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An 8-year-old boy presented with Staphylococcus aureus osteomyelitis affecting the left (non-dominant) scaphoid. Surgical drainage resulted in the expulsion of the primary ossification centre as a sequestrum. Seven years later the wrist function was minimally impaired and X-rays showed complete ossification of the cartilage remnant with a relatively normal scaphoid.
PURPOSE: Prophylactic radiotherapy (RT) can prevent ectopic bone formation about the hip after total hip arthroplasty. The German Cooperative Group on Radiotherapy for Benign Diseases conducted a patterns of care study about this indication addressing the involved institutions, RT dose concepts, clinical handling, and treatment outcome of prophylactic RT about the hip joint. METHODS AND MATERIALS: In 1999, a patterns of care study was conducted in all German institutions to analyze the accrual pattern, number of patients, and different indications for the use and performance of prophylactic RT about the hip. The applied RT concepts of prophylactic RT were evaluated with regard to the RT technique, timing of RT (pre- or postoperative), RT dose prescription (median, range of single and total doses), and treatment outcome. All institutions were asked about the radiologic and functional failure rates at least 1 year after the completion of RT using the established radiologic (Brooker) and functional (Harris) scores with objective and subjective evaluation components. RESULTS: One hundred fourteen institutions reported their clinical experience with prophylactic RT for the prevention of heterotopic ossification about the hip joint: 70 community hospitals, 23 university hospitals, and 21 private RT practices. In 1999, 5677 patients (5989 hips) had received prophylactic RT. The median number per institution was 36 patients (range 8-240). The interdisciplinary referral included orthopedic surgery (89 institutions; 3763 patients), trauma surgery (82 institutions; 1611 patients), or other disciplines (8 institutions; 298 patients). Preoperative RT was applied in 53 institutions 0.5-24 h before surgery, and postoperative RT was applied in 54 institutions 1-120 h after surgery. Most patients received 1 x 7 Gy either pre- or postoperatively. The total dose range was 5-10 Gy (preoperative RT) or 5-16 Gy (postoperative RT); the median total RT dose of both RT concepts was 7 Gy. Cobalt-60 (n = 15), linear accelerators (n = 95), and a few lower energy units (n = 4) were used. Bony structures or prostheses were shielded with standard blocks in 31 and with individual blocks in 27 institutions. Long-term clinical evaluation was available in 30 institutions from 4377 hips. Of those, 475 (11%) developed radiologic failures according to Brooker's criteria. Functional hip evaluation was available in 5 institutions from 685 hips. Of those, 34 (5%) had functional failures according to the criteria of Harris. No difference in outcome was found between pre- and postoperative RT, but was with regard to the patient's referral and the timing of RT. The patients who were treated >8 h before surgery or >72 h after surgery experienced a higher radiologic failure rate; radiologic failures were an important precondition for functional failures (p <0.05). CONCLUSION: This patterns of care study comprises the largest number of cases reported for prophylactic hip RT to date. The results reveal that both preoperative (within 24 h) and postoperative RT (within 72 h) are effective in preventing heterotopic ossification after hip surgery. Both RT concepts achieved a similar low radiologic and functional failure rate. Single-dose RT concepts, especially, can be recommended as an excellent treatment alternative for patients with contraindications to long-term steroid or nonsteroidal anti-inflammatory agents, and this approach has become standard in most German RT institutions.
Intraabdominal heterotopic ossification is a very rare lesion, especially in the mesentery. In all reported series, there was a history of traumatic injury of the abdomen. We report two cases of heterotopic mesenteric ossification occurring after laparotomy in adults.
UNLABELLED: Clinical evaluation and MR imaging of microangiopathy associated with hypertension is limited. We describe a case that illustrates sensitivity of MRI at 8 Tesla for imaging of microvasculature, iron, calcium deposits and silent white matter lesions (WML). A 60-year-old black hypertensive woman was evaluated for numbness in the face and extremities. MRI at 1.5 Tesla was unrevealing.MRI at 8 Tesla: Axial and sagittal Gradient Echo images were obtained with an 8T/80 cm human scanner and showed: 1) Large areas of signal voids due to ossifications and fat deposits within the falx. 2) Obstructed small vessels in the periventricular regions and distended cortical veins. 3) Numerous small WML, suggestive of mini-infarcts (<1 cm) and microhemorrhages. 4) Intracranial calcifications in the falx, tentorium, basal ganglia and chorioid plexus that were confirmed by CT scan. Atherosclerotic plaque in right carotid artery and reduced vasomotor reserve in middle cerebral arteries, documented by ultrasound, indicated large and small vessel disease. CONCLUSIONS: MRI at 8 Tesla improves visualization of microangiopathy, ossifications and iron deposits due to enhanced magnetic susceptibility at ultra high magnetic field.
Heterotopic ossification development within the interosseous membrane of the ankle is an uncommon occurrence after routine ankle sprains. We present a case of a high school football player who sustained a syndesmosis ankle sprain. After 4 weeks, he continued to have pain, swelling, and range of motion restriction despite being treated with cryotherapy, NSAIDs, supportive taping, and progressive rehabilitation. The radiographs revealed a heterotopic ossification within the interosseous membrane of the distal extremity. The patient was initially treated conservatively and went on to have surgical excision with an excellent result. Symptomatic patients will require definitive surgery even without frank synostosis.
Ninety-eight consecutive primary total knee arthroplasties (TKAs) in 70 patients were retrospectively evaluated for heterotopic ossification (HO). A radiographic classification was devised based on the extent and location of the ectopic bone. Twenty-five knees (26%) in 19 patients developed HO. Eight of 11 patients (73%) with preexisting heterotopic bone at other sites developed HO in the index knee. Multivariate analysis demonstrated that advanced HO was associated with restricted knee motion. Eight knees with advanced HO had a mean 14 degrees decrease in postoperative, as compared with preoperative, knee flexion (P < .05). For all patients with HO, mean lumbar spine bone mineral density (BMD) was significantly elevated compared with a matched control group not developing HO (P < .05). Heterotopic ossification following primary TKA correlates with a limitation of postoperative knee flexion and is predicted by increased lumbar BMD. Preoperative measurement of spinal BMD may identify those patients at risk for HO and allow for the institution of preoperative prophylaxis and modification of postoperative rehabilitation to optimize functional outcome following TKA.
Heterotopic ossification has been reported to occur in less than 10% of total knee arthroplasties. When this condition has occurred, it has previously been reported either to be asymptomatic or to cause discomfort that resolves with the passage of time. This case report is the first to note persistent pain and snapping due to heterotopic ossification adherent to the distal femoral cortex that required surgical excision to relieve symptoms after total knee arthroplasty.
Heterotopic ossification following an uncemented total hip arthroplasty should theoretically demonstrate a higher incidence than a cemented arthroplasty. This is due to increased production of bone debris following vigorous femoral canal and pelvic reaming, which should provide increased stimulatory factors for ectopic bone production. The authors examined 196 consecutive primary total hip arthroplasties prospectively for 1 year. The overall incidence of heterotopic ossification was 26% with only one patient having a Grade III (severe) amount of ectopic bone. This incidence is consistent with those reported in cemented total hip arthroplasties. This paper does not support Puzas et al theory of bone dust providing a stimulatory factor for the production of heterotopic bone.
Although indomethacin is effective in preventing heterotopic ossification (HO) after total hip arthroplasty (THA) when used for 8 to 14 days, side effects are frequently observed. We conducted a prospective, nonrandomized pilot study of prophylaxis for HO in THA using indomethacin for 3 days. We used a 2-stage design for phase 2 clinical data, based on earlier studies in our department. Our study group consisted of 19 patients, of whom 14 (74%) developed HO; 7 (37%) showed grade 1, 4 (21%) grade II, and 3 (15.8%) grade III according to the Brooker classification. We compared these results with 2 historic control groups; one group received indomethacin for 7 days, and the other group received no prophylaxis. We did not see any reduction of the ossification relative to the group that received no prophylaxis. Indomethacin for 3 days seems not to be sufficient to prevent HO.
A retrospective study of the outcomes of multilevel anterior decompression and interbody fusion for cervical myelopathy due to ossification of the posterior longitudinal ligament (OPLL) was performed to both investigate the long-term results and assess the cause of late deterioration. Twenty-seven patients (mean age, 58.1 years) underwent this procedure and were followed for at least 5 years. The severity of the clinical symptoms was described using the scoring system for cervical myelopathy proposed by the Japanese Orthopaedic Association (JOA score). The average preoperative JOA score was 7.7, and the score at final follow-up was 13.4 with a recovery rate of 62.0%. A delayed deterioration was attributed to a thoracolumbar lesion other than a compromising alteration of the cervical spine. Consequently, this method of treatment for OPLL could stop the progress of ossification and keep a physiological cervical alignment and thus provide good long-term results.
We present a case of heterotopic ossification in the bilateral knees of a 26-year-old woman following viral encephalitis. After surgical excision, the patient was followed up for 10 years. Heterotopic ossification in knee joints associated with encephalitis has not been reported previously.
PURPOSE: To present a case of ossification of the eyelid, episclera and orbit in a patient with pseudo-pseudohypoparathyroidism (pPHP). METHODS: A 20-year-old woman diagnosed with pseudo-pseudohypoparathyroidism underwent clinical and histopathological examination of calcified plaques of the right eyelid and orbit. The patient presented with a round face, tousled short hair and retarded speech. She had been diagnosed with pPHP at 3 years of age. During her first decade, calcified plaques developed in the right eyelid and orbit. Gradually, she developed horizontal diplopia, pseudo-ptosis and periorbital pain. Vertical eye movements were reduced to 10 mm, although levator function remained intact. Computer tomography scans of the orbit showed three separate dense structures. Radiographic findings also showed bilateral shortening of the fourth metacarpus and a calcified subcutaneous plaque in the left thigh. The patient's blood status revealed an elevated level of thyroid stimulating hormone, but was otherwise normal. The patient was treated with eltroxin and shortly afterwards regained normal hair and normal speech function. RESULTS: The calcified structures were removed surgically and almost normal eye movements were re-established. Histological examination of the excised tissue demonstrated bone formation. CONCLUSION: This is the first reported case of ossification of the eyelid and orbit in a patient with pseudo-pseudohypoparathyroidism.
This article describes an unusual case of pleomorphic adenoma arising in the submandibular salivary glands that was associated with marked ossification. CT scan showed an irregular high-density mass in the left submandibular region. Histologic examination of the resected mass revealed a well-circumscribed pleomorphic adenoma with chondroid tissue intermingled with glandular and trabecular epithelial components. Irregularly formed osseous tissue was present in the chondroid tissue. The osseous tissue showed bone matrix on von Kossa's staining. Alkaline phosphatase expression was restricted to the vicinity of osseous tissue. Tartrate-resistant acid phosphatase-positive osteoclasts were observed at the periphery of the osseous tissue. CD34 staining demonstrated many microvascular vessels in both the chondroid and osseous tissues. We conclude the osseous tissue in pleomorphic adenoma was bone in nature, and via the process of endochondral ossification most likely depended on angiogenesis.
Heterotopic ossification (HO) is a frequent complication in patients with a spinal cord injury (SCI), although the aetiology is unknown. A study was undertaken of 654 SCI patients with traumatic aetiology, admitted for the first time to the Hospital Nacional de Paraplejicos, Toledo, during 1988 and 1989. Of the total number of patients, 85 (13%) were diagnosed HO and 569 without HO. The diagnosis was mainly achieved by x-ray studies and clinical signs. From the 569 patients with traumatic aetiology without HO, 44 were selected at random, as were 44 of the 85 patients with HO. The mean time lapse between the occurrence of the accident and admission for patients with HO was 40.79 days (typical deviation (TD) = 45.2), and for patients without HO was 32.84 (TD = 38) days, resulting in a value of F = 0.796 through analysis of variance, which is not a statistically significant variation between the 2 groups. In both groups we have taken account of the following variables: age at time of lesion, lesion level, type of lesion (complete or incomplete), spasticity, urinary tract complications, deep vein thrombosis, important associated injuries occurring at the moment of lesion, time elapsed before admission and the existence of pressure sores. In those SCI patients with HO the number of ossifications and their localisations were also verified. By use of the chi square test (X2) over all 9 variables which were studied, we found that 3 variables (complete spinal lesion, presence of pressure sores and spasticity) were significantly related to HO formation.(ABSTRACT TRUNCATED AT 250 WORDS)
Three patients are presented with traumatic spinal cord injury (SCI) complicated by acute heterotopic ossification (HO), and concurrent deep vein thrombosis 15 months, 18 months and 22 years after SCI, accompanied by persistent hypercoagulation. The diagnosis of HO preceded deep vein thrombosis in all three patients. All were treated with etidronate disodium and therapeutic heparin followed by oral anticoagulation. As these patients were not acutely injured, the questions arose as to what predisposed them to deep vein thrombosis and when was the appropriate time to discontinue anticoagulation. Over a course of 3 years following deep vein thrombosis, these patients were monitored for evidence of hypercoagulation by D-dimer assay, plasma fibrinogen estimation, and rate of whole blood clotting by Sonoclot coagulation analyzer. The activity of acute HO was assessed by three-phase bone scan. A steady state of hypercoagulation, reflected by an increase in all three parameters, ran parallel to the extent of acute HO for the entire observation period. Moreover, hypercoagulation was persistently greater during increased acute HO activity even when the warfarin-induced prothrombin time ratio was 1.2-1.5. In addition, as acute heterotopic ossification activity decreased, the test values returned to near normal during warfarin therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Compression of neurovascular structures from heterotopic ossification can result in neurological and vascular sequelae. Three cases of neurovascular compression due to heterotopic ossification illustrate the potential for neurovascular compression resulting from this condition and underscore the importance of recognising this uncommon, but notable complication following spinal cord injury.
Two spinal cord injured patients had extensive heterotopic ossifications around their hips surgically removed. The use of disodium etidronate from 2 weeks presurgery to 2-5 months postsurgery and in particular indomethacin 25 mg twice daily, from 2 weeks prior to surgery to 6 weeks postsurgery may have helped to prevent recurrence of the ossifications in the follow up periods of 4 and 5 years respectively.
A case of progressive cauda equina syndrome secondary to ossification of the lumbosacral dura arachnoid following an incomplete spinal cord injury is presented. The etiology of the ossification is unclear and may be secondary to heterotopic osseous metaplasia such as occurs in other sites in spinal cord injured patients.