Poincaré Hospital, 92380, Garches, France.
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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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Abstract
Heterotopic ossification (HO) is a complication of musculoskeletal injury characterized by the formation of mature bone in soft tissues. The etiology of HO is unknown. We investigated the role of bone marrow derived progenitor cells in HO pathophysiology. We isolated the cells from HO specimens by cell explantation. Using flow cytometry and immunofluorescence microscopy, we found that 35 to 65% of the HO cells exhibit a bone marrow derived fibrocyte profile consisting in spindle-shaped morphology associated with type 1 pro-collagen and LSP1 expression. When cultured in osteogenic differentiation medium, active machinery for bone mineralization (high gene expression of Anx2, TNAP, and Pit-1), and calcium/phosphate deposits were found. Interestingly, interferon-alpha 2b significantly reduced the proliferation rate and COL1 gene expression in HO cells. We have characterized a novel subset of bone marrow derived progenitor cells in the HO specimens. The findings from this research study will provide new insights into the development of HO in burn patients.
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Abstract
Successful management of the mangled extremity is difficult; however, recent advancements are changing the outcomes of these difficult cases. Multiple centers are working on new bionic limbs with real-time feedback and better performance parameters. Research progress, particularly in the military sector, has aided in our understanding of heterotopic ossification after devastating limb injuries. This progress has also allowed a better treatment program for the residual limb in surgery and postsurgery. It is an exciting time in the management and rehabilitation of amputated limbs, as both biologic and technological advancements are enabling better patient satisfaction. This article looks at some of these discoveries and how they are changing the treatment of the residual limb.
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Chen S, Yu SY, Yan H, Cai JY, Ouyang Y, Ruan HJ, Fan CY. The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise. J Shoulder Elbow Surg 2015; 24:1165-71. [PMID: 26189802 DOI: 10.1016/j.jse.2015.05.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/28/2015] [Accepted: 05/04/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary. METHODS We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated. RESULTS Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups (P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively. CONCLUSIONS Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened.
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Affiliation(s)
- Shuai Chen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shi-yang Yu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hede Yan
- Division of Plastic and Hand Surgery, Department of Orthopaedics, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiang-yu Cai
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuanming Ouyang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hong-jiang Ruan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cun-yi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Shrivats AR, Hsu E, Averick S, Klimak M, Watt ACS, DeMaio M, Matyjaszewski K, Hollinger JO. Cationic Nanogel-mediated Runx2 and Osterix siRNA Delivery Decreases Mineralization in MC3T3 Cells. Clin Orthop Relat Res 2015; 473:2139-49. [PMID: 25448327 PMCID: PMC4418993 DOI: 10.1007/s11999-014-4073-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/17/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) may occur after musculoskeletal trauma, traumatic brain injury, and total joint arthroplasty. As such, HO is a compelling clinical concern in both military and civilian medicine. A possible etiology of HO involves dysregulated signals in the bone morphogenetic protein osteogenic cascade. Contemporary treatment options for HO (ie, nonsteroidal antiinflammatory drugs and radiation therapy) have adverse effects associated with their use and are not biologically engineered to abrogate the molecular mechanisms that govern osteogenic differentiation. QUESTIONS/PURPOSES We hypothesized that (1) nanogel-mediated short interfering RNA (siRNA) delivery against Runt-related transcription factor 2 (Runx2) and osterix (Osx) genes will decrease messenger RNA expression; (2) inhibit activity of the osteogenic marker alkaline phosphatase (ALP); and (3) inhibit hydroxyapatite (HA) deposition in osteoblast cell cultures. METHODS Nanogel nanostructured polymers delivered siRNA in 48-hour treatment cycles against master osteogenic regulators, Runx2 and Osx, in murine calvarial preosteoblasts (MC3T3-E1.4) stimulated for osteogenic differentiation by recombinant human bone morphogenetic protein (rhBMP-2). The efficacy of RNA interference (RNAi) therapeutics was determined by quantitation of messenger RNA knockdown (by quantitative reverse transcription-polymerase chain reaction), downstream protein knockdown (determined ALP enzymatic activity assay), and HA deposition (determined by OsteoImage™ assay). RESULTS Gene expression assays demonstrated that nanogel-based RNAi treatments at 1:1 and 5:1 nanogel:short interfering RNA weight ratios reduced Runx2 expression by 48.59% ± 19.53% (p < 0.001) and 43.22% ± 18.01% (both p < 0.001). The same 1:1 and 5:1 treatments against both Runx2 and Osx reduced expression of Osx by 51.65% ± 10.85% and 47.65% ± 9.80% (both p < 0.001). Moreover, repeated 48-hour RNAi treatment cycles against Runx2 and Osx rhBMP-2 administration reduced ALP activity after 4 and 7 days. ALP reductions after 4 days in culture by nanogel 5:1 and 10:1 RNAi treatments were 32.4% ± 12.0% and 33.6% ± 13.8% (both p < 0.001). After 7 days in culture, nanogel 1:1 and 5:1 RNAi treatments produced 35.9% ± 14.0% and 47.7% ± 3.2% reductions in ALP activity. Osteoblast mineralization data after 21 days suggested that nanogel 1:1, 5:1, and 10:1 RNAi treatments decreased mineralization (ie, HA deposition) from cultures treated only with rhBMP-2 (p < 0.001). However, despite RNAi attack on Runx2 and Osx, HA deposition levels remained greater than non-rhBMP-2-treated cell cultures. CONCLUSIONS Although mRNA and protein knockdown were confirmed as a result of RNAi treatments against Runx2 and Osx, complete elimination of mineralization processes was not achieved. RNAi targeting mid- and late-stage osteoblast differentiation markers such as ALP, osteocalcin, osteopontin, and bone sialoprotein) may produce the desired RNAi-nanogel nanostructured polymer HO prophylaxis. CLINICAL RELEVANCE Successful HO prophylaxis should target and silence osteogenic markers critical for heterotopic bone formation processes. The identification of such markers, beyond RUNX2 and OSX, may enhance the effectiveness of RNAi prophylaxes for HO.
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Affiliation(s)
- Arun R. Shrivats
- />Department of Biomedical Engineering, Carnegie Mellon University, 700 Technology Drive, Pittsburgh, PA 15219 USA
| | - Eric Hsu
- />Department of Biomedical Engineering, Carnegie Mellon University, 700 Technology Drive, Pittsburgh, PA 15219 USA
| | - Saadyah Averick
- />Department of Chemistry, Carnegie Mellon University, 4400 Fifth Ave, Pittsburgh, PA 15213 USA
| | - Molly Klimak
- />Department of Biomedical Engineering, Carnegie Mellon University, 700 Technology Drive, Pittsburgh, PA 15219 USA
| | - April C. S. Watt
- />Department of Biomedical Engineering, Carnegie Mellon University, 700 Technology Drive, Pittsburgh, PA 15219 USA
| | - Marlene DeMaio
- />Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Portsmouth, VA 23708 USA
| | - Krzysztof Matyjaszewski
- />Department of Chemistry, Carnegie Mellon University, 4400 Fifth Ave, Pittsburgh, PA 15213 USA
| | - Jeffrey O. Hollinger
- />Department of Biomedical Engineering, Carnegie Mellon University, 700 Technology Drive, Pittsburgh, PA 15219 USA
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Min HW, Liu KM, Han XZ, Gu R. Management of multijoint stiffness of bilateral upper limbs secondary to heterotopic ossification: Case report and literature review. ACTA ACUST UNITED AC 2014; 51:497-502. [DOI: 10.1682/jrrd.2013.03.0073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 10/10/2013] [Indexed: 11/05/2022]
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Dolomisiewicz EA, Miller ME, Potter BK. Fulminant heterotopic ossification after combat-related amputation: a report of 2 cases. PM R 2013; 6:279-83. [PMID: 24374089 DOI: 10.1016/j.pmrj.2013.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 09/29/2013] [Accepted: 10/12/2013] [Indexed: 11/24/2022]
Abstract
Heterotopic ossification (HO) is the process of abnormal formation of lamellar bone in nonosseous tissues. In this case presentation, we describe patients with aggressive HO, which becomes symptomatic shortly after injury for which we have suggested the term "fulminant heterotopic ossification." These atypical presentations of fulminant HO highlight the necessity for continued research directed at improved understanding of HO and may suggest a role for early partial surgical excision as a definitive management strategy.
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Affiliation(s)
- Edward A Dolomisiewicz
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889(∗).
| | - Matthew E Miller
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD(†)
| | - Benjamin K Potter
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD(‡)
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Sullivan MP, Torres SJ, Mehta S, Ahn J. Heterotopic ossification after central nervous system trauma: A current review. Bone Joint Res 2013; 2:51-7. [PMID: 23610702 PMCID: PMC3626201 DOI: 10.1302/2046-3758.23.2000152] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 01/10/2013] [Indexed: 11/17/2022] Open
Abstract
Neurogenic heterotopic ossification (NHO) is
a disorder of aberrant bone formation affecting one in five patients sustaining
a spinal cord injury or traumatic brain injury. Ectopic bone forms
around joints in characteristic patterns, causing pain and limiting
movement especially around the hip and elbow. Clinical sequelae
of neurogenic heterotopic ossification include urinary tract infection,
pressure injuries, pneumonia and poor hygiene, making early diagnosis
and treatment clinically compelling. However, diagnosis remains
difficult with more investigation needed. Our pathophysiological
understanding stems from mechanisms of basic bone formation enhanced
by evidence of systemic influences from circulating humor factors
and perhaps neurological ones. This increasing understanding guides
our implementation of current prophylaxis and treatment including
the use of non-steroidal anti-inflammatory drugs, bisphosphonates,
radiation therapy and surgery and, importantly, should direct future, more
effective ones.
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Affiliation(s)
- M P Sullivan
- Hospital of the University of Pennsylvania, Department of Orthopaedic Surgery, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA
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Daugherty LC, Bell JR, Fisher BJ, Sankhla N, Tzou K, Troicki F, Wong ML, Komarnicky LT, Brady LW. Radiation prophylaxis as primary prevention of heterotopic ossification of the knee: classification of disease and indications for treatment. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13566-012-0077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Impact of the Operative Delay and the Degree of Neurologic Sequelae on Recurrence of Excised Heterotopic Ossification in Patients With Traumatic Brain Injury. J Head Trauma Rehabil 2012; 27:443-8. [DOI: 10.1097/htr.0b013e31822b54ba] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Early Selective Surgical Resection of Traumatic Heterotopic Ossification After Extensive Crush Injuries: A Case Report. PM R 2011; 3:982-5. [DOI: 10.1016/j.pmrj.2011.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 06/06/2011] [Accepted: 06/12/2011] [Indexed: 11/24/2022]
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Genêt F, Jourdan C, Lautridou C, Chehensse C, Minooee K, Denormandie P, Schnitzler A. The impact of preoperative hip heterotopic ossification extent on recurrence in patients with head and spinal cord injury: a case control study. PLoS One 2011; 6:e23129. [PMID: 21853078 PMCID: PMC3154269 DOI: 10.1371/journal.pone.0023129] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 07/12/2011] [Indexed: 11/28/2022] Open
Abstract
Background The preoperative Heterotopic Ossification (HO) extent is usually one of the main used criteria to predict the recurrence before excision. Brooker et al built a radiologic scale to assess this pre operative extent around the hip. The aim of this study is to investigate the relationship between the recurrence risk after hip HO excision in Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) patients and the preoperative extent of HO. Methodology/Principal Findings A case control study including TBI or SCI patients following surgery for troublesome hip HO with (case, n = 19) or without (control, n = 76) recurrence. Matching criteria were: sex, pathology (SCI or TBI) and age at the time of surgery (+/−4.5 years). For each etiology (TBI and SCI), the residual cognitive and functional status (Garland classification), the preoperative extent (Brooker status), the modified radiological and functional status (GCG-BD classification), HO localization, side, mean age at the CNS damage, mean delay for the first HO surgery, and for the case series, the mean operative delay for recurrence after the first surgical intervention were noted. Conclusions/Significance The median delay for first HO surgery was 38.6 months (range 4.5 to 414.5;) for the case subgroup and 17.6 months (range 5.7 to 339.6) for the control group. No significant link was found between recurrence and operative delay (p = 0.51); the location around the joint (0.07); the Brooker (p = 0.52) or GCG-BD status (p = 0.79). Including all the matching factors, no significant relationship was found between the recurrence HO risk and the preoperative extent of troublesome hip HO using Brooker status (OR = 1.56(95% CI: 0.47–5.19)) or GCG-BD status (OR class 3 versus 2 = 0.67(95% CI: 0.11–4.24) and OR class 4 versus 2 = 0.79(95%CI: 0.09–6.91)). Until the pathophysiology of HO development is understood, it will be difficult to create tools which can predict HO recurrence.
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Affiliation(s)
- François Genêt
- Service de Médecine Physique et de Réadaptation, CHU R.Poincaré, Garches, France.
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Moreta-Suárez J, Sáez de Ugarte-Sobrón O, Martínez-de Los Mozos J. Osificaciones heterotópicas neurogénicas de cadera. A propósito de 2 casos. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recot.2011.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Genêt F, Jourdan C, Schnitzler A, Lautridou C, Guillemot D, Judet T, Poiraudeau S, Denormandie P. Troublesome heterotopic ossification after central nervous system damage: a survey of 570 surgeries. PLoS One 2011; 6:e16632. [PMID: 21304993 PMCID: PMC3031592 DOI: 10.1371/journal.pone.0016632] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 01/06/2011] [Indexed: 11/18/2022] Open
Abstract
Background Heterotopic ossification (HO) is a frequent complication after central nervous system (CNS) damage but has seldom been studied. We aimed to investigate features of HO for the first time in a large sample and the rate of early recurrence of HO in terms of the time of surgery. Methodology/Principal Findings We retrospectively analyzed data from an anonymous prospective survey of patients undergoing surgery between May 1993 and November 2009 in our institution for troublesome HO related to acquired neurological disease. Demographic and HO characteristics and neurological etiologies were recorded. For 357 consecutive patients, we collected data on 539 first surgeries for HO (129 surgeries for multiple sites). During the follow-up, recurrences requiring another surgery appeared in 31 cases (5.8% [31/539]; 95% confidence interval [CI]: 3.8%–7.8%; 27 patients). Most HO requiring surgery occurred after traumatic brain injury (199 patients [55.7%]), then spinal cord injury (86 [24.0%]), stroke (42 [11.8%]) and cerebral anoxia (30 [8.6%]). The hip was the primary site of HO (328 [60.9%]), then the elbow (115 [21.3%]), knee (77 [14.3%]) and shoulder (19 [3.5%]). For all patients, 181 of the surgeries were performed within the first year after the CNS damage, without recurrence of HO. Recurrence was not associated with etiology (p = 0.46), sex (p = 1.00), age at CNS damage (p = 0.2), multisite localization (p = 0.34), or delay to surgery (p = 0.7). Conclusions/Significance In patients with CNS damage, troublesome HO and recurrence occurs most frequently after traumatic brain injury and appears frequently in the hip and elbow. Early surgery for HO is not a factor of recurrence.
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Affiliation(s)
- François Genêt
- Service de Médecine Physique et de Réadaptation, Hôpital Raymond Poincaré, Garches, France.
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Neurogenic heterotopic ossification of the hip. Presentation of two cases. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/s1988-8856(11)70322-4] [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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Abstract
Rehabilitation following traumatic brain injury (TBI) is best provided by an interdisciplinary team of health care providers that takes advantage of the unique skills of multiple specialists, as well as their combined strengths that address problems that cut across disciplines. The setting where rehabilitation is provided is determined by the medical stability of patients, their ability to tolerate intensive therapies, and their likelihood of community reintegration within a reasonable period of time. Successful rehabilitation requires prompt recognition and treatment of TBI-related medical, cognitive, and behavioral problems to promote recovery and enhance community reintegration, using a combination of rehabilitation modalities and medications.
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Affiliation(s)
- Jaime M Levine
- Rusk Institute of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA.
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Anagnostakos K, Schmid N, Kohn D. [Hip joint arthrolysis due to heterotopic ossification]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2010; 21:557-70. [PMID: 20087717 DOI: 10.1007/s00064-009-2005-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Restoration of joint mobility with preservation of femoral head perfusion and warranty of joint stability. Pain reduction. Enhancement of the autonomous daily mobility (if possible regarding the cognitive status) as well as the ability to sit. For nonambulatory, bedridden patients ease of sanitary tasks and improvement of patients' convenience. INDICATIONS Joint stiffness with limitation of the quality of life. Pain. Joint deformity, especially in cases of progressive subluxation. CONTRAINDICATIONS Relative: radiologically and scintigraphically immature heterotopic ossification (HO) with moderate limitation of motion and patients who are not able to tolerate the demanding postoperative management. SURGICAL TECHNIQUE The patient is positioned depending on size and location of ectopic bone. Ectopic bone is released from surrounding soft tissue or by making use of a gap between original bone and ectopic bone from the femur or pelvis. If ectopic bone is close to neurovascular structures, these have to be identified and protected. POSTOPERATIVE MANAGEMENT Postoperative irradiation in patients > 50 years. Generally, medicamentous prevention for recurrent cases with nonsteroidal anti-inflammatory drugs. Intensive and aggressive physical therapy, especially in patients with neurologic disorders. Depending on the extent of arthrolysis and the cause of HO, full, partial, or no weight bearing of the extremity over the first 6 postoperative weeks. RESULTS The literature does not allow to draw firm conclusions regarding the occurrence of HO. The incidence of HO after primary total hip arthroplasty is estimated at 42%. In 9% of these cases, a severe HO with major limitation of motion or ankylosis occurs. In patients with neurologic injuries (brain injuries, spinal cord injuries) the incidence varies between 20-40%, but only one third of these patients show limited function or ankylosis. After surgical arthrolysis, the recurrence rate amounts to 25-30% at a mean follow-up of 6 years.
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Assessment und Management medizinischer Komplikationen. NeuroRehabilitation 2010. [DOI: 10.1007/978-3-642-12915-5_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Genet F, Marmorat JL, Lautridou C, Schnitzler A, Mailhan L, Denormandie P. Impact of late surgical intervention on heterotopic ossification of the hip after traumatic neurological injury. ACTA ACUST UNITED AC 2009; 91:1493-8. [PMID: 19880896 DOI: 10.1302/0301-620x.91b11.22305] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings. In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications. The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO.
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Affiliation(s)
- F Genet
- Service de Médecine, Physioque et de Réadaptation, L'Hôpital Raymond Poincaré, Garches, France.
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Zeckey C, Hildebrand F, Mommsen P, Schumann J, Frink M, Pape HC, Krettek C, Probst C. Risk of symptomatic heterotopic ossification following plate osteosynthesis in multiple trauma patients: an analysis in a level-1 trauma centre. Scand J Trauma Resusc Emerg Med 2009; 17:55. [PMID: 19825174 PMCID: PMC2765935 DOI: 10.1186/1757-7241-17-55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 10/13/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Symptomatic heterotopic ossification (HO) in multiple trauma patients may lead to follow up surgery, furthermore the long-term outcome can be restricted. Knowledge of the effect of surgical treatment on formation of symptomatic heterotopic ossification in polytrauma is sparse. Therefore, we test the effects of surgical treatment (plate osteosynthesis or intramedullary nailing) on the formation of heterotopic ossification in the multiple trauma patient. METHODS We retrospectively analysed prospectively documented data of blunt multiple trauma patients with long bone fractures which were treated at our level-1 trauma centre between 1997 and 2005. Patients were distributed to 2 groups: Patients treated by intramedullary nails (group IMN) or plate osteosynthesis (group PLATE) were compared. The expression and extension of symptomatic heterotopic ossifications on 3-6 months follow-up x-rays in antero-posterior (ap) and lateral views were classified radiologically and the maximum expansion was measured in millimeter (mm). Additionally, ventilation time, prophylactic medication like indomethacine and incidence and correlation of head injuries were analysed. RESULTS 101 patients were included in our study, 79 men and 22 women. The fractures were treated by intramedullary nails (group IMN n = 50) or plate osteosynthesis (group PLATE n = 51). Significantly higher radiologic ossification classes were detected in group PLATE (2.9 +/- 1.3) as compared to IMN (2.2 +/- 1.1; p = 0.013). HO size in mm ap and lateral showed a tendency towards larger HOs in the PLATE group. Additionally PLATE group showed a higher rate of articular fractures (63% vs. 28% in IMN) while IMN demonstrated a higher rate of diaphyseal fractures (72% vs. 37% in PLATE; p = 0.003). Ventilation time, indomethacine and incidence of head injuries showed no significant difference between groups. CONCLUSION Fracture care with plate osteosynthesis in polytrauma patients is associated with larger formations of symptomatic heterotopic ossifications (HO) while intramedullary nailing was associated with a higher rate of remote HO. For future fracture care of multiply injured patients these facts may be considered by the responsible surgeon.
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Affiliation(s)
- Christian Zeckey
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Frank Hildebrand
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Philipp Mommsen
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Julia Schumann
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Michael Frink
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Hans-Christoph Pape
- Trauma Department, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Christian Probst
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
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Hosalkar H, Hsu J, Pandya NK, Keenan MA. What's new in orthopaedic rehabilitation. J Bone Joint Surg Am 2008; 90:2301-11. [PMID: 18829929 DOI: 10.2106/jbjs.h.00943] [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: 02/01/2023]
Affiliation(s)
- Harish Hosalkar
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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