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.     

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.     

彩色多普勒超声及X线平片对异位骨化诊断的比较

目的比较彩色多普勒超声(彩超)及X线平片检查对脊髓损伤后异位骨化的早期诊断价值。方法对39例临床可疑异位骨化的脊髓损伤患者,在发生下肢水肿48h内进行首次彩超检查,每周复查,直至出现明确钙化灶。39例患者均同时进行X平片检查。结果脊髓损伤后异位骨化彩超所见:正常肌肉板层状结构肿胀增厚或被紊乱不规则结构取代,回声增强34例;出现弧形或长条形强回声带后伴声影39例;肌层内出现无回声血肿8例。外压性血管狭窄,流速增高4例。动态变化表现为:下肢水肿48h内,受累肌层肌纤维肿胀,回声增强,或病变中央区出现局限、形态不规则的非特异性低回声区;下肢水肿1周出现岛状回声增强区;1～2周后,出现大片弧形或长条形强回声带后伴声影,表面光滑或凹凸不平。下肢水肿1周内,彩超对异位骨化的检出率比X平片明显提高(P<0.01)。结论彩色多普勒超声可在患者起病初期检出阳性表现,是早期诊断异位骨化的可靠方法。     

Noninflammatory knee joint effusions in spinal cord-injured and other paralyzed patients. Four case studies.

Four patients with knee effusions are described. Three had spinal cord injuries and the fourth had Guillain-Barrè syndrome. Of the spinal cord-injured patients, the effusions were unilateral in one case and bilateral in another. The third patient developed effusions on two separate occasions with bilateral involvement once and unilateral involvement once. The patient with Guillain-Barrè syndrome had bilateral knee joint effusions. All effusions were tapped and revealed type I synovial fluid except for one joint that contained some blood cells. Two of the three spinal cord-injured patients had heterotopic ossification at the knees documented by 99mTe bone scans and two were lying prone for the treatment of decubitus ulcers. Similar knee joint effusions have been described by several authors in the past. The etiology is unknown; however, we offer the hypothesis that paralysis of the muscles adjusting intra-articular knee joint structures may be the cause. It is important for clinicians to recognize that benign knee joint effusions are likely to be encountered in paralyzed patients. They can be evaluated with a simple synovial fluid analysis.     

Heterotopic ossification and HLA antigens

Thirty patients with neurogenic (nontraumatic) heterotopic ossification following spinal cord injury in 20 and head injury in 10, were comprehensively screened for HLA antigens. The frequencies of 68 HLA-A, -B and -C antigens were examined. The HLA-A2 locus was present in 18 patients (60%) as compared to the phenotypically adjusted normal of 48.4% and was not statistically significant at the 0.05 level. No statistically significant increased frequency of the HLS-B18 or HLA-B27 antigens was detected. A positive correlation does not exist between the HLA antigen system and patient susceptibility to heterotopic ossification following head injury or spinal cord injury.     

Neurogenic heterotopic ossification

Neurogenic heterotopic ossification is a potential sequela of neurological disorders, especially spinal cord injury and head injury. The etiology is unknown. Clinical, radiologic, and bone scan findings are typical. Complications may threaten function. The differential diagnosis is crucial in its early stages. Treatment options include diphosphonates, non-steroidal anti-inflammatory drugs, and surgery. This article has reviewed the literature on neurogenic heterotopic ossification (HO), soft tissue ossification of neurologic disease, including pathogenesis, histology, presentation, diagnosis, natural history, complications, and current treatments.     

Heterotopic bone formation about the hip and unilateral decubitus ulcers in spinal cord injury.

Of 131 patients having spinal cord injury who were admitted to the hospital for chronic symptoms over a two-year period, 62 (47 percent) developed heterotopic ossifications in hip muscles. Of these 62 cases, 51 were unilateral. In 83 (63 percent) of the 131 patients, decubitus ulcers developed and these were unilateral in 71 cases. A high correlation between ulceration and heterotopic ossification was observed (phi = 0.69, P less than 0.001). Because heterotopy in the absence of ulceration was infrequent (less than 1 percent of cases), it appears that ossification and reduced mobility of a limb predipose to the development of the decubitus ulcer.     

Heterotopic ossification in children with burns: two case reports.

Heterotopic ossification is the formation of ectopic bone in soft tissue, and has been reported as a rare complication in pediatric burn patients. At our hospital, two 86% body surface area burn patients developed heterotopic ossification in the shoulder, elbows, distal femur, proximal tibia, fibula, and ribs approximately four months after the burn injury. These two rare and unusual cases are presented documenting the clinical involvement, radiological studies, laboratory data, as well as treatment of their heterotopic ossification. Discussion will focus on the incidence, diagnosis, pathophysiology, and treatment of heterotopic ossification in burn patients and how this information relates to the specific diagnosis and management of the complication of heterotopic ossification in the burn child.     

Heterotopic ossification in Guillain-Barré syndrome]

INTRODUCTION: Heterotopic ossification are frequent in central nervous disease, on the opposite just a few cases have been described in peripheral disorders.PURPOSE: To describe three cases of Guillain-Barré syndrome complicated by heterotopic ossification.METHODS: From the detailed case reports and a review of the literature.RESULTS: The authors report three cases of heterotopic ossification in Guillain-Barré syndrome. Each of them had serious symptom and had to go in intensive care. Two of them had encephalopathy. A patient had compression of ulnar nerve as complication of heterotopic ossification. In all cases the consequence of the heterotopic ossifications lead to a great functional handicap. DISCUSSION: Heterotopic ossification is a frequent complication in central neurologic lesions such spinal cord injury or brain injury. Just a few cases following peripheral nerve disorders have been reported. Serious neurologic deficit and encephalopathy may influence the apparition of heterotopic ossifications in patients suffering from Guillain-Barre syndrome. This possibility of complication must be known by the clinicians who should have a special attention to such patients.     

颈椎后纵韧带骨化症病人的围手术期护理

颈椎后纵韧带骨化症(OPLL)是一种原因未明的病理现象,表现为颈椎后纵韧带内异位骨的形成,骨化发展到一定阶段会造成严重脊髓损害,并且短时间内会出现四肢瘫痪。我科自2008年9月~2010年9月采用一期前后联合手术减压融合内固定治疗严重颈椎后纵韧带骨化症30例,效果良好,通过对这些病人的护理,我们认为,术前加强心理护理,充分术前评估,严密观察术后病情变化,加强基础护理和专科护理,积极预防并发症,加之及时康复指导是颈椎后纵韧带骨化症病人顺利康复的重要保证。     

CRITICAL DRUG APPRAISAL: ETIDRONATE INTERMITTENT CYCLIC THERAPY FOR POSTMENOPAUSAL OSTEOPOROSIS

SUMMARY An overview of intermittent cyclical therapy with oral etidronate disodium in the treatment of postmenopausal osteoporosis is given. Etidronate has been used successfully in the treatment of Paget's disease and for the prevention and treatment of heterotopic ossification after hip replacement and spinal cord injury. It is approved for the treatment of postmenopausal osteoporosis in many European countries, Canada and Australia. Studies of such therapy indicate that etidronate significantly increases bone mass, reduces the risk of future vertebral fracture, and is safe and generally well tolerated.     

Heterotopic ossification in patients after total hip replacement

Heterotopic ossification (HO) is defined as pathological bone formation in soft tissues, for example in muscles, where physiologically there is no osseous tissue present. It is one of the most common complications of total hip joint replacement surgery. A wide variety of risk factors for heterotopic ossification have been identified to date. Almost 90% of total hip arthroplasty patients are at high risk for HO. There are two primary methods of preventing heterotopic ossification: pharmacotherapy with NSAIDs (non steroid anti-inflammatory drugs) and radiotherapy. Symptomatic heterotopic ossifications are treated by extracorporeal shock wave therapy (ESWT) and surgery, followed by NSAID pharmacotherapy or radiotherapy. The arterioles adjacent to areas of heterotopic ossification are usually embolized prior to the operation. This article describes the state of the art in the prevention and treatment of heterotopic ossifications based on the available literature.     

Orthopedic strategies in the management of the adult head-injured patient

The purpose of this paper is to outline a systematic approach to the care of adult patients with traumatic head injury. The orthopedic management of these individuals is divided in three phases. In the acute period after the initial trauma, musculoskeletal injuries should be diagnosed and treated. Delayed diagnoses of fractures and peripheral nerve injuries are common. Fracture care often differs from the care given to patients without head injuries because open reduction and internal fixation are more frequently indicated. The results of fracture treatment are compromised by spasticity and heterotopic ossification. The second phase is the subacute period during which neurologic recovery is occurring. This period may last up to 18 months. While neurologic recovery is proceeding, heterotopic ossification and spasticity with its resulting deformities are treated. Drugs, casting, and phenol blocks of peripheral nerves and motor points are used in the control of spasticity. Drugs and aggressive range-of-motion exercises aid in maintenance of joint motion when heterotopic ossification is present. When neurologic recovery has stabilized, the third phase begins. At this time, residual limb deformities may be surgically corrected and heterotopic bone may be excised.     

Correlates of Valvular Ossification in Patients with Aortic Valve Stenosis

Valvular calcification may include a regulated process of active ossification; however, the determinants of ossification are unclear. The aim of this study was to identify subject and disease characteristics associated with valvular ossification among patients with calcified aortic valves. Medical records were reviewed for variables associated with aortic stenosis and skeletal bone in a series of 195 patients requiring aortic valve excision. Thirty patients had valvular bone on histopathology. Univariate analyses suggested that warfarin therapy (p= 0.004), African American race (p= 0.006), height (p= 0.03), and male sex (p= 0.07) were associated with greater odds of valvular ossification while diabetes was associated with lower odds (p= 0.07). Multivariate analysis demonstrated that warfarin use (OR 5.7; 95% CI: 1.5–21.3; p= 0.009) and African American race (OR 8.3; 95% CI: 1.8–39.0; p= 0.007) were strongly and independently associated with increased odds of valvular ossification. Valvular ossification was not associated with greater ossification of costochondral cartilage on chest radiography. Warfarin therapy and African American race were associated with increased risk of valvular ossification in patients with aortic stenosis. Future studies are needed to confirm this finding and determine if inhibition of matrix GLA protein by warfarin mediates this effect.     

Heterotopic ossification

Heterotopic ossification is becoming increasingly recognized as a phenomenon that can complicate trauma to the head and spinal cord. It can be a disabling accompaniment of thermal injury, and it may seriously compromise results in hip arthroplasty and the treatment of acetabular fractures. Etiologic factors, which are imprecise and incompletely understood, vary with the clinical situation. The five cases reported here illustrate the radiologic appearances, complications, and diagnostic problems, including the difficulty in determining the timing of surgical resection. Reported for the first time are cases of neurogenic heterotopic ossification associated with bilateral shoulder involvement and bilateral ulnar nerve entrapment at the elbow. Heterotopic ossification may mimic acute arthritis.     

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.     

Medical complications of spinal cord injury

Recent medical advances have greatly improved the prognosis for people who sustain spinal cord injury (about 10 000 people initially survive spinal cord injury each year in the US). Physicians may become involved with the acute care of spinal cord injured persons or care for complications which develop later. Certain conditions such as heterotopic bone formation and autonomic dysreflexia are seen almost exclusively in this group of patients; other complications such as urinary tract and soft tissue infections occur quite often. Common medical complications of spinal cord injured persons are reviewed, as well as their diagnosis and treatment.     

Collagen metabolite excretion as a predictor of bone- and skin-related complications in spinal cord injury

Immediately after the trauma, spinal cord injury patients have an increased rate of collagen synthesis and an even greater increase of collagen degradation. Collagen lost from bone is implicated in the etiology of osteoporosis and heterotopic ossification, and collagen lost from skin might lead to a propensity to develop pressure ulcers. The urinary excretion of two collagen metabolites has been monitored and their fluctuation related to the onset of skin or bone complications in these patients. One metabolite, glucosyl-galactosyl hydroxylysine, is more abundant in skin collagen; the other, galactosyl hydroxylysine, is more abundant in bone collagen. The excretion of both metabolites increases after injury, reaching a peak between three and six months after injury, and declines gradually, reaching control values about a year after injury. If a skin pressure ulcer develops, the urinary excretion of the diglycoside remains elevated instead of gradually decreasing. Similarly, if osteoporosis or heterotopic ossification is diagnosed, the monoglycoside excretion does not return to control values until the bone turnover stabilizes. Monitoring of the urinary excretion of both glycosides might prove helpful in prompting early examination to establish the presence of emerging skin and bone complications. Thus, aggressive preventive therapy could be given sooner.     

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。     

Brain injury severity and autonomic dysregulation accurately predict heterotopic ossification in patients with traumatic brain injury

OBJECTIVE: To assess brain injury severity, autonomic dysregulation and systemic infection as risk factors for the occurrence of heterotopic ossification in patients with severe traumatic brain injury. DESIGN: Historic cohort study. SETTING: Radboud University Medical Centre. SUBJECTS: All consecutively admitted patients with severe traumatic brain injury (admission Glasgow Coma Scale score 8 or less) during the years 2002-2003. MAIN MEASURES: The development of clinically relevant heterotopic ossification, defined as painful swelling of joints with redness and decreased range of motion, confirmed radiographically. RESULTS: Seventy-six (64%) of the 119 patients survived and were eligible for further follow-up. Nine patients (12%) developed 20 symptomatic heterotopic ossifications, in one or more joints. Patients with heterotopic ossification had sustained more severe brain injuries, compared to the group without heterotopic ossification. The mean coma duration in the heterotopic ossification group was 28.11 days (SD 20.20) versus 7.54 days (SD 7.47) in the patients without heterotopic ossification (P < 0.001). The occurrence of autonomic dysregulation (relative risk (RR) 59.55, 95% confidence interval (CI) 8.39-422.36), diffuse axonal injury (RR 20.68, 95% CI 4.92-86.91), spasticity (RR 16.96, 95% CI 3.96-72.57) and systemic infection (RR 13.12, 95% CI 3.01-57.17) were all associated with an increased risk of developing symptomatic heterotopic ossification. However, only autonomic dysregulation had a high positive (88.9%, 95% CI 51.7-99.7) and negative (98.5%, 95% CI 91.9-99.9) predictive value with regard to heterotopic ossification. CONCLUSIONS: The occurrence of autonomic dysregulation may predict the chance of developing heterotopic ossification in patients with severe head injury.