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Louis EM, Nicolaou S. Bowel obstruction and perforation secondary to progressive heterotopic mesenteric ossificans. Radiol Case Rep 2022; 17:3651-3654. [PMID: 35936874 PMCID: PMC9352512 DOI: 10.1016/j.radcr.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 12/03/2022] Open
Abstract
Heterotopic mesenteric ossification (HMO) is a rare condition which usually affects male patients. Its defining feature is hyperdense ossification in the mesentery, usually following surgery or trauma. Due to potentially serious complications that can arise from HMO, it is essential to recognize it in its nascent stages. In this case study, a 65-year-old male was imaged by CT scan serially over several years for recurrent bowel obstruction as a result of worsening HMO, providing new insight into the natural progression of this condition. Mechanical injury of the bowel eventually caused perforation and abscess formation.
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Zhang X, Xia PT, Ma YC, Dai Y, Wang YL. Heterotopic ossification beneath the upper abdominal incision after radical gastrectomy: Two case reports. World J Clin Cases 2022; 10:5805-5809. [PMID: 35979096 PMCID: PMC9258368 DOI: 10.12998/wjcc.v10.i17.5805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/31/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Heterotopic ossification (HO) is a rare clinical phenomenon that refers to bone formation in nonossifying tissues.
CASE SUMMARY This report presents two cases of HO beneath the upper abdominal median incision after radical gastrectomy. The first patient had postoperative pain below the incision area. There were no signs of anastomotic leakage, and the wound healed. Computed tomography (CT) findings 2 wk postoperatively were negative for HO, but the 6-wk CT showed HO beneath the incision. The patient refused reoperation, and after conservative therapy, the pain was gradually relieved after 2 wk. In the second case, postoperative recovery was uneventful, and HO was only detected on routine follow-up CT after 4 mo. An anti-adhesion membrane was applied beneath the peritoneum in both patients. Our findings suggest that HO beneath the abdominal incision might form at approximately 1 mo postoperatively. It may cause intractable pain; however, reoperation is usually not required.
CONCLUSION In our cases, we suspect that HO may be related to the use of foreign materials beneath the peritoneum, which needs to be further investigated.
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Affiliation(s)
- Xiang Zhang
- Department of Colorectal Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Ping-Tian Xia
- Department of Colorectal Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yan-Chao Ma
- Department of Radiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yong Dai
- Department of Colorectal and Anal Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yan-Lei Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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Bohner M, Maazouz Y, Ginebra MP, Habibovic P, Schoenecker JG, Seeherman H, van den Beucken JJ, Witte F. Sustained local ionic homeostatic imbalance caused by calcification modulates inflammation to trigger heterotopic ossification. Acta Biomater 2022; 145:1-24. [PMID: 35398267 DOI: 10.1016/j.actbio.2022.03.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
Abstract
Heterotopic ossification (HO) is a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues. Despite being a frequent complication of orthopedic and trauma surgery, brain and spinal injury, the etiology of HO is poorly understood. The aim of this study is to evaluate the hypothesis that a sustained local ionic homeostatic imbalance (SLIHI) created by mineral formation during tissue calcification modulates inflammation to trigger HO. This evaluation also considers the role SLIHI could play for the design of cell-free, drug-free osteoinductive bone graft substitutes. The evaluation contains five main sections. The first section defines relevant concepts in the context of HO and provides a summary of proposed causes of HO. The second section starts with a detailed analysis of the occurrence and involvement of calcification in HO. It is followed by an explanation of the causes of calcification and its consequences. This allows to speculate on the potential chemical modulators of inflammation and triggers of HO. The end of this second section is devoted to in vitro mineralization tests used to predict the ectopic potential of materials. The third section reviews the biological cascade of events occurring during pathological and material-induced HO, and attempts to propose a quantitative timeline of HO formation. The fourth section looks at potential ways to control HO formation, either acting on SLIHI or on inflammation. Chemical, physical, and drug-based approaches are considered. Finally, the evaluation finishes with a critical assessment of the definition of osteoinduction. STATEMENT OF SIGNIFICANCE: The ability to regenerate bone in a spatially controlled and reproducible manner is an essential prerequisite for the treatment of large bone defects. As such, understanding the mechanism leading to heterotopic ossification (HO), a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues, would be very useful. Unfortunately, the mechanism(s) behind HO is(are) poorly understood. The present study reviews the literature on HO and based on it, proposes that HO can be caused by a combination of inflammation and calcification. This mechanism helps to better understand current strategies to prevent and treat HO. It also shows new opportunities to improve the treatment of bone defects in orthopedic and dental procedures.
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Martinbianco EM, Lilley CM, Grech J, Mirza KM, Chen X. Heterotopic Mesenteric Ossification With Trilineage Hematopoiesis. Cureus 2022; 14:e24620. [PMID: 35664416 PMCID: PMC9150764 DOI: 10.7759/cureus.24620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 11/05/2022] Open
Abstract
Heterotopic ossification (HO) histologically refers to extraskeletal bone formation in non-ossifying tissues, most commonly noted in the extremities, buttocks, abdominal wall, and hip joints. HO developing in the mesentery (heterotopic mesenteric ossification, HMO) is very rare, with fewer than 100 cases reported in the literature. It usually occurs in adult male patients with a history of repeated abdominal trauma. So far, only two cases of HMO have been reported with the development of hematopoietic bone marrow. Here, we report the third case of HMO with true trilineage hematopoiesis in a 66-year-old female with suspicious mesenteric-retained foreign material from prior surgical procedures, including hysterectomy for endometrial adenocarcinoma and multiple repairs for incisional hernia.
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Lee JHT, Balasooriya J, Ncube T. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac086. [PMID: 35444790 PMCID: PMC9015769 DOI: 10.1093/jscr/rjac086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/18/2022] [Indexed: 11/24/2022] Open
Abstract
Heterotopic ossification (HO) is a condition where aberrant bone grows in tissues. This case study presents a rare complication of trauma and laparotomies, where the rapid and extensive occurrence of HO has delayed abdominal incision closure resulting in multiple surgeries and prolonged recovery. A 44-year-old man was retrieved after a truck accident resulting in multi-organ injuries. He required damage control trauma laparotomy followed by several relooks and multiple orthopaedic procedures. Despite several attempts, approximation of the laparostomy wound was not possible due to abdominal rigidity. Computed tomography scans done 20 days after injury demonstrated advanced HO over the wound edge. Early development of HO may explain why the abdominal incision was difficult to close and highlights the importance of being aware of HO as an early complication after trauma and midline laparotomy.
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Affiliation(s)
- Jae H T Lee
- Correspondence address. The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory 2605, Australia. Tel: 61-2-5124-0000; Fax: 61-2-5124-5743; E-mail:
| | - Janaka Balasooriya
- Department of General Surgery, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Thembekile Ncube
- Department of General Surgery, The Canberra Hospital, Garran, Australian Capital Territory, Australia
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6
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Althaqafi RMM, Assiri SA, Aloufi RA, Althobaiti F, Althobaiti B, Al Adwani M. A case report and literature review of heterotopic mesenteric ossification. Int J Surg Case Rep 2021; 82:105905. [PMID: 33962265 PMCID: PMC8113807 DOI: 10.1016/j.ijscr.2021.105905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction and importance Heterotopic mesenteric ossification is a benign bony tissue growth in the mesentery that mostly follows repetitive or severe abdominal injuries leading to reactive bone formation in the mesentery. There are only 73 cases (51 publications) identified in the literature up to the beginning of 2020. Case presentation 45-year-old Saudi male underwent multiple laparotomies to manage complicated appendicitis which ended with a diverting ileostomy and a colostomy as a mucus fistula. After 9 months, the patient was admitted to the General Surgery department in Al-Hada Armed Forces Hospital for an open ileostomy and colostomy reversal surgery where several irregular bone-like tissues of hard consistency and sharp edges with some spindle-shaped structures resembling needles were found in the mesentery of the small intestine and histopathology revealed of trabecular bone fragments confirming the diagnosis. Clinical discussion The majority of cases occur mid to late adulthood with a predilection in the male gender, and usually present with bowel obstruction or an enterocutaneous fistula. Although it has no malignant potential, it may cause severe bowel obstruction that can lead to mortality, it's a rare occurrence and, therefore, is difficult to diagnose among many common abdominal disturbances. Conclusion Here we report a rare case of heterotopic mesenteric ossification, which should be considered as one of the delayed complications of abdominal surgery or trauma. The time range of expecting the presentation of heterotopic mesenteric ossification following major abdominal trauma or surgery should be extended and continuously considered during differential diagnosis. One of the delayed complications of abdominal surgery or trauma is Heterotopic mesenteric ossification. Since 1983 there are only 73 cases of Heterotopic mesenteric ossification published to date. Preoperative diagnosis of Heterotopic mesenteric ossification should be based mainly on the characteristic radiographic findings without relying on the levels of calcium or alkaline phosphatase. The only way to reach the definitive diagnosis is through excision and histopathological analysis. Heterotopic mesenteric ossification has no malignant potential, but it can cause severe bowel obstruction that can lead to mortality in already sick patients.
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Affiliation(s)
| | | | | | - Fawaz Althobaiti
- Department of General Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Budur Althobaiti
- Department of General Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Mohammad Al Adwani
- Department of General Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
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7
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Amalfitano M, Fyfe B, Thomas SV, Egan KP, Xu M, Smith AG, Kaplan FS, Shore EM, Pignolo RJ. A case report of mesenteric heterotopic ossification: Histopathologic and genetic findings. Bone 2018; 109:56-60. [PMID: 29320714 DOI: 10.1016/j.bone.2018.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/06/2018] [Indexed: 02/08/2023]
Abstract
Mesenteric heterotopic ossification (MHO) is very rare and occurs in mid- to late-adulthood, usually in the context of prior abdominal surgery. The mechanisms of MHO are unknown. Here we describe the case of a 72-year-old man with MHO. Standard histological staining revealed that MHO occurred through an endochondral process. By comparison to known mutations in genetic conditions of HO such as fibrodysplasia ossificans progressiva (FOP) and progressive osseous heteroplasia (POH), DNA sequencing analysis demonstrated the presence of a commonly occurring heterozygous synonymous polymorphism (c.690G>A; E230E) in the causative gene for FOP (ACVR1/ALK2). However, no frameshift, missense, or nonsense mutations in ACVR1, or in the causative gene for POH (GNAS), were found. Although genetic predisposition may play a role in MHO, our data suggest that mutations which occur in known hereditary conditions of HO are not the primary cause.
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Affiliation(s)
- Matthew Amalfitano
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Billie Fyfe
- Department of Pathology and Laboratory Medicine, Rutgers - Robert Wood Johnson Medical School, Department of Pathology and Laboratory Medicine, United States
| | - Sumi V Thomas
- Department of Pathology and Laboratory Medicine, Rutgers - Robert Wood Johnson Medical School, Department of Pathology and Laboratory Medicine, United States
| | - Kevin P Egan
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Meiqi Xu
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Center for Research in FOP and Related Disorders, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Andrew G Smith
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Center for Research in FOP and Related Disorders, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Eileen M Shore
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Center for Research in FOP and Related Disorders, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Department of Genetics, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
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Abstract
We present a case of a 26-year-old man with mesenteric heterotopic ossification following blunt abdominal trauma and multiple surgical operations. Computed tomography 10 months after the initial trauma demonstrated linear, branching opacities within the small bowel mesentery that had a cortical and trabecular structure indicative of mature bone. We found only 25 reports in the literature of small bowel mesentery heterotopic ossification. The significance of this non-neoplastic process is three-fold: (1) patients often present with bowel obstruction; (2) the process tends to worsen or reoccur after repeat laparotomy, and (3) rare forms of malignant neoplasms such as extraskeletal osteosarcoma may have a similar appearance.
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9
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Heterotopic mesenteric ossification after a ruptured abdominal aortic aneurism: case report with a review of literatures. Int Surg 2015; 99:479-84. [PMID: 25058788 DOI: 10.9738/intsurg-d-13-00074.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Heterotopic mesenteric ossification (HMO) is a rare disease that results in intra-abdominal ossification of unknown origin. An 88-year-old man developed an intestinal obstruction 2 weeks after undergoing an operation for a ruptured abdominal aortic aneurysm, resulting in intestinal obstructions those did not improved concervatively. During relaparotomy performed 30 days after the first operation, hard adhesions of the small intestine and mesentery were found; these adhesions were difficult to separate without damaging the serosa of the small intestine. We removed 240 cm of the small intestine and performed a jejuno-ileo anastomosis. Microscopically, trabecular bone tissue had increased irregularly in the fat tissue of the nodules with fibrosis, which were partially lined with osteoblasts. Accordingly, we histopathologically diagnosed the patient as having HMO. The patient was treated with NSAIDs and cimetidine to prevent the recurrence of HMO. No signs of recurrence have occurred as of one year after the second operation.
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10
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Gurzu S, Bara T, Bara T, Jung I. Metaplastic bone formation in the abdominal wall--an incidental finding in a patient with gastric cancer. Case report and hypothesis about its histogenesis. Am J Dermatopathol 2013; 35:844-6. [PMID: 24257191 DOI: 10.1097/dad.0b013e318285db5c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A 64-year-old man was hospitalized showing symptoms suggesting gastric cancer. The gastroscopy showed a 70 × 30-mm tumor. The intraoperatory findings indicated an inoperable gastric tumor located in the antrum and gastric body, which invaded the spleen and pancreas. The abdominal incision was closed without performing gastrectomy. Considering his general condition, after 1 month, he was transferred to our hospital. We decided to perform a total gastrectomy of necessity, spleno-pancreatectomy, and dissection of regional lymph nodes. The surgical incision was performed along to the previous one. At palpation, a well-defined nodule with hard consistency was observed in the surgical scar, which microscopically was composed by osteoblasts-lining mature lamellar bone intermingled with osteoid and cartilage in the intermediary layer and fibroblasts in the central area, without atypia. The final diagnosis was localized metaplastic bone formation. This is a rare condition which can be related to trauma or surgery and should be differentiated by foreign-body granuloma and osteosarcoma.
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Affiliation(s)
- Simona Gurzu
- Departments of *Pathology; †Surgery, University of Medicine and Pharmacy of Targu-Mures, Romania
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11
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Ectopic bone in the abdominal cavity: a surgical nightmare. J Gastrointest Surg 2013; 17:1708-11. [PMID: 23677432 DOI: 10.1007/s11605-013-2228-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 05/02/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Heterotopic mesenteric ossification (HMO) is a rare clinical entity with less than 40 reported cases in the literature. Frequently associated with prior abdominal surgery or trauma, the precise etiology and optimal approach to its management remain undefined. CASE REPORT The index patient is a 58-year-old male who originally presented with perforated diverticulitis. Following resection, the patient developed an enterocutaneous fistula. After a trial of conservative management, the patient underwent exploration and was found to have widespread intra-abdominal calcification. Sheets of calcific tissue were resected, and a diagnosis of HMO was confirmed via pathology. The patient had a postoperative course complicated by bleeding and redevelopment of enteric fistula. Following a prolonged hospital course requiring multiple operations, the fistula persists, and the patient remains on parenteral nutrition. DISCUSSION The etiology of HMO is unknown. Diagnosis requires a high degree of clinical suspicion, as radiologic findings are often misleading. A review of 18 cases demonstrates significant morbidity associated with operative intervention. Nonsteroidals, in particular indomethacin, have been shown to decrease heterotopic ossification, but their role in mesenteric disease is not clearly defined. CONCLUSION HMO is a rare but complicated pathologic process. A trial of conservative management with NSAIDs, bowel rest, and total parenteral nutrition is prudent, given the high rate of morbidity and mortality associated with operative intervention.
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Reynoso JF, Christensen D, Latifi R. Heterotopic mesenteric ossification as a cause of persistent enterocutaneous fistula: overview of the literature and addition of a new case*. Eur Surg 2011. [DOI: 10.1007/s10353-011-0020-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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13
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Shi X, Zhang W, Nabieu PF, Zhao W, Fu C. Early postoperative heterotopic omental ossification: report of a case. Surg Today 2010; 41:137-40. [PMID: 21191707 DOI: 10.1007/s00595-009-4213-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 12/17/2009] [Indexed: 11/26/2022]
Abstract
Heterotopic mesenteric ossification (HMO) is an uncommon disorder that may sometimes be misdiagnosed. It can cause bowel or intestinal perforation, which may also lead to serious complications or even death. Heterotopic bone formation in the omentum, which is called heterotopic omental ossification (HOO) and is one type of HMO, is considered to be an exceedingly rare event. To our knowledge, about 29 cases of HMO have been reported in previous studies, of which three were HOO. We herein describe a case of HOO occurring in a 39-year-old Chinese man with no medical history of abdominal surgery. He underwent a left hemicolectomy, which was performed for the treatment of descending colon adenocarcinoma. Two weeks later, he developed a small bowel obstruction associated with multiple foci of heterotopic bone formation within the omentum. He therefore underwent a second surgical procedure for adhesiolysis and a partial omentectomy. The postoperative course was uneventful. He is still alive and disease-free 16 months later.
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Affiliation(s)
- Xiaohui Shi
- Department of Colorectal Surgery, Changhai Hospital, Second Military Medical University, No 168 Changhai Road, Shanghai 200433, PR China
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Hayashi H, Takamura H, Nakamura K, Fujita H, Ninomiya I, Nishimura G, Fujimura T, Kayahara M, Ota T. A Case of Heterotopic Mesenteric Ossification after Multiple Pelvic Bone Fracture. ACTA ACUST UNITED AC 2009. [DOI: 10.5833/jjgs.42.1621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Axelrad TW, Steen B, Lowenberg DW, Creevy WR, Einhorn TA. Heterotopic ossification after the use of commercially available recombinant human bone morphogenetic proteins in four patients. ACTA ACUST UNITED AC 2008; 90:1617-22. [PMID: 19043134 DOI: 10.1302/0301-620x.90b12.20975] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results.
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Affiliation(s)
- T W Axelrad
- Boston University Medical Center, Boston, Massachusetts 02118, USA
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