Wertigkeit einer kombinierten Ossifikationsprophylaxe mit Indometacin und Bestrahlung bei Azetabulumfrakturen

Angiogenesis in heterotopic ossification: From mechanisms to clinical significance

Heterotopic ossification (HO) refers to the formation of pathologic bone in nonskeletal tissues (including muscles, tendons or other soft tissues). HO typically occurs after a severe injury and can occur in any part of the body. HO lesions are highly vascularized. Angiogenesis, which is the formation of new blood vessels, plays an important role in the pathophysiology of HO. Surgical resection is considered an effective treatment for HO. However, it is difficult to completely remove new vessels, which can lead to the recurrence of HO and is often accompanied by significant problems such as intraoperative hemorrhage, demonstrating the important role of angiogenesis in HO. Here, we broadly summarize the current understanding of how angiogenesis contributes to HO; in particular, we focus on new insights into the cellular and signaling mechanisms underlying HO angiogenesis. We also review the development and current challenges associated with antiangiogenic therapy for HO.

Fulminant Heterotopic Ossification of the Lower Extremity After Gunshot Injury and Blunt Trauma: A Case Report

Traumatic heterotopic ossification (HO) of the lower extremity is relatively rare but is of major importance in clinical practice. They are defined as posttraumatic abnormal formations of bone within soft tissue outside of the skeletal system. This article describes the clinical case of a 31-year-old male patient who suffered 2 traumatic events within 12 months-a gunshot wound in the lumbar spine/gluteal region followed by a severe traumatic brain injury with intracranial hemorrhage in a traffic accident as a pedestrian. Clinically, the patient was bedridden because of complete stiffening of the lumbar spine, both hip joints, and the left knee joint. After preoperative diagnosis, 3 surgical ablations of the HO were performed on both the hip joints and the left knee joint. In addition, physiotherapeutic exercise, postoperative nonsteroidal anti-inflammatory drug administration (25 mg of indomethazine for 6 weeks, 3 times a day), and perioperative radiation with 7 Gy for each operation were advised. After 4 years of follow-up, the patient showed significant improvement. In HO treatment, prophylactic local radiotherapy (pre- and postoperative radiation with a local single dose of 7 Gy) and postoperative administration of nonsteroidal anti-inflammatory drugs are often recommended. For therapeutic purposes, surgical resection is still indicated for pronounced cases.

Heterotopic Ossification in Acetabular Fracture Surgery

Heterotopic ossification (HO) is a common complication of the surgical treatment of acetabular fractures. HO is the formation of trabecular bone in soft tissues where bone does not usually occur. Over the last decade, many risk factors have been identified for HO after surgical fixation of acetabular fractures; however, prophylaxis and treatment of this condition are controversial. Potential preventive measures range from NSAIDs to external beam irradiation, but recent studies have questioned the utility of these measures. The Brooker classification system, which has been correlated with patient function and outcomes, is most commonly used to describe HO severity. Advances will assist in the diagnosis, prevention, and management of HO as well as the assessment of risk factors that could affect outcomes.

Heterotopic Ossification and Entrapment of the Tibial Nerve Within the Tarsal Tunnel: A Case Report

Heterotopic ossification has been reported to occur after musculoskeletal trauma (including orthopedic procedures). This has been known to cause nerve entrapment syndromes and persistent pain, limiting joint mobility. We present a case of a 19-year old female collegiate athlete who had previously undergone ankle arthroscopy and arthrotomy to remove 2 ossicles. At approximately 1 year postoperatively, the patient developed pain when planting and pivoting her foot. Imaging revealed a radiodense lesion at the posteromedial ankle consistent with heterotopic ossification and entrapment of the tibial nerve within the tarsal tunnel. The patient underwent surgical resection and postoperative indomethacin prophylaxis. At the 1-year follow-up visit, the patient remained asymptomatic, without evidence of recurrence of the heterotopic ossification. In our review of the published data, we found no previously reported cases of heterotopic ossification causing entrapment of the tibial nerve within the tarsal tunnel. In the present case report, we describe this rare case and the postulated etiologies and pathophysiology of this disease process. In addition, we discuss the clinical signs and symptoms and recommended imaging modalities and treatment.

Severe heterotopic ossifications after Rockwood type II acromioclavicular joint injury: a case report

INTRODUCTION

Heterotopic ossification (HO) is a benign condition of abnormal bone formation in soft tissue. It is frequently asymptomatic, though it manifests as decreased range of motion in the affected joints that may occur in the shoulder after a substantial traumatic injury and can complicate the functional outcome of the affected upper extremity. However, severe HO is an extremely rare event following acromioclavicular joint (ACJ) injury.

MATERIALS AND METHODS

We are presenting a case of a 29-year-old male patient who had a trauma with resultant Rockwood type II injury. He subsequently complained of left shoulder pain with decreased range of motion 3 years later. HO was diagnosed after X-rays and the severity was assessed with a computerized tomography scan and magnetic resonance imaging. The patient was treated with a combination of pre-operative radiotherapy, surgical excision, mobilization under anesthesia, non-steroidal anti-inflammatory drug (NSAID) therapy and physiotherapy.

RESULTS

At 6-month follow-up, excellent clinical and radiological outcomes were achieved with a Constant score of 92 points, DASH score of 24%, and ASES score 100%, with a full range of motion of the left shoulder. Furthermore, there was no more radiological evidence of HO on plain radiographs.

CONCLUSION

Severe heterotopic ossification after a Rockwood type II ACJ injury in this case was successfully treated with combination of pre-operative radiotherapy, surgical excision and manipulation under anesthesia as well as NSAID therapy and physiotherapy.

Heterotopic ossification in the reaming tract of a percutaneous antegrade femoral nail: a case report

Introduction

Heterotopic ossification is a rare complication of musculoskeletal injuries, characterized by bone growth in soft tissues. Percutaneous antegrade intramedullary nailing represents the ‘gold standard’ for the treatment of femur shaft fractures. Minor bone growth is frequently seen around the proximal end of reamed femoral nails (so-called ‘callus caps’), which are asymptomatic and lack a therapeutic implication. The occurrence of excessive, symptomatic heterotopic ossification around the entry site of an antegrade femoral nail is rarely described in the literature.

Case presentation

We present the case of a 28-year-old Caucasian woman who developed extensive heterotopic ossification around the reaming seeds of a reamed femoral nail. She developed severe pain and significantly impaired range of motion of the hip joint, requiring revision surgery for heterotopic ossification resection and adjunctive local irradiation. She recovered full function of the hip and remained asymptomatic at her two-year follow-up appointment.

Conclusions

Severe heterotopic ossification represents a rare but potentially detrimental complication after percutaneous femoral nailing of femur shaft fractures. Diligent care during the reaming procedure, including placement of a trocar to protect from osteogenic seeding of the soft tissues, may help decrease the risk of developing heterotopic ossification after reamed antegrade femoral nailing.

[Bilateral acetabulum fracture after suffering sport trauma]

This case study describes a 37-year-old male who suffered a bilateral transverse acetabulum fracture with a fracture of the posterior wall and a double-sided dorsal hip dislocation in combination with a left-sided femoral head fracture (Pipkin IV) while skiing in a "fun park". The accurate diagnosis and presurgical planning was made by means of a computed tomography (CT) scan and a subsequent 3D reconstruction. After a primarily executed shielded repositioning of the bilateral hip dislocationearly secondary and anatomical reconstruction of the double-sided acetabulum fracture was possible using the Kocher-Langenbeck approach. A consistent physiotherapy as well as rehabilitation finally led to a positive clinical result for the patient.

Bilateral heterotopic ossification after bilateral hip arthroplasty in a geriatric patient

The case of a geriatric patient with total hip arthroplasty for coxarthrosis and an inpatient fall 12 days after the first operation is reported. Six weeks after the first operation, the patient reported new pain in the area of both hips and thighs. X-ray and scintigraphy confirmed the diagnosis of bilateral heterotopic ossification. NSAID therapy was started, and rapid improvement was observed. At discharge, the patient was able to walk with aids in- and outside. At the 12-month follow-up, x-ray control showed Brooker state 3 for the right and 4 for the left hip. Walking ability did not change during follow-up.

Modified Kocher-Langenbeck approach for the stabilization of posterior wall fractures of the acetabulum

This article describes a modification of Kocher-Langenbeck approach for the treatment of select posterior wall fractures of acetabulum. The technique aims at achieving osteosynthesis by creating two windows: between the gluteus medius and piriformis superiorly and between the external rotators and ischial tuberosity inferiorly. The approach spares the division of external rotators and of the abductors of the hip, thus preventing iatrogenic damage to the vascularity of the head of the femur and of the fracture fragments. The reconstruction plate can be slid under the piriformis and the short external rotators, thus preserving the soft tissue sleeve of the hip posteriorly. The gluteus minimus is not stripped from the ilium. The technique is ideally suited for isolated, displaced, noncomminuted posterior wall fractures of acetabulum of less than 10 days' duration without marginal impaction. The technique is biologic, takes a shorter operative time in our hands, and prevents further damage to vascularity of the head of the femur and heterotopic ossification.

Prophylaxis of heterotopic ossification - an updated review

Heterotopic ossification (HO) is defined as the process by which trabecular bone forms outside of the skeletal structure, occupying space in soft tissue where it does not normally exist. The current popular prophylactic treatment modalities include non-steroidal anti-inflammatory drugs (NSAIDs) and radiation therapy, although the literature remains inconclusive as to which is superior. Additionally, both treatments can lead to adverse effects to the patient. Recently there have been several studies attempting to identify new aspects of the etiology of heterotopic bone formation and introduce new prophylactic modalities with increased efficacy and fewer side effects. For this review, we selectively retrieved articles from Medline published from 1958–2008 on the prophylaxis of HO with the aim of assisting readers in quickly grasping the current status of research and clinical aspects of HO prophylaxis.

Is radiation superior to indomethacin to prevent heterotopic ossification in acetabular fractures?: a systematic review

Heterotopic ossification is a well-known complication after fixation of an acetabular fracture. Indomethacin and radiation therapy are used as prophylaxis to prevent heterotopic ossification. It is unclear, however, whether either is superior, although this may relate to lack of power in individual studies. To compare the effectiveness of indomethacin with the effectiveness of radiation therapy, we conducted a systematic review in which all published prospective studies were evaluated. We performed a literature search in PubMed, MEDLINE, EMBASE, and the Cochrane Controlled Trial Register. The retrieved studies were analyzed and categorized according to the quality and validity score of Jadad et al. We found five appropriate prospective studies, describing 384 patients. Although the quality of the available studies made a proper meta-analysis inappropriate, the incidence of heterotopic ossification was significantly lower in patients treated with radiation than in patients receiving indomethacin (five of 160 versus 20 of 224, respectively). Until further information is available, we believe the evidence supports radiation therapy as the preferred method for preventing heterotopic ossification after operative treatment of acetabular fractures.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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.