1
|
Hwang CD, Pagani CA, Nunez JH, Cherief M, Qin Q, Gomez-Salazar M, Kadaikal B, Kang H, Chowdary AR, Patel N, James AW, Levi B. Contemporary perspectives on heterotopic ossification. JCI Insight 2022; 7:158996. [PMID: 35866484 PMCID: PMC9431693 DOI: 10.1172/jci.insight.158996] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Heterotopic ossification (HO) is the formation of ectopic bone that is primarily genetically driven (fibrodysplasia ossificans progressiva [FOP]) or acquired in the setting of trauma (tHO). HO has undergone intense investigation, especially over the last 50 years, as awareness has increased around improving clinical technologies and incidence, such as with ongoing wartime conflicts. Current treatments for tHO and FOP remain prophylactic and include NSAIDs and glucocorticoids, respectively, whereas other proposed therapeutic modalities exhibit prohibitive risk profiles. Contemporary studies have elucidated mechanisms behind tHO and FOP and have described new distinct niches independent of inflammation that regulate ectopic bone formation. These investigations have propagated a paradigm shift in the approach to treatment and management of a historically difficult surgical problem, with ongoing clinical trials and promising new targets.
Collapse
Affiliation(s)
- Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Chase A Pagani
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Johanna H Nunez
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Masnsen Cherief
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qizhi Qin
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Balram Kadaikal
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Heeseog Kang
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ashish R Chowdary
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron W James
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benjamin Levi
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
2
|
Sun Y, Lin Y, Chen Z, Breland A, Lineaweaver WC, Zhang F. Heterotopic Ossification in Burn Patients. Ann Plast Surg 2022; 88:S134-S137. [PMID: 34270474 DOI: 10.1097/sap.0000000000002901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Heterotopic ossification (HO) is a known complication of burns. The incidence of this complication is low. The etiology is unclear, but experiment conducted about HO can be significant. Currently, there are still no targeted, effective preventive and therapeutic measures against it. In this study, the relevant literature is summarized to demonstrate the potential pathogenic mechanisms, diagnosis, prophylaxis, and treatment measures of HO in burn patients. Early diagnosis and treatment can be effective in improving the prognosis of patients.
Collapse
Affiliation(s)
- Yi Sun
- From the Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University
| | - Yuzhe Lin
- From the Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University
| | | | | | | | | |
Collapse
|
3
|
Edwards NJ, Hobson E, Dey D, Rhodes A, Overmann A, Hoyt B, Walsh SA, Pagani CA, Strong AL, Hespe GE, Padmanabhan KR, Huber A, Deng C, Davis TA, Levi B. High Frequency Spectral Ultrasound Imaging Detects Early Heterotopic Ossification in Rodents. Stem Cells Dev 2021; 30:473-484. [PMID: 33715398 PMCID: PMC8106252 DOI: 10.1089/scd.2021.0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/12/2021] [Indexed: 12/12/2022] Open
Abstract
Heterotopic ossification (HO) is a devastating condition in which ectopic bone forms inappropriately in soft tissues following traumatic injuries and orthopedic surgeries as a result of aberrant mesenchymal progenitor cell (MPC) differentiation. HO leads to chronic pain, decreased range of motion, and an overall decrease in quality of life. While several treatments have shown promise in animal models, all must be given during early stages of formation. Methods for early determination of whether and where endochondral ossification/soft tissue mineralization (HO anlagen) develop are lacking. At-risk patients are not identified sufficiently early in the process of MPC differentiation and soft tissue endochondral ossification for potential treatments to be effective. Hence, a critical need exists to develop technologies capable of detecting HO anlagen soon after trauma, when treatments are most effective. In this study, we investigate high frequency spectral ultrasound imaging (SUSI) as a noninvasive strategy to identify HO anlagen at early time points after injury. We show that by determining quantitative parameters based on tissue organization and structure, SUSI identifies HO anlagen as early as 1-week postinjury in a mouse model of burn/tenotomy and 3 days postinjury in a rat model of blast/amputation. We analyze single cell RNA sequencing profiles of the MPCs responsible for HO formation and show that the early tissue changes detected by SUSI match chondrogenic and osteogenic gene expression in this population. SUSI identifies sites of soft tissue endochondral ossification at early stages of HO formation so that effective intervention can be targeted when and where it is needed following trauma-induced injury. Furthermore, we characterize the chondrogenic to osteogenic transition that occurs in the MPCs during HO formation and correlate gene expression to SUSI detection of the HO anlagen.
Collapse
Affiliation(s)
- Nicole J. Edwards
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric Hobson
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Devaveena Dey
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Alisha Rhodes
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Archie Overmann
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Benjamin Hoyt
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sarah A. Walsh
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Chase A. Pagani
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Amy L. Strong
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Geoffrey E. Hespe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Amanda Huber
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Cheri Deng
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas A. Davis
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Benjamin Levi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
4
|
Botman E, Bevers MSAM, Wyers CE, van Rietbergen B, Teunissen BP, Raijmakers PG, Netelenbos JC, van den Bergh JP, Eekhoff EMW. Microarchitecture of Heterotopic Ossification in Fibrodysplasia Ossificans Progressiva: An HR-pQCT Case Series. Front Cell Dev Biol 2021; 9:627784. [PMID: 33777936 PMCID: PMC7991097 DOI: 10.3389/fcell.2021.627784] [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: 11/10/2020] [Accepted: 02/02/2021] [Indexed: 11/13/2022] Open
Abstract
It is challenging to study heterotopic ossification (HO) in patients with fibrodysplasia ossificans progressiva (FOP) due to the contraindication of invasive techniques (i.e., bone biopsies), which can trigger flare-ups. The aim of this case study was to assess mature HO at the microarchitectural level non-invasively with high-resolution peripheral quantitative computed tomography (HR-pQCT). Depending on the patient’s mobility, HR-pQCT scans were acquired of peripherally located HO and standard distal radius and tibia regions in two FOP patients, a 33-year-old woman and a 23-year-old man, with the classical mutation (p.R206H). HO was located around the halluces, the ankles, and in the Achilles tendon. Standard HR-pQCT analyses were performed of the distal radius, tibia, and HO to quantify bone mineral density (BMD) and bone microarchitecture. Micro-finite element analysis was used to estimate failure load (FL). The outcomes were compared between HO and neighboring skeletal bone and with an age- and gender-matched normative dataset from literature. The bone parameters of the radius were within the interquartile range (IQR) of normative data. In contrast, in the tibiae of both patients, total and trabecular BMD were below the IQR, as were trabecular bone volume fraction, number, and thickness, cortical thickness, and FL. Trabecular separation and heterogeneity were above the IQR. Isolated HO in the Achilles tendon had a lower total, trabecular, and cortical BMD, trabecular bone volume fraction, and cortical thickness than the normative tibia data. Trabecular microarchitecture was within the IQR, and FL was approximately 10% higher than that of the neighboring tibia after accounting for areal differences. Other scanned HO could only be qualitatively assessed, which revealed coalescence with the neighboring skeletal bone, development of a neo-cortex, and partial replacement of the original skeletal cortex with trabeculae. To conclude, isolated HO seemed microarchitecturally more comparable to reference tibia data than the peripheral skeleton of the FOP patients. HO and skeleton also appear to be able to become one entity when contiguous.
Collapse
Affiliation(s)
- Esmée Botman
- Department of Internal Medicine Section Endocrinology, Amsterdam Bone Center, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Melissa S A M Bevers
- Department of Internal Medicine, VieCuri Medical Center, Venlo, Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, Netherlands.,Orthopedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Caroline E Wyers
- Department of Internal Medicine, VieCuri Medical Center, Venlo, Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Internal Medicine, Subdivision Rheumatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Bert van Rietbergen
- Orthopedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Department of Orthopedic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Bernd P Teunissen
- Department of Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Pieter G Raijmakers
- Department of Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Jan Coen Netelenbos
- Department of Internal Medicine Section Endocrinology, Amsterdam Bone Center, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Joop P van den Bergh
- Department of Internal Medicine, VieCuri Medical Center, Venlo, Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Internal Medicine, Subdivision Rheumatology, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Elisabeth M W Eekhoff
- Department of Internal Medicine Section Endocrinology, Amsterdam Bone Center, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
5
|
Hoffseth KF, Simkin J, Busse E, Stewart K, Watt J, Chapple A, Hargrove A, Sammarco MC. A new approach to analyzing regenerated bone quality in the mouse digit amputation model using semi-automatic processing of microCT data. Bone 2021; 144:115776. [PMID: 33276153 PMCID: PMC7906109 DOI: 10.1016/j.bone.2020.115776] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/04/2020] [Accepted: 11/25/2020] [Indexed: 11/25/2022]
Abstract
Bone regeneration is a critical area of research impacting treatment of diseases such as osteoporosis, age-related decline, and orthopaedic implants. A crucial question in bone regeneration is that of bone architectural quality, or how "good" is the regenerated bone tissue structurally? Current methods address typical long bone architecture, however there exists a need for improved ability to quantify structurally relevant parameters of bone in non-standard bone shapes. Here we present a new analysis approach based on open-source semi-automatic methods combining image processing, solid modeling, and numerical calculations to analyze bone tissue at a more granular level using μCT image data from a mouse digit model of bone regeneration. Examining interior architecture, growth patterning, spatial mineral content, and mineral density distribution, these methods are then applied to two types of 6-month old mouse digits - 1) those prior to amputation injury (unamputated) and 2) those 42 days after amputation when bone has regenerated. Results show regenerated digits exhibit increased inner void fraction, decreased patterning, different patterns of spatial mineral distribution, and increased mineral density values when compared to unamputated bone. Our approach demonstrates the utility of this new analysis technique in assessment of non-standard bone models, such as the regenerated bone of the digit, and aims to bring a deeper level of analysis with an open-source, integrative platform to the greater bone community.
Collapse
Affiliation(s)
- Kevin F Hoffseth
- Department of Biological & Agricultural Engineering, Louisiana State University, 149 E.B. Doran Building, Baton Rouge, LA 70803, USA.
| | - Jennifer Simkin
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, 533 Bolivar Street, New Orleans, LA 70112, USA.
| | - Emily Busse
- Department of Surgery, Tulane School of Medicine, 1400 Tulane Ave, DEPT 8622, New Orleans, LA. 70112, USA.
| | - Kennon Stewart
- Department of Surgery, Tulane School of Medicine, 1400 Tulane Ave, DEPT 8622, New Orleans, LA. 70112, USA.
| | - James Watt
- Department of Surgery, Tulane School of Medicine, 1400 Tulane Ave, DEPT 8622, New Orleans, LA. 70112, USA.
| | - Andrew Chapple
- Department of Biostatistics, Louisiana State University Health Sciences Center, New Orleans, 533 Bolivar Street, New Orleans, LA 70112, USA.
| | - Aaron Hargrove
- Department of Biological & Agricultural Engineering, Louisiana State University, 149 E.B. Doran Building, Baton Rouge, LA 70803, USA.
| | - Mimi C Sammarco
- Department of Surgery, Tulane School of Medicine, 1400 Tulane Ave, DEPT 8622, New Orleans, LA. 70112, USA.
| |
Collapse
|
6
|
Immunological and morphological analysis of heterotopic ossification differs to healthy controls. BMC Musculoskelet Disord 2018; 19:327. [PMID: 30205831 PMCID: PMC6134767 DOI: 10.1186/s12891-018-2246-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/27/2018] [Indexed: 12/17/2022] Open
Abstract
Background Formation of lamellar bone in non-osseus tissue is a pathological process called heterotopic ossification. It is the aim of this study to analyse the morphology and immunological status of patients with heterotopic ossification compared to individual healthy persons. Methods Human bone marrow and blood samples were obtained from 6 systemically healthy individuals and 4 patients during resection of heterotopic ossification from bone at hip arthroplasty. Bone was fragmented and treated with purified collagenase. Immunofluorescence surface staining was performed and analyzed with flow cytometry. Microcomputed tomography scanning was done performed at a resolution of 11 and 35 μm isometric voxel size respectively using a two different cone beam X-computer tomography systems and a microfocus X-ray tube. Subsequently the volume data was morphometrically analysed. Results The monocytes, stem cells, stroma cells and granulocytes progenitor cells were strongly reduced in the heterotopic ossification patient. Additionally a significant reduction of stromal stem cells cells and CD34 positive stem cells was observed. The frequency of NK-cells, B cells and T cells were not altered in the patients with heterotopic ossification compared to a healthy person. Micromorphometric parameters showed a lower content of mineralized bone tissue compared to normal bone. Mean trabecular thickness showed a high standard deviation, indicating a high variation in trabecular thickness, anisotropy and reducing bone strength. Conclusions This work shows altered immunological distribution that is accompanied by a low decrease in bone volume fraction and tissue mineral density in the heterotopic ossification sample compared to normal bone. Compared to healthy subjects, this might reflect an immunological participation in the development of this entity.
Collapse
|
7
|
Ozkocak G, Cakir Kandemirli G, Ozcakir S. Massive heterotopic ossification after distal femur fracture. Scott Med J 2018; 63:95-98. [PMID: 29984623 DOI: 10.1177/0036933018783941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Heterotopic ossification is the formation of lamellar bone in periarticular soft tissue that can be seen in paralysed patients or following trauma. It can cause significant burden to already debilitated patients. Case presentation A 12-year-old boy with paraplegia due to neuromyelitis optica presented with progressive right knee pain and swelling. There was no history of trauma to the knee. Anteroposterior radiograph of femur at the initial presentation showed a supracondylar femur fracture for which casting was performed. Six weeks later, when casting was removed, swelling along with increased rubor in distal thigh region was noted. Radiography of the right femur revealed an unhealed distal femur fracture along with massive ossification extending from lesser trochanter to fracture line along the soft tissue around the femoral shaft. Conclusion This case presented the clinical and imaging findings of a giant heterotopic ossification in the thigh region following an extra-articular fracture.
Collapse
Affiliation(s)
- Gokhan Ozkocak
- 1 MD, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Uludag University, Turkey
| | - Guzin Cakir Kandemirli
- 2 MD, Department of Physical Medicine and Rehabilitation, Taksim Training and Research Hospital, Turkey
| | - Suheda Ozcakir
- 3 Associate Professor, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Uludag University, Turkey
| |
Collapse
|
8
|
Abstract
OBJECTIVE The purpose of this study is to develop a scoring system that stratifies burn patients at the time of hospital admission according to risk of developing heterotopic ossification (HO). SUMMARY OF BACKGROUND DATA HO in burns is an uncommon but severely debilitating problem with a poorly understood mechanism and no fully effective prophylactic measures. METHODS Data were obtained from the Burn Model System National Database from 1994 to 2010 (n = 3693). The primary outcome is diagnosis of HO at hospital discharge. Logistic regression analysis was used to determine significant demographic and medical predictors of HO. A risk scoring system was created in which point values were assigned to predictive factors and final risk score is correlated with the percent risk of developing HO. The model was internally and externally validated. RESULTS The mean age of the subjects is 42.5 ± 16.0 years, the mean total body surface area (TBSA) burned is 18.5 ± 16.4%, and the population is 74.9% male. TBSA and the need for grafting of the arm, head/neck, and trunk were significant predictors of HO development (P < 0.01). A 13-point risk scoring system was developed using these significant predictors. The model c-statistic is 0.92. The risk scoring system demonstrated evidence of internal and external validity. An online calculator was developed to facilitate translation of knowledge to practice and research. CONCLUSIONS This HO risk scoring system identifies high-risk burn patients suitable for diagnostic testing and interventional HO prophylaxis trials.
Collapse
|
9
|
The traumatic bone: trauma-induced heterotopic ossification. Transl Res 2017; 186:95-111. [PMID: 28668522 PMCID: PMC6715128 DOI: 10.1016/j.trsl.2017.06.004] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/22/2017] [Accepted: 06/08/2017] [Indexed: 01/08/2023]
Abstract
Heterotopic ossification (HO) is a common occurrence after multiple forms of extensive trauma. These include arthroplasties, traumatic brain and spinal cord injuries, extensive burns in the civilian setting, and combat-related extremity injuries in the battlefield. Irrespective of the form of trauma, heterotopic bone is typically endochondral in structure and is laid down via a cartilaginous matrix. Once formed, the heterotopic bone typically needs to be excised surgically, which may result in wound healing complications, in addition to a risk of recurrence. Refinements of existing diagnostic modalities, like micro- and nano-CT are being adapted toward early intervention. Trauma-induced HO is a consequence of aberrant wound healing, systemic and local immune system activation, infections, extensive vascularization, and innervation. This intricate molecular crosstalk culminates in activation of stem cells that initiate heterotopic endochondral ossification. Development of animal models recapitulating the unique traumatic injuries has greatly facilitated the mechanistic understanding of trauma-induced HO. These same models also serve as powerful tools to test the efficacy of small molecules which specifically target the molecular pathways underlying ectopic ossification. This review summarizes the recent advances in the molecular understanding, diagnostic and treatment modalities in the field of trauma-induced HO.
Collapse
|
10
|
Sung Hsieh HH, Chung MT, Allen RM, Ranganathan K, Habbouche J, Cholok D, Butts J, Kaura A, Tiruvannamalai-Annamalai R, Breuler C, Priest C, Loder SJ, Li J, Li S, Stegemann J, Kunkel SL, Levi B. Evaluation of Salivary Cytokines for Diagnosis of both Trauma-Induced and Genetic Heterotopic Ossification. Front Endocrinol (Lausanne) 2017; 8:74. [PMID: 28484423 PMCID: PMC5401868 DOI: 10.3389/fendo.2017.00074] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/27/2017] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Heterotopic ossification (HO) occurs in the setting of persistent systemic inflammation. The identification of reliable biomarkers can serve as an early diagnostic tool for HO, especially given the current lack of effective treatment strategies. Although serum biomarkers have great utility, they can be inappropriate or ineffective in traumatic acute injuries and in patients with fibrodysplasia ossificans progressiva (FOP). Therefore, the goal of this study is to profile the cytokines associated with HO using a different non-invasive source of biomarkers. METHODS Serum and saliva were collected from a model of trauma-induced HO (tHO) with hind limb Achilles' tenotomy and dorsal burn injury at indicated time points (pre-injury, 48 h, 1 week, and 3 weeks post-injury) and a genetic non-trauma HO model (Nfatc1-Cre/caAcvr1fl/wt ). Samples were analyzed for 27 cytokines using the Bio-Plex assay. Histologic evaluation was performed in Nfatc1-Cre/caAcvr1fl/wt mice and at 48 h and 1 week post-injury in burn tenotomy mice. The mRNA expression levels of these cytokines at the tenotomy site were also quantified with quantitative real-time PCR. Pearson correlation coefficient was assessed between saliva and serum. RESULTS Levels of TNF-α and IL-1β peaked at 48 h and 1 week post-injury in the burn/tenotomy cohort, and these values were significantly higher when compared with both uninjured (p < 0.01, p < 0.03) and burn-only mice (p < 0.01, p < 0.01). Immunofluorescence staining confirmed enhanced expression of IL-1β, TNF-α, and MCP-1 at the tenotomy site 48 h after injury. Monocyte chemoattractant protein-1 (MCP-1) and VEGF was detected in saliva showing elevated levels at 1 week post-injury in our tHO model when compared with both uninjured (p < 0.001, p < 0.01) and burn-only mice (p < 0.005, p < 0.01). The Pearson correlation between serum MCP-1 and salivary MCP-1 was statistically significant (r = 0.9686, p < 0.001) Similarly, the Pearson correlation between serum VEGF and salivary VEGF was statistically significant (r = 0.9709, p < 0.05). CONCLUSION In this preliminary study, we characterized the diagnostic potential of specific salivary cytokines that may serve as biomarkers for an early-stage diagnosis of HO. This study identified two candidate biomarkers for further study and suggests a novel method for diagnosis in the context of current difficult diagnosis and risks of current diagnostic methods in certain patients.
Collapse
Affiliation(s)
- Hsiao Hsin Sung Hsieh
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Experimental Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michael T. Chung
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ronald M. Allen
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Kavitha Ranganathan
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Joe Habbouche
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David Cholok
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan Butts
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Arminder Kaura
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Chris Breuler
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Caitlin Priest
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Shawn J. Loder
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - John Li
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Shuli Li
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jan Stegemann
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Steven L. Kunkel
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin Levi
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
11
|
Rajapakse CS, Lindborg C, Wang H, Newman BT, Kobe EA, Chang G, Shore EM, Kaplan FS, Pignolo RJ. Analog Method for Radiographic Assessment of Heterotopic Bone in Fibrodysplasia Ossificans Progressiva. Acad Radiol 2017; 24:321-327. [PMID: 27989444 DOI: 10.1016/j.acra.2016.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES Severe progressive multifocal heterotopic ossification (HO) is a rare occurrence seen predominantly in patients who have fibrodysplasia ossificans progressiva (FOP) and is difficult to quantitate owing to patient-, disease-, logistical-, and radiation-related issues. The purpose of this study was to develop and validate a scoring system based on plain radiographs for quantitative assessment of HO lesions in patients with FOP. MATERIALS AND METHODS Institutional review board approval was obtained from the University of Pennsylvania, and all data comply with Health Insurance Portability and Accountability Act regulations. The University of Pennsylvania Institutional Animal Care and Use Committee approved the use of mice in this study. First, we used a mouse model of FOP-like HO to validate a semiquantitative analog scale for estimating relative heterotopic bone volume. Second, we used this validated scale to estimate the relative amount of HO from a retrospective analysis of plain radiographs from 63 patients with classic FOP. Finally, the scale was applied to a retrospective analysis of computed tomographic images from three patients with FOP. RESULTS In the FOP-mouse model, the observed rating on the analog scale is highly correlated to heterotopic bone volumes measured by microcomputed tomography (R2 = 0.89). The scoring system that was applied to radiographs of patients with FOP captured the clinical range of HO typically present at all axial and appendicular sites. Analysis of computed tomographic scans of patients with FOP found that observed radiograph ratings were highly correlated with HO volume (R2 = 0.80). CONCLUSIONS The scoring system described here could enable practical, quantitative assessment of HO in clinical trials to evaluate new treatment modalities, especially for FOP. The development of the six-point analog scale described here provides and validates a much-needed, reproducible, and quantifiable method for describing and assessing HO in patients with FOP. This scale has the potential to be a key descriptor that can inform patients with FOP and clinicians about disease progression and response of HO lesions to interventions and treatments.
Collapse
Affiliation(s)
- Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104; Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104.
| | - Carter Lindborg
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Haitao Wang
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Benjamin T Newman
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104
| | - Elizabeth A Kobe
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104
| | - Gregory Chang
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Eileen M Shore
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Department of Radiology, NYU Langone Medical Center, New York, New York
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Robert J Pignolo
- Division of Geriatric Medicine & Gerontology, Mayo Clinic College of Medicine, Rochester, Minnesota
| |
Collapse
|
12
|
Moore SN, Hawley GD, Smith EN, Mignemi NA, Ihejirika RC, Yuasa M, Cates JMM, Liu X, Schoenecker JG. Validation of a Radiography-Based Quantification Designed to Longitudinally Monitor Soft Tissue Calcification in Skeletal Muscle. PLoS One 2016; 11:e0159624. [PMID: 27438007 PMCID: PMC4954695 DOI: 10.1371/journal.pone.0159624] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 07/06/2016] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Soft tissue calcification, including both dystrophic calcification and heterotopic ossification, may occur following injury. These lesions have variable fates as they are either resorbed or persist. Persistent soft tissue calcification may result in chronic inflammation and/or loss of function of that soft tissue. The molecular mechanisms that result in the development and maturation of calcifications are uncertain. As a result, directed therapies that prevent or resorb soft tissue calcifications remain largely unsuccessful. Animal models of post-traumatic soft tissue calcification that allow for cost-effective, serial analysis of an individual animal over time are necessary to derive and test novel therapies. We have determined that a cardiotoxin-induced injury of the muscles in the posterior compartment of the lower extremity represents a useful model in which soft tissue calcification develops remote from adjacent bones, thereby allowing for serial analysis by plain radiography. The purpose of the study was to design and validate a method for quantifying soft tissue calcifications in mice longitudinally using plain radiographic techniques and an ordinal scoring system. METHODS Muscle injury was induced by injecting cardiotoxin into the posterior compartment of the lower extremity in mice susceptible to developing soft tissue calcification. Seven days following injury, radiographs were obtained under anesthesia. Multiple researchers applied methods designed to standardize post-image processing of digital radiographs (N = 4) and quantify soft tissue calcification (N = 6) in these images using an ordinal scoring system. Inter- and intra-observer agreement for both post-image processing and the scoring system used was assessed using weighted kappa statistics. Soft tissue calcification quantifications by the ordinal scale were compared to mineral volume measurements (threshold 450.7mgHA/cm3) determined by μCT. Finally, sample-size calculations necessary to discriminate between a 25%, 50%, 75%, and 100% difference in STiCSS score 7 days following burn/CTX induced muscle injury were determined. RESULTS Precision analysis demonstrated substantial to good agreement for both post-image processing (κ = 0.73 to 0.90) and scoring (κ = 0.88 to 0.93), with low inter- and intra-observer variability. Additionally, there was a strong correlation in quantification of soft tissue calcification between the ordinal system and by mineral volume quantification by μCT (Spearman r = 0.83 to 0.89). The ordinal scoring system reliably quantified soft tissue calcification in a burn/CTX-induced soft tissue calcification model compared to non-injured controls (Mann-Whitney rank test: P = 0.0002, ***). Sample size calculations revealed that 6 mice per group would be required to detect a 50% difference in STiCSS score with a power of 0.8. Finally, the STiCSS was demonstrated to reliably quantify soft tissue calcification [dystrophic calcification and heterotopic ossification] by radiographic analysis, independent of the histopathological state of the mineralization. CONCLUSIONS Radiographic analysis can discriminate muscle injury-induced soft tissue calcification from adjacent bone and follow its clinical course over time without requiring the sacrifice of the animal. While the STiCSS cannot identify the specific type of soft tissue calcification present, it is still a useful and valid method by which to quantify the degree of soft tissue calcification. This methodology allows for longitudinal measurements of soft tissue calcification in a single animal, which is relatively less expensive, less time-consuming, and exposes the animal to less radiation than in vivo μCT. Therefore, this high-throughput, longitudinal analytic method for quantifying soft tissue calcification is a viable alternative for the study of soft tissue calcification.
Collapse
Affiliation(s)
- Stephanie N. Moore
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, 1215 21th Avenue South, Nashville TN, 37232, United States of America
- Department of Pharmacology, Vanderbilt University, 2200 Pierce Ave, Robinson Research Building Nashville, TN, 37232, United States of America
| | - Gregory D. Hawley
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, 1215 21th Avenue South, Nashville TN, 37232, United States of America
| | - Emily N. Smith
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, 1215 21th Avenue South, Nashville TN, 37232, United States of America
| | - Nicholas A. Mignemi
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, 1215 21th Avenue South, Nashville TN, 37232, United States of America
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN, 37232, United States of America
| | - Rivka C. Ihejirika
- School of Medicine, Vanderbilt University, 2215 Garland Ave, Light Hall, Room 215, Nashville, TN, 37232, United States of America
| | - Masato Yuasa
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, 1215 21th Avenue South, Nashville TN, 37232, United States of America
| | - Justin M. M. Cates
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN, 37232, United States of America
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University, 2525 West End, Ste 11000, Nashville, TN, 37203, United States of America
| | - Jonathan G. Schoenecker
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, 1215 21th Avenue South, Nashville TN, 37232, United States of America
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN, 37232, United States of America
- Department of Pediatrics, Vanderbilt University Medical Center, 4202 Doctor’s Office Tower, 2200 Children’s Way, Nashville, TN, 37232, United States of America
- Department of Pharmacology, Vanderbilt University, 2200 Pierce Ave, Robinson Research Building Nashville, TN, 37232, United States of America
| |
Collapse
|
13
|
Ter Meulen DP, Nota SPFT, Hageman MGJS, Ring DC. Progression of Heterotopic Ossification around the Elbow after Trauma. THE ARCHIVES OF BONE AND JOINT SURGERY 2016; 4:228-230. [PMID: 27517067 PMCID: PMC4969368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/26/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND This study addresses the null hypothesis that there is no expansion of heterotopic ossification (HO) in the elbow beyond what can be seen early on. METHODS The area of HO was measured on lateral radiographs of 38 consecutive patients that had operative treatment of HO between 2000 and 2013. Measurements from radiographs obtained between 3 to 7 weeks were compared to measurements from radiographs made 3 months or more after injury. RESULTS There was no significant difference between the average area of HO on the first (median 2.8 square centimeters, Q1: 1.5, Q3: 5.1) and later radiographs (median of 2.8 square centimeters, Q1: 1.4, Q3: 5.0) (P = 0.99). CONCLUSION According to our results the area of HO does not expand beyond what can be seen early in the disease process.
Collapse
Affiliation(s)
| | | | | | - David C Ring
- Dell Medical School, The University of Texas at Austin, Austin, USA
| |
Collapse
|