异位骨化

通过复习异位骨化的相关文献，详细介绍了异位骨化的发病机制、分类、发生率、分型、发病因素、临床表现、诊断、预防及治疗方法。异位骨化是指在正常情况下没有骨组织的软组织内形成的新生骨，在组织学上，成熟的异位骨化与骨痂一致。其形成一般需三个条件：①成骨诱导物；②成骨的前体细胞；③允许成骨的组织环境。早期表现包括关节周围疼痛、发热、红肿，逐渐出现关节活动受限。三相核素骨扫描是早期检测异位骨化的最敏感指标，并可以判断病变的活动性和成熟度。非甾体类消炎药(NSAIDs)是目前公认的预防人工髋关节置换和髋臼骨折术后异位骨化形成的最有效的药物。手术切除是异位骨化形成后导致严重关节功能障碍患者的唯一治疗手段。     

髋臼骨折术后异位骨化研究进展

异位骨化是髋臼骨折经切开复位内固定术后常见的并发症,术后未经预防性治疗患者异位骨化的发病率为18%～90%,晚期可出现关节功能受损或丧失.异位骨化的发生主要与髋臼骨折手术的入路、手术时间及伴发损伤等因素有关,目前主要预防方法有药物治疗和放射疗法.该文就异位骨化发生病因及治疗研究进展作一综述.     

吲哚美辛预防髋臼骨折术后异位骨化的疗效分析

[目的]探讨吲哚美辛在预防髋臼骨折术后异位骨化中的作用。[方法]回顾性分析本院自2009年1月~2012年1月收治的120例采用Kocher-Langenbeck入路治疗的髋臼骨折病例,将上述患者随机分为两组,无药物组患者60例,术后无任何药物干预,吲哚美辛组患者60例,术后1d开始口服吲哚美辛,25 mg/次,3次/d,持续4周;术后门诊随访X线片并记录异位骨化发生情况,随访时间最短6个月,最长18个月。[结果]在所有的患者中,异位骨化发生率为49%,其中Brooker Ⅰ级16例,Ⅱ级18例,Ⅲ级15例,Ⅳ级10例,18例患者有症状,4例需要再次手术。吲哚美辛组与无药物组相比,轻度异位骨化发生率明显降低,但重度异位骨化的发生率无明显差异。[结论]髋臼骨折术后应用吲哚美辛并不能有效预防重度异位骨化的发生,应提高医生手术技巧,降低发生率。     

全髋关节置换术后异位骨化预防的研究进展

异位骨化(heterotopic ossification, HO)是指在正常骨组织以外的组织中出现骨形成。HO是全髋关节置换术常见的并发症。目前已知的危险因素包括髋部强直、男性、既往HO史。最常用分型是采用Brooker分型将其分为4个等级。最有效的预防措施是放疗或服用NSAIDs。放疗方案是术后一次性给予7 Gy的照射治疗。预防HO最常用的非甾体药物是消炎痛,布洛芬的疗效也得到了证实。选择性COX-2抑制剂预防HO效果显著,且副作用更小。症状性HO的治疗方法是手术切除HO或翻修性关节成形术。本文总结有关全髋关节置换术后异位骨化的影响因素及预防措施的研究进展。     

人工颈椎间盘置换术后异位骨化的临床研究进展

颈椎间盘置换手术目前已经成为治疗颈椎病的有效手段，但是近年来随着手术例数的增加，相关的并发症发生率也随之增加，其中发生率较高的就是异位骨化。异位骨化出现后会出现手术部位了出现活动度下降以及疼痛，文章就异位骨化的发生机制、影响因素，以及治疗方法进行综述。     

肘关节开放松解术后并发症的研究进展

目的对肘关节开放松解术后并发症的研究进展作一综述,为临床预防、处理并发症提供参考。方法广泛查阅近年来国内外有关肘关节开放松解术及术后并发症的研究报道,并进行总结分析。结果肘关节开放松解术后并发症包括尺神经症状和病变、肘关节不稳、异位骨化、血肿等。目前临床对于并发症的预防和处理已取得一定进展,但由于手术技术有限以及并发症发生机制尚未明确,在手术创伤的控制、术后异位骨化、关节不稳的防治及术后镇痛等方面仍面临挑战。结论肘关节开放松解术治疗肘关节僵硬安全、有效,但仍需研究其并发症发生的相关机制,以进一步提高手术疗效。     

手术治疗脊髓损伤后髋关节严重异位骨化

目的分析脊髓损伤后髋关节严重异位骨化手术治疗的疗效及预防对策。方法对23例脊髓损伤后髋关节严重异位骨化患者行手术治疗。结果所有病例经0.5～11.0年(平均5.6年)随访,髋关节功能主动或被动活动明显改善。结论手术凿除异位骨化结合早期即应常规服用NSAIDS或进行放疗,是治疗脊髓损伤后髋关节严重异位骨化的一种理想方法。     

预防创伤后肘关节异位骨化的研究进展

创伤后肘关节异位骨化在临床中相当常见,若肘关节出现严重的异位骨化,只有通过手术才能重新恢复关节的活动功能,且术后易复发,疗效较差。因此,创伤后肘关节异位骨化重在预防。创伤后肘关节异位骨化的预防方法多种多样,非甾体类药物及放射治疗在临床中应用较多,许多方法仍处于动物实验研究或假说阶段,目前尚缺乏高效安全的预防方法。本文主要通过对创伤后肘关节异位骨化预防方法的总结,明确目前相对有效的方法,为将来研究创伤后肘关节异位骨化的预防方法提供指导依据。     

放疗治疗肘关节异位骨化的疗效评价

[目的]评价放射治疗(radiation therapy,RT)对于肘关节异位骨化(heterotopic ossification,HO)的治疗效果.[方法]本科自2003年6月～2009年10月,对20例有异位骨化症状的患者在围手术期使用单剂量7 Gy的照射.其中15例患者接受异位骨化灶的手术切除,之后进行放疗以防止异位骨化复发;有5例患者因为存在高危因素而进行预防性的放疗.13例患者在术前4 h内放疗,7例患者则在术后接受放疗.采用X线片结合Mayo肘关节评分来评价疗效.[结果]本组患者随访6～72个月,平均随访时间为26.3个月.20例患者中有2例复发,随后予病灶再次切除.患者的Mayo评分最低为45分,最高为100分;其中13例患者功能恢复良好,Mayo评分100分.5例患者存在关节活动轻度受限,Mayo评分从75～95分不等;还有2例有持续的关节疼痛、活动明显受限,Mayo分为45、50分.本组未发现皮肤溃疡、尺神经炎等放疗副作用.[结论]围手术期应用单剂量7 Gy的放疗对于肘关节异位骨化防治是安全、有效的.     

复杂髋臼骨折的手术治疗

目的　寻求一种能够较好治疗复杂髋臼骨折的手术以期提高手术疗效。方法　对 37例复杂性髋臼骨折按不同类型分别用加压螺丝、加压空心钉及重建钢板等予以内固定治疗。结果　术后无一例伤口感染及深静脉栓塞发生。复位情况按Judet等人方法评估 ,达解剖复位者 2 9例 ,满意复位者 6例 ,不满意复位者 2例 ,所有病例均 8～ 15月 (平均 11个月 )的随访。髋关节按Harris评分系统进行评估 :优 19例、良 9例、可 5例、差 4例 ,其中发生异位骨化者 2 3例 ,坐骨神经损伤功能未恢复 1例。结论　手术是治疗复杂的髋臼骨折较为有效可靠的方法 ,手术切口的选择是复位成功的关键 ,术后物理加压及药物预防等综合处理为预防深静脉栓塞可靠的方法。异位骨化是影响术后疗效的主要因素 ,应引起重视     

Heterotopic ossification revisited

Heterotopic ossification is the abnormal formation of mature lamellar bone within extraskeletal soft tissues where bone does not exist. Heterotopic ossification has been classified into posttraumatic, nontraumatic or neurogenic, and myositis ossificans progressiva or fibrodysplasia ossificans progressive. The pathophysiology is unknown. Anatomically, heterotopic ossification occurs outside the joint capsule without disrupting it. The new bone can be contiguous with the skeleton but generally does not involve the periosteum. Three-phase technetium-99m (99mTc) methylene diphosphonate bone scan is the most sensitive imaging modality for early detection and assessing the maturity of heterotopic ossification. Nonsurgical treatment with indomethacin and radiation therapy is appropriate for prophylaxis or early treatment of heterotopic ossification. Although bisphosphonates are effective prophylaxis if initiated shortly after the trauma, mineralization of the bone matrix resumes after drug discontinuation. During the acute inflammatory stage, the patient should rest the involved joint in a functional position; once acute inflammatory signs subside, passive range of motion exercises and continued mobilization are indicated. Surgical indications for excision of heterotopic ossification include improvement of function, standing posture, sitting or ambulation, independent dressing, feeding and hygiene, and repeated pressure sores from underlying bone mass. The optimal timing of surgery has been suggested to be a delay of 12 to 18 months until radiographic evidence of heterotopic ossification maturation and maximal recovery after neurological injury. The ideal candidate for surgical treatment before 18 months should have no joint pain or swelling, a normal alkaline phosphatase level, and 3-phase bone scan indicating mature heterotopic ossification.     

Heterotopic Ossification After Minimally Invasive Rotator Cuff Repair

Heterotopic ossification is a common phenomenon after spinal cord injury, head injury, neurologic disorders, burns and other trauma, and joint arthroplasty. Periarticular ossifications after shoulder surgery have been known to occur since the 19th century, at an incidence of up to 27%. After arthroscopic and minimally invasive shoulder surgical procedures were introduced and came into broad use, reports about heterotopic ossification became very rare. We describe here a case of heterotopic bone formation in the subdeltoid fascia after arthroscopic subacromial decompression, acromioclavicular joint resection, and mini-open rotator cuff reconstruction were performed with 2 absorbable suture anchors 3 months postoperatively. Computed tomography (CT) confirmed a massive heterotopic ossification of the deltoid muscle. During revision surgery, a 4 × 6.5-cm bone shell that consisted primarily of immature trabecular bone and lamellar bone in smaller proportions was removed. The case presented here is unique in the scientific literature. Although risk factors have been identified, the underlying pathomorphogenetic mechanism of such heterotopic bone formation remains unclear. Prophylactic administration of nonsteroidal anti-inflammatory drugs (NSAIDs) or radiation for arthroscopic or minimally invasive shoulder surgery is not justified, given the low incidence of heterotopic ossification and the known adverse effects. Apparently, information on basic science and on evidence-based therapy is lacking.     

The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty

Heterotopic ossification following joint replacement in the lower limb occurs in 3% to 90% of cases. Higher grades of heterotopic ossification can result in significant limitation of function and can negate the benefits of joint replacement. The understanding of the pathophysiology of this condition has improved in recent years. It would appear to be related to a combination of systemic and local factors, including over-expression of bone morphogenetic protein-4. There is currently little evidence to support the routine use of prophylaxis for heterotopic ossification in arthroplasty patients, but prophylaxis is recommended by some for high-risk patients. Radiotherapy given as one dose of 7 Gy to 8 Gy, either pre-operatively (< four hours before) or post-operatively (within 72 hours of surgery), appears to be more effective than indometacin therapy (75 mg daily for six weeks). In cases of prophylaxis against recurrent heterotopic ossification following excision, recent work has suggested that a combination of radiotherapy and indometacin is effective. Advances in our understanding of this condition may permit the development of newer, safer treatment modalities.     

Multipotent progenitors resident in the skeletal muscle interstitium exhibit robust BMP-dependent osteogenic activity and mediate heterotopic ossification

Heterotopic ossification is a debilitating condition that can result from traumatic injury, surgery, or genetic disease. We investigated the cellular origins of heterotopic skeletogenesis in the mouse using lineage tracing and bioassays of heterotopic ossification based on intramuscular transplantation. We identified, characterized, and purified a tissue-resident stem/progenitor cell population that exhibits robust osteogenic potential and represents a major cell-of-origin for heterotopic ossification. These progenitors reside in the interstitium of skeletal muscle and other tissues, and are distinct from the endothelium, which does not exhibit osteogenic activity in response to bone morphogenetic protein 2 (BMP2) stimulation. Intramuscular transplantation, together with clonal analysis in culture, revealed that these progenitors are multipotent, exhibiting the capacity for both BMP-dependent skeletogenic differentiation and spontaneous adipogenic differentiation. Identifying the cells-of-origin responsible for heterotopic ossification provides a potential therapeutic target to treat, mitigate, or prevent this disabling condition.     

HETEROTOPIC BONE FORMATION IN ASSOCIATION WITH PELVIC FRACTURE AND URETHRAL DISRUPTION

PURPOSE: The initial and secondary management of pelvic fracture associated with disruption of the membranous urethra is the subject of a wide literature containing varied and controversial viewpoints. We have noted the presence of heterotopic bone formation surrounding the area of urethral injury in patients undergoing delayed repair. We investigated the etiology, incidence and risk factors associated with such an injury, as well as potential means of prophylaxis. MATERIALS AND METHODS: We reviewed the current literature on heterotopic bone formation with similar traumatic injury. While instances of severe urethral disruption of this type are fortunately rare in children we describe prepubertal boys with such an injury complicated by heterotopic ossification. RESULTS: The incidence of heterotopic ossification reported in children and adolescents is 3 to 15%, which is less than 15 to 80% reported in adults. Risk factors associated with traumatic heterotopic ossification include prolonged operating time, hematoma formation, degree of bony debris, devitalized muscle and concomitant infection. Prophylaxis with single low dose radiation or nonsteroidal anti-inflammatory drugs has been shown to be effective in the prevention of heterotopic ossification and may be beneficial in this patient population. CONCLUSIONS: Heterotopic bone formation associated with severe traumatic injury in the presence of devitalized tissue resulting in the pathological formation of new bone is rare. This complication is only associated with the most severe pelvic fractures. Prophylaxis in these most severe cases with low dose radiation or nonsteroidal anti-inflammatory drugs can prevent the formation of heterotopic bone.     

Elbow heterotopic ossification in head-trauma patients: diagnosis and treatment

Heterotopic ossification is a disorder characterized histologically and radiographically by normal bone formation in soft tissues that normally have no ossification properties. In severe head-trauma patients, a high incidence of heterotopic ossification occurs. The diagnosis of this pathology in these patients often is difficult for residual neurological damage. The etiology of heterotopic ossification following head trauma is unknown. Similarities have been found between heterotopic ossification and myositis ossificans, a hereditary autosomal dominant disease.     

Heterotopic ossification after total hip arthroplasty

We studied 178 patients undergoing total hip arthroplasty (66 men and 112 women) retrospectively, with regard to the incidence and severity of heterotopic ossification and the significance of postoperative prophylaxis with non-steroid anti-inflammatory drugs. The overall incidence of heterotopic ossification was 32% 1 year after surgery. The factors increasing the incidence were male gender, previous arthroplasty of the contralateral hip joint, previous surgery on the hip, absence of preoperative treatment with non-steroidal anti-inflammatory drugs and an operating time of more than 100 min. The incidence of heterotopic ossification was lower in the patients of O blood group.     

Heterotopic ossification following total hip arthroplasty: a review

Heterotopic ossification is the most frequent complication of total hip arthroplasty. When formed in the para-articular tissues, it may cause pain and restriction of hip motion. The present article extensively reviews the current literature on heterotopic ossification following total hip arthroplasty with regard to epidemiologic factors, clinical presentation and possible pathogenesis. Preventive measures are emphasized. Postoperative treatment with radiation and nonsteroidal antiinflammatory drugs have yielded good results in the prevention of heterotopic ossification. On the other hand, biophosphonates were ineffective. In comparison with radiation therapy, prophylaxis with nonsteroidal antiinflammatory drugs gave better results. Further research is still needed to define the most effective and safe medication regimen.     

Nonsteroid anti-inflammatory drugs prevent the recurrence of heterotopic ossification after excision

Summary The prophylactic effect of nonsteroid anti-inflammatory drugs on the recurrence of high-grade periarticular heterotopic ossification after resection was studied in ten patients operated on for loosening of one or both components of a cemented total hip prosthesis. These drugs, given at a standard dosage for 1–3 weeks after surgery, prevented the recurrence of heterotopic ossification. In some patients the range of motion of their joint increased following surgery, while it remained unaffected in the majority. At follow-up 2–5 years after surgery, all patients walked well and there were no clinical or radiographs signs of loosening of the prosthetic components. It is concluded that treatment with NSAIDs following resection of periarticular heterotopic ossification prevents recurrence.     

Neurosurgical management of symptomatic thoracic spinal ossification in a patient with fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder characterized by heterotopic ossification of soft connective and muscle tissues, often as the result of minor trauma. The sequelae include joint fusion, accumulation of calcified foci within soft tissues, thoracic insufficiency syndrome, and progressive immobility. The authors report on a patient with FOP who developed severe spinal canal stenosis in the thoracic spine causing substantial myelopathy. He underwent a thoracic laminectomy and resection of a large posterior osteophyte. Unique considerations are required in treating patients with FOP, including steroid administration to prevent ossification and anesthetic technique. The nuances of neurosurgical and medical management as they pertain to this disease are discussed.