1
|
Galietta E, Gaiani L, Giannini C, Sambri A, Buwenge M, Macchia G, Deodato F, Cilla S, Strigari L, Arcelli A, Fiore M, Cammelli S, DE Paolis M, Morganti AG. Personalizing Prophylactic Radiotherapy for Hip Heterotopic Ossification: An AMSTAR-2 Compliant Review of Meta-analyses. In Vivo 2024; 38:1530-1536. [PMID: 38936917 PMCID: PMC11215626 DOI: 10.21873/invivo.13603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND/AIM Heterotopic ossification (HO) is a common complication following total hip arthroplasty. Various prophylactic treatments have been proposed, including radiotherapy (RT). This review summarizes the evidence from meta-analyses on the efficacy of RT in preventing hip HO. MATERIALS AND METHODS A literature search was conducted on PubMed. The quality of the meta-analyses was assessed using the AMSTAR-2 tool. RESULTS Seven meta-analyses were included. One meta-analysis reported a significant reduction in HO occurrence after RT compared to the control group. Comparing RT and non-steroidal anti-inflammatory drugs, one and two meta-analyses showed significantly greater efficacy of RT in preventing severe HO and better outcomes in patients receiving drugs, respectively. Regarding RT settings, the postoperative and preoperative RT were each supported by one meta-analysis. Furthermore, two meta-analyses showed an advantage of multi-fractionated RT over single fraction RT. The overall confidence rate of the meta-analyses was moderate, low, and critically low in one, three, and three meta-analyses, respectively. CONCLUSION RT is a confirmed prophylactic intervention for HO. However, the precise optimization of timing, dosage, and fractionation requires elucidation. Future research should focus on the development of predictive models through large-scale data collection and advanced analytics to refine individualized treatment strategies and assess RT comparative effectiveness with drugs.
Collapse
Affiliation(s)
- Erika Galietta
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-Bologna University, Bologna, Italy;
| | - Luca Gaiani
- U.O. Ortopedia e Traumatologia, AUSL Imola, Imola, Italy
| | | | - Andrea Sambri
- UOC Ortopedia e Traumatologia, IRCCS Azienda Ospedaliera Universitaria di Bologna, Bologna, Italy
| | - Milly Buwenge
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-Bologna University, Bologna, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Lidia Strigari
- Medical Physics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandra Arcelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Silvia Cammelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-Bologna University, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Massimiliano DE Paolis
- UOC Ortopedia e Traumatologia, IRCCS Azienda Ospedaliera Universitaria di Bologna, Bologna, Italy
| | - Alessio Giuseppe Morganti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-Bologna University, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| |
Collapse
|
2
|
Puri S, Sculco PK, Abdel MP, Wellman DS, Gausden EB. Total Hip Arthroplasty After Proximal Femoral Nailing: Preoperative Preparation and Intraoperative Surgical Techniques. Arthroplast Today 2023; 24:101243. [PMID: 37964916 PMCID: PMC10641077 DOI: 10.1016/j.artd.2023.101243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/20/2023] [Accepted: 09/13/2023] [Indexed: 11/16/2023] Open
Abstract
The combination of an aging population and increased utilization of total hip arthroplasty (THA) is leading to a higher incidence of conversion THA, defined as conversion from previous hip fracture surgery to THA. Conversion THA is a more technically challenging, time-consuming, and costly procedure compared to primary THA and frequently involve more medically complex patients. Thus, the aim of this review is to provide a rubric for surgeons to use when preparing for a conversion THA. We have assessed the compatibility of commonly available extraction devices with popular femoral nails. Furthermore, we review technical pearls for conversion THA including equipment planning, operative setup, intraoperative imaging, extraction sequencing, and troubleshooting commonly encountered obstacles.
Collapse
Affiliation(s)
- Simarjeet Puri
- Department of Orthopedic Surgery, Ascension Providence Hospital, Southfield, MI, USA
| | - Peter K. Sculco
- Department of Orthopedic Surgery, Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Matthew P. Abdel
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David S. Wellman
- Department of Othopaedic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Elizabeth B. Gausden
- Department of Orthopedic Surgery, Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| |
Collapse
|
3
|
Dean RS, Hamama BA, Cavinatto L, Nho SJ, Chahla J, Hinckel BB. Chemoprophylaxis for heterotopic ossification following hip arthroscopy: A systematic review. J ISAKOS 2023; 8:484-489. [PMID: 37619960 DOI: 10.1016/j.jisako.2023.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/05/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Heterotopic ossification (HO) is a known complication diagnosed following hip arthroscopy. PURPOSE/HYPOTHESIS This study sought to review the current literature on chemoprophylaxis for HO following hip arthroscopy and to describe what agents and doses are being utilized. STUDY DESIGN Systematic Review. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines on the use of chemoprophylactic medications for HO prevention following hip arthroscopy. Mechanical and radiation prophylaxis were not included in the current analysis. RESULTS A total of 203 studies were identified, of which 15 were included with 6463 patients. There was one randomized control trial (RCT) and 4 additional comparative studies. The most commonly utilized chemoprophylactic agents were the following: naproxen (n = 8), celecoxib (n = 3), indomethacin (n = 3), aspirin (n = 1), etoricoxib (n = 1), and etodolac (n = 1), and non-specific non-steroidal anti-inflammatory drugs (NSAIDs) (n = 1). Naproxen was either given at a dose of 500 mg once or twice daily for 2-4 weeks. RCTs and additional comparative studies showed significant HO prevention using chemoprophylactic agents following hip arthroscopy. CONCLUSIONS HO is a known and common complication following hip arthroscopy. The current systematic review found significant heterogeneity across the literature with respect to specific chemoprophylactic agents and their dosing regimens aimed to reduce the incidence and severity of HO following hip arthroscopy. Additionally, this review demonstrates that most studies that utilize chemoprophylaxis use NSAIDs with successful reduction in the incidence of HO. LEVEL OF EVIDENCE Level IV Evidence.
Collapse
Affiliation(s)
| | - Britanny A Hamama
- Central Michigan University College of Medicine, Mount Pleasant, MI, 48073, USA
| | | | - Shane J Nho
- Midwest Orthopaedics at Rush, Chicago, IL, 48073, USA
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Chicago, IL, 48073, USA
| | | |
Collapse
|
4
|
Beom JY, Low W, Park KS, Yoon TR, Lee CY, Song H. Surgical Resection of Neurogenic Heterotopic Ossification around Hip Joint in Stroke Patients: A Safety and Outcome Report. Hip Pelvis 2023; 35:268-276. [PMID: 38125274 PMCID: PMC10728050 DOI: 10.5371/hp.2023.35.4.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 12/23/2023] Open
Abstract
Purpose Resection remains the most reliable treatment for established heterotopic ossification, despite questions regarding its effectiveness due to the potential for complications. This study evaluated the clinical outcomes and complications of neurogenic heterotopic ossification (NHO) resection in stroke patients' ankylosed hips. Materials and Methods We retrospectively analyzed nine hip NHO resections performed on seven patients from 2010 to 2018. The pre- and postoperative range of motion of the operated hip were compared. Analysis of postoperative complications, including infection, recurrence, iatrogenic fracture, and neurovascular injury was performed. Results The mean operative time was 132.78±21.08 minutes, with a mean hemoglobin drop of 3.06±0.82 g/dL within the first postoperative week. The mean duration of postoperative follow-up was 52.08±28.72 months for all patients. Postoperative range of motion showed improvement from preoperative. Flexion and external rotation (mean, 58.89±30.60° and 16.67±18.03°, respectively) showed the greatest gain of motion of the operated hip joint. Postoperative infections resolved in two cases through surgical debridement, and one case required conversion to total hip arthroplasty due to instability. There were no recurrences, iatrogenic fractures, or neurovascular injuries. Conclusion Resection is a beneficial intervention for restoring the functional range of motion of the hip in order to improve the quality of life for patients with NHO and neurological disorders. We recommend performance of a minimal resection to achieve a targeted functional arc of motion in order to minimize the risk of postoperative complications.
Collapse
Affiliation(s)
- Jae-Young Beom
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - WengKong Low
- Orthopaedic and Traumatology Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Kyung-Soon Park
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Taek-Rim Yoon
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Chan Young Lee
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Hyeongmin Song
- Department of Orthopedic Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| |
Collapse
|
5
|
Li M, Li D, Jiang Y, He P, Li Y, Wu Y, Lei W, de Bruijn JD, Cannon RD, Mei L, Zhang H, Ji P, Zhang H, Yuan H. The genetic background determines material-induced bone formation through the macrophage-osteoclast axis. Biomaterials 2023; 302:122356. [PMID: 37898023 DOI: 10.1016/j.biomaterials.2023.122356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 06/28/2023] [Accepted: 10/15/2023] [Indexed: 10/30/2023]
Abstract
Osteoinductive materials are characterized by their ability to induce bone formation in ectopic sites. Thus, osteoinductive materials hold promising potential for repairing bone defects. However, the mechanism of material-induced bone formation remains unknown, which limits the design of highly potent osteoinductive materials. Here, we demonstrated a genetic background link among macrophage polarization, osteoclastogenesis and material-induced bone formation. The intramuscular implantation of an osteoinductive material in FVB/NCrl (FVB) mice resulted in more M2 macrophages at week 1, more osteoclasts at week 2 and increased bone formation after week 4 compared with the results obtained in C57BL/6JOlaHsd (C57) mice. Similarly, in vitro, with a greater potential to form M2 macrophages, monocytes derived from FVB mice formed more osteoclasts than those derived from C57 mice. A transcriptomic analysis identified Csf1, Cxcr4 and Tgfbr2 as the main genes controlling macrophage-osteoclast coupling, which were further confirmed by related inhibitors. With such coupling, macrophage polarization and osteoclast formation of monocytes in vitro successfully predicted in vivo bone formation in four other mouse strains. Considering material-induced bone formation as an example of acquired heterotopic bone formation, the current findings shed a light on precision medicine for both bone regeneration and the treatment of pathological heterotopic bone formation.
Collapse
Affiliation(s)
- Mingzheng Li
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Dan Li
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Yucan Jiang
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Ping He
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Yeming Li
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Yan Wu
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Wei Lei
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Joost D de Bruijn
- Kuros Biosciences BV, Prof. Bronkhorstlaan 10, 3723 MB Bilthoven, the Netherlands; Queen Mary University of London, London, UK
| | - Richard D Cannon
- Department of Oral Sciences, Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Li Mei
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China; Department of Oral Sciences, Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Hua Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ping Ji
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China.
| | - Hongmei Zhang
- Stomatological Hospital of Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China.
| | - Huipin Yuan
- Kuros Biosciences BV, Prof. Bronkhorstlaan 10, 3723 MB Bilthoven, the Netherlands; Huipin Yuan's Lab, Chengdu, China.
| |
Collapse
|
6
|
von Kroge S, Büyükyilmaz Z, Alimy AR, Hubert J, Citak M, Amling M, Beil FT, Ohlmeier M, Rolvien T. Do Clinical Parameters Reflect Local Bone Metabolism in Heterotopic Ossification After Septic or Aseptic THA? Clin Orthop Relat Res 2023; 481:2029-2041. [PMID: 37462509 PMCID: PMC10499090 DOI: 10.1097/corr.0000000000002758] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/06/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a common complication after THA. Although current research primarily focuses on treatment and prevention, little is known about the local bone metabolism of HO and clinical contributing factors. QUESTIONS/PURPOSES We aimed to assess bone remodeling processes in HO using histomorphometry, focusing on the effects of inflammation and prior NSAID treatment. Specifically, we asked: (1) Are HO specimens taken from patients with periprosthetic joint infection (PJI) more likely to exhibit active bone modeling and remodeling than specimens taken at the time of revision from patients without infection? (2) Do clinical or inflammatory serum and synovial parameters reflect the microstructure of and remodeling in both HO entities? (3) Is NSAID treatment before revision surgery associated with altered local bone mineralization or remodeling properties? METHODS Between June 2021 and May 2022, we screened 395 patients undergoing revision THA at two tertiary centers in Germany. Of those, we considered all patients with radiographic HO as potentially eligible. Based on that, 21% (83 of 395) were eligible; a further 43 were excluded because of an inability to remove the implant intraoperatively (16 patients), insufficient material (11), comorbidities with a major effect on bone metabolism (10), or bone-specific drugs (six), leaving 10% (40) for analysis in this retrospective, comparative study. HO specimens were collected during aseptic (25 patients: 18 male, seven female, mean age 70 ± 11 years, mean BMI 29 ± 4 kg/m 2 ) and septic (15 patients: 11 male, four female, mean age 69 ± 9 years, mean BMI 32 ± 9 kg/m 2 ) revision THA at a mean of 6 ± 7 years after primary implantation and a mean age of 70 ± 9 years at revision. Septic origin (PJI) was diagnosed based on the 2018 International Consensus Meeting criteria, through a preoperative assessment of serum and synovial parameters. To specify the local bone microstructure, ossification, and cellular bone turnover, we analyzed HO specimens using micro-CT and histomorphometry on undecalcified sections. Data were compared with those of controls, taken from femoral neck trabecular bone (10 patients: five female, five male, mean age 75 ± 6 years, mean BMI 28 ± 4 kg/m 2 ) and osteophytes (10 patients: five female, five male, mean age 70 ± 10 years, mean BMI 29 ± 7 kg/m 2 ). The time between primary implantation and revision (time in situ), HO severity based on the Brooker classification, and serum and synovial markers were correlated with HO microstructure and parameters of cellular bone turnover. In a subgroup of specimens of patients with NSAID treatment before revision, osteoid and bone turnover indices were evaluated and compared a matched cohort of specimens from patients without prior NSAID treatment. RESULTS Patients with aseptic and septic HO presented with a higher bone volume (BV/TV; aseptic: 0.41 ± 0.15, mean difference 0.20 [95% CI 0.07 to 0.32]; septic: 0.43 ± 0.15, mean difference 0.22 [95% CI 0.08 to 0.36]; femoral neck: 0.21 ± 0.04; both p < 0.001), lower bone mineral density (aseptic: 809 ± 66 mg HA/cm 3 , mean difference -91 mg HA/cm 3 [95% CI -144 to -38]; septic: 789 ± 44 mg HA/cm 3 , mean difference -111 mg HA/cm 3 [95% CI -169 to -53]; femoral neck: 899 ± 20 mg HA/cm 3 ; both p < 0.001), and ongoing bone modeling with endochondral ossification and a higher proportion of woven, immature bone (aseptic: 25% ± 17%, mean difference 25% [95% CI 9% to 41%]; septic: 37% ± 23%, mean difference 36% [95% CI 19% to 54%]; femoral neck: 0.4% ± 0.5%; both p < 0.001) compared with femoral neck specimens. Moreover, bone surfaces were characterized by increased osteoblast and osteoclast indices in both aseptic and septic HO, although a higher density of osteocytes was detected exclusively in septic HO (aseptic: 158 ± 56 1/mm 2 versus septic: 272 ± 48 1/mm 2 , mean difference 114 1/mm 2 [95% CI 65 to 162]; p < 0.001). Compared with osteophytes, microstructure and turnover indices were largely similar in HO. The Brooker class was not associated with any local bone metabolism parameters. The time in situ was negatively associated with bone turnover in aseptic HO specimens (osteoblast surface per bone surface: r = -0.46; p = 0.01; osteoclast surface per bone surface: r = -0.56; p = 0.003). Serum or synovial inflammatory markers were not correlated with local bone turnover in septic HO. Specimens of patients with NSAID treatment before revision surgery had a higher osteoid thickness (10.1 ± 2.1 µm versus 5.5 ± 2.6 µm, mean difference -4.7 µm [95% CI -7.4 to -2.0]; p = 0.001), but there was no difference in other osteoid, structural, or cellular parameters. CONCLUSION Aseptic and septic HO share phenotypic characteristics in terms of the sustained increase in bone metabolism, although differences in osteocyte and adipocyte numbers suggest distinct homeostatic mechanisms. These results suggest persistent bone modeling or remodeling, with osteoblast and osteoclast indices showing a moderate decline with the time in situ in aseptic HO. Future studies should use longitudinal study designs to correlate our findings with clinical outcomes (such as HO growth or recurrence). In addition, the molecular mechanisms of bone cell involvement during HO formation and growth should be further investigated, which may allow specific therapeutic and preventive interventions. CLINICAL RELEVANCE To our knowledge, our study is the first to systematically investigate histomorphometric bone metabolism parameters in patients with HO after THA, providing a clinical reference for evaluating modeling and remodeling activity. Routine clinical, serum, and synovial markers are not useful for inferring local bone metabolism.
Collapse
Affiliation(s)
- Simon von Kroge
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Assil-Ramin Alimy
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Hubert
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank Timo Beil
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Ohlmeier
- Department of Joint Surgery, Helios ENDO-Klinik, Hamburg, Germany
- Department of Orthopaedic and Trauma Surgery, UKM Marienhospital, Steinfurt, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
7
|
Rosenthal R, Ting RS, Sher D. Management of distal biceps tendon ruptures: a survey of fellowship-trained subspecialist elbow surgeons. J Shoulder Elbow Surg 2023; 32:e495-e503. [PMID: 37414354 DOI: 10.1016/j.jse.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/17/2023] [Accepted: 05/28/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND There are several approaches to the management of distal biceps tendon ruptures, with no consensus on what constitutes best practice. METHODS An online survey queried the perceptions and management of distal biceps tendon ruptures amongst fellowship-trained subspecialty elbow surgeons, which primarily comprised of members of the Shoulder and Elbow Society of Australia, the national subspecialist interest group of the Australian Orthopaedic Association and the Mayo Clinic Elbow Club (Rochester, MN, USA). RESULTS One hundred surgeons responded. The median (IQR) experience as orthopedic surgeons amongst respondents was 17 (10-23) years; 78% of respondents saw >10 cases of distal biceps tendon ruptures annually; 95% of respondents would recommend surgery for symptomatic radiologically-confirmed partial tears, the most common indications being pain (83%), weakness (60%), and tear size (48%). Forty-three percent of respondents would have grafts available for tears older than 6 weeks. The one-incision approach (70%) was preferred over two incisions (30%); 78% of one-incision users believed that their repair location was anatomic, compared to 100% of two-incision users. One-incision users were more likely to have encountered lateral antebrachial cutaneous nerve (78% vs. 46%) and superficial radial nerve palsies (28% vs. 11%). Two-incision users were more likely to have encountered posterior interosseus nerve palsy (21% vs. 15%), heterotopic ossification (54% vs. 42%), and synostosis (14% vs. 0%). Re-ruptures were the most common cause of reoperation. The more conservative a respondent's postoperative immobilization was, the less likely they were to have ever encountered re-rupture (14% amongst cast users, 29% amongst splint/brace users, 49% amongst sling users, 100% amongst non-immobilizers). Thirty percent of respondents who placed elbow strength restrictions for 6 months postoperatively encountered re-rupture, compared to 40% amongst those who restricted for 6-12 weeks postoperatively. CONCLUSIONS The operation rate for repair of distal biceps tendon ruptures amongst subspecialist elbow surgeons is high, as seen in our cohort. However, there is a large variation in the approach toward its management. One incision (anterior) was preferred over two incisions (anterior and posterior). Complications from repair of distal biceps tendon ruptures can be expected even amongst subspecialists, and are associated with surgical approach. The responses imply that more conservative postoperative rehabilitation may be associated with a lower risk of re-rupture.
Collapse
Affiliation(s)
- Ron Rosenthal
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Ryan S Ting
- University of New South Wales, St. George and Sutherland Clinical Campuses, Sydney, NSW, Australia
| | - Doron Sher
- Concord Repatriation General Hospital, Sydney, NSW, Australia.
| |
Collapse
|
8
|
Kubiak J, Farng E, Gust M, Sharpe F. Treatment of an Ulnar Fracture Bone Defect Using Heterotopic Bone Autograft: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00046. [PMID: 38096335 DOI: 10.2106/jbjs.cc.23.00477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
CASE Autologous bone grafting has wide applications for the treatment of bony defects. Generally, cancellous or corticocancellous bone grafts are used depending on the characteristics and size of the bony defect and wound bed. The use of heterotopic bone as a potential source of bone graft has not been widely reported. We present a 56-year-old right-hand-dominant male victim of dog mauling who sustained a right ulnar fracture with a 5-cm bony defect, treated with the use of heterotopic bone autograft. CONCLUSION Heterotopic bone can be successfully used as an autograft in the treatment of bony defects.
Collapse
Affiliation(s)
- Jeremy Kubiak
- Department of Plastic Surgery, Loma Linda University, Loma Linda, California
| | - Eugene Farng
- Department of Orthopedic Surgery, Kaiser Permanente Fontana, Fontana, California
| | - Madeleine Gust
- Department of Plastic Surgery, Kaiser Permanente Ontario, Ontario, California
| | - Frances Sharpe
- Department of Orthopedic Surgery, Kaiser Permanente Fontana, Fontana, California
| |
Collapse
|
9
|
Sapire R, Nenova R, Gounder P, Rampersad A, Maboho V, Nhlapo N, Tibatshi K, Rampurtab S, Ranchod AI, Saggers RT, Patricios J. Myositis ossificans in a child athlete: a case study. SOUTH AFRICAN JOURNAL OF SPORTS MEDICINE 2023; 34:v34i1a14931. [PMID: 36815913 PMCID: PMC9924576 DOI: 10.17159/2078-516x/2022/v34i1a14931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background A 13-year-old female athlete presented with a painful lesion in her right buttock for which she had been receiving physiotherapy. It was keeping her from participating in sports. Aim To report on a case of traumatic myositis ossificans in a child athlete - including the presentation, investigations, management, and outcome. Findings Palpation of the right buttock indicated a tender mass. Investigation by musculoskeletal ultrasound detected a large hypoechoic lesion. An MRI revealed patterns of calcification that were inconclusive in differentiating between a malignant or benign lesion. Macroscopic and microscopic histological examination, as well as immunohistochemistry, were consistent with myositis ossificans (MO), a non-malignant condition. The patient improved remarkably within three months of treatment with rest, non-steroidal anti-inflammatory drugs (NSAIDs) and extracorporeal shock wave therapy (ESWT). Implications Accurate differentiation of myositis ossificans from other benign and malignant soft tissue lesions may require histological evaluation in addition to a comprehensive radiological workup. Successful treatment with the patient being able to return to a pain-free and active state is achievable. Extracorporeal shock-wave therapy can play an important role in the management of this condition and should be considered when presented with a case of MO.
Collapse
Affiliation(s)
- R Sapire
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - R Nenova
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - P Gounder
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - A Rampersad
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - V Maboho
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - N Nhlapo
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - K Tibatshi
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - S Rampurtab
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - AI Ranchod
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Department of Diagnostic Radiology, University of the Witwatersrand, Johannesburg,
South Africa
| | - RT Saggers
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital and School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - J Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Netcare Waterfall Sports Orthopaedic Surgery, Johannesburg,
South Africa
| |
Collapse
|
10
|
Severe Heterotopic Ossification After Revision Total Knee Arthroplasty: A Case Report and Review of the Literature. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202211000-00009. [PMID: 36733984 PMCID: PMC9663138 DOI: 10.5435/jaaosglobal-d-22-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 09/08/2022] [Indexed: 12/04/2022]
Abstract
The incidence of primary and revision total knee arthroplasty (TKA) is increasing worldwide. Heterotopic ossification is a common and concerning complication of TKA. There are few described cases of severe heterotopic ossification after revision TKA and no known cases of heterotopic ossification causing functional ankylosis after revision TKA. We describe a case of extensive heterotopic ossification in a patient who underwent right TKA for extensive adhesions and stiffness. After early range of motion improvement postoperatively, the patient discontinued a physical therapy regimen. The patient presented 13 years after revision TKA with radiographically evidenced severe heterotopic ossification resulting in a functional ankylosis. The patient elected for nonsurgical management. This case demonstrates a delayed finding of severe heterotopic ossification. The case prompted an applied literature review of several topics: heterotopic ossification as a complication of revision arthroplasty, the contribution of autoimmune and inflammatory conditions to heterotopic ossification; the use of medication, radiation, and physical therapy as prophylaxis against heterotopic ossification; and the range of treatment strategies for severe heterotopic ossification at the knee joint. Consent by the patient involved in this case report was obtained.
Collapse
|
11
|
Progressive brachial plexopathy secondary to heterotopic ossification formation after shoulder trauma: a case report. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Bohner M, Maazouz Y, Ginebra MP, Habibovic P, Schoenecker JG, Seeherman H, van den Beucken JJ, Witte F. Sustained local ionic homeostatic imbalance caused by calcification modulates inflammation to trigger heterotopic ossification. Acta Biomater 2022; 145:1-24. [PMID: 35398267 DOI: 10.1016/j.actbio.2022.03.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
Abstract
Heterotopic ossification (HO) is a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues. Despite being a frequent complication of orthopedic and trauma surgery, brain and spinal injury, the etiology of HO is poorly understood. The aim of this study is to evaluate the hypothesis that a sustained local ionic homeostatic imbalance (SLIHI) created by mineral formation during tissue calcification modulates inflammation to trigger HO. This evaluation also considers the role SLIHI could play for the design of cell-free, drug-free osteoinductive bone graft substitutes. The evaluation contains five main sections. The first section defines relevant concepts in the context of HO and provides a summary of proposed causes of HO. The second section starts with a detailed analysis of the occurrence and involvement of calcification in HO. It is followed by an explanation of the causes of calcification and its consequences. This allows to speculate on the potential chemical modulators of inflammation and triggers of HO. The end of this second section is devoted to in vitro mineralization tests used to predict the ectopic potential of materials. The third section reviews the biological cascade of events occurring during pathological and material-induced HO, and attempts to propose a quantitative timeline of HO formation. The fourth section looks at potential ways to control HO formation, either acting on SLIHI or on inflammation. Chemical, physical, and drug-based approaches are considered. Finally, the evaluation finishes with a critical assessment of the definition of osteoinduction. STATEMENT OF SIGNIFICANCE: The ability to regenerate bone in a spatially controlled and reproducible manner is an essential prerequisite for the treatment of large bone defects. As such, understanding the mechanism leading to heterotopic ossification (HO), a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues, would be very useful. Unfortunately, the mechanism(s) behind HO is(are) poorly understood. The present study reviews the literature on HO and based on it, proposes that HO can be caused by a combination of inflammation and calcification. This mechanism helps to better understand current strategies to prevent and treat HO. It also shows new opportunities to improve the treatment of bone defects in orthopedic and dental procedures.
Collapse
|
13
|
Incidence of heterotopic ossification following hip arthroscopy is low: considerations for routine prophylaxis. INTERNATIONAL ORTHOPAEDICS 2022; 46:1489-1500. [PMID: 35482060 PMCID: PMC9166824 DOI: 10.1007/s00264-022-05402-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/04/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE This scoping review aims to map and summarise the available literature on heterotopic ossification (HO) following hip arthroscopy, with particular focus on incidence, distribution as per Brooker classification, efficacy of prophylactic measures and factors that may influence the likelihood of production of HO. METHODS A computer-based search was performed on PubMed, Embase, Emcare, Cinahl, ISI web of science and Scopus using the terms 'heterotopic ossification' and 'hip arthroscopy'. Articles reporting heterotopic ossification following hip arthroscopy for any condition were included after two-stage title/abstract and full-text screening. RESULTS Of the 663 articles retrieved, 45 studies were included. The proportion of patients with HO ranged from 0 to 44%. The majority of the cases were either Brooker grade I or II. Of the six studies investigating the effect of NSAID prophylaxis, five reported a significantly lower incidence of heterotopic ossification associated with its use. Weak evidence suggests that an outside-in arthroscopic approach, no capsular closure, male sex and mixed cam and pincer resection may be associated with an increased risk of HO. CONCLUSION Although there is a large variation in rates of HO following hip arthroscopy in the current literature, the majority of studies report a low incidence. Evidence exists advocating the administration of post-operative NSAIDs to reduce the incidence of HO following hip arthroscopy. This, combined with the low risk of complications, means there is a favourable risk-benefit ratio for prophylactic NSAID used in HA. Future research should work to identify patient clinical and demographic factors which may increase the risk of development of HO, allowing clinicians to risk stratify and select only specific patients who would benefit from receiving NSAID prophylaxis.
Collapse
|
14
|
Hegde A, Mane PP, Shetty CB, Thakkar SA. Neurogenic heterotopic ossificans of hips in a case of expanded dengue syndrome following critical illness polyneuropathy. BMJ Case Rep 2022; 15:e246186. [PMID: 35264380 PMCID: PMC8915274 DOI: 10.1136/bcr-2021-246186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 11/04/2022] Open
Abstract
We present a case of 71-year-old man with bilateral hip neurogenic heterotopic ossificans following critical illness polyneuropathy as a complication of expanded dengue syndrome. His left hip was stiff and showed a circumferential ossific mass. After initial medical management, the patient underwent excision of ossific mass using posterior approach. For adequate excision, femoral head and neck were resected and a hybrid total hip arthroplasty was performed. The patient was followed up for 2 years and showed good clinical outcome without recurrence of heterotopic ossification. This case highlights the rare aetiology of neurogenic heterotopic ossification which is critical illness polyneuropathy following expanded dengue syndrome. It highlights that adequate resection and a total hip arthroplasty can be a viable option in selected cases of circumferential heterotopic ossification in old individuals.
Collapse
Affiliation(s)
- Atmananda Hegde
- Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, MAHE, Manipal, Karnataka, India
| | - Prajwal Prabhudev Mane
- Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, MAHE, Manipal, Karnataka, India
| | - Chethan B Shetty
- Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, MAHE, Manipal, Karnataka, India
| | - Samarth Ajay Thakkar
- Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, MAHE, Manipal, Karnataka, India
| |
Collapse
|
15
|
BUENO THIAGOSANCHEZPIRES, GODOY GABRIELPARISDE, FURUKAVA REBECABARROS, GAGGIOLI NICOLETAKAKURA, TAMAOKI MARCELJUNSUGAWARA, MATSUNAGA FABIOTERUO, BELLOTI JOÃOCARLOS. HETEROTOPIC OSSIFICATION IN ACETABULAR FRACTURES: SYSTEMATIC REVIEW AND META-ANALYSIS OF PROPHYLAXIS. ACTA ORTOPEDICA BRASILEIRA 2021; 29:331-340. [PMID: 34849100 PMCID: PMC8601386 DOI: 10.1590/1413-785220212906244689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
Objective: Heterotopic ossification is defined as the formation of trabecular bone in soft tissues. It is a common complication after surgical treatment of acetabular fractures. However, its prophylaxis and treatment are still controversial. The objective of this research is to evaluate the effectiveness of actions to prevent the development of heterotopic ossification after surgical correction of acetabular fractures. Methods: A systematic review was carried out with research in the databases PubMed/MEDLINE, Embase, LILACS and Cochrane until August 4, 2020, without restrictions on language and year of publication. Only randomized clinical studies carried out in humans without restrictions based on the dosage of treatments, use and duration of prophylaxis were included in this review. Results: Two studies compared the use of radiotherapy and indomethacin and three compared the use of indomethacin with a placebo or non-indomethacin group. The meta-analysis calculations did not indicate statistical differences between radiotherapy versus indomethacin (RR 1.45, IC 95% 0.97 to 2.17, p = 0,55) and indomethacin versus placebo or not indomethacin (RR 0.85, IC 95% 0.68 to 1.06, p = 0,59). Conclusion: There is insufficient evidence to affirm that the use of radiotherapy or indomethacin are effective to prevent the formation of heterotopic ossification after surgery for fractures of the acetabulum. In addition, the number of complications was higher in the indomethacin group when compared to placebo or no intervention. Level of Evidence I, Systematic Review.
Collapse
|
16
|
Kassem MS, Elsayed MA. Total hip replacements following acetabular fractures. 7 to 15 years clinical and radiological results. Acta Orthop Belg 2021. [DOI: 10.52628/87.3.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study is reporting the long term clinical and radiographic results of a group of 45 patients who underwent total hip arthroplasty following acetabular fractures. The study included 39 males and 6 females. The age of the patients ranged from 32 to 61 with a mean of 46.4 years. The indication for surgery was secondary osteoarthritis in 35 patients and avascular necrosis of the femoral head in the remaining ten. The follow up period ranged from 7 to 15 years with a median of 10.3 years. Uncemented total hip prostheses were used in 37 cases while 8 cases had hybrid prostheses with cemented cups and uncemented stems. Thirty patients (66.7%) needed autogenous acetabular bone grafting. There has been a statistically significant improvement from a preoperative mean Oxford hip score of 16 to a postoperative mean score of 39.8 (p < 0.001). At the end of follow up, two cases had revision for cup loosening. The complications included one case of transient sciatic nerve palsy, and two cases of heterotopic ossification. Currently, total hip replacement remains the best option for end stage post traumatic arthritis. There are technical challenges associated with this replacement surgery which the surgeon should be aware of.
Collapse
|
17
|
Antonacci CL, Brown SM, O'Brien MJ, Mulcahey MK. Prophylaxis for Heterotopic Ossification Following Distal Biceps Tendon Repair. Orthopedics 2021; 44:e588-e592. [PMID: 34292837 DOI: 10.3928/01477447-20210618-22] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Heterotopic ossification (HO) is a possible complication of distal biceps tendon repair (DBTR). Several agents can prevent HO formation, although relatively few studies have investigated prophylaxis specifically after DBTR. The purposes of this study were to survey members of the American Shoulder and Elbow Surgeons (ASES) to determine (1) what percentage use HO prophylaxis after DBTR; (2) type, dosage, and duration of prophylaxis used; and (3) use of single-incision or double-incision surgical technique. An anonymous electronic survey was distributed to ASES members to determine the use of HO prophylaxis and DBTR technique. The survey included questions regarding the number of DBTRs performed annually; preferred surgical technique and implants; and type, dosage, and duration of HO prophylaxis used before, during, and after surgery. Descriptive statistics were used to analyze the results. Of 173 respondents, 98 (56.6%) performed 1 to 10 DBTRs per year, 65 (37.6%) performed 11 to 25 DBTRs per year, and 10 (5.8%) performed 26 to 50 DBTRs per year. A total of 131 (75.7%) preferred the single-incision technique, whereas 42 (24.3%) preferred the double-incision technique. A total of 94 (54.3%) performed DBTR using a metal button and interference screw, 35 (20.2%) through drill holes, 25 (14.5%) with suture anchors, and 19 (11.0%) with a metal button alone. A total of 132 (76.3%) respondents did not use HO prophylaxis, and 41 (23.7%) used nonsteroidal anti-inflammatory drugs following surgery. A total of 35 (85.4%) used indomethacin, 18 (51.4%) of whom preferred 75 mg/d for 3 to 4 weeks. Heterotopic ossification is a commonly reported complication following DBTR, especially with the double-incision technique. Prophylaxis with anti-inflammatory medications and suppressive modalities (radiation therapy) appear to reduce the incidence of HO. Despite these data, most surgeons (76.3%) do not use HO prophylaxis. Low annual volume of cases, lack of large-volume studies with outcome data, and the dominant use of the single-incision repair technique may explain this. [Orthopedics. 2021;44(4):e588-e592.].
Collapse
|
18
|
Onsen LT, Ouyang VW, Jimenez AE, Monahan PF, Lall AC, Domb BG. Simplified biplanar classification for heterotopic ossification is more predictive of patient-reported outcomes than the Brooker classification after anterior total hip arthroplasty. Hip Int 2021; 33:420-425. [PMID: 34510950 DOI: 10.1177/11207000211039173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) commonly occurs after total hip arthroplasty (THA) and can adversely impact clinical outcomes. The purpose of this study is to propose a more reliable HO grading method that is better predictive of patient-reported outcomes (PROs) after THA than the Brooker classification. METHODS 513 THAs (62 ± 10 years old) were reviewed. The incidence and grade of HO was evaluated using the Brooker grading system and a simplified biplanar classification system (grade 1: ⩾1 cm between bone on both anteroposterior and lateral views, grade 2: <1 cm between bone on either view). The modified Harris Hip Score (mHHS), Forgotten Joint Score (FJS), and visual analogue scale (VAS) for pain were collected at minimum of 2 years after surgery and were compared between HO grades using multiple regression models. RESULTS The incidence of HO varied by Brooker grade (grade 1, 23.4%; grade 2, 22.4%; grade 3, 7.2%; grade 4, 0%) and biplanar grade (grade 1: 45.6%; grade 2: 7.4%). The biplanar classification demonstrated higher interobserver reliability than the Brooker classification (κ = 0.95 and 0.91, respectively). Brooker grade 3 HO decreased the mHHS by 6.5 (standard error: 2.7) but did not have a significant effect on FJS or VAS. Biplanar grade 2 HO decreased the mHHS by 9.9 (standard error: 2.7), the FJS by 12.9 (standard error: 4.51) and increased the VAS pain score by 0.81 (standard error: 0.35). The Cox test was used to compare the fit of regression models and determined the biplanar classification was a significantly better predictor than the Brooker classification (p < 0.001). CONCLUSIONS Biplanar grade 2 HO had a significant negative influence on PROs. Contrary to previous literature, these results show clinical significance of non-bridging HO. Compared with the Brooker classification, the biplanar classification has greater interobserver reliability and is more predictive of outcomes after THA.
Collapse
Affiliation(s)
- Leonard T Onsen
- American Hip Institute Research Foundation, Chicago, IL, USA.,The University of Illinois at Chicago Medical Center, Chicago, IL, USA
| | - Vivian W Ouyang
- American Hip Institute Research Foundation, Chicago, IL, USA
| | | | - Peter F Monahan
- American Hip Institute Research Foundation, Chicago, IL, USA
| | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, IL, USA.,American Hip Institute, Chicago, IL, USA.,AMITA Health St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, IL, USA.,American Hip Institute, Chicago, IL, USA.,AMITA Health St. Alexius Medical Center, Hoffman Estates, IL, USA
| |
Collapse
|
19
|
Tu B, Yu B, Wang W, Li J, Yuan F, Zhu J, Fan C. Inhibition of IL-17 prevents the progression of traumatic heterotopic ossification. J Cell Mol Med 2021; 25:7709-7719. [PMID: 34189826 PMCID: PMC8358870 DOI: 10.1111/jcmm.16617] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 04/05/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022] Open
Abstract
Traumatic heterotopic ossification (HO) is the abnormal formation of bone in soft tissues as a consequence of injury. However, the pathological mechanisms leading to traumatic HO remain unknown. Here, we report that aberrant expression of IL-17 promotes traumatic HO formation by activating β-catenin signalling in mouse model. We found that elevated IL-17 and β-catenin levels are correlated with a high degree of HO formation in specimens from patients and HO animals. We also show that IL-17 initiates and promotes HO progression in mice. Local injection of an IL-17 neutralizing antibody attenuates ectopic bone formation in a traumatic mouse model. IL-17 enhances the osteoblastic differentiation of mesenchymal stem cells (MSCs) by activating β-catenin signalling. Moreover, inhibition of IL-17R or β-catenin signalling by neutralizing antibodies or drugs prevents the osteogenic differentiation of isolated MSCs and decreases HO formation in mouse models. Together, our study identifies a novel role for active IL-17 as the inducer and promoter of ectopic bone formation and suggests that IL-17 inhibition might be a potential therapeutic target in traumatic HO.
Collapse
Affiliation(s)
- Bing Tu
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Bo Yu
- Department of Orthopaedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Juehong Li
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Feng Yuan
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jing Zhu
- Department of Anatomy, School of Basic Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Cunyi Fan
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| |
Collapse
|
20
|
Di Martino A, Coppola MAR, Bordini B, Stefanini N, Geraci G, Pilla F, Traina F, Faldini C. Clinical and radiological outcomes of total hip arthroplasty in patients affected by Paget's disease: a combined registry and single-institution retrospective observational study. J Orthop Traumatol 2021; 22:13. [PMID: 33733386 PMCID: PMC7969678 DOI: 10.1186/s10195-021-00574-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) in patients with Paget's disease can be associated with technical difficulties related to deformities and altered mechanical bone properties, and hypervascularity leads to significative intra-operative bleeding. The purpose of this registry and single-institution study was to investigate overall survival and causes of failure of THA in pagetic patients, together with an analysis of the clinical and radiological complications. MATERIAL AND METHODS Registry-based survival and complication analysis, type of fixation, intra- and post-operative complications, clinical (pharmacological history, blood transfusions, Harris hip score [HHS]) and radiographic (cup orientation, stem axial alignment, osteolysis around the cup and the stem and heterotopic ossification [HO]) data were reviewed. RESULTS In total, 66 patients (27 males and 39 females, mean age at surgery 71.1 years for males and 74.8 years for female) from the registry study presented a 10-year survival of 89.5%. In the institutional study, involving 26 patients (14 males and 12 females, 69 years average) and 29 THAs, hip function improved significantly. Average cup orientation was 40.5°, while varus stem alignment was 13.8%. In total, 52% of hips had heterotopic ossifications. Peri-acetabular osteolysis was in 13.8% of implants and in 45% of hips was found around the stem. Allogenic and autologous blood transfusion rate were 68.2% and 31.8%, respectively, with an average transfusion of 2 units of blood (range 1-6 units). HHS improved by an average of 34 points, with excellent result in 64.3% of patients. Two implants failed, one due to traumatic ceramic head fracture 64 months after surgery, and one due to mobilization of the cup on the second post-operative day. CONCLUSION THA surgery in Paget's patients is a safe procedure, and implant survival is only partly affected by bone remodelling and choice of fixation. The post-operative functional outcome is largely similar to that of other patients. Bleeding-related complications are the main complications; a careful pharmacological strategy should be recommended to decrease the risk of transfusions and of HO development. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Alberto Di Martino
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy.
| | | | - Barbara Bordini
- Laboratorio Di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano, 1/10, 40136, Bologna, Italy
| | - Niccolò Stefanini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Geraci
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Federico Pilla
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Francesco Traina
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
- Orthopaedic-Traumatology and Prosthetic Surgery and Revisions of Hip and Knee Implants, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
- University of Messina, Messina, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| |
Collapse
|
21
|
Wong KR, Mychasiuk R, O'Brien TJ, Shultz SR, McDonald SJ, Brady RD. Neurological heterotopic ossification: novel mechanisms, prognostic biomarkers and prophylactic therapies. Bone Res 2020; 8:42. [PMID: 33298867 PMCID: PMC7725771 DOI: 10.1038/s41413-020-00119-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/20/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023] Open
Abstract
Neurological heterotopic ossification (NHO) is a debilitating condition where bone forms in soft tissue, such as muscle surrounding the hip and knee, following an injury to the brain or spinal cord. This abnormal formation of bone can result in nerve impingement, pain, contractures and impaired movement. Patients are often diagnosed with NHO after the bone tissue has completely mineralised, leaving invasive surgical resection the only remaining treatment option. Surgical resection of NHO creates potential for added complications, particularly in patients with concomitant injury to the central nervous system (CNS). Although recent work has begun to shed light on the physiological mechanisms involved in NHO, there remains a significant knowledge gap related to the prognostic biomarkers and prophylactic treatments which are necessary to prevent NHO and optimise patient outcomes. This article reviews the current understanding pertaining to NHO epidemiology, pathobiology, biomarkers and treatment options. In particular, we focus on how concomitant CNS injury may drive ectopic bone formation and discuss considerations for treating polytrauma patients with NHO. We conclude that understanding of the pathogenesis of NHO is rapidly advancing, and as such, there is the strong potential for future research to unearth methods capable of identifying patients likely to develop NHO, and targeted treatments to prevent its manifestation.
Collapse
Affiliation(s)
- Ker Rui Wong
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Stuart J McDonald
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Physiology, Anatomy and Microbiology, School of Life Sciences, La Trobe University, Bundoora, VIC, Australia
| | - Rhys D Brady
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia. .,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.
| |
Collapse
|
22
|
Rüdiger HA, Dittrich M, Robinson J, Mansour T, Schwab T, Stadelmann VA, Leunig M. The Impact of Heterotopic Ossification on Self-Reported Outcomes After Total Hip Arthroplasty Using the Direct Anterior Approach. J Bone Joint Surg Am 2020; 102:91-98. [PMID: 32530877 DOI: 10.2106/jbjs.20.00071] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a known finding after total hip arthroplasty (THA) that potentially affects clinical outcomes. The incidence of HO is related to various factors, including soft-tissue trauma, postoperative medication, surgical approach, and the surgeon's experience. Because use of the direct anterior approach (DAA) is gaining popularity, we aimed (1) to determine the incidence of HO after DAA-THA and (2) to evaluate the impact of HO on patient-reported outcomes (PROs). METHODS We retrospectively reviewed 401 THAs (67 ± 10 years old, 210 men). The incidence and grade of HO were evaluated using the Brooker classification with anteroposterior and lateral radiographs. PROs were collected with use of the Oxford Hip Score (OHS) and the Core Outcome Measures Index (COMI)-Hip and were correlated with HO grades using generalized multiple regression models. RESULTS The incidence of HO was 29.9% on the anteroposterior radiographic views (Brooker grade 1, 14.5%; grade 2, 11.1%; grade 3, 2.7%; and grade 4, 0.57%); the lateral radiographic views detected 9% additional HO when compared with the anteroposterior radiographs alone (Brooker grade 1, 8%, and grade 2, 1%). HO was more frequent in men. The American Society of Anesthesiologists (ASA) grade, age in women, and higher body mass index (BMI) in men were associated with higher HO grades. A transverse "bikini" incision was associated with a lower rate (4%) of Brooker grades 3 and 4 HO when compared with a longitudinal incision (12%). A Brooker grade of 0 to 3 HO did not impact outcomes. Only Brooker grade-4 HO was associated with significantly worse PROs; however, pain was not affected. CONCLUSIONS Low-grade HO after DAA-THA is not uncommon, and its rate is underestimated when anteroposterior radiographic views are evaluated without lateral views. The risk factors for developing HO in our cohort were an ASA grade of >3, male sex (especially with a high BMI), older age in women, and use of longitudinal incisions. With use of the bikini incision, patients had lower rates of severe HO, but mostly senior surgeons with more experience performed their surgery. Age, ASA grade, experience level of the surgeon, and Brooker grade-4 HO all had a significant influence on PROs. Clinically important HO (Brooker grade 4) remains rare after DAA-THR. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Hannes A Rüdiger
- Department of Hip and Knee Surgery, Schulthess Clinic, Zürich, Switzerland
| | - Michael Dittrich
- Department of Hip and Knee Surgery, Schulthess Clinic, Zürich, Switzerland
| | - Jonathan Robinson
- The Maurice E. Muller Foundation of North America, St. Louis, Missouri
| | - Toni Mansour
- Department of Hip and Knee Surgery, Schulthess Clinic, Zürich, Switzerland.,Mount Lebanon Hospital, Hazmieh, Lebanon
| | - Tobias Schwab
- Department of Hip and Knee Surgery, Schulthess Clinic, Zürich, Switzerland
| | - Vincent A Stadelmann
- Department of Teaching, Research, and Development, Schulthess Clinic, Zürich, Switzerland
| | - Michael Leunig
- Department of Hip and Knee Surgery, Schulthess Clinic, Zürich, Switzerland
| |
Collapse
|
23
|
Strong AL, Spreadborough PJ, Pagani CA, Haskins RM, Dey D, Grimm PD, Kaneko K, Marini S, Huber AK, Hwang C, Westover K, Mishina Y, Bradley MJ, Levi B, Davis TA. Small molecule inhibition of non-canonical (TAK1-mediated) BMP signaling results in reduced chondrogenic ossification and heterotopic ossification in a rat model of blast-associated combat-related lower limb trauma. Bone 2020; 139:115517. [PMID: 32622875 PMCID: PMC7945876 DOI: 10.1016/j.bone.2020.115517] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
Heterotopic ossification (HO) is defined as ectopic bone formation around joints and in soft tissues following trauma, particularly blast-related extremity injuries, thermal injuries, central nerve injuries, or orthopaedic surgeries, leading to increased pain and diminished quality of life. Current treatment options include pharmacotherapy with non-steroidal anti-inflammatory drugs, radiotherapy, and surgical excision, but these treatments have limited efficacy and have associated complication profiles. In contrast, small molecule inhibitors have been shown to have higher specificity and less systemic cytotoxicity. Previous studies have shown that bone morphogenetic protein (BMP) signaling and downstream non-canonical (SMAD-independent) BMP signaling mediated induction of TGF-β activated kinase-1 (TAK1) contributes to HO. In the current study, small molecule inhibition of TAK1, NG-25, was evaluated for its efficacy in limiting ectopic bone formation following a rat blast-associated lower limb trauma and a murine burn tenotomy injury model. A significant decrease in total HO volume in the rat blast injury model was observed by microCT imaging with no systemic complications following NG-25 therapy. Furthermore, tissue-resident mesenchymal progenitor cells (MPCs) harvested from rats treated with NG-25 demonstrated decreased proliferation, limited osteogenic differentiation capacity, and reduced gene expression of Tac1, Col10a1, Ibsp, Smad3, and Sox2 (P < 0.05). Single cell RNA-sequencing of murine cells harvested from the injury site in a burn tenotomy injury model showed increased expression of these genes in MPCs during stages of chondrogenic differentiation. Additional in vitro cell cultures of murine tissue-resident MPCs and osteochondrogenic progenitors (OCPs) treated with NG-25 demonstrated reduced chondrogenic differentiation by 10.2-fold (P < 0.001) and 133.3-fold (P < 0.001), respectively, as well as associated reduction in chondrogenic gene expression. Induction of HO in Tak1 knockout mice demonstrated a 7.1-fold (P < 0.001) and 2.7-fold reduction (P < 0.001) in chondrogenic differentiation of murine MPCs and OCPs, respectively, with reduced chondrogenic gene expression. Together, our in vivo models and in vitro cell culture studies demonstrate the importance of TAK1 signaling in chondrogenic differentiation and HO formation and suggest that small molecule inhibition of TAK1 is a promising therapy to limit the formation and progression of HO.
Collapse
Affiliation(s)
- Amy L Strong
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Philip J Spreadborough
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; Academic Department of Military Surgery and Trauma, Royal Centre for Defense Medicine, Birmingham, United Kingdom
| | - Chase A Pagani
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Ryan M Haskins
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America
| | - Devaveena Dey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Patrick D Grimm
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Keiko Kaneko
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Simone Marini
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Amanda K Huber
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Charles Hwang
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Kenneth Westover
- Departments of Biochemistry and Radiation Oncology, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States of America
| | - Yuji Mishina
- Department of Biologic and Materials Science and Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, United States of America
| | - Matthew J Bradley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Benjamin Levi
- Division of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America.
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States of America; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America.
| |
Collapse
|
24
|
Beggs I. Biological Basis of Treatments of Acute Muscle Injuries: A Short Review. Semin Musculoskelet Radiol 2020; 24:256-261. [PMID: 32987424 DOI: 10.1055/s-0040-1708087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Muscle strains occur frequently in recreational and professional sports. This article considers various treatment options in a biological context and reviews evidence of their efficacy. Treatments reviewed include the PRICE principle (P: rotection, R: est, I: ce, C: ompression, E: levation), early mobilization, physical therapy, hematoma aspiration, platelet-rich plasma injections, use of nonsteroidal anti-inflammatory drugs, corticosteroids, and local anesthetics, cellular therapies, and surgery.
Collapse
Affiliation(s)
- Ian Beggs
- Analytic Imaging, Edinburgh, United Kingdom
| |
Collapse
|
25
|
Pakos EE, Papadopoulos DV, Gelalis ID, Tsantes AG, Gkiatas I, Kosmas D, Tsekeris PG, Xenakis TA. Is prophylaxis for heterotopic ossification with radiation therapy after THR associated with early loosening or carcinogenesis? Hip Int 2020; 30:559-563. [PMID: 30990093 DOI: 10.1177/1120700019842724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Heterotopic ossification may develop after major hip surgeries, thus preventive strategies including radiation therapy and non steroid anti-inflammatory drugs are commonly employed. There are certain concerns regarding the effects of radiation therapy on implant loosening and carcinogenesis. Our study aims to evaluate whether radiation therapy results in implant loosening or radiation-induced tumours in the long term. PATIENTS AND METHODS This was a prospective study including 97 high-risk patients for heterotopic ossification who underwent total hip arthroplasty. Patients were divided into 2 groups and received either a combination of radiation therapy and indomethacin (Group A), or indomethacin alone (Group B). Evaluated outcomes included implant loosening or development of radiation-induced tumours during the follow-up period. RESULTS The follow-up period of the study was 10 years. Group A consisted of 50 patients, while Group B consisted of 47 patients. 3 patients died during the follow-up. There were 2 cases of implant loosening, 1 from each of the 2 groups at 9 and 10 years after surgery respectively; thus, no statistically significant difference regarding implant loosening was found (p < 0.05). During the follow-up period no cases of radiation-induced tumours were identified. CONCLUSION Our results are consistent with those of other studies supporting the safety of radiation therapy as a preventive strategy for heterotopic ossification following major surgeries in high risk patients. Further studies with even longer follow-up may be required to definitely exclude the possibility of adverse outcomes linked with radiation therapy.
Collapse
Affiliation(s)
- Emilios E Pakos
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | | | - Ioannis D Gelalis
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | - Andreas G Tsantes
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | - Ioannis Gkiatas
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | - Dimitrios Kosmas
- Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
| | - Pericles G Tsekeris
- Department of Radiation Oncology, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Theodoros A Xenakis
- Laboratory of Orthopedics and Biomechanics, University of Ioannina, School of Medicine, Ioannina, Greece
| |
Collapse
|
26
|
Nieuwenhuizen CJ, van Veldhoven PLJ, van Oosterom RF. Rare case of a traumatic myositis ossificans in the tibialis anterior muscle. BMJ Case Rep 2020; 13:13/8/e233210. [PMID: 32816878 DOI: 10.1136/bcr-2019-233210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Athletes involved in contact sports can be diagnosed with traumatic myositis ossificans. Myositis ossificans is characterised by a benign ossifying lesion in soft tissue mass, most commonly preceded by a muscle contusion in the thigh. Despite the fact that it is often a self-limiting disease, treatment modalities are anti-inflammatory drugs, physiotherapy, shockwave therapy, radiation therapy or surgical resection. We report a 22-year-old competitive football player with severe ongoing pain in the lower leg after a direct trauma. An X-ray showed calcification between the tibia and fibula. An additional ultrasound confirmed the diagnosis: myositis ossificans of the tibialis anterior muscle. After treating him with anti-inflammatory drugs and physiotherapy, he was able to return to sports. Myositis ossificans of the lower leg is an uncommon, though if present, troublesome condition, occurring after a contusion.
Collapse
Affiliation(s)
| | | | - Robert F van Oosterom
- Sports Medicine, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| |
Collapse
|
27
|
A Model to Improve the Workflow for Radiation Treatments in the Era of Bundled Payments: A Quality Improvement Project Report. Adv Radiat Oncol 2020; 5:490-494. [PMID: 32529145 PMCID: PMC7276685 DOI: 10.1016/j.adro.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/26/2019] [Accepted: 12/27/2019] [Indexed: 12/04/2022] Open
Abstract
The Centers for Medicare and Medicaid Services has proposed alternate payment models to improve the efficiency and decrease the redundancy of health care. Bundled payments or episode-based care is one example. Herein, we report on the successful implementation of a quality improvement project in which changing the clinical workflow for postoperative radiation treatment to the hip to prevent heterotopic ossification improved the efficiency of patient care and decreased cost by eliminating redundant imaging through multidisciplinary participation. This project is a model for interdisciplinary collaboration to improve patient care and reduce unnecessary health care spending in the era of bundled payment/episodes of care program implementation.
Collapse
|
28
|
Dikmen G, Ozden VE, Gulagaci F, Tozun IR. Long-term results of cementless total hip arthroplasty for the treatment of ankylosed hip. J Orthop Surg (Hong Kong) 2020; 27:2309499019858038. [PMID: 31262219 DOI: 10.1177/2309499019858038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this study was to report the long-term results of total hip arthroplasty (THA) for the treatment of ankylosed hip. METHODS Twenty-nine consecutive THAs were performed in 26 patients. The mean age of the patients at the time of the operation was 43.3 years (range, 19-69 years). We used cementless fixation in all hips and the mean duration of follow-up was 10.1 years (range, 4.5-20 years). Radiological evaluation of components, osteolysis, radiolucent lines and loosening were assessed. The Harris Hip Score (HHS), range of motion (ROM), limb-length discrepancy and walking capacity with or without any support were used preoperatively and at final follow-up for clinical evaluation. Survivorship analysis was conducted using the Kaplan-Meier method using second revision for any reason as the endpoint. RESULTS The mean HHS was 85.6 (range, 55-98) points and mean ROM was 110.5° for flexion. The mean limb-length discrepancy improved from 4.1 cm to 1.1 cm. Positive Trendelenburg sign was recorded in 31% of the patients and 24% of patients needed any support for walking postoperatively. We observed surgical complications related to abductor arm in 25% of the patients. Radiolucency on the acetabular side was seen on one or more zones in 15 patients (16 hips). One aseptic acetabular component loosening was observed. On the femoral side, 11 patients demonstrated non-progressive radiolucent lines and osteolysis around the stem was seen in four hips but there was no aseptic stem loosening. The Kaplan-Meier survival rate considering revision for any reason as the endpoint was 81.5%, for aseptic loosening 91.3%, for a worst-case scenario of 66.4% at 10 years. CONCLUSION Cementless fixation showed good to excellent results at 10 years. Preoperative and postoperative abductor status of the patient is critical for patient satisfaction.
Collapse
Affiliation(s)
- Goksel Dikmen
- Department of Orthopaedic Surgery and Traumatology, Acibadem School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Vahit Emre Ozden
- Department of Orthopaedic Surgery and Traumatology, Acibadem School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Fırat Gulagaci
- Department of Orthopaedic Surgery and Traumatology, Acibadem School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - I Remzi Tozun
- Department of Orthopaedic Surgery and Traumatology, Acibadem School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| |
Collapse
|
29
|
Heterotopic Ossification following Total Elbow Arthroplasty in a Patient with Parkinson's Disease: Case Report and Literature Review. Case Rep Surg 2020; 2020:2068045. [PMID: 32231845 PMCID: PMC7085846 DOI: 10.1155/2020/2068045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/11/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction. Heterotopic ossification (HO) usually develops following surgery or trauma. Risk factors for HO following elbow fractures include delay to surgery (>7 days), floating fractures, and elbow subluxation. Systemic risk factors for HO include male sex; concurrent cranial, neurological, or abdominal injury; high-energy trauma; previous development of HO; and contralateral fracture. To date, no studies have reported on Parkinson's disease (PD) as a risk factor for the development of HO. Case Presentation. A 68-year-old female with PD (treated with levodopa-carbidopa) sustained a right closed (OTA type A3) distal humerus fracture and was treated with a total elbow arthroplasty. Postoperatively, development of significant near-ankylosing HO was observed and contributed to significant restriction of elbow motion with activities of daily living. After HO maturation, the osseous growth was excised, and the area irradiated. The patient regained excellent elbow motion with no recurrence of HO. Discussion. A literature review revealed six cases of HO development in PD patients following arthroplasty. Patients with PD have higher serum concentrations of interleukins (IL) and tumor necrosis factor- (TNF-) α. These factors stimulate BMP-2 production which may promote osteogenesis. Levodopa-carbidopa may also influence HO through stimulation of growth hormone and IGF-1. Conclusion. Parkinsonism may promote heterotopic bone growth through the release of osteoinductive factors. HO development may also be mediated by levodopa-carbidopa therapy. Future research should highlight the link between HO and PD and identify if prophylaxis is warranted in PD patients undergoing arthroplasty.
Collapse
|
30
|
Zheng L, Hwang JM, Hwang DS, Kang C, Lee JK, Park YC. Incidence and location of heterotopic ossification following hip arthroscopy. BMC Musculoskelet Disord 2020; 21:132. [PMID: 32111223 PMCID: PMC7049198 DOI: 10.1186/s12891-020-3150-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 02/20/2020] [Indexed: 11/24/2022] Open
Abstract
Background We investigated the incidence and location of heterotopic ossification (HO) following hip arthroscopy. Methods This retrospective study enrolled 327 patients who underwent hip arthroscopy from January 2010 to December 2015. From this cohort, we extracted an HO group with simple radiographs or three-dimensional computed tomography (3D CT). Findings consistent with HO were classified according to the Brooker classification aided with 3D CT for the location of HO. The indication for revision arthroscopic excision of HO was painful, functional impairment of the hip. Patient clinical outcomes were assessed pre- and postoperatively, with modified Harris Hip Scores (mHHS), a visual analogue scale (VAS) for pain, and the Hip Outcome Score-Activity of Daily Living (HOS-ADL) and Sport Specific Subscales (HOS-SSS). Results In all, 14 (4.28%) of the 327 patients had confirmed HO radiographically. The mean follow-up was 39 months. In 13 patients, HO formed in the central area of the arthroscopic portals or capsulotomy. Ten patients had Brooker Grade 1 and four had Grade 2. At the last follow-up, 12 asymptomatic patients had significant (P < 0.001) improvements in all clinical outcome scores (mHHS, pain VAS, HOS-ADL, and HOS-SSS). Two patients developed symptoms sufficient to require revision hip arthroscopy for HO excision. After revision hip arthroscopy, both symptomatic patients had improved significantly in all clinical outcomes at the final follow-up. Conclusions HO is a minor complication of hip arthroscopy, but sometimes induces severe pain and functional impairment. Usually, HO forms in the arthroscopic portal or capsulotomy area.
Collapse
Affiliation(s)
- Long Zheng
- Department of Orthopedic Surgery, Yanbian University Hospital, Yanji, China
| | - Jung-Mo Hwang
- Department of Orthopedic Surgery, Chungnam National University Hospital, 266, Munwha-ro, Jung-gu, Daejeon, 35015, South Korea.
| | - Deuk-Soo Hwang
- Department of Orthopedic Surgery, Chungnam National University Hospital, 266, Munwha-ro, Jung-gu, Daejeon, 35015, South Korea
| | - Chan Kang
- Department of Orthopedic Surgery, Chungnam National University Hospital, 266, Munwha-ro, Jung-gu, Daejeon, 35015, South Korea
| | - Jeong-Kil Lee
- Department of Orthopedic Surgery, Chungnam National University Hospital, 266, Munwha-ro, Jung-gu, Daejeon, 35015, South Korea
| | - Young-Cheol Park
- Department of Orthopedic Surgery, Chungnam National University Hospital, 266, Munwha-ro, Jung-gu, Daejeon, 35015, South Korea
| |
Collapse
|
31
|
Lespasio MJ, Guarino AJ. Awareness of Heterotopic Ossification in Total Joint Arthroplasty: A Primer. Perm J 2020; 24:19.211. [PMID: 32069212 DOI: 10.7812/tpp/19.211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Heterotopic ossification (HO) is the presence of normal bone in soft tissue where bone should not exist. After direct musculoskeletal trauma of the surrounding soft tissue, HO is hypothesized to develop from a dysfunction of normal lamellar bone formation and remodeling that appears in nonskeletal areas of the body. Acquired HO related to total joint arthroplasty (TJA) of the hip and knee forms outside the joint capsule and can be a challenging condition when it impairs the essential healing process after elective surgery. Although HO is rare after elective TJA and thus clinically immaterial, when clinically relevant HO develops, patients may experience the following: 1) limited ambulation, 2) restricted range of motion, and 3) severe pain and discomfort that may lead to loss of function. Ultimately, patients with clinically relevant HO after elective TJA may require additional treatment, including medication, radiation therapy, manipulation under anesthesia, surgical excision of the HO, and possibly revision TJA. Awareness of HO and an understanding of the associated risk factors along with the various management options will enable health care practitioners and their patients to optimize their surgical outcomes.
Collapse
|
32
|
Heterotopic Ossification in Orthopaedic and Trauma surgery: A Histopathological Ossification Score. Sci Rep 2019; 9:18401. [PMID: 31804584 PMCID: PMC6895226 DOI: 10.1038/s41598-019-54986-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/19/2019] [Indexed: 01/12/2023] Open
Abstract
Heterotopic Ossification (HO) is a potential long-term complication in orthopaedic surgery. It is commonly classified according to the Brooker classification, which is based on radiological findings. To our knowledge the correlation of histological features to the Brooker grade is unknown as is the association between HO and the indication for revision. The aim of this paper is to analyze the ossification grade of HO tissue in patients undergoing revision hip and knee arthroplasty and to propose a histologically based classification system for HO. We also assess the relationship between the grade of HO and the indication for revision (septic and aseptic revision). From January to May 2019 we collected 50 human HO samples from hip and knee revision arthroplasty cases. These tissue samples were double-blinded and sent for histopathological diagnostic. Based on these results, we developed a classification system for the progression of HO. The grade of ossification was based on three characteristics: Grade of heterotopic ossification (Grade 1–3), presence of necrosis (N0 or N1) and the presence of osteomyelitis (HOES-Score Type 1 to 5). Demographic data as well as surgical details and indication for surgery was prospectively collected from clinical records. Fifty tissue samples were harvested from 44 hips and 6 knee joints. Of these 33 exhibited Grade I ossifications (66%), followed by 11 Grade II (22%) and one Grade III (2%). Necrosis was noted in two tissue samples (4%) and 2 more had osteomyelitis findings according to HOES-Score. Six samples (12%) with radiologically suggestive of HO turned out to be wear-induced synovitis, SLIM Type 1. Of these cases 16 were septic (32%) and 34 aseptic (68%) revisions. Most of the HO tissue samples were classified as a low-grade. High-grade ossification-Score is rare. Higher grades of ossification seem to be associated with septic revision cases. Wear-induced synovitis potentially influences HO development. A histological scoring system for ossification grading can be derived from the data presented in this study.
Collapse
|
33
|
Li F, Mao D, Pan X, Zhang X, Mi J, Rui Y. Celecoxib cannot inhibit the progression of initiated traumatic heterotopic ossification. J Shoulder Elbow Surg 2019; 28:2379-2385. [PMID: 31757369 DOI: 10.1016/j.jse.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND HYPOTHESIS Heterotopic ossification (HO) is a recognized sequela after trauma and arthroplasty. The purpose of this study was to evaluate the therapeutic effect of celecoxib on HO. We hypothesized that celecoxib may inhibit the progression of initiated HO. METHODS We performed a retrospective review of 37 patients who underwent elbow joint surgery between January 2014 and June 2018. Seventeen patients were prescribed orally administered celecoxib (200 mg/dose, twice daily) for 2 months after the diagnosis of HO, whereas the remaining 20 patients were administered celecoxib for 1 month starting immediately after surgery. HO progression was evaluated by plain radiographs. By use of an Achilles tendon puncture-induced HO mouse model, the curative effect of celecoxib was illustrated at different HO progression stages. The mice were assigned to 1 of 4 groups: sham group, vehicle group, group receiving celecoxib on day 1, and group receiving celecoxib in week 6. Achilles tendons were analyzed by micro-computed tomography and histochemistry after 12 weeks. RESULTS Celecoxib did not inhibit the progression of initiated HO in the patients in whom HO was diagnosed, whereas those who received celecoxib after surgery had lower morbidity. Achilles tendon puncture effectively induced typical HO in mice. The ectopic bone volume was significantly reduced in the day 1 celecoxib group compared with the vehicle group; however, the difference was not statistically significant in the week 6 celecoxib group. CONCLUSIONS Administration of celecoxib starting immediately after surgery can significantly inhibit the formation of HO. Once HO is visible on plain radiographs or micro-computed tomography, celecoxib cannot effectively attenuate further progression of HO in humans and mice.
Collapse
Affiliation(s)
- Fengfeng Li
- Department of Orthopedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Dong Mao
- Research Institute of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Xiaoyun Pan
- Research Institute of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Xin Zhang
- Research Institute of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Jingyi Mi
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Yongjun Rui
- Department of Orthopedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China.
| |
Collapse
|
34
|
Kokubu N, Tsujii M, Akeda K, Iino T, Sudo A. BMP-7/Smad expression in dedifferentiated Schwann cells during axonal regeneration and upregulation of endogenous BMP-7 following administration of PTH (1-34). J Orthop Surg (Hong Kong) 2019; 26:2309499018812953. [PMID: 30442072 DOI: 10.1177/2309499018812953] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE: To determine the expression and distribution of bone morphogenetic protein (BMP)-7 and related molecules during peripheral nerve regeneration and to assess whether administration of parathyroid hormone (PTH) drug (1-34) potentiates the intrinsic upregulation of BMP-7/Smad signaling. METHODS: The rat sciatic nerves were crushed with an aneurysm clip resulting in axonal degeneration. In the normal nerve, and at 1, 2, 4, and 8 weeks after injury, BMP-7, BMP receptors, p-Smad 1/5/8, and Noggin, the endogenous BMP antagonist, were evaluated. Additionally, the distribution of BMP-7 was assessed by fluorescent double immunostaining. In vitro studies were also performed to examine the effect of BMP-7 and PTH (1-34) administration on rat Schwann cells (SCs). RESULTS: Aneurysm clip made reliable animal model of the nerve injury with recovery at 8 weeks after the injury. BMP-7/Smad protein and mRNA were significantly upregulated on axon-SCs units at 1 week after injury, and this upregulated expression was maintained for 4 weeks. Besides, significant upregulation of Noggin's expression was observed on axon-SCs units at 2 weeks after injury. Moreover, fluorescent double immunostaining showed co-localization between expression of BMP-7 and p75NTR during axonal regeneration. In the in vitro study, administration of BMP-7 induced significant proliferation of SCs. Application of PTH (1-34) upregulated BMP-7 on SCs. DISCUSSION/CONCLUSION: BMPs were reported to be involved in protection and recovery after injury as well as in neurogenesis. Our current study showed that BMP/Smad signaling molecules were upregulated on dedifferentiated SCs after peripheral nerve injury and that administration of BMP-7 increased SC viability in vitro. These results suggested that axonal regeneration could be induced via upregulation of endogenous BMP-7 on SCs by PTH (1-34) administration.
Collapse
Affiliation(s)
| | | | | | | | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| |
Collapse
|
35
|
Heterotopic ossification: radiological and pathological review. Radiol Oncol 2019; 53:275-284. [PMID: 31553710 PMCID: PMC6765162 DOI: 10.2478/raon-2019-0039] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Heterotopic Ossification (HO) is a common condition referring to ectopic bone formation in soft tissues. It has two major etiologies, acquired (more common) and genetic. The acquired form is closely related to tissue trauma. The exact pathogenesis of this disease remains unclear; however, there is ongoing research in prophylactic and therapeutic treatments that is promising. Conclusions Due to HO potential to cause disability, it is so important to differentiate it from other causes in order to establish the best possible management.
Collapse
|
36
|
Kim BS, Song KS, Bae KC, Lee SW, Um SH, Cho CH. Total Ankylosis by Heterotopic Ossification in an Adolescent Anterior Trans-olecranon Fracture Dislocation: A Case Report. Clin Shoulder Elb 2019; 22:154-158. [PMID: 33330213 PMCID: PMC7714282 DOI: 10.5397/cise.2019.22.3.154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/09/2019] [Accepted: 05/18/2019] [Indexed: 02/02/2023] Open
Abstract
The incidence of heterotopic ossification in adolescents appears to be lower than in adults. There exist very few reports of heterotopic ossification with total bony ankylosis in child or adolescent populations. We describe a case of total bony ankylosis of the elbow secondary to heterotopic ossification, in a 14-year-old female. Total ankylosis of the elbow at 45 degrees of flexion was noted 6 months post-surgery, and complete surgical excision of the heterotopic mass was performed. After an additional one-time dose of radiation therapy and nonsteroidal anti-inflammatory drug medication, full range of motion was obtained without any recurrence or other complications, up to the last follow-up of 30 months.
Collapse
Affiliation(s)
- Beom-Soo Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Kwang-Soon Song
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Ki-Cheor Bae
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Si-Wook Lee
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sang-Hyun Um
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| |
Collapse
|
37
|
Greiffenstein P, Adams E, Scheuermann A, Rogers C. Treatment of symptomatic intercostal heterotopic ossification after surgical stabilization of rib fractures: report of two cases and review of the literature. J Thorac Dis 2019; 11:S1106-S1112. [PMID: 31205770 DOI: 10.21037/jtd.2019.01.37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Patrick Greiffenstein
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Emily Adams
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Alexis Scheuermann
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Camille Rogers
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| |
Collapse
|
38
|
Ju J, Yu D, Xue F, Zhao Y, Shi W, Pan M, Tang G, Xiao H. Inhibition of Nf-ҝb prevents trauma-induced heterotopic ossification in rat model. Connect Tissue Res 2019; 60:304-310. [PMID: 30288996 DOI: 10.1080/03008207.2018.1530771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To investigate the pathogenesis and find a better prophylactic method of acquired heterotopic ossification (HO). MATERIALS AND METHODS In the first part, we designed the brain-traumatic/burn/tenotomy rat model and testified its efficacy as HO model. 44 rats were randomly divided into experimental group and control group. After operation, the bilateral tendons of 2 rats were collected at the 2nd, 3rd, 4th, 6th, 8th, and 10th weeks to determine the expression levels of p65. Additionally, the remaining rats were exposed to X-Ray examination at the 10th week. In the second part, 124 rats were randomly divided into four groups based on the administration dosage of Ammonium pyrrolidinedithiocarbamate (PDTC). Then, three rats of each group were euthanized every week in the first seven weeks to collect tendon to detect the expression levels of p65 by qRT-PCR and Western Blot. The remaining rats were exposed to X-Ray examination at the 10th week to assess the size of HO before being euthanized for HE staining. RESULTS The success rate of Brain-traumatic/Burn/Tenotomy model was 100%. Pharmacologic inhibition of Nf-ҝb signaling pathway by PDTC could significantly reduce the expression levels of p53 and the size of HO, and the reduction was most significant in the 0.6mg dosage group. CONCLUSIONS Brain-traumatic/Burn/Tenotomy model was highly reliable HO model. Inhibition of Nf-ҝb signaling pathway by PDTC could significantly reduce HO formation, and the most effective concentration was 6 mg/ml for local injection.
Collapse
Affiliation(s)
- Jinyong Ju
- a Department of Orthopedics , Ji'ning NO.1 People's Hospital , Shandong , China
| | - Du Yu
- b Department of Orthopedics , Shanghai Fenxian District Central Hospital , Shanghai , China
| | - Feng Xue
- b Department of Orthopedics , Shanghai Fenxian District Central Hospital , Shanghai , China
| | - Yong Zhao
- b Department of Orthopedics , Shanghai Fenxian District Central Hospital , Shanghai , China
| | - Weizhe Shi
- b Department of Orthopedics , Shanghai Fenxian District Central Hospital , Shanghai , China
| | - Mingmang Pan
- b Department of Orthopedics , Shanghai Fenxian District Central Hospital , Shanghai , China
| | - Guo Tang
- b Department of Orthopedics , Shanghai Fenxian District Central Hospital , Shanghai , China
| | - Haijun Xiao
- b Department of Orthopedics , Shanghai Fenxian District Central Hospital , Shanghai , China
| |
Collapse
|
39
|
Kurz AZ, LeRoux E, Riediger M, Coughlin R, Simunovic N, Duong A, Laskovski JR, Ayeni OR. Heterotopic Ossification in Hip Arthroscopy: an Updated Review. Curr Rev Musculoskelet Med 2019; 12:147-155. [PMID: 30810970 DOI: 10.1007/s12178-019-09543-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Heterotopic ossification (HO) in hip arthroscopy is a common post-operative complication. This review was undertaken to provide an update (2014 present) on the current literature regarding HO in hip arthroscopy. RECENT FINDINGS Risk factors for HO post-hip arthroscopy include male gender, mixed impingement, picture, and the size of CAM resection. HO prophylaxis with NSAIDs has been proven to decrease the rate of HO post-hip arthroscopy; however, there is inherent risk to long-standing NSAIDs therapy. HO post-hip arthroscopy is not uncommon as a radiological finding, but symptomatic HO post-hip arthroscopy requiring revision surgery is a rare event, at < 1%. The outcomes for revision surgery for HO excision have fair outcomes. The hip arthroscopist should stratify their patients based on known risk factors, and determine whether NSAIDs prophylaxis is warranted.
Collapse
Affiliation(s)
- Adrian Z Kurz
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Eugenie LeRoux
- School of Medicine, St. George's University, St. George's, Grenada
| | - Michael Riediger
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Ryan Coughlin
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Andrew Duong
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Jovan R Laskovski
- Crystal Clinic Orthopedic Center, 1622 East Turkeyfoot Lake Road, Akron, OH, 44312, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St. West, 4E15, Hamilton, ON, L8N 3Z5, Canada.
| |
Collapse
|
40
|
Di Benedetto P, Zangari A, Magnanelli S, Cainero V, Beltrame A, Gisonni R, Causero A. Heterotopic Ossification in Primary Total Hip Arthroplasty: which is the role of drainage? ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:92-97. [PMID: 30715005 PMCID: PMC6503416 DOI: 10.23750/abm.v90i1-s.8077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 11/23/2022]
Abstract
Background and aim of the work: The Heterotopic Ossification (HO) is a common complication following Total Hip Arthroplasty (THA). Although there is no concordance in Literature regarding the etiopathogenic mechanism, various HO risk factors have been recognized, both related to the patient and associated with the surgical procedureLiterature does not consider the use of intra-articular drainage as a possible risk factor. Our hypothesis is that this item can contribute to the development of HO. Materials and Methods: 425 implants of hip arthroplasty performed between 2014 and 2017 at the Ortopedic Clinic of Udine were included in the study. No patient performed pre-operative or post-operative anti-HO prophylaxis during follow-up. Radiographs of preoperative and postoperative at 1 year were analyzed according to the Brooker Classification.Results: The incidence of HO in patients with intra-articular drainage is 24.6%, while the incidence of HO in patients without intra-articular drainage is 15.3%, with a statistically significant difference. Conclusions: The data obtained suggest to consider the use of intra-articular drainage as a possible intra-operative risk factor for HO. This is a retrospective cohort study, so we need more studies and more robust experimental designs to confirm these results. (www.actabiomedica.it)
Collapse
|
41
|
Kim JH, Park C, Son SM, Shin WC, Jang JY, Jeong HS, Lee IS, Moon TY. Preoperative arterial embolization of heterotopic ossification around the hip joint. Yeungnam Univ J Med 2018; 35:130-134. [PMID: 31620584 PMCID: PMC6784659 DOI: 10.12701/yujm.2018.35.1.130] [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: 04/18/2018] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 11/12/2022] Open
Abstract
Heterotopic ossification (HO) around the hip joint is not uncommon following neurological injury. Often, surgical treatment is performed in patients with restricted motion and/or refractory pain due to grade III or IV HO according to Brooker classification. The major complication that occurs as a result of surgical HO removal is perioperative bleeding due to hyper-vascularization of the lesion. Here, we report a case of preoperative embolization in a 51-year-old male patient presenting with restricted bilateral hip range of motion (ROM) due to HO following a spinal cord injury. In the right hip without preoperative arterial embolization, massive bleeding occurred during surgical removal of HO. Thus, the patient received a transfusion postoperatively due to decreased serum hemoglobin levels. For surgery of the left hip, preoperative embolization of the arteries supplying HO was performed. Surgical treatment was completed without bleeding complications, and the patient recovered without a postoperative transfusion. This case highlights that, while completing surgical removal for ROM improvements, orthopedic surgeons should consider preoperative arterial embolization in patients with hip HO.
Collapse
Affiliation(s)
- Jin Hyeok Kim
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chankue Park
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seung Min Son
- Department of Orthopedic Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Won Chul Shin
- Department of Orthopedic Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Joo Yeon Jang
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hee Seok Jeong
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - In Sook Lee
- Department of Radiology, Pusan National University Hospital, Busan, Korea
| | - Tae Young Moon
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| |
Collapse
|
42
|
Yoon BH, Park IK, Sung YB. Ankylosing Neurogenic Myositis Ossificans of the Hip: A Case Series and Review of Literature. Hip Pelvis 2018; 30:86-91. [PMID: 29896457 PMCID: PMC5990535 DOI: 10.5371/hp.2018.30.2.86] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/25/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose Neurogenic myositis ossificans (NMO) in patients with traumatic spinal cord or brain injuries can cause severe joint ankylosis or compromise neurovascularture. The purpose of this study was to evaluate the clinical and radiological outcomes of and review considerations relevant to surgical resection of NMO of the hip joint. Materials and Methods Six patients (9 hips) underwent periarticular NMO resection between 2015 and 2017. The medical records of these patients were retrospectively reviewed. Preoperative computed tomography including angiography was performed to determine osteoma location and size. Improvement in hip motion allowing sitting was considered the sole indicator of a successful surgery. The anterior approach was used in all patients. The ranges of motion (ROM) before and after surgery were compared. Results The mean time from accident to surgery was 3.6 years. Average ROM improved from 24.3°(flexion and extension) to 98.5°(flexion and extension) after surgery, and improvement was maintained at the last follow-up. No commom complications (e.g., deep infection, severe hematoma, deep vein thrombosis) occurred in any patient. Improvement in ROM in one hip in which surgical resection was performed 10 years after the accident was not satisfactory owing to the pathologic changes in the joint. Conclusion Surgical excision of periarticular NMO of the hip joint can yield satisfactory results, provided that appropriate preoperative evaluation is performed. Early surgical intervention yields satisfactory results and may prevent the development of intra-articular pathology.
Collapse
Affiliation(s)
- Byung-Ho Yoon
- Department of Orthopaedic Surgery, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - In Keun Park
- Department of Orthopaedic Surgery, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yerl-Bo Sung
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| |
Collapse
|
43
|
Tao MJ, Probyn L, Drost L, Kreder H, Nousiainen M, Tsao M, Barnes E, Jenkinson R, Wan BA, Poon M, Chan S, Chow E. Efficacy of Prophylactic Radiotherapy in the Treatment of Heterotopic Ossification. Clin Oncol (R Coll Radiol) 2018; 30:393-395. [DOI: 10.1016/j.clon.2018.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 11/25/2022]
|
44
|
Abston E, Novaco R, Hon S, Scalera J, Steiling K. Breath of relief: apparent pulmonary nodule due to heterotopic ossification. Clin Case Rep 2018; 6:1174-1175. [PMID: 29881589 PMCID: PMC5986018 DOI: 10.1002/ccr3.1378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/08/2017] [Accepted: 12/13/2017] [Indexed: 11/09/2022] Open
Abstract
Extrapulmonary heterotopic ossification appears similarly to pulmonary nodules on CXR, and is in the differential for pulmonary nodules. It occurs following the bone trauma, and in early stages appears similarly to tumors. Heterotopic ossification is diagnosed by its calcification pattern via MRI or ultrasound and managed conservatively unless symptoms develop.
Collapse
Affiliation(s)
- Eric Abston
- Department of Pulmonology, Allergy, Sleep, and Critical Care MedicineBoston University School of MedicineBostonMassachusetts
| | - Robert Novaco
- Department of RadiologyBoston University School of MedicineBostonMassachusetts
| | - Stephanie Hon
- Department of Pulmonology, Allergy, Sleep, and Critical Care MedicineBoston University School of MedicineBostonMassachusetts
| | - Jonathan Scalera
- Department of RadiologyBoston University School of MedicineBostonMassachusetts
| | - Katrina Steiling
- Department of Pulmonology, Allergy, Sleep, and Critical Care MedicineBoston University School of MedicineBostonMassachusetts
| |
Collapse
|
45
|
Vanlommel J, Vanlommel L, Molenaers B, Simon JP. Hybrid total hip arthroplasty for multiple epiphyseal dysplasia. Orthop Traumatol Surg Res 2018; 104:301-305. [PMID: 29274861 DOI: 10.1016/j.otsr.2017.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 07/13/2017] [Accepted: 11/19/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Multiple Ephiphyseal Dysplasia (MED) is a rare autosomal dominant skeletal dysplasia that causes deformation of the epiphysis of the involved joints. The hips are invariably affected and symptoms due to incapacitating early onset degenerative hip disease often begin between the second and fourth decade of life. Literature regarding the clinical and radiographical outcomes after total hip arthroplasty in this young population are very scarce. Hypothesis in patients with multiple epiphyseal dysplasia and early onset degenerative hip disease, hybrid total hip arthroplasty is a safe and reliable procedure. PATIENTS AND METHODS We followed 10 hybrid total hip arthroplasties in 6 patients with respect to the early and medium term complications. The average age at surgery was 32 years old (17 to 41). All stems were cemented polished straight tapered stems, all cups were porous coated uncemented cups. The mean duration of follow-up was 10.3 (7-14, SD2.8) years. Clinical outcomes were measured using the Charnley modification of the Merle d'Aubigné-Postel grading system and VAS-scores. RESULTS No early complications and no revisions occurred and patients significantly improved for pain, function and mobility. The Charnley, Merle d'Aubigné and Postel hip scores significantly improved from 9.6 points pre-operatively (range: 8-11 points) to 17 points (range: 16-18 points) and the VAS-score significantly improved after surgery from respectively 7 at rest and 8.5 during activity preoperatively to 1 at rest and 1.5 during activity postoperatively. Radiographic evaluation showed no cases of radiolucency around the cemented femoral components. No migration or subsidence of the components was noted. With regard to the acetabular component, osteolysis was noted in 4 hips, but serial radiographs showed no progression or migration of the component and the patients were completely pain free. CONCLUSION Hybrid total hip arthroplasty is a viable treatment option in multiple epiphyseal dysplasia patients, with excellent mid-term clinical and radiographical outcomes. LEVEL OF EVIDENCE Level IV, retrospective study.
Collapse
Affiliation(s)
- J Vanlommel
- Orthoclinic, AZ Sint Lucas Brugge, Sint Lucaslaan 29, 8310, Brugge Belgium.
| | - L Vanlommel
- UZ Pellenberg, department of Orthopaedics, Weligerveld 1, Leuven, Belgium
| | - B Molenaers
- UZ Pellenberg, department of Orthopaedics, Weligerveld 1, Leuven, Belgium
| | - J-P Simon
- UZ Pellenberg, department of Orthopaedics, Weligerveld 1, Leuven, Belgium
| |
Collapse
|
46
|
Juarez JK, Wenke JC, Rivera JC. Treatments and Preventative Measures for Trauma-Induced Heterotopic Ossification: A Review. Clin Transl Sci 2018; 11:365-370. [PMID: 29697199 PMCID: PMC6039201 DOI: 10.1111/cts.12552] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/25/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jessica K Juarez
- Unites States Army Institute of Surgical Research, Joint Base Fort Sam Houston, Texas, USA.,University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Joseph C Wenke
- Unites States Army Institute of Surgical Research, Joint Base Fort Sam Houston, Texas, USA
| | - Jessica C Rivera
- Unites States Army Institute of Surgical Research, Joint Base Fort Sam Houston, Texas, USA
| |
Collapse
|
47
|
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.
Collapse
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
| | | | | | | | | |
Collapse
|
48
|
Cholok D, Chung MT, Ranganathan K, Ucer S, Day D, Davis TA, Mishina Y, Levi B. Heterotopic ossification and the elucidation of pathologic differentiation. Bone 2018; 109:12-21. [PMID: 28987285 PMCID: PMC6585944 DOI: 10.1016/j.bone.2017.09.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/27/2017] [Accepted: 09/27/2017] [Indexed: 01/23/2023]
Abstract
Tissue regeneration following acute or persistent inflammation can manifest a spectrum of phenotypes ranging from the adaptive to the pathologic. Heterotopic Ossification (HO), the endochondral formation of bone within soft-tissue structures following severe injury serves as a prominent example of pathologic differentiation; and remains a persistent clinical issue incurring significant patient morbidity and expense to adequately diagnose and treat. The pathogenesis of HO provides an intriguing opportunity to better characterize the cellular and cell-signaling contributors to aberrant differentiation. Indeed, recent work has continued to resolve the unique cellular lineages, and causative pathways responsible for ectopic bone development yielding promising avenues for the development of novel therapeutic strategies shown to be successful in analogous animal models of HO development. This review details advances in the understanding of HO in the context of inciting inflammation, and explains how these advances inform the current standards of diagnosis and treatment.
Collapse
Affiliation(s)
- David Cholok
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael T Chung
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kavitha Ranganathan
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Serra Ucer
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Devaveena Day
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, USA
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, USA; Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Yuji Mishina
- School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
| |
Collapse
|
49
|
Abstract
A 21-year-old woman initiated physical therapy 4 days following hip arthroscopic labrum debridement and osteochondroplasty. During postoperative rehabilitation, the patient's status regressed. With persistent symptoms, at 10 weeks postsurgery a computed tomography scan revealed, as confirmed by radiographs, heterotopic ossification development. J Orthop Sports Phys Ther 2018;48(4):344. doi:10.2519/jospt.2018.7420.
Collapse
|
50
|
Wang X, Li F, Xie L, Crane J, Zhen G, Mishina Y, Deng R, Gao B, Chen H, Liu S, Yang P, Gao M, Tu M, Wang Y, Wan M, Fan C, Cao X. Inhibition of overactive TGF-β attenuates progression of heterotopic ossification in mice. Nat Commun 2018; 9:551. [PMID: 29416028 PMCID: PMC5803194 DOI: 10.1038/s41467-018-02988-5] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 01/11/2018] [Indexed: 12/24/2022] Open
Abstract
Acquired heterotopic ossification (HO) is a painful and debilitating disease characterized by extraskeletal bone formation after injury. The exact pathogenesis of HO remains unknown. Here we show that TGF-β initiates and promotes HO in mice. We find that calcified cartilage and newly formed bone resorb osteoclasts after onset of HO, which leads to high levels of active TGF-β that recruit mesenchymal stromal/progenitor cells (MSPCs) in the HO microenvironment. Transgenic expression of active TGF-β in tendon induces spontaneous HO, whereas systemic injection of a TGF-β neutralizing antibody attenuates ectopic bone formation in traumatic and BMP-induced mouse HO models, and in a fibrodysplasia ossificans progressive mouse model. Moreover, inducible knockout of the TGF-β type II receptor in MSPCs inhibits HO progression in HO mouse models. Our study points toward elevated levels of active TGF-β as inducers and promoters of ectopic bone formation, and suggest that TGF-β might be a therapeutic target in HO.
Collapse
MESH Headings
- Achilles Tendon/drug effects
- Achilles Tendon/injuries
- Adult
- Animals
- Antibodies, Neutralizing/pharmacology
- Becaplermin/metabolism
- Bone Remodeling
- Brain Injuries, Traumatic
- Cartilage
- Case-Control Studies
- Disease Models, Animal
- Elbow Joint/surgery
- Female
- Fracture Fixation, Internal
- Fractures, Bone
- Humans
- Male
- Mesenchymal Stem Cells/metabolism
- Mice
- Mice, Knockout
- Mice, Transgenic
- Middle Aged
- Muscle, Skeletal/pathology
- Myositis Ossificans/metabolism
- Ossification, Heterotopic/metabolism
- Osteoclasts
- Osteogenesis/drug effects
- Receptor, Transforming Growth Factor-beta Type II/genetics
- Spinal Cord Injuries
- Tendon Injuries
- Tendons
- Transforming Growth Factor beta/antagonists & inhibitors
- Transforming Growth Factor beta/metabolism
- Transforming Growth Factor beta1/metabolism
- Young Adult
- Elbow Injuries
Collapse
Affiliation(s)
- Xiao Wang
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Fengfeng Li
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, 200030, Shanghai, China
| | - Liang Xie
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Janet Crane
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Gehua Zhen
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Yuji Mishina
- School of Dentistry, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Ruoxian Deng
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Bo Gao
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Hao Chen
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Shen Liu
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, 200030, Shanghai, China
| | - Ping Yang
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Manman Gao
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Manli Tu
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Yiguo Wang
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Mei Wan
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Cunyi Fan
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, 200030, Shanghai, China
| | - Xu Cao
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
| |
Collapse
|