Nonarticular complication of heterotopic ossification: a clinical review

Heterotopic ossification (HO) is a complication in neurologic lesions such as head injury and spinal cord injury. Limitation of range of motion and ankylosis as results of HO are well documented. In this report, ten instances of nonarticular complications after development of HO are described. There were three instances of vascular compression, five instances of ulnar nerve compression at the elbow, and two instances of suspected lymphedema. Clinical findings and radiographic evidence of these complications are described. Clinicians should be aware of these complications when HO is diagnosed. In addition, HO should be considered in the differential diagnosis of deep venous thrombosis in spinal cord injured and head injured patients.     

创伤后肘关节僵硬合并异位骨化手术疗效评价

目的评价手术治疗对创伤后肘关节僵硬合并异位骨化患者的治疗效果。方法 2008年7月至2010年12月,16例创伤后肘关节僵硬合并异位骨化患者进行手术治疗。其中,男12例,女4例,平均年龄38.1岁(14⁵9岁),手术松解距受伤时间8.9个月(659岁),手术松解距受伤时间8.9个月(6¹9个月)。所有病例行肘关节松解、异位骨化切除术,术后由同一组康复师训练,应用吲哚美辛预防异位骨化复发。测量患者术前、术后的肘关节屈伸、前臂旋转角度,并进行Mayo评分。术后由经过培训的专业医生进行标准化随访,评估疗效。结果肘关节屈伸活动度平均由术前32°±17.4°提高到108°±16.7°(t=13.295,P=0.000),旋转活动度由术前45°±8.8°提高到80°±11.0°(t=16.051,P=0.000),Mayo评分由术前平均(52.0±11.2)分提高到(82.0±8.1)分(t=8.722,P=0.001),术前、术后评分有统计学差异。有1例出现异位骨化的复发,2例采用外固定架后出现外固定尺骨针孔处骨折。结论异位骨化切除和肘关节松解术对治疗合并异位骨化创伤后肘关节僵硬的疗效满意。     

Hemiplegia and heterotopic ossification on the non-paretic extremity: a case report.

Heterotopic ossification is the formation of new bone in an abnormal location. It is usually seen following central nervous system disorders, including spinal cord injury, traumatic brain injury, encephalitis, and burn and trauma. Heterotopic ossification in post-stroke hemiplegia is rare; the reported incidence is 0.5-1.2%. It usually occurs on the paretic side of hemiplegic patients. We present here a case of post-stroke hemiplegia with heterotopic ossification in the non-paretic limb.     

获得性异位骨化动物模型的系统综述

目的 系统综述获得性异位骨化(AHO)相关动物模型,为研究疾病防治方案提供可靠造模方法。方法 检索PubMed、Web of Science、中国知网、万方数据库自建库至2021年11月AHO动物模型相关文献,筛选并提取文献关键内容,采用文献归纳法对各型AHO动物模型进行分析与评价。结果 最终共纳入20篇动物实验研究相关文献,可归纳为创伤后和神经源性两大类异位骨化动物模型,用于模拟AHO的发生发展过程。创伤后异位骨化动物模型主要有肌肉损伤、跟腱切断、肌肉损伤联合关节制动、髋关节损伤、异位植入、爆炸伤和烧伤7种。神经源性异位骨化动物模型主要包括脊髓损伤和脑外伤。目前实验室中常用跟腱切断法和成骨因子植入法造模,此类方法可靠、易行、成功率高,但无法准确解释临床中复杂条件下异位骨化的发病机制。基于爆炸伤、烧伤、神经损伤等条件下造模方法正在完善,为临床研究某些特殊病因所致异位骨化的分子生物学机制及防治方案提供了支持。结论 目前存在的几种造模方法各有利弊,但均无法完整复制人类异位骨化的全部特征,因此,临床上在判定模型的选择方面尚无统一标准。针对疾病的不同病因,选用合适的动物模型,对不同类型AHO在早期制定有效干预措施至关重要。     

Postoperative heterotopic ossification in the child with cerebral palsy: three case reports.

Three children with cerebral palsy and mental retardation showed irritability after surgical procedures. They were subsequently diagnosed as having heterotopic ossification. Heterotopic ossification developed around the hip in all cases--two after bilateral adductor releases at the operative site and the third after spinal fusion at a site unrelated to the surgery.     

Post-traumatic heterotopic ossification of the crus. A case study

The formation of mature lamellar bone at an ectopic site in the body is called heterotopic ossification. We report the case of a 28 year-old patient with heterotopic ossification (HO) in the left crus. He complained of difficulties with walking and limited ROM of the ankle joint. At surgery, an incision was made through the center of the HO focus, which was palpable. No change in ROM of the ankle joint was observed following HO removal. The decision was made to lengthen the Achilles tendon. After the lengthening of the Achilles tendon, the ROM of the ankle joint was increased. Lengthening of the Achilles tendon following the removal of posttraumatic HO in the crus is a safe and effective procedure; if the ROM of the ankle joint is restricted.     

Extracorporeal shock wave therapy as a treatment for heterotopic ossification

Abstract

Background: Extracorporeal shock wave therapy (ESWT) is an intervention treatment in musculoskeletal conditions. Heterotopic ossification (HO) is a painful osseous condition of various origins, with the potential to cause significant incapacity.

Objectives: To summarize the published data and assess the effectiveness of ESWT as a therapeutic intervention for patients with HO.

Methods: A systematic search of the literature using Medline via Ovid, Scopus, CINAHL, and Web of Science databases. Reference lists of all articles found were also hand-searched. Articles were assessed using the Oxford Centre for Evidence Based Medicine (OCEBM) hierarchy of evidence and were critically appraised using the McMaster Critical Review Form for Quantitative Studies.

A meta-analysis of data from four independent case studies totaling 52 HO patients treated with ESWT was performed. Outcome was assessed by pain and range of motion (ROM) of hip and knee flexion, since this was the only recorded movement data in the studies. Data were analyzed with a fixed effects model.

Results: Only four articles met the inclusion criteria. Hierarchical evidence scores were low, but the articles scored well on the critical appraisal tool. ESWT led to an improvement in knee flexion by approximately 82% [95% confidence interval (CI): 66·58–96·87; P<0·001] and hip flexion of ～10% (95% CI: 1·36–20·44; P?=?0·086). Approximately 25% of relative improvement in ROM can be attributed to alleviation of pain after ESWT (r²?=?0·25; P?=?0·496).

Conclusion: ESWT may be associated with clinically significant improvement of ROM of lower extremities in patients with HO although larger studies are needed to confirm these findings.     

Deep venous thrombosis associated with heterotopic ossification.

The differential diagnosis of the swollen lower extremity in the patient with spinal cord injury includes deep venous thrombosis, fracture, cellulitis, joint sepsis, heterotopic ossification, hematoma formation, and neoplasm. A patient with an asymmetrically swollen limb who was found to have concurrent ipsilateral acute deep venous thrombosis and active heterotopic ossification is described. The diagnostic workup included various laboratory and radiologic studies. Therapy included anticoagulation with heparin and warfarin. To treat the heterotopic ossification, indomethacin, etidronate, and graded range of motion were used. We learned from this patient and several similar cases that acute deep-venous thrombosis and active heterotopic ossification may occur concurrently, and therapeutic anticoagulation did not lead to bleeding within or around the area of active heterotopic ossification. The possibility of a relationship between heterotopic ossification and deep venous thrombosis is presently being studied at our institution.     

Continuous passive motion in the management of heterotopic ossification in a brain injured patient

We report a man admitted to inpatient rehabilitation 6 wk after traumatic brain injury, who presented with bilateral knee heterotopic ossification. In addition to conventional physical therapy, we applied a continuous passive motion device during 4 wk increasing the range of motion of the knees. On the basis of the limited current literature and this case, we suggest that the use of continuous passive motion devices for heterotopic ossification may be effective and safe and should be the subject of further study.     

Warfarin in prevention of heterotopic ossification.

Patients with spinal cord injuries among others, commonly develop neurogenic heterotopic ossification. Current treatment with Didronel (disodium etidronate) inhibits bone matrix mineralization but not matrix production. To eliminate much morbidity and cost, a more efficatious prophylactic treatment is desirable. Because one of the proteins in bone, osteocalcin, is produced by a vitamin K-dependent carboxylation, this raises the possibility that treatment with warfarin may prevent the formation of ectopic bone. In the present study, 227 cases of spinal cord injury were reviewed. Among these patients, 15% were treated with warfarin and another 15% developed heterotopic ossification. None of the patients who were treated with warfarin developed heterotopic ossification, thus suggesting that warfarin may inhibit heterotopic ossification. Further prospective studies are planned.     

Heterotopic ossification: a review.

Heterotopic ossification is defined as the presence of lamellar bone at locations where bone normally does not exist. The condition must be distinguished from metastatic calcifications, which mainly occur in hypercalcaemia, and dystrophic calcifications in tumours. It is a frequent complication following central nervous system disorders (brain injuries, tumours, encephalitis, spinal cord lesions), multiple injuries, hip surgery and burns. In addition to this acquired form, hereditary causes also exist, such as fibrodysplasia ossificans progressiva, progressive osseous heteroplasia and Albright's hereditary osteodystrophy. Although these conditions are extremely rare, they can provide useful information on the physiopathology of heterotopic ossification, and thus lead to novel and causal treatment modalities. Heterotopic ossification is no trivial complication. A limitation of the range of joint motion may have serious consequences for the daily functioning of people who are already severely incapacitated because of their original lesion. Increased contractures and spasticity, pressure ulcers and increasing pain further compromise the patient's capabilities. Consequently, we feel that attention should be paid to the pathogenesis and particularly the prevention and treatment of this disorder.     

Post-traumatic heterotopic ossification in front of the ankle joint for 23 years: A case report and review of literature

BACKGROUNDHeterotopic ossification (HO) refers to the formation of new bone in non-skeletal tissues such as muscles, tendons or other soft tissues. Severe muscle and soft tissue injury often lead to the formation of HO. However, anterior HO of the ankle is rarely reported.CASE SUMMARYWe report a patient with massive HO in front of the ankle joint for 23 years. In 1998, the patient was injured by a falling object on the right lower extremity, which gradually formed a massive heterotopic bone change in the right calf and dorsum of the foot. The patient did not develop gradual ankle function limitations until nearly 36 mo ago, and underwent resection of HO. Even after 23 years and resection of HO, the ankle joint was still able to move.CONCLUSIONIt is recommended that the orthopedist should be aware of HO and distinguish it from bone tumor.     

Early detection of heterotopic ossification in young patients with traumatic brain injury.

Heterotopic ossification (HO) is frequently a complication in patients with severe head injury, impeding the rehabilitation process. Detection of HO is often delayed until the appearance of clinical manifestations. To better characterize the frequency and distribution of HO, a three-year prospective study at a pediatric brain injury rehabilitation unit was done. Triple-phase bone scans were performed routinely on all patients. Early intervention followed, with intensive physical therapy and indomethacin. We report an incidence of HO in 25 of 111 cases (22.5%). Of 55 sites identified, the hip was most commonly affected. Clinically significant heterotopic bone impeded the rehabilitation process in five patients (20%), although none of these patients required surgical intervention. Bone scanning identified HO in patients whose symptoms were clinically silent, as well as in those who were symptomatic. In addition, multiple sites of involvement were found in areas not clinically suspect. This study suggests that HO may be more prevalent in young, traumatically brain injured patients than previously suspected.     

环氧化酶2、骨形态形成蛋白2和血管内皮生长因子在异位骨化组织中的表达

背景：研究发现环氧化酶2抑制剂具有预防肘关节周围异位骨化的作用。目的：观察环氧化酶2、骨形态形成蛋白2和血管内皮生长因子在肘关节创伤后异位骨化组织中的表达,并分析其相关性。方法：采用免疫组化SP法检测18例肘关节创伤后异位骨化组织及10例正常骨组织中环氧化酶2、骨形态形成蛋白2和血管内皮生长因子的表达水平,利用HPIAS-1000图像分析系统测定异位骨化组织与正常骨组织中环氧化酶2、骨形态形成蛋白2和血管内皮生长因子的平均吸光度和阳性区域面积百分率,并分析3种蛋白阳性区域面积百分率之间的相关性。结果与结论：异位骨化组织中环氧化酶2、骨形态形成蛋白2和血管内皮生长因子呈高表达;正常骨组织中呈低表达或不表达。图像分析结果显示异位骨化组织中3种蛋白平均吸光度及阳性区域面积百分率显著高于正常骨组织（P〈0.01）。异位骨化组织中环氧化酶2与骨形态形成蛋白2、血管内皮生长因子的阳性区域面积百分率呈正相关（P〈0.01）。提示环氧化酶2、骨形态形成蛋白2和血管内皮生长因子在异位骨化的形成过程中起重要作用,环氧化酶2可能通过诱导骨形态形成蛋白2和血管内皮生长因子的表达从而促进异位骨化组织中的成骨和血管形成。     

Radiotherapy in the prevention of heterotopic ossification after arthroplasty

Heterotopic ossification (HO) is defined as the formation of mature lamellar bone in nonosseous tissues. HO is a common problem following total hip replacement (THR) and surgical repair of traumatic acetabular fracture (TAF). Without receiving any kind of prophylaxis the incidence of HO in patients with THR is about 30-80%. The etiology of this disorder is not well understood. The treatment of symptomatic HO is excision of heterotopic bone. Radiation therapy is a safe and effective metod for prevention of HO. The present article extensively reviews the clinical studies to define the role of radiotherapy for prevention of HO.     

Ulnar nerve compression by heterotopic ossification in a head-injured patient

Although heterotopic ossification (HO) at the elbow is a frequent occurrence following head injury, nerve compression by heterotopic bone is quite rare. We report the case of a 22-year-old woman with head injury and well-documented HO at the left elbow who developed signs and symptoms of an ulnar neuropathy four months after her original injury. Electrodiagnostic studies confirmed the presence of a severe ulnar nerve lesion at the level of the elbow. Anterior transposition of the left ulnar nerve showed the nerve to have been compressed by heterotopic bone.