Heterotopic Ossification in Trauma




Better understanding of the biology of heterotopic ossification (HO) formation will lead to treatment and prevention modalities that can be directed specifically at the cellular level. Early identification of HO precursor cells and target genes may provide prognostic value that guides individualized prophylactic treatment. Better understanding of molecular signaling and proteomics variability will allow surgeons to individualize preemptive treatment to suppress inflammation and formation of HO. Careful surgical technique to avoid muscle damage is important. Damaged muscle should be debrided as a prophylactic measure. Hemostasis and avoidance of a postoperative hematoma may decrease the chance of formation of HO.




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    Surgical excision is an option for established, symptomatic HO.




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    Surgical excision is an option for established, symptomatic HO.






    • Twenty-five percent of US military personnel who sustain extremity amputations as a result of combat have bilateral amputations. Bilateral amputees (BLAs) were compared with a control group that also sustained blast injuries. The BLA group showed increases in the levels of systemic and local wound proinflammatory cytokines, including IL-6 (serum), tumor necrosis factor alpha (exudate), and IL-1 (exudate). The BLA group also had higher rates of wound dehiscence and HO.




    Evaluation of patients with heterotopic ossification


    Patients with HO typically complain of limited range of motion of the affected joint as well as pain and limited function. In the upper extremity this may cause restricted range of motion in the elbow leading to difficulties with activities of daily living, such as eating and grooming. In the hips HO may result in pain, gait disturbance, limp, and difficulty sitting or using the toilet. A careful history should be conducted to evaluate for past medical history, trauma, head injury, spinal cord injury, and any previous surgery. Examine the patient for range of motion, strength, and any neurovascular abnormalities. The imaging work-up starts with plain radiographs, which are easy to obtain and inexpensive. On the radiograph the extent of the HO can be seen. A computed tomography (CT) scan with three-dimensional reconstruction gives detailed visualization of HO. HO often crosses anatomic fascial planes and can be very close to important neurovascular structures. In patients after open reduction and internal fixation (ORIF) of acetabular fracture, HO is almost always in the location of the previous surgery. Because the Kocher-Langenbeck approach is the most commonly used, HO usually involves the hip abductors and short external rotators. Typically, the sciatic nerve cannot be definitively visualized by CT, but HO is often near the nerve and can occasionally encase the nerve. Other studies, such as bone scans and single-photon emission CT scans, can help with understanding the metabolic activity of the bone, but are not useful in terms of planning a surgical excision because these studies lack the detailed resolution of a CT scan.






    Pain may occur when the patient tries to sleep or lie on the affected hip. Pain may also occur from compression of neurovascular structures around the hip. Compression of the sciatic nerve at the level of the hip by HO can lead to neuropathic pain, numbness, or weakness in the leg.




    Most reports do not indicate a difference in development of HO by race, gender, or age. However, a recent report on patients undergoing excision of HO around the hip found a higher incidence of severe HO requiring resection in African American men.








    There are no reports of a surgical topical or injectable agent to prevent formation of HO. Careful surgical technique, excision of damaged muscle, and avoidance of postoperative hematoma are important. Rath and colleagues reported on the excision of necrotic gluteus minimus muscle at the conclusion of ORIF of acetabular fracture repair surgery. HO occurred in 12 of 29 patients, but Brooker grade II or IV HO occurred in only 3 patients.




    References



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    Feb 23, 2017 | Posted by in ORTHOPEDIC | Comments Off on Heterotopic Ossification in Trauma

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