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Vishlaghi N, Guo L, Griswold-Wheeler D, Sun Y, Booker C, Crossley JL, Bancroft AC, Juan C, Korlakunta S, Ramesh S, Pagani CA, Xu L, James AW, Tower RJ, Dellinger M, Levi B. Vegfc-expressing cells form heterotopic bone after musculoskeletal injury. Cell Rep 2024; 43:114049. [PMID: 38573853 DOI: 10.1016/j.celrep.2024.114049] [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: 08/30/2023] [Revised: 02/09/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024] Open
Abstract
Heterotopic ossification (HO) is a challenging condition that occurs after musculoskeletal injury and is characterized by the formation of bone in non-skeletal tissues. While the effect of HO on blood vessels is well established, little is known about its impact on lymphatic vessels. Here, we use a mouse model of traumatic HO to investigate the relationship between HO and lymphatic vessels. We show that injury triggers lymphangiogenesis at the injury site, which is associated with elevated vascular endothelial growth factor C (VEGF-C) levels. Through single-cell transcriptomic analyses, we identify mesenchymal progenitor cells and tenocytes as sources of Vegfc. We demonstrate by lineage tracing that Vegfc-expressing cells undergo osteochondral differentiation and contribute to the formation of HO. Last, we show that Vegfc haploinsufficiency results in a nearly 50% reduction in lymphangiogenesis and HO formation. These findings shed light on the complex mechanisms underlying HO formation and its impact on lymphatic vessels.
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Affiliation(s)
- Neda Vishlaghi
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Lei Guo
- Department of Population and Data Sciences, University of Texas Southwestern, Dallas, TX, USA
| | | | - Yuxiao Sun
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Cori Booker
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Janna L Crossley
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Alec C Bancroft
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Conan Juan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Sneha Korlakunta
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Sowmya Ramesh
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Chase A Pagani
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Lin Xu
- Department of Population and Data Sciences, University of Texas Southwestern, Dallas, TX, USA
| | - Aaron W James
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Robert J Tower
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Michael Dellinger
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA.
| | - Benjamin Levi
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA.
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2
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Lucas SL, Gallagher BP, Mullinix KP, Brumback RJ, Cunningham BW. 3D-Printed Model in Preoperative Planning of Sciatic Nerve Decompression Because of Heterotopic Ossification: A Case Report. JBJS Case Connect 2024; 14:01709767-202403000-00033. [PMID: 38394316 DOI: 10.2106/jbjs.cc.23.00483] [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: 02/25/2024]
Abstract
CASE A 31-year-old patient presented with an encapsulated sciatic nerve secondary to extensive hip heterotopic ossification (HO), which prevented visualization of a safe osteotomy site to avoid nerve damage. The 3D-printed model demonstrated an easily identifiable osseous reference point along the inferior aspect of the heterotopic mass, allowing for a vertical osteotomy to be safely performed. CONCLUSION HO is associated with loss of normal anatomic topography. The current case report illustrates the use of a 3D-printed model to identify pertinent anatomic landmarks required for safe decompression of an encapsulated sciatic nerve within the anatomic region of the hip.
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Affiliation(s)
- Sarah L Lucas
- Georgetown University School of Medicine, Washington, District of Columbia
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Brian P Gallagher
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Kenneth P Mullinix
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Robert J Brumback
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Bryan W Cunningham
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, MedStar Union Memorial Hospital, Baltimore, Maryland
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3
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Olivero M, Capurro B, Reis-Campos P, Aprato A, Ayeni O, Chawla A, Larrainzar Garijo R, Marín-Peña O. Low-dose prophylaxis protocol for heterotopic ossification after hip preservation surgery in a sport participants cohort. SICOT J 2023; 9:27. [PMID: 37668540 PMCID: PMC10478760 DOI: 10.1051/sicotj/2023024] [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] [Received: 04/17/2023] [Accepted: 07/30/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Heterotopic ossification (HO) is a well-known complication of arthroscopic and open surgical treatment of femoroacetabular impingement (FAI). Incidence of heterotopic ossification has been reported in the literature between 0% and 44% after hip arthroscopy and between 18.2% and 25% after anterior mini-open surgery. Currently, pharmacological prophylaxis with NSAIDs and selective COX-2 inhibitors are commonly used and their effectiveness is well documented in literature. HYPOTHESIS We hypothesized that the low-dose prophylaxis protocol with selective cox-2 inhibitors decreases the risk of heterotopic ossification in open or arthroscopic hip preservation surgery in athletes. METHODS This study is an analysis of prospectively gathered data on 98 sport participant patients who underwent arthroscopic or anterior mini-open treatment for FAI between April 2008 and April 2018. All the patients received postoperative oral prophylaxis with 60 mg etoricoxib once daily for two weeks. Post-operative X-rays were performed at 1, 3, and 12 months after surgery and reviewed by two orthopedic surgeons blinded to the type and side of surgery. HO were graded according to the Brooker classification. Descriptive statistics was used to analyze demographic data. Bivariate analysis was performed to analyze the association of HO with each of the following variables: type of surgery, physical activity, time of evolution of symptoms, age at surgery, and sex. Finally, a regression model analysis was performed to determine the presence of confounding effects between variables. RESULTS The study cohort was composed of 54 patients in the arthroscopic treatment group and 44 patients in the anterior mini-open group. HO was identified in 6 (13.6%) patients in the mini-open group. No HO was identified in the arthroscopic group. In the bivariate analysis, "type of surgery" was the only variable that showed a statistically significant association with HO (p = 0.007). CONCLUSION Results of this study suggest that anterior mini-open treatment was characterized by a higher risk of HO development compared to hip arthroscopy for femoroacetabular impingement treatment regardless of pharmacological prophylaxis. The treatment regimen of 60 mg etoricoxib daily for two weeks was an effective prophylaxis for HO formation in sport participant patients compared with data available in the literature.
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Affiliation(s)
- Matteo Olivero
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Centro Traumatológico Ortopédico, (CTO), University of Torino 10126 Torino Italy
| | - Bruno Capurro
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Department of Orthopaedic Surgery and Sport Traumatology, IMSKE Hospital 46024 Valencia Spain
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European Hip Preservation Associates, EHPA-ESSKA Section Europe
| | - Pedro Reis-Campos
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Orthopedic and Traumatology Department, Hospital Vila Franca de Xira 2600-009 Portugal
| | - Alessandro Aprato
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Centro Traumatológico Ortopédico, (CTO), University of Torino 10126 Torino Italy
| | - Olufemi Ayeni
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Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Center L8S 4S4 Hamilton Canada
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European Hip Preservation Associates, EHPA-ESSKA Section Europe
| | - Anuj Chawla
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Department of Orthopaedic Surgery, Tan Tock Seng Hospital PC 308433 Novena Singapore
| | - Ricardo Larrainzar Garijo
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Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Infanta Leonor 28031 Madrid Spain
| | - Oliver Marín-Peña
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Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Infanta Leonor 28031 Madrid Spain
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European Hip Preservation Associates, EHPA-ESSKA Section Europe
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4
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Selmene MA, Upex P, Zaraa M, Moreau PE, Riouallon G. Computer Navigation-Assisted Resection of Heterotopic Ossification Around the Hip: A Technical Note. Cureus 2023; 15:e42897. [PMID: 37664301 PMCID: PMC10474822 DOI: 10.7759/cureus.42897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Heterotopic ossification is a rare but debilitating situation. It occurs in patients who have undergone paralysis and/or immobilization. Hip osteoma is one of the most frequent locations and is associated with a significant functional handicap. Its treatment is based on surgical resection, which is a risky surgery that is not devoid of complications such as infections, hematoma, and recurrence. We describe in this paper a new surgical technique that adds to the classic hip osteoma resection: guidance with a navigation system coupled to a 3D imaging tool. We performed this technique on two patients (three hips, one bilateral case). We think that this technique makes the surgery safer with fewer complications.
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Affiliation(s)
| | - Peter Upex
- Orthopaedic Surgery, Paris Saint-Joseph Hospital Group, Paris, FRA
| | - Mourad Zaraa
- Orthopaedic Surgery, Paris Saint-Joseph Hospital Group, Paris, FRA
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5
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Kent SE, Ryan SP. Heterotopic Ossification Remodeling After Acetabular Surgery: A Natural History Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00032. [PMID: 37535810 DOI: 10.2106/jbjs.cc.23.00055] [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: 08/05/2023]
Abstract
CASE A 30-year-old woman presented with a transverse plus posterior wall acetabular fracture and underwent operative fixation through a Kocher-Langenbeck approach. Shared decision was made for no heterotopic ossification (HO) prophylaxis. The patient developed symptomatic HO and was scheduled for resection, which was delayed because of the pandemic. She returned with interval remodeling of HO and symptom resolution. No surgery was required. CONCLUSION HO is a common complication after acetabular injury. Resection is the treatment of choice for symptomatic HO. We are not aware of other reports of spontaneous remodeling of symptomatic HO such that it no longer required surgery.
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Affiliation(s)
- Suzanne E Kent
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
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6
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Smits I, Koenders N, Stirler V, Hermans E. Hip Function after Surgically Treated Isolated Traumatic Acetabular Fracture: A Prospective Series of Consecutive Cases. Hip Pelvis 2023; 35:133-141. [PMID: 37323548 PMCID: PMC10264231 DOI: 10.5371/hp.2023.35.2.133] [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: 10/19/2022] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 06/17/2023] Open
Abstract
Purpose Isolated acetabular fractures can occur as a result of a high energy impact on the hip joint. Surgery is required for most patients with an isolated acetabular fracture in order to alleviate pain, restore joint stability, and regain hip function. This study was conducted in order to examine the course of hip function in patients after surgical treatment of an isolated traumatic acetabular fracture. Materials and Methods This prospective series of consecutive cases included patients who underwent surgery for treatment of an isolated acetabular fracture in a European level one trauma center between 2016 and 2020. Patients with relevant concomitant injuries were excluded. Scoring of hip function was performed by a trauma surgeon using the Modified Merle d'Aubigné and Postel score at six-week, 12-week, six-month, and one-year follow-up. Scores between 3-11 indicate poor, 12-14 fair, 15-17 good, and 18 excellent hip function. Results Data on 46 patients were included. The mean score for hip function was 10 (95% confidence interval [CI] 7.09-12.91) at six-week follow-up (23 patients), 13.75 (95% CI 10.74-16.76) at 12-week follow-up (28 patients), 16 (95% CI 13.40-18.60) at six-month follow-up (25 patients), and 15.50 (95% CI 10.55-20.45) at one-year follow-up (17 patients). After one-year follow-up, the scores reflected an excellent outcome in 11 patients, good in five patients, and poor in one patient. Conclusion This study reports on the course of hip function in patients who have undergone surgical treatment for isolated acetabular fractures. Restoration of excellent hip function takes six months.
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Affiliation(s)
- Indy Smits
- Department of Rehabilitation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Niek Koenders
- Department of Rehabilitation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Vincent Stirler
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erik Hermans
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
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7
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Purcell KF, Lachiewicz PF. Heterotopic Ossification After Modern Total Hip Arthroplasty: Predisposing Factors, Prophylaxis, and Surgical Treatment. J Am Acad Orthop Surg 2023; 31:490-496. [PMID: 36972521 DOI: 10.5435/jaaos-d-22-01070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Indexed: 03/29/2023] Open
Abstract
Heterotopic ossification (HO) is a common radiographic finding and potentially serious complication after modern total hip arthroplasty. Although historically associated with the posterolateral approach, HO has been noted in 10% to 40% of patients having direct anterior or anterior-based muscle sparing approaches. The available data are uncertain whether robotic arm-assisted procedures are associated with this complication. Current prophylaxis for patients considered high risk of this complication includes postoperative, nonsteroidal, anti-inflammatory medication for several weeks or low-dose perioperative irradiation. The surgical treatment of symptomatic HO associated with severely restricted motion or ankylosis of the hip should be individualized but may include wide excision of bone, acetabular revision to prevent instability, and prophylaxis to prevent recurrence.
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Affiliation(s)
- Kevin F Purcell
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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8
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Boissonneault A, O Hara N, Pogorzelski D, Marchand L, Higgins T, Gitajn L, Gage MJ, Natoli RM, Sharma I, Pierrie S, O'Toole RV, Sprague S, Slobogean G. The impact of heterotopic ossification prophylaxis after surgical fixation of acetabular fractures: national treatment patterns and related outcomes. Injury 2023; 54:S0020-1383(23)00197-3. [PMID: 37002119 PMCID: PMC10480339 DOI: 10.1016/j.injury.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 03/04/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a common complication after surgical fixation of acetabular fractures. Numerous strategies have been employed to prevent HO formation, but results are mixed and optimal treatment strategy remains controversial. The purpose of the study was to describe current national heterotopic ossification (HO) prophylaxis patterns among academic trauma centers, determine the association between prophylaxis type and radiographic HO, and identify if heterogeneity in treatment effects exist based on outcome risk strata. METHODS We used data from a subset of participants enrolled in the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. We included only patients with closed AO-type 62 acetabular fractures that were surgically treated via a posterior (Kocher-Langenbeck), combined anterior and posterior, or extensile exposure. PREPARE Clinical Trial Registration Number: NCT03523962 Patient population This cohort study was nested within the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. The PREPARE trial is a multicenter cluster-randomized crossover trial evaluating the effectiveness of two alcohol-based pre-operative antiseptic skin solutions. All PREPARE trial clinical centers that enrolled at least one patient with a closed AO-type 62 acetabular fracture were invited to participate in the nested study. RESULTS 277 patients from 20 level 1 and level 2 trauma centers in the U.S. and Canada were included in this study. 32 patients (12%) received indomethacin prophylaxis, 100 patients (36%) received XRT prophylaxis, and 145 patients (52%) received no prophylaxis. Administration of XRT was associated with a 68% reduction in the adjusted odds of overall HO (OR 0.32, 95% CI, 0.14 - 0.69, p = 0.005). The overall severe HO (Brooker classes III or IV) rate was 8% for the entire cohort; XRT reduced the rate of severe HO in high-risk patients only (p=0.03). CONCLUSION HO prophylaxis patterns after surgical fixation of acetabular fractures have changed dramatically over the last two decades. Most centers included in this study did not administer HO prophylaxis. XRT was associated with a marked reduction in the rate of overall HO and the rate of severe HO in high-risk patients. Randomized trials are needed to fully elucidate the potential benefit of XRT. PREPARE Clinical Trial Registration Number: NCT03523962.
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Affiliation(s)
- Adam Boissonneault
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA.
| | - Nathan O Hara
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
| | - David Pogorzelski
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lucas Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Thomas Higgins
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Section of Orthopaedic Trauma, Duke University, Durham, North Carolina
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ishani Sharma
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarah Pierrie
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
| | - Sheila Sprague
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gerard Slobogean
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
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9
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Seijas R, Barastegui D, Celis CLD, Montaña F, Cuscó X, Cugat R. Heterotopic Ossification in Hip Arthroscopy. Surg J (N Y) 2023; 9:e8-e12. [PMID: 36756198 PMCID: PMC9902196 DOI: 10.1055/s-0042-1758160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 09/22/2022] [Indexed: 02/09/2023] Open
Abstract
Introduction Hip arthroscopy is a rising surgical technique due to the increase in hip diseases, especially femoroacetabular impingement. One of the several complications related to such procedures is heterotopic ossifications (HO). The aim of this study is to describe the prevalence of HO after hip arthroscopy in a series of patients with femoroacetabular impingement and to compare its preoperative and intraoperative variables with a matched control group of patients without HO. Methods All patients who underwent hip arthroscopy for femoroacetabular impingement between 2010 and 2017 with a minimum follow-up of 2 years were included in this analysis. Radiographic examinations were recorded to select cases with HO. A case-control analysis was performed comparing preoperative and intraoperative variables between cases with HO and a matched control group without HO. Results A total of 700 cases were included in the analysis. HO was found in 15 (2.14%) of subjects. Cases with HO showed more severe cartilage injuries, less cam morphology ratio, and a higher proportion of partial labrectomies than the control group. No significant differences were observed in preoperative hip pain or function between groups. Conclusions The prevalence of HO after hip arthroscopy in subjects with femoroacetabular impingement was 2.14%. Cases with HO had more severe cartilage injuries, lower ratio of cam morphology, and higher proportion of partial labrectomies than the control cases without HO. Level of Evidence Level III.
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Affiliation(s)
- Roberto Seijas
- Instituto Cugat, Barcelona, Spain,Basic Sciences Department, Faculty of Medicine and Health Sciences, Universitat International de Catalunya, Barcelona, Spain,Foundation Garcia Cugat, Barcelona, Spain,Address for correspondence Roberto Seijas, MD, PhD Instituto Cugat, Hospital Quiron Barcelona Floor -1, Pza. Alfonso Comín 5, 08023 BarcelonaSpain
| | - David Barastegui
- Instituto Cugat, Barcelona, Spain,Basic Sciences Department, Faculty of Medicine and Health Sciences, Universitat International de Catalunya, Barcelona, Spain,Foundation Garcia Cugat, Barcelona, Spain,Mutualidad Catalana de Futbolistas, Federación Española de Fútbol, Barcelona, Spain
| | - Carlos López de Celis
- Basic Sciences Department, Faculty of Medicine and Health Sciences, Universitat International de Catalunya, Barcelona, Spain
| | - Ferran Montaña
- Instituto Cugat, Barcelona, Spain,Basic Sciences Department, Faculty of Medicine and Health Sciences, Universitat International de Catalunya, Barcelona, Spain
| | - Xavier Cuscó
- Instituto Cugat, Barcelona, Spain,Foundation Garcia Cugat, Barcelona, Spain
| | - Ramón Cugat
- Instituto Cugat, Barcelona, Spain,Foundation Garcia Cugat, Barcelona, Spain,Mutualidad Catalana de Futbolistas, Federación Española de Fútbol, Barcelona, Spain
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Orth M, Osche D, Pohlemann T. [Management of complications of acetabular fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:109-118. [PMID: 36477256 DOI: 10.1007/s00113-022-01256-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 12/12/2022]
Abstract
Surgical treatment of acetabular fractures represents a special challenge in the field of trauma surgery. Complications are mostly due to the trauma itself or are iatrogenic. The handling and strategy to overcome complications in acetabular surgery are oriented towards the type of complication and the time of occurrence. Generally, a differentiation is made between early perioperative complications and late complications. The present article describes the most frequent complications during the surgical treatment of acetabular fractures, discusses the various treatment options based on individual case examples and gives differentiated recommendations to overcome the complications. The treatment concept should initially comprise a comprehensive primary prophylaxis to prevent complications. In cases of early perioperative complications, e.g. postoperative wound infections, hemorrhage or incorrect implant positioning, rapid and systematic surgical revision should be performed. In contrast, the treatment of late complications (e.g. implant associated failures, secondary osteoarthrosis of the hip, periarticular heterotopic ossification, non-unions and late infections) depends on the clinical and functional condition of the patient. In symptomatic elderly patients secondary total hip replacement is usually a valid option, whereas younger patients with late complications can be candidates for joint-preserving procedures. The management of complications in acetabular surgery regularly requires intense patient guidance as well as thorough clarification and should be performed in specialized centers.
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Affiliation(s)
- M Orth
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland.
| | - D Osche
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland
| | - T Pohlemann
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland
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Abstract
Heterotopic ossification (HO) refers to benign ectopic bone formation in soft tissue and is common following trauma surgery. HO bone can restrict movement and progress into ankylosis that may necessitate surgical intervention. This article discusses the current literature on the pathophysiology, prophylaxis, treatment, and epidemiology of postoperative HO following orthopedic trauma.
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Affiliation(s)
- Jad Lawand
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA.
| | - Zachary Loeffelholz
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Bilal Khurshid
- Texas College of Osteopathic Medicine, Fort Worth, Texas, USA
| | - Eric Barcak
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
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12
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Yeung P, Zarnett O, Lefaivre KA, Guy P. Risk Factors for the Development of Heterotopic Ossification Following Acetabular Fractures: A Systematic Review. JBJS Rev 2022; 10:01874474-202209000-00005. [PMID: 36137013 DOI: 10.2106/jbjs.rvw.20.00263] [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: 11/14/2022]
Abstract
BACKGROUND Heterotopic ossification (HO) following acetabular fractures is a common complication that may affect clinical outcomes. However, the effects of prophylactic treatment with nonsteroidal anti-inflammatory drugs or radiation therapy remain controversial. While several factors have been related to the development of HO, there is considerable uncertainty regarding their importance or effect size in the setting of acetabular surgery. Therefore, this systematic review aims to summarize the risk factors for HO following the operative fixation of acetabular fractures and clarify their interrelationships. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, MEDLINE, Embase, and CINAHL databases were searched from inception to February 2021. Studies that assessed factors related to HO development among patients with operatively repaired acetabular fractures were included. Outcomes were risk factors and their effect size (p values, odds ratios, and 95% confidence intervals). RESULTS Twenty-five studies and 1 conference abstract with a total of 3,940 patients were included. The following risk factors for HO were identified. Patient factors were increased body mass index, male sex, and increased age. Injury factors were intensive care unit (ICU) admission and length of stay, non-ICU hospitalization for >10 days, the need for mechanical ventilation for ≥2 days, abdominal and/or chest injuries, the number and type of associated fractures, traumatic brain injuries, T-type acetabular fractures, pelvic ring injuries, and hip dislocation. Care factors were a delay to surgery, extensile and posterior surgical approaches to the hip, trochanteric osteotomy, postoperative step-off of >3 mm, and a delay to prophylaxis following injury or surgery. Ethnicity, Injury Severity Score, cause of the fracture, femoral head injuries, degloving injuries, comminution, intra-articular debris, the type of bone void filler, gluteus minimus muscle preservation, prolonged operative time, and intraoperative patient position were not risk factors for developing HO. CONCLUSIONS HO following operative fixation of acetabular fractures is not uncommon, with severe-grade HO associated with substantial disability. Careful consideration of the risk factor effect sizes and interdependencies could aid physicians in identifying patients at risk for developing HO and guide their prophylactic management. The results of this study could establish a framework for future studies. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Phillip Yeung
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Oren Zarnett
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kelly A Lefaivre
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Guy
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, British Columbia, Canada
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Heterotopic ossification prophylaxis after acetabular fracture fixation using a posterior approach: a retrospective study at a level 1 trauma center. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001158] [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]
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Tariq MA, Ahmed B, Shaikh S, Amin H, Ali SU. Eficácia do ibuprofeno após artroplastia total de quadril para prevenção de ossificação heterotópica: Revisão sistemática e meta-análise. Rev Bras Ortop 2022. [DOI: 10.1055/s-0042-1748947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
ResumoO objetivo deste estudo foi realizar uma revisão sistemática e meta-análise de estudos clínicos randomizados (ECRs) relevantes para determinar o papel do ibuprofeno, sua dose ideal, e a duração do tratamento na prevenção de ossificação heterotópica (OH) após a artroplastia total primária do quadril (ATQ). Uma pesquisa bibliográfica foi feita nos bancos de dados PubMed/MEDLINE e Cochrane Library para a obtenção de ECRs que comparassem o uso de ibuprofeno e de placebo como profilaxia para OH em pacientes submetidos à ATQ. Os principais desfechos deste estudo foram ocorrência geral de OH, classificação de Brooker da OH, e complicações gastrintestinais. No total, 27 artigos foram identificados nos bancos de dados e 4 estudos, com 1.153 pacientes, foram incluídos na análise final. Em comparação ao placebo, o uso de ibuprofeno reduziu a incidência de OH aos 3 e 12 meses de acompanhamento e a incidência de OH Brooker II e III (p < 0,05). No entanto, não houve diferença significativa entre os grupos que receberam ibuprofeno e placebo em termos de interrupção do tratamento devido a complicações gastrintestinais ou da incidência de OH Brooker I e IV (p > 0,05). Os dados existentes indicam que o ibuprofeno é seguro e eficaz na redução da incidência total de OH e de OH Brooker II e III durante o acompanhamento. No entanto, as conclusões são limitadas devido ao pequeno número de estudos; logo, mais estudos clínicos de alta qualidade são necessários para o desenvolvimento de diretrizes em relação à dose e duração ideal da terapia.
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Affiliation(s)
- Muhammad Ali Tariq
- Departamento de Cirurgia Ortopédica, Dow International Medical College, Karachi, Paquistão
| | - Bilal Ahmed
- Departamento de Cirurgia Ortopédica, Dow International Medical College, Karachi, Paquistão
| | - Shehryar Shaikh
- Departamento de Cirurgia Ortopédica, Dow International Medical College, Karachi, Paquistão
| | - Hamza Amin
- Departamento de Cirurgia Ortopédica, Dr. Ruth K. M. Pfau Civil Hospital, Karachi, Paquistão
| | - Syed Uzair Ali
- Departamento de Cirurgia Ortopédica, Dow International Medical College, Karachi, Paquistão
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Liu G, Chen J, Liang C, Zhang C, Li X, Hu Y. The Pararectus approach in acetabular fractures treatment: functional and radiologcial results. BMC Musculoskelet Disord 2022; 23:370. [PMID: 35443641 PMCID: PMC9022322 DOI: 10.1186/s12891-022-05275-z] [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: 10/26/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The surgical treatment of complex acetabular fractures is one of the most challenging procedures for orthopedic surgeons. The Pararectus approach, as a reasonable alternative to the existing surgical procedures, was performed for the treatment of acetabular fractures involving the anterior column. This study aimed to evaluate outcome using the Pararectus approach for acetabular fractures involving anterior columns. METHODS Thirty-seven with displaced acetabular fractures involving anterior columns were treated between July 2016 and October 2019 using the Pararectus approach. The functional outcomes (using the Merle d Aubigné and Postel scoring system, WOMAC and modified Harris scoring), the quality of surgical reduction (using the Matta criteria), and postoperative complications were assessed during approximately 26 months follow-up period. RESULTS Thirty-seven patients (mean age 53 years, range: 30-71; 28 male) underwent surgery. Mean intraoperative blood loss was 840 ml (rang: 400-2000 ml) and mean operating time was 210 min (rang: 140-500 min). The modified Merle d Aubigné score was excellent and good in 27 cases (73%), fair in 6 cases (16%), and poor in 3 cases (11%). The mean score was 88.5 (range:77-96) for the modified Harris Hip scores, and 22 (range:7-35) for the WOMAC scores after operation. Postoperative functional outcomes were significantly improved compared with preoperative outcomes (P < 0.0001). The quality of reduction was anatomical in 21 cases (57%), satisfactory in 9 cases (24%), and unsatisfactory in 7 cases (19%). At follow-up, four patients developed a DVT, and heterotopic bone formation was observed in one patient. The hip osteoarthritis was not observed. CONCLUSION The Pararectus approach achieved good functional outcomes and anatomical reduction in the treatment of acetabular fractures involving anterior column with minimal access morbidity.
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Affiliation(s)
- Guoming Liu
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Jinli Chen
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Chengzhi Liang
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Chengdong Zhang
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Xuwen Li
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Yanling Hu
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China.
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Joseph NM, Flanagan CD, Heimke IM, Cho E, Pothireddy S, Scarcella N, Vallier HA. Factors influencing functional outcomes following open reduction internal fixation of acetabular fractures. Injury 2021; 52:1396-1402. [PMID: 33228993 DOI: 10.1016/j.injury.2020.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/15/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recent large series of patient-reported outcomes after acetabulum fracture are limited, and potentially modifiable risk factors may be unidentified. The goal of this study was to describe patient and injury factors which negatively influence functional outcomes following operative management of acetabular fractures. METHODS 699 patients with acetabular fractures were treated with open reduction and internal fixation (ORIF). Musculoskeletal Function Assessment (MFA) questionnaire was completed after a minimum 12 months post-injury by 283 adults. MFA scores range from 1 to 100 and higher scores represent greater dysfunction. Factors were assessed for potential association with MFA scores, and univariate and multiple linear regression analyses were performed. RESULTS Survey respondents were more severely injured than non-respondents, with more chest injury (38% vs 22%, p<0.001) and higher Injury Severity Score (19.3 vs 16.8, p=0.003). Patients were 69% male with mean age 44.0 years. Approximately one-third were smokers (31%), while 14% had comorbid diabetes mellitus type II. The majority of injuries occurred during a motor vehicle collision (65%); low-energy mechanisms were rare (4.2%). The most common fracture pattern was isolated posterior wall (23%), followed by transverse/posterior wall (21%). Heterotopic ossification (HO) was noted in 22%: Brooker 1: 29.5%, 2: 23.0%, 3: 32.8%, and 4: 14.8%. Tobacco use (β = 18.4, p<0.001), obesity (β = 0.39, p=0.009), diabetes (β = 8.2, p=0.029), post-traumatic arthrosis (PTA) (β = 5.94 p=0.035), and increasing HO severity (β = 8.93, p<0.001) were independently associated with worse MFA scores. Tobacco use had the strongest association, followed by the severity of HO. CONCLUSION In a large series of patient-reported functional outcomes following fixation of acetabular fractures, tobacco use, obesity, comorbid diabetes, PTA, and HO were associated with worse MFA scores. Further study to mitigate HO should be considered. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Noah M Joseph
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Christopher D Flanagan
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Isabella M Heimke
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elizabeth Cho
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sahini Pothireddy
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Nicholas Scarcella
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Heather A Vallier
- Study performed at MetroHealth Medical Center, an affiliate of Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
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Broggi MS, Yoon CJ, Allen J, Maceroli M, Moore T, Schenker M, Hernandez-Irizarry R. Higher altitude leads to increased risk of venous thromboembolism after acetabular and pelvic ring injury. J Clin Orthop Trauma 2021; 19:192-195. [PMID: 34141573 PMCID: PMC8178120 DOI: 10.1016/j.jcot.2021.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/14/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION There is a high post-operative incidence of venous thromboembolisms (VTEs), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), in pelvic ring and acetabular fractures, and identification of risk factors for VTEs is crucial to decrease this highly morbid complication. High altitudes have a known physiological effect on the body that may predispose patients to developing VTEs in the postoperative period. The purpose of this study was to investigate the relationship between pelvic ring and acetabular fractures occurring at high altitudes and the development of postoperative VTEs. METHODS In this retrospective study, the Truven MarketScan claims database was used to identify patients who underwent surgical fixation of a pelvic ring and/or acetabular fracture from January 2009 to December 2018 using Current Procedural Terminology (CPT) codes. Patient characteristics, including medical comorbidities, were collected. The zip codes of where the surgeries took place were used to determine recovery altitude and patients were separated into either the high altitude (>4000 feet) or low altitude (<100 feet) cohorts. Chi-squared and multivariate analyses were performed to investigate the association between altitude and the development of VTE postoperatively. RESULTS In total, 68,923 patients were included for analysis. At 30-days postoperatively, a higher altitude was associated with increased odds of developing a PE (OR 1.47, p = 0.019). At 90-days postoperatively, a higher altitude was associated with increased odds of DVT (OR 1.24, p = 0.029) and PE (OR 1.63, p < 0.001). CONCLUSION Surgical fixation of pelvic ring and acetabular fractures performed at a higher altitude (>4,000feet) are associated with increased odds of developing a PE in the first 30 days as well as developing a DVT or PE at 90 days postoperatively. Future prospective studies are needed to further elucidate the causality of altitude on the development of postoperative VTEs.
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Affiliation(s)
- Matthew S. Broggi
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA,Corresponding author. MD 59 Executive Park South, Atlanta, GA 30324, USA.
| | - Camilla J. Yoon
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Jerad Allen
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Michael Maceroli
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Thomas Moore
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Mara Schenker
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Roberto Hernandez-Irizarry
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
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Grossner T, Haberkorn U, Gotterbarm T. Evaluation of the Impact of Different Pain Medication and Proton Pump Inhibitors on the Osteogenic Differentiation Potential of hMSCs Using 99mTc-HDP Labelling. Life (Basel) 2021; 11:life11040339. [PMID: 33920381 PMCID: PMC8069736 DOI: 10.3390/life11040339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 01/08/2023] Open
Abstract
First-line analgetic medication used in the field of musculoskeletal degenerative diseases, like Nonsteroidal anti-inflammatory drugs (NSAIDs), reduces pain and prostaglandin synthesis, whereby peptic ulcers are a severe adverse effect. Therefore, proton pump inhibitors (PPI) are frequently used as a concomitant medication to reduce this risk. However, the impact of NSAIDs or metamizole, in combination with PPIs, on bone metabolism is still unclear. Therefore, human mesenchymal stem cells (hMSCs) were cultured in monolayer cultures in 10 different groups for 21 days. New bone formation was induced as follows: Group 1 negative control group, group 2 osteogenic differentiation media (OSM), group 3 OSM with pantoprazole (PAN), group 4 OSM with ibuprofen (IBU), group 5 OSM with diclofenac (DIC), group 6 OSM with metamizole (MET), group 7 OSM with ibuprofen and pantoprazole (IBU + PAN), group 8 OSM with diclofenac and pantoprazole (DIC + PAN), group 9 OSM with metamizole and pantoprazole (MET + PAN) and group 10 OSM with diclofenac, metamizole and pantoprazole (DIC + MET + PAN). Hydroxyapatite content was evaluated using high-sensitive radioactive 99mTc-HDP labeling. Within this study, no evidence was found that the common analgetic medication, using NSAIDs alone or in combination with pantoprazole and/or metamizole, has any negative impact on the osteogenic differentiation of mesenchymal stem cells in vitro. To the contrary, the statistical results indicate that pantoprazole alone (group 3 (PAN) (p = 0.016)) or diclofenac alone (group 5 (DIC) (p = 0.008)) enhances the deposition of minerals by hMSCS in vitro. There is an ongoing discussion between clinicians in the field of orthopaedics and traumatology as to whether post-surgical (pain) medication has a negative impact on bone healing. This is the first hMSC in vitro study that investigates the effects of pain medication in combination with PPIs on bone metabolism. Our in vitro data indicates that the assumed negative impact on bone metabolism is subsidiary. These findings substantiate the thesis that, in clinical medicine, the patient can receive every pain medication needed, whether or not in combination with PPIs, without any negative effects for the osteo-regenerative potential.
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Affiliation(s)
- Tobias Grossner
- Trauma Surgery and Paraplegiology, Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-56-35-443
| | - Uwe Haberkorn
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany;
- Clinical Cooperation Unit Nuclear Medicine, Deutsches Krebsforschungszentrum (DKFZ), 69120 Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), 69120 Heidelberg, Germany
| | - Tobias Gotterbarm
- Department of Orthopedics and Traumatology, Kepler University Hospital, 4020 Linz, Austria;
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Beck EC, Gowd AK, Paul K, Chahla J, Marquez-Lara AJ, Rasio J, Irie T, Williams J, Nho SJ. Pelvic osteotomies for acetabular dysplasia: Are there outcomes, survivorship and complication differences between different osteotomy techniques? J Hip Preserv Surg 2021; 7:764-776. [PMID: 34377519 PMCID: PMC8349594 DOI: 10.1093/jhps/hnab009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 12/09/2020] [Accepted: 01/13/2021] [Indexed: 01/06/2023] Open
Abstract
The purpose of this study was to evaluate the safety and efficacy of Periacetabular osteotomy (PAO), rotational acetabular osteotomy (RAO), and eccentric rotational acetabular osteotomy (ERAO) for treating hip dysplasia by comparing complication rates, survivorship, and functional outcomes after treatment. A systematic review in the MEDLINE and CINAHL databases was performed, and studies reporting outcomes after pelvic osteotomy for hip dysplasia with a minimum of 1-year follow-up or reported postoperative complications was included. Patient demographics, radiographic measurements, patient reported outcomes including the modified Harris hip score (mHHS), complications using the modified Clavien-Dindo classification, and reoperations were extracted from each study. A meta-analysis of outcome scores, complications, change in acetabular coverage, and revision rates for the 3 pelvic osteotomies was performed. A total of 47 articles detailing outcomes of 6,107 patients undergoing pelvic osteotomies were included in the final analysis. When stratified by procedure, RAO had a statistically greater change in LCEA when compared to PAO (33.9° vs 18.0°; P <0.001). The average pooled mHHS improvement was 15.6 (95% CI: 8.3–22.8, I2= 99.4%). Although ERAO had higher mean score improvements when compared to RAO and PAO, the difference was not statistically significant (P >0.05). Lastly, patients undergoing PAO had a statistically greater complication rate than those undergoing ERAO and RAO (P <0.001 for both), while revision rate was not statistically different between the 3 techniques. In summary, there are many more publications on PAO surgery with a wide range of reported complications. Complications after ERAO and RAO surgery are lower than PAO surgery in the literature, but it is unclear whether this represents an actual difference or a reporting bias. Lastly, there are no significant differences between revisions, or postoperative reported outcomes between the 3 techniques.
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Affiliation(s)
- Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Medical Center Blvd., Winston-Salem, NC 27157, USA
| | - Anirudh K Gowd
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Medical Center Blvd., Winston-Salem, NC 27157, USA
| | - Katlynn Paul
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Jorge Chahla
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Alejandro J Marquez-Lara
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Medical Center Blvd., Winston-Salem, NC 27157, USA
| | - Jonathan Rasio
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Torhu Irie
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Joel Williams
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Shane J Nho
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
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Freije SL, Kushdilian MV, Burney HN, Zang Y, Saito NG. A Retrospective Analysis of 287 Patients Undergoing Prophylactic Radiation Therapy for the Prevention of Heterotopic Ossification. Adv Radiat Oncol 2020; 6:100625. [PMID: 34195485 PMCID: PMC8233464 DOI: 10.1016/j.adro.2020.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/30/2020] [Accepted: 11/11/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose Heterotopic ossification (HO) is a potentially disabling disorder of ectopic bone formation secondary to orthopedic surgery or trauma. In this retrospective analysis we evaluated the outcomes of patients who received radiation therapy (RT) for HO prophylaxis. Methods and Materials A total of 287 patients who received RT for HO prophylaxis at a major trauma center from 2007 to 2018 were analyzed. Data collected included types of injury, surgery, time intervals between key events, development of postprophylaxis HO, and secondary malignancies. Associations between various factors and the risk of developing HO were analyzed. Kaplan-Meier analysis was used to estimate failure rates. Results The most common indication for RT was traumatic acetabular fracture (83.3%). Twelve patients (4.2%) developed postprophylaxis HO with a median time to failure of 8.6 months (2.8-24.5). Kaplan-Meier 1-, 2-, and 5-year failure rates were 3.7%, 4.4%, and 7.4%, respectively. Injury type and timing of RT were not associated with the risk of failure, but we observed a trend of increased risk of failure in patients with longer time between surgery and RT (odd ration [OR] 1.68, P = .056). Current or former smokers (51.7%) were less likely to fail (OR 0.10, P = .03). There was no incidence of in-field secondary malignancy. Conclusions There was no significant association between injury and fracture type, surgical approach, or timing of RT and development of HO, contrary to published reports of increased HO risk with certain surgical approaches and longer time intervals between injury and surgery, suggesting that prophylactic RT might play a role in mitigating these effects. Decreased risk of postprophylaxis HO among former or current smokers was unexpected. No secondary malignancy in the RT field was identified, although the median follow-up was only 17 months. Compared with published HO incidences (17%-39%) in patients who receive no prophylaxis after traumatic acetabular fractures, our results are highly suggestive of the efficacy of prophylactic RT.
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Affiliation(s)
- Samantha L Freije
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael V Kushdilian
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Heather N Burney
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yong Zang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Naoyuki G Saito
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
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Do Indomethacin or Radiation for Heterotopic Ossification Prophylaxis Increase the Rates of Infection or Wound Complications After Acetabular Fracture Surgery? J Orthop Trauma 2020; 34:455-461. [PMID: 32815831 DOI: 10.1097/bot.0000000000001775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the rates of infection and wound complications in patients undergoing operative fixation (ORIF) of acetabular fractures receiving heterotopic ossification (HO) prophylaxis using indomethacin or external beam radiation therapy (XRT) versus no prophylaxis. DESIGN Retrospective cohort. SETTING Level I trauma center. PATIENTS We reviewed 473 patients undergoing ORIF of acetabular fractures through posterior, combined, or extensile surgical approaches from 2012 to 2017, with a median follow-up of 13 months (0.5-77 months). MAIN OUTCOME MEASUREMENT Rates of infection and wound complications were stratified according to their HO prophylaxis method into three groups as indomethacin, XRT, and no prophylaxis. RESULTS Overall, 167 patients (35.3%) received indomethacin, 104 patients (22.0%) received postoperative XRT, and 202 patients (42.7%) received no prophylactic treatment. There was no difference between the 3 groups for the risk of surgical site infection (P = 0.280). The XRT group had a significantly increased risk of noninfectious wound complications (20.2%) compared with the indomethacin group (6.6%, P = 0.002) and the no prophylaxis group (5.0%, P < 0.0001). Multivariate analysis revealed XRT remained a significant risk factor for noninfectious wound complications compared with no prophylaxis (odds ratio 5.39; 95% confidence interval 2.37-12.22; P < 0.0001). CONCLUSIONS Although there is no difference between XRT, indomethacin, and no HO prophylaxis for the risk of surgical site infection, the use of XRT results in more than 5 times increased risk of noninfectious wound complications compared with no prophylaxis. This increased risk should be considered when contemplating XRT for HO prophylaxis in acetabular fracture patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Thrombin Hemostatic Matrix Reduces Heterotopic Ossification in Acetabular Fractures Fixed Through the Kocher-Langenbeck Approach. J Orthop Trauma 2020; 34:451-454. [PMID: 32815830 DOI: 10.1097/bot.0000000000001783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether an injectable thrombin product [thrombin hemostatic matrix (THM)] at closure of a Kocher-Langenbeck approach reduces the risk of heterotopic ossification (HO) formation after an acetabular fracture. DESIGN Case control. SETTING Two Level 1 trauma centers. PATIENTS Patients with operatively treated acetabulum fractures fixed through Kocher-Langenbeck from 2013 to 2018. INTERVENTION Records were reviewed for demographics, history of traumatic brain injury, HO medication or radiation prophylaxis, THM (Surgiflo, Ethicon, Bridgewater New Jersey) administration, and length of follow-up. Radiographs were reviewed for dislocation, fracture, Letournel and Orthopaedic Trauma Association classifications, HO, and Brooker grade if applicable. Patients receiving HO prophylaxis (eg, nonsteroidal anti-inflammatory drugs and radiation) were excluded. Remaining patients were divided into 2 groups: THM administration (intervention) and no THM. Continuous variables were compared using t-tests and categorical variables with chi-square or Fisher's exact tests. MAIN OUTCOME MEASUREMENTS Risk ratios for the association between HO occurrence and THM administration. RESULTS Three-hundred and twenty-eight acetabular fractures met inclusion criteria (126 intervention, 202 control) in patients with a mean age of 38.7 ± 15.9 years; 62.2% were male, and 42.1% were African American. Traumatic brain injury and posterior dislocation rates were equivalent between groups (P = 0.505, 0.754, respectively). HO rate in the control group was 42.6% compared with 21.4% in the THM group (P < 0.001). Booker grade 3/4 in control group was 17.3% versus 3.2% in the THM group (P < 0.001). Patients receiving THM had a 50% reduced risk of HO (95% confidence interval 0.35-0.73) compared to those who did not; adjustment for age, gender, ethnicity, and traumatic brain injury did not meaningfully change the association (risk ratio 0.46; 95% confidence interval 0.29-0.73; P < 0.001). CONCLUSION The use of a surgiflo product at closure of a KO approach may reduce the risk of HO formation by 50% after an acetabular fracture. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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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.
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Dow T, King JP, Wong IHB. The Reduction of Heterotopic Ossification Incidence After Hip Arthroscopy in Patients Treated With Selective Cyclooxygenase 2 Inhibitor (Celecoxib). Arthroscopy 2020; 36:453-461. [PMID: 31734042 DOI: 10.1016/j.arthro.2019.08.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effectiveness of celecoxib, a selective cyclooxygenase 2 inhibitor, in reducing heterotopic ossification (HO) after hip arthroscopic surgery and to evaluate celecoxib's impact on clinical outcomes. METHODS We performed a retrospective review of patients who received hip arthroscopy performed by the same surgeon between January 1, 2012, and December 31, 2016. Patients who had an allergy to sulfa drugs, had pre-existing HO or previous surgery on the operative side, or failed to complete radiographic follow-up at 6 months postoperatively were excluded. Patients in the treatment group received 400 mg of celecoxib postoperatively for 6 weeks, whereas the control group received no postoperative celecoxib. The incidence of HO was assessed using anteroposterior radiographs obtained at 6 months, 1 year, and 2 years postoperatively. Patients completed the International Hip Outcome Tool 33 survey, and the proportion of patients who met the minimal clinically important difference, substantial clinical benefit (SCB), and absolute SCB was calculated. RESULTS A total of 559 patients were identified. After application of the exclusion criteria, 454 patients were included in the study (211 in control group and 243 in treatment group). The overall incidence of HO was 20.3% (n = 92). The treatment group had a significantly lower incidence of HO at 6 months (P = .006), 1 year (P < .001), and 2 years (P = .008) postoperatively. At 2 years postoperatively, the treatment group had a significantly higher International Hip Outcome Tool 33 score on average: 64.2 versus 57.3 (P = .023). No significant difference in the proportion of patients reaching the minimal clinically important difference, SCB, or absolute SCB was found at any of the postoperative time points. CONCLUSION The findings of this study suggest that a prophylactic treatment regimen of 400 mg of celecoxib once daily for 6 weeks significantly reduces the incidence of HO formation after hip arthroscopic surgery; however, it did not impact clinical outcomes. LEVEL OF EVIDENCE Level III, retrospective, comparative case-control study.
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Affiliation(s)
- Todd Dow
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John-Paul King
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ivan Ho-Bun Wong
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
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Soni A, Gupta R, Vashisht S, Kapoor A, Sen R. Combined Anterior Pelvic (CAP) approach for fracture acetabulum fixation - Functional outcome evaluation and predictors of outcome. J Clin Orthop Trauma 2020; 11:1136-1142. [PMID: 33192020 PMCID: PMC7656484 DOI: 10.1016/j.jcot.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Ilio-inguinal approach has been considered standard anterior approach for acetabulum fracture fixation. Different modifications of this approach have been described. This study analysed the patients treated using a Combined Anterior Pelvic (CAP) approach - minimal AIP (anterior intra-pelvic) with modified ilio-femoral along with 'anterior superior iliac spine' osteotomy. This combined approach provides wide exposure of pelvis to direct visualise the entire anterior column from sacroiliac joint to pubic symphysis, medial side of quadrilateral plate and entire iliac wing with minimal retraction of soft tissues required. METHODS Data of patients treated from July 2014 to June 2018 for acetabulum fracture using CAP approach was retrieved from hospital record system. Inclusion criteria were - acetabulum fractures treated surgically using CAP approach. Exclusion criteria were - age less than 18 years, associated pelvis ring injury and incomplete peri-operative radiological record (pre-operative/post-operative antero-posterior, 45° obturator and 45° iliac oblique radiographs and pre-operative computed tomographic (CT) scans. 62 patients who met inclusion exclusion criteria were called in out-patient-department for final functional evaluation using Matta modified Merle d'aubigne score. RESULTS Out of 62 patients 47 patients who turned up for final functional evaluation were included in study. 19 patients had excellent, 15 had good, 2 had fair and 11 had poor results. Age less than 40 years, anterior column fracture pattern, Pre-operative fracture displacement >20 mm, fracture comminution and post-operative fracture reduction within 3 mm were the predictors of the functional outcome. When analysed using logistic regression model, post-operative fracture reduction was found to be the only significant predictor of functional outcome. CONCLUSION CAP approach is useful anterior approach to acetabulum. Fracture reduction is the independent predictor of functional outcome. Comparison of this approach with other anterior approaches to acetabulum can be area of further research.
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Affiliation(s)
- Ashwani Soni
- Department of Orthopaedics, Government Medical College and Hospital Sector – 32, Chandigarh, 160030, India,Corresponding author.
| | - Ravi Gupta
- Department of Orthopaedics, Government Medical College and Hospital Sector – 32, Chandigarh, 160030, India
| | - Saurabh Vashisht
- Department of Orthopaedics, Government Medical College and Hospital Sector – 32, Chandigarh, 160030, India
| | - Anil Kapoor
- Department of Orthopaedics, Government Medical College and Hospital Sector – 32, Chandigarh, 160030, India
| | - Ramesh Sen
- Department of Orthopaedics Max Multi-speciality Hospital Mohali, 160062, India
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Lehmann W, Spering C, Jäckle K, Acharya MR. Solutions for failed osteosynthesis of the acetabulum. J Clin Orthop Trauma 2020; 11:1039-1044. [PMID: 33192007 PMCID: PMC7656531 DOI: 10.1016/j.jcot.2020.09.024] [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] [Received: 08/28/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 11/16/2022] Open
Abstract
Osteosynthesis of the acetabulum is complex and requires very careful planning and preoperative preparation. The goal is to achieve anatomical reduction without steps or gaps in the articular surface. If it has not been possible to achieve an optimal reconstruction, one has to consider whether it makes sense to carry out reosteosynthesis or revise the fixation. The risk of infection, heterotopic ossification, avascular necrosis of the femur and cartilage damage is much higher than with the primary procedure. Often, especially in older patients, it may make more sense to achieve fracture union and to implant a total hip prosthesis in due course. In younger patients, every attempt should be made to achieve optimum anatomical reduction and this may mean consideration of reosteosynthesis after careful planning and counselling of the patient. If reosteosynthesis is considered adequate imaging including a postoperative CT is essential as part of the planning. This article looks at the possible solutions for failed osteosynthesis of the acetabulum.
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Affiliation(s)
- Wolfgang Lehmann
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany,Corresponding author.
| | - Christopher Spering
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Katharina Jäckle
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Mehool R. Acharya
- Pelvic and Acetabular Reconstruction Unit. Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Bristol, BS10 5NB, UK
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Jodoin M, Rouleau DM, Therrien E, Chauny JM, Sandman E, Larson-Dupuis C, Leduc S, Gosselin N, De Beaumont L. Investigating the incidence and magnitude of heterotopic ossification with and without joints involvement in patients with a limb fracture and mild traumatic brain injury. Bone Rep 2019; 11:100222. [PMID: 31463337 PMCID: PMC6706636 DOI: 10.1016/j.bonr.2019.100222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/25/2019] [Accepted: 08/12/2019] [Indexed: 01/01/2023] Open
Abstract
Objectives This study seeks to evaluate the incidence rate of heterotopic ossification (HO) formation in patients afflicted by an isolated limb fracture (ILF) and a concomitant mild traumatic brain injury (mTBI). Methods The current study is an observational study including ILF patients with or without a concomitant mTBI recruited from an orthopedic clinic of a Level 1 Trauma Hospital. Patients were diagnosed with a mTBI according to the American Congress of Rehabilitation Medicine (ACRM) criteria. Radiographs taken on average 3 months post-trauma were analyzed separately by two distinct specialists for the presence of HO proximally to the fracture site (joints or extra joints). Both raters referred to Brooker's and Della's Valle's classification to establish signs of HO. First, analyses were conducted for the full sample. Secondly, a matched cohort was used in order to control for specific factors, namely age, sex, type of injury, and time elapsed between the accident and the analyzed radiograph. Results The full sample included a total of 183 patients with an ILF (94 females; 47.5 years old), of which 50 had a concomitant mTBI and 133 without. Radiographic evidence of HO was significantly higher in patients with an ILF and a mTBI compared to ILF patients (X2 = 6.50; p = 0.01). The matched cohort consisted of 94 participants (i.e.; 47 patients from the ILF + mTBI group and 47 patients from the ILF group). Again, ILF + mTBI patients presented significantly higher rates of HO signs in comparison to ILF patients (X2 = 3.69; p = 0.04). Presence of HO was associated with prolonged delays to return to work (RTW) only in ILF + mTBI patients (F = 4.055; p = 0.05) but not in ILF patients (F = 0.823; p = 0.37). Conclusions Study findings suggest that rates of HO are significantly higher proximally to fracture sites when ILF patients sustain a concomitant mTBI, even after controlling for factors known to influence HO. Moreover, results show that HO is associated with a prolonged RTW only in ILF patients with a concomitant mTBI but not in ILF-only patients. The impact of mTBI on HO formation warrants further attention to detect early signs of HO, to identify shared physiopathological mechanisms and, ultimately, to design targeted therapies. Rates of HO are significantly higher in patients with a fracture and a mTBI compared to patients with a fracture only. Factors such as sex, age, joint involvement, and surgical procedures were unrelated to the detection of signs of HO Presence of HO negatively impacted RTW delays in patients with a concomitant mTBI
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Affiliation(s)
- Marianne Jodoin
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Départment de Psychologie, Université de Montréal, Montréal, Québec, Canada
| | - Dominique M Rouleau
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Départment de Chirurgie, Université de Montréal, Montréal, Québec, Canada
| | - Erik Therrien
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Départment de Chirurgie, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Marc Chauny
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Emilie Sandman
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Départment de Chirurgie, Université de Montréal, Montréal, Québec, Canada
| | - Camille Larson-Dupuis
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Départment de Psychologie, Université de Montréal, Montréal, Québec, Canada
| | - Stephane Leduc
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Départment de Chirurgie, Université de Montréal, Montréal, Québec, Canada
| | - Nadia Gosselin
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Départment de Psychologie, Université de Montréal, Montréal, Québec, Canada
| | - Louis De Beaumont
- Centre de Recherche de l'Hôpital Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Départment de Chirurgie, Université de Montréal, Montréal, Québec, Canada
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Combat-related acetabular fractures: Outcomes of open versus closed injuries. Injury 2018; 49:290-295. [PMID: 29203201 DOI: 10.1016/j.injury.2017.11.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/07/2017] [Accepted: 11/25/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. METHODS We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. RESULTS The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DISCUSSION Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.
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