Osificación heterotópica mesentérica como causa de obstrucción intestinal en un paciente con abdomen séptico / Mesenteric Heterotopic Ossification as a Cause of Intestinal Obstruction in a Patient with a Septic Abdomen

Presentación del caso. Se trata de un masculino de 49 años, con historia de un trauma abdominal cerrado con un objeto contuso sin alteraciones hemodinámicas. La ecografía focalizada de traumatismos resultó positiva a líquido libre en la cavidad abdominal en tres ventanas. Intervención terapéutica. Fue sometido a múltiples laparotomías exploratorias con lavados de cavidad abdominal posterior a presentar un cuadro de abdomen séptico Björk 4, quien después de 38 días de estancia intrahospitalaria presentó una fístula enteroatmosférica que causaba un déficit nutricional. En una intervención quirúrgica se realizó el cierre de la fístula enteroatmosférica, con el hallazgo de tejido óseo trabecular en cavidad abdominal, correspondiente a osificación heterotópica intraabdominal de formación reciente. Evolución clínica. Luego de la anastomosis del intestino delgado presentó signos de obstrucción intestinal, a causa de esto, se realizó una nueva laparotomía exploratoria, en la que se encontró tejido óseo adherido al mesenterio del intestino delgado que generó una obstrucción completa, se extirpó el material óseo y se logra restablecer el flujo intestinal liberando la obstrucción en el intestino delgado

Case presentation. A 49-year-old male, with a history of blunt abdominal trauma with a blunt object without hemodynamic alterations. The focused trauma ultrasound was positive for free fluid in the abdominal cavity in three windows. Treatment.The patient underwent multiple exploratory laparotomies with peritoneal lavage after presenting a septic abdomen (Björk 4), who after 38 days of intrahospital stay presented an enteroatmospheric fistula that caused a large nutritional deficit. In a surgical intervention, the enteroatmospheric fistula was closed, with the finding of trabecular bone tissue in the abdominal cavity, corresponding to intra-abdominal heterotopic ossification of recent formation. Outcome. After the small intestine anastomosis, he presented signs of intestinal obstruction, because of this, a new exploratory laparotomy was performed, in which bone tissue was found adhered to the mesentery of the small intestine that generated a complete obstruction. The bone material was removed and the intestinal flow was reestablished, freeing the obstruction in the small intestine

Efficacy of Ibuprofen after Total Hip Arthroplasty to Prevent Heterotopic Ossification: Systematic Review and Meta-Analysis / Eficácia do ibuprofeno após artroplastia total de quadril para prevenção de ossificação heterotópica: Revisão sistemática e metanálise

Abstract The objective of this study was to conduct a systematic review and meta-analysis of relevant randomized control trials (RCTs) to determine the role of ibuprofen, as well as the optimum dose and duration of therapy, in preventing the incidence of heterotopic ossification (HO) after primary total hip arthroplasty (THA). A literature search was performed using the PubMed/MEDLINE and Cochrane Library databases for RCTs that compared the use of ibuprofen versus placebo as prophylaxis for HO in patients after THA. The main outcomes for this study were overall occurrence of HO, occurrence according to the Brooker classification, and gastrointestinal complications. A total of 27 potential articles were identified from the database. Eventually, four trials with 1,153 patients were included in the final analysis. When compared with placebo, the use of ibuprofen is associated with a reduction in the incidence of HO at the 3- and 12-month follow-up appointments, as well as the incidence of Brooker II and III HO (p < 0.05). However, there was no significant difference between the ibuprofen and placebo groups in terms of treatment discontinuation due to gastrointestinal complications or the incidence of Brooker I and IV HO (p > 0.05). The existing data indicates that ibuprofen is safe and efficacious in reducing the total incidence of HO along with Brooker II and III HO at follow-up. However, due to the small number of studies, the conclusions are limited; therefore, more high-quality clinical trials are required to develop guidelines for optimal dose and duration of therapy.

Resumo O objetivo deste estudo foi realizar uma revisão sistemática e metanálise de estudos clínicos randomizados (ECRs) relevantes para determinar o papel do ibuprofeno, sua dose ideal, e a duração do tratamento na prevenção de ossificação heterotópica (OH) após a artroplastia total primária do quadril (ATQ). Uma pesquisa bibliográfica foi feita nos bancos de dados PubMed/MEDLINE e Cochrane Library para a obtenção de ECRs quecomparassem ouso de ibuprofeno edeplacebo como profilaxiaparaOHem pacientes submetidos à ATQ. Os principais desfechos deste estudo foram ocorrência geral de OH, classificação de Brooker da OH, e complicações gastrintestinais. No total, 27 artigos foram identificados nos bancos de dados e 4 estudos, com 1.153 pacientes, foram incluídos na análise final. Em comparação ao placebo, o uso de ibuprofeno reduziu a incidência de OH aos 3 e 12 meses de acompanhamento e a incidência de OH Brooker II e III (p < 0,05). No entanto, não houve diferença significativa entre os grupos que receberam ibuprofeno e placebo em termos de interrupção do tratamento devido a complicações gastrintestinais ou da incidência de OH Brooker I e IV (p > 0,05). Os dados existentes indicam que o ibuprofeno é seguro e eficaz na redução da incidência total de OH e de OH Brooker II e III durante o acompanhamento. No entanto, as conclusões são limitadas devido ao pequeno número de estudos; logo, mais estudos clínicos de alta qualidade são necessários para o desenvolvimento de diretrizes em relação à dose e duração ideal da terapia.

Prevalence and distribution of ossification of ligamentum flavum at the adjacent segment of the apex in patients with degenerative kyphosis / 中华骨科杂志

Objective:To evaluate the prevalence and distribution of ossification of ligamentum flavum (OLF) at the segments adjacent to the apex in patients with degenerative kyphosis.Methods:All of 74 patients with degenerative kyphosis from January 2018 to December 2021 were retrospective reviewed. All patients were taken anteroposterior and lateral radiographs, CT scan and magnetic resonance imaging (MRI) of the entire spine. Global kyphosis, the morphology of kyphosis and the occurrence of OLF at three segments adjacent to the kyphosis apex were recorded.Results:Of the 74 patients, 54 patients (73%) developed OLF in three segments adjacent to the kyphotic apex. The mean age of the 54 patients was 61.4±6.8 years, and the mean global kyphosis was 49.5°±21.2°. Among other 20 patients without OLF, the mean age was 56.1±7.5 years, and the mean kyphosis angle was 52.1°±19.1°. There was a statistically significant difference in ages ( t=2.92, P=0.005), but no statistically significant difference was observed regarding global kyphosis ( t=0.48, P=0.634). In these 74 patients, 9 patients had angular kyphosis, of which 8 (89%) developed OLF; of the 65 patients without angular kyphosis, 46 patients (71%) developed OLF. There was no significant difference between them (χ 2=1.32, P=0.251). Among the 54 patients diagnosed with OLF, 5 patients (9%) suffered ossification of the posterior longitudinal ligament (OPLL) and 20 patients (37%) suffered dural ossification; 43 patients (80%) developed OLF at proximal segments of apex, 6 patient (11%) developed OLF at distal segments of apex, and 5 patients (9%) developed OLF both at proximal and distal segments of apex. Thirty-two patients (59%) developed OLF at the first segment adjacent to the kyphotic apex, 27 patients (50%) developed OLF at the second segment, and 15 patients (28%) developed OLF at the third segment. Conclusion:Among patients with degenerative kyphosis, about 73% may development OLF within three segments adjacent to the kyphotic apex, and it mostly occurred within two segments adjacent to the apex proximally.

Heterotopic ossification after spinal cord injury: prevention and treatment - a sistematic review / Ossificação heterotópica no lesado medular: prevenção e tratamento - revisão sistemática

ABSTRACT Trauma configures the main cause of spinal cord injuries. Patients with traumatic spinal cord injury often develop severe and debilitating outcomes that require multidisciplinary care to adapt patients to their new reality. Heterotopic ossification (HO) is one of the frequent comorbidities in these patients but it still lacks well-established treatments or a gold standard one. Thus, this systematic review aimed to search the current literature for HO treatment and prevention. This study was conducted following PRISMA recommendations (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and searches were conducted in three databases (PubMed, Embase, and Web of Science). A total of 193 articles were found in an initial search. After screening following the established criteria, eight articles were included in this review; of these, two reported prevention and the others, treatments. Based on data analysis, the use of non-steroidal anti-inflammatory drugs in the acute post-traumatic period proved to be the best method of prevention. In cases of mature HO or accompanied by ankylosis, surgical resection proved to be the most effective treatment despite the high rate of postoperative infections. Level of Evidence III, Systematic Review.

RESUMO A principal causa de lesão medular é o trauma. O paciente com trauma raquimedular frequentemente evolui com incapacidades graves e debilitantes, fazendo com que necessite de cuidado multiprofissional para se adaptar a uma nova realidade. A ossificação heterotópica (OH) é uma comorbidade comum nesses pacientes, mas que ainda não tem tratamentos bem estabelecidos ou considerados padrão-ouro. Esta revisão sistemática teve como objetivo buscar formas de tratamento e prevenção da OH na literatura atual. O estudo seguiu a recomendação Principais Itens para Relatar Revisões Sistemáticas e Meta-Análises (PRISMA) e realizou buscas em três bases de literatura (PubMed, Embase e Web of Science). Foram encontrados 193 artigos inicialmente, e, após triagem considerando os critérios estabelecidos, oito foram eleitos para o trabalho final. Dois trabalhos abordaram a prevenção; e os demais, tratamentos. Pela análise dos dados, o uso de anti-inflamatórios não esteroidais (AINEs) no período agudo pós-traumático se mostrou como o melhor método de prevenção. Já em relação ao tratamento, nos casos de OH maduras ou com anquilose, a ressecção cirúrgica revelou-se como o método mais efetivo, a despeito da grande taxa de infecção pós-operatória. Nível de Evidência III, Revisão Sistemática.

Association between cervical curve and the cranio-cervical curve and ossification of ligaments in patients with cervical degenerative diseases / 中华骨科杂志

Objective:To explore the correlation between cervical curve and ossification of ligaments in cranio-cervical junction and cervical spine in patients with cervical degenerative diseases.Methods:A retrospective study was conducted among 458 patients with cervical degenerative disease who underwent cervical spine X-ray and CT examinations at the Orthopedics Department of Beijing Tiantan Hospital, Capital Medical University between January 2016 and July 2020. There were 265 males and 193 females, with an average age of 57.02±10.41 years (range, 22-87 years). Patients were divided into 5 types (lordosis, straight, S-type degenerative kyphosis, R-type degenerative kyphosis and C-type degenerative kyphosis). Cervical lordosis was defined as C 2-C 7 curve <-4°, cervical kyphosis was defined as >4°, cervical straight was defined as -4° to 4°. C 2-C 7 curve, C 0-C 2 curve were measured respectively, and correlations among these imaging parameters were analyzed. CT images were used to assess the presence of ossification of ligaments in cranio-cervical and cervical spine, including ossification of the posterior longitudinal ligament, nuchal ligament, ligamentum flavum, transverse ligament, apical ligament, diffuse idiopathic skeletal hyperostosis (DISH), as well as capped dens sign (CDS), and correlations between these cervical curve and presence of ossification of ligaments were analyzed. The different grades were based on the length of the ossification of interest with respect to the distance from the posterosuperior rim of the anterior arch of the atlas to the inferior margin of the foramen magnum on mid-sagittal cervical spine CT images, Grade 3 CDS was determined when the length was more than two-thirds. Results:There were 245 patients with cervical lordosis, 114 patients with straight, 53 patients with S-type degenerative cervical kyphosis, 36 patients with R-type degenerative cervical kyphosis and 10 patients with C-type degenerative cervical kyphosis. C 0-C 2 curve showed a negative correlation with C 2-C 7 curve in all enrolled patients ( r=-0.45, P<0.001) and R-type degenerative kyphosis group ( r=-0.58, P<0.001); C 0-C 2 curve showed no correlation with C 2-C 7 curve in lordosis ( r=-0.10, P=0.124), straight ( r=-0.11, P=0.233), S-type degenerative kyphosis ( r=-0.01, P=0.943) or C-type degenerative kyphosis groups ( r=0.03, P=0.946). CDS was detected in 38.4% (176/458) of patients, and Grade 3 was detected in 17.9% (82/458) of patients. The prevalence of CDS was correlated with R-type degenerative cervical kyphosis ( r=0.10, P=0.030). Cervical kyphosis, S-type degenerative kyphosis, C-type degenerative kyphosis, C 2-C 7 curve and C 0-C 2 curve showed no correlation with ossification of the posterior longitudinal ligament, nuchal ligament, ligamentum flavum, transverse ligament, apical ligament, diffuse idiopathic skeletal hyperostosis (DISH) or different grades CDS ( P>0.05). Conclusion:R-type degenerative cervical kyphosis are more likely to correlate with the cranio-cervical curve and CDS, which is an ossification of ligament in cranio-cervical junction.

Locational distribution characteristics and risk factors of heterotopic ossification following traumatic elbow stiffness / 中华创伤骨科杂志

Objective:To study the locational distribution characteristics of the heterotopic ossification (HO) following traumatic elbow stiffness and the risk factors for HO development at different locations.Methods:Consecutively included according to our inclusion criteria in the present study were the patients who had been admitted to Department of Orthopaedic Trauma, Beijing Jishuitan Hospital from January 2018 to December 2018 for elbow release due to traumatic elbow stiffness but developed postoperative HO. Their baseline data and CT data were collected and processed using Mimics 20.0. The HO distribution for each patient was characterized at the anteromedial, anterolateral, posteromedial, posterolateral, posterior, medial, lateral, and proximal radioulnar locations. The patient's original injury was categorized into 5 types: distal humerus fracture, olecranon fracture, radial head fracture, coronoid fracture, and elbow dislocation. After the univariate analysis with the HO occurrence at a specific location as the dependent variable and the original injury and baseline data as the independent variables, the factors with P value less than 0.1 were included in the logistic regression analysis to determine the risk factors for HO at each location.Results:A total of 91 patients were included in this study. Of them, 88 had posteromedial HO (96.7%, 88/91), 62 posterior HO (68.1%, 62/91), 60 posterolateral HO (65.9%, 60/91), 41 anteromedial HO (45.1%, 41/91), 26 anterolateral HO (28.6%, 26/91), 13 proximal radioulnar HO (14.3%, 13/91), 8 lateral HO (8.8%, 8/91), and 7 medial HO (7.7%, 7/91). Logistic regression analysis showed that presence of ulnar nerve symptoms ( OR=4.354, P=0.017) and presence of original elbow dislocation ( OR=2.927, P=0.042) were the independent risk factors for the anteromedial HO development and that presence of original olecranon fracture ( OR=0.277, P=0.023) was the protective factor for the anteromedial HO development. Presence of original radial head fracture was the independent risk factor for the anterolateral HO development ( OR=2.891, P=0.033) and the posterolateral HO development ( OR=3.123, P=0.043). Conclusions:HO development in patients with post-traumatic elbow stiffness is closely related to their original injury. Posteromedial HO may develop in almost all the patients. Patients with ulnar nerve symptoms and original elbow dislocation are more prone to anteromedial HO development, but patients with original olecranon fracture are less likely to develop anteromedial HO. Patients with original radial head fracture are more likely to develop anterolateral and posterolateral HO.

Prevalence and distribution of diffuse idiopathic skeletal hyperostosis in patients with thoracic ossification of the ligamentum flavum / 中华骨科杂志

Objective:To analyze the prevalence and distribution characteristics of diffuse idiopathic skeletal hyperostosis (DISH) in hospitalized patients with thoracic ossification of the ligamentum flavum (TOLF).Methods:The clinical records of 132 consecutive TOLF patients from January 2018 to June 2019 were retrospectively studied. DISH was identified by the preoperative X-ray and CT and its prevalence was calculated. The prevalence of patients with different genders, different age groups and different ossification types was compared. The segmental distribution of DISH and the distribution in the upper (T 1-T 4), middle (T 5-T 8), and lower thoracic spine (T 9-T 12) were analyzed. Ossification degree of DISH was evaluated based on the Meta scoring system. The demographic characteristics (age, gender, BMI, etc.) were compared between DISH and non-DISH group. Results:Forty-nine patients was diagnosed as DISH with the prevalence of 37.1% in all included cases. The prevalence was about twice as high in male (46.3%) than in female (23.1%) ( χ2=8.806, P=0.003). The prevalence in the age groups of <40, 40-49, 50-59, 60-69 and ≥70 years was 20.0%, 28.0%, 34.4%, 44.0%, and 66.7%, respectively. The prevalence in long-segment TOLF patients (45.1%) was significantly higher than that in short-segment TOLF patients (24.0%) ( χ2=5.937, P=0.015). DISH most frequently affected T 8,9 levels (91.8%). The total number and mean number of ossified segments were 365 and 7.4, respectively. Ossification lesions in the upper, middle, lower thoracic spine accounted for 26.03%, 40.54%, and 33.15%, respectively. Grade I, grade II, and grade III ossification accounted for 21.4%, 28.5% and 50.1%, respectively. The mean age of the DISH group was older than the non-DISH group ( t=2.024, P=0.045). The proportion of male patients in the DISH group was significantly higher than that in the non-DISH group ( χ2=8.806, P=0.003). The average height and weight in the DISH group were significantly greater than those in the non-DISH group ( t=2.564, P=0.012; t=2.191, P=0.030), whereas no significant differences in BMI and constituent ratio of concurrent diabetes, cardiac disease, hypertension between two groups were observed. Conclusion:The prevalence of DISH in patients with TOLF is 37.1%. Male, elderly and long-segment TOLF patients are associated with higher prevalence. DISH frequently occurs in the middle and lower thoracic spine, and T 8,9 is the common affected segment. Ossification lesions may develop with age. Demographic characteristics of DISH group differ, to some extent, from those of non-DISH group.

Clinical efficacy of posterior percutaneous endoscopic cervical discectomy for single level cervical spondylopathy with intraspinal ossification / 中国骨伤

OBJECTIVE@#To evaluate the effectiveness and security of posterior percutaneous endoscopic cervical discectomy (PPECD) in the treatment of single level cervical spondylopathy with intraspinal ossification.@*METHODS@#Twenty three patients with single level cervical spondylopathy with intraspinal ossification were treated by posterior percutaneous endoscopic cervical discectomy between August 2017 and July 2019. There were 16 males and 7 females, aged from 29 to 74 years old with an average of (50±13) years.The disease duration were 3 to 120 months with a median of 6 months. There were 9 cases of cervical spondylotic radiculopathy, 6 cases of cervical spondylotic myelopathy, and 8 cases of mixed cervical spondylopathy. According to the characteristics of ossification, 17 cases were osteophytes on the posterior edge of the vertebral body;3 cases were protrusion ossification;3 cases were posterior longitudinal ligament ossification. According to the position of ossification in spinal canal, 14 cases were medial and lateral type, 5 cases were central type, and 4 cases were mixed type. Posterior percutaneous cervical endoscopic cervical discectomy in patients performed by the same surgeon. Japanese Orthopaedic Association (JOA) score and visual analogue scale(VAS) were compared separately before and after operation. At 3 months after operation, clinical effect was assessed according to modified Macnab standard.@*RESULTS@#All operations were successful. The operative time was 30 to 155 (69.1±27.2) min. The bedridden time was 2 to 3(3.0±0.9) h, length of postoperative hospitalization was 2 to 7(4.1± 1.5) d. Three dimensional CT reconstruction of the cervical spine at 3 days after operation showed that ossified tissue of 13 cases were completely removed, and 10 cases were left after operation, and the residual was located at the posterior edge and/or center of the upper vertebral body. VAS score at discharge from hospital was significantly lower than that before operation (@*CONCLUSION@#For an experienced surgeon, percutaneous posterior cervical endoscopic discectomy is safe and reliable in treating single level cervical spondylopathy with intraspinal ossification, and can obtain good clinical results.

Multifocal papillary carcinoma of the thyroid with heterotopic ossification and extramedullary hematopoiesis associated with a lipomatous follicular nodule

Heterotopic ossification has been described in papillary thyroid carcinoma in association with high incidence of extrathyroidal invasion, multifocality, lymph node metastasis, and older age. Nevertheless, it has not been described as a specific subtype of papillary thyroid carcinoma, because of its rarity. We described the case of an 80-year-old female patient, with familial history of papillary thyroid carcinoma. In the annual screening examination, she was diagnosed with thyroid nodules. The patient was submitted to a thyroidectomy because the fine needle aspiration cytology was positive for malignancy according to the Bethesda classification. The surgical specimen analyses showed a multifocal papillary carcinoma with one major lesion in the left lobe measuring 0.9 cm, and two small lesions (0.4 cm and 0.2 cm) in the right lobe. Only the biggest lesion in the right lobe had the osteoid matrix with rare osteoclasts and fat metaplasia with progenitor cells. There was perineural invasion, but vascular invasion was not identified. The margins were free and there was no extrathyroidal extension. In the left lobe there was an oncocytic nodule and a lipomatous follicular nodule. In recent years there has been a significant increase in the diagnosis of thyroid cancer, mainly because of the finding of microcarcinomas as a result of many requests for cervical image exams. Future studies may define (i) whether papillary thyroid carcinoma with heterotopic ossification is a true histological variant; (ii) the causes of that alteration; and (iii) eventual follow-up implications.

Retrospective analysis of 4 rare cases of temporomandibular joint disc ossification / 中华口腔医学杂志

Objective@#To summarize the clinical manifestation and treatment of temporomandibular joint (TMJ) disc ossification, providing reference for clinical diagnosis and treatment of TMJ disc ossification.@*Methods@#From January 2006 to January 2018, 4 patients with TMJ disc ossification (2 males and 2 females, aged 20-55 years with an average age of 35.5 years) which were admitted to the Department of Oral and Maxillofacial Surgery, Shenzhen Second People′s Hospital were analyzed retrospectively. Ossification of TMJ disc was found in 4 cases during TMJ surgery. Two cases underwent partial ossification resection plus disc reduction and anchorage, and two cases underwent discectomy plus temporalis myofascial flap replacement. The causes, clinical manifestations and surgical effects of TMJ disc ossification were analyzed by comparing the maximal interincisal opening, visual analogue scale (VAS) score and MRI imaging indexes before and after operation.@*Results@#The history of anterior disc displacement of TMJ in 4 patients was long (average 11.5 years). In clinic, TMJ disc ossification was characterized by TMJ pain and limitation of mouth opening. The maximal interincisal opening was (32.1±6.1) mm and the VAS score was (7.3±0.4) before operation. MRI showed that the displaced discs of the affected sides were displaced and the condyle bones were worn. During the operation, ossification of TMJ discs was found yellow and hard, and the original elasticity was lost. Pathologic findings showed that the TMJ disc cartilage were ossified to osteoid tissue. Under the microscope, bone cells scattered around the bone cells and red trabecular bone were seen, and there were bone trabecula formed. In a follow-up of one year, TMJ pain was significantly decreased [VAS: (1.7±0.2)], and the maximal interincisal opening was (38.5±2.2) mm. MRI showed that the TMJ disc returned to normal position, and the sign of repairing and reconstruction of condyle bone could be found.@*Conclusions@#Long term displacement of TMJ disc may cause ossification with pain and limitation of interincisal opening. According to the degree and extent of ossification, partial ossification plus disc reduction and anchorage or discectomy plus temporalis myofascial flap replacement is feasible, and the clinical effects are satisfactory.

Clinical analysis of 11 children with primary osteoma cutis / 中华皮肤科杂志

Objective To investigate clinical manifestations,pathological features and outcomes of primary osteoma cutis in children.Methods Eleven children with confirmed primary osteoma cutis diagnosed in Department of Dermatology,Beijing Children's Hospital between 2011 and 2018 were included into this study.The clinical manifestations,histopathological features,and outcomes were analyzed retrospectively.Results Among the 11 patients,7 were males and 4 were females.Primary osteoma cutis occurred within 22 months after birth in all the children,the median age of onset was 1 month,and the disease occurred during the first 6 months of life in 10 children.The skin lesions were characterized by skincolored or reddish indurated papules,plaques or nodules of varying size with slight epidermal atrophy.Three patients had local skin lesions,and 8 had multiple skin lesions.Serum calcium and parathyroid hormone levels were within normal limits in all the children,and no developmental deformity was observed at birth in any of the children.Histopathological examination revealed the formation of mature lamellar bone in the dermis in all the cases,which involved the subcutaneous adipose tissue in 5 cases.The skin lesions became stable 8-18 months after the occurrence in 10 patients,which was consistent with primary plaquelike osteoma cutis.Only 1 patient underwent a slowly progressive course,and the skin lesions involved subcutaneous deep tissues,leading to dyskinesia,which was consistent with progressive osseous heteroplasia.Conclusions Primary osteoma cutis in children mostly occurs in infancy,whose clinical manifestations are atrophic,indurated plaques or nodules,and its main pathological feature is the formation of mature lamellar bone.Long-term follow-up is needed,and attention should be paid to the occurrence of progressive osseous heteroplasia.

Imaging and pathogenic characteristics of thoracic ossification of the ligamentum flavum complicated with dural ossification / 中华骨科杂志

Objective To investigate the imaging characteristics and pathogenic manifestations of thoracic ossification of the ligamentum flavum complicated with dural ossification.Methods CT and MRI imaging data of 62 segments from 29 patients with thoracic ossification of the ligamentum flavum (TOLF) treated with "en bloc resection of lamina and ossified mass" were retrospectively analyzed.There were 19 males and 10 females,aged 54.9±10.25 years (36-77 years),16 segments in 11 cases with dural ossification (DO) and 46 segments in 18 cases without DO.The ossified mass shape,the relationship between ossified mas and dura mater on cross section of CT bone window and MRI T2WI,and the ossified mass occupational rate (OR) of the spinal canal were investigated.Pathologic features of TOLF-DO from 2 patients were analyzed by H&E staining.Results The shape of ossified mass was as followed,in 16 segments with DO,7 segments (43.8％) by CT and 2 segments (12.5％) by MRI showing ossification layer on the dural sac side of ligamentum flavum;1 segment (6.3％) by CT and 2 segments (12.5％) by MRI showing typical Tram track sign.The relationship between ossified mass and dura mater was that 7 segments (43.8％) by CT and 7 segments (43.8％) by MRI with "C" sign and 7 segments (43.8％) by CT and 8 segments (50.0％) by MRI with "V" sign.The ossified mass OR was 60.5％± 13.0％ in the group with DO and 42.2％± 12.3％ in the group without DO.There was a significant difference between the two groups (t=5.192,P＜0.001).Among the 16 segments with DO,the ossified mass OR of 7 segments with "C" sign was 68.8％± 12.8％ and that of the other 9 segments without "C" sign was 54.39％±9.9％.There was significant difference between the two groups (t=2.45,P=-0.028).Histological examination showed that there were two pathological phenomena in the dura tissue adjacent to ossified mass.The one,there were fibrocartilage,cartilage and osteogenesis in the dura mater.The other,the unossified dura mater fused with the ossified mass but with clear histological demarcation,while the dura mater on the ventral side of the ossified ligamentum flavum atrophies or disappeared.Conclusion The occurrence of dural sac ossification is associated with the ossification of ligamentum flavum beginning at the side of the dural sac and the persistent thickening of the ossified mass.The pathological manifestations of DO are ossification of dural tissue or fusion of dural with ligamentum flavum ossification.

Enfermedad de Forestier en paciente mayor de 65 años: reporte de caso con seguimiento a 6 años de manejo conservador / Diffuse idiopathic skeletal hyperostosis (DISH): report of one case

Forestier Disease, or Diffuse Idiopathic Skeletal Hyperostosis (DISH), causes a considerable ossification of the anterior longitudinal ligament of the spine. When it involves cervical segments, it can be accompanied by dysphagia, dysphonia and/or dyspnea. This entity usually has a benign course. Surgical treatment is required for progressive cases. We report a 72-year-old male with a history of chronic cervical pain and slight neck stiffness. On the imaging studies, there was an exuberant ossification of the anterior longitudinal ligament, at the cervical spine level, between C2 and C7. He was managed conservatively without clinical deterioration in a six-year follow-up.

NSAIDs combined with radiotherapy to prevent heterotopic ossification after total hip arthroplasty / 中国骨伤

<p><b>OBJECTIVE</b>To investigate the preventive effects and differences of NSAIDs combined with radiotherapy, NSAIDs and radiotherapy for heterotopic ossification(HO) after total hip arthroplasty(THA).</p><p><b>METHODS</b>From February 2015 to July 2016, 168 hips undergoing primary THA were divided into group A, B and C, and 163 patients were followed up (54 cases and 54 hips in group A, 55 cases and 55 hips in group B, 54 cases and 54 hips in group C). Among group A, 5 hips were primary osteoarthritis, 37 hips were secondary osteoarthritis due to avascular necrosis of the femoral head, 12 hips were secondary osteoarthritis due to acetabular dysplasia. Patients in group A received oral celecoxib (0.2 g, 2 times a day) for 2 weeks after operation. Among group B, 6 hips were primary osteoarthritis, 32 hips were secondary osteoarthritis due to avascular necrosis of the femoral head, 17 hips were secondary osteoarthritis due to acetabular dysplasia, all of which in group B were treated with preoperative single 7 Gy radiotherapy. Among group C, 5 hips were primary osteoarthritis, 35 hips were secondary osteoarthritis due to avascular necrosis of the femoral head, 14 hips were secondary osteoarthritis due to acetabular dysplasia. Patients in group C were treated with preoperative radiotherapy and celecoxib after operation. The side effects of gastrointestinal reactions were observed after operation, and the heterotopic ossification was evaluated by pelvic anterior and posterior X-ray (Brooker grading).</p><p><b>RESULTS</b>The mean clinical and radiological follow-up was 21 months(12 to 30 months). In group A, 54 hips were followed up with 7 hips with heterotopic ossification, including 5 hips of Brooker I and 2 hips of Brooker II. In group B, 55 hips were successfully followed up, with 8 hips of heterotopic ossification occurred, including 6 hips of Brooker I, 2 hips of Brooker II. In group C, 54 hips were successfully followed up, with 5 hips of heterotopic ossification occurred , including 4 hips of Brooker I, 1 hip of Brooker II. There was no significant difference in efficacy among 3 groups (²=0.743, 0.690) by chi-square test. The prevalence of side effects were as following: in group A, there were 6 hips with side effects;in group B, there were 6 hips with side effects;in group C, there were 7 hips with side effects. There was also no significant difference in side effects among 3 groups (²=0.135, 0.935).</p><p><b>CONCLUSIONS</b>The combined-therapy group has lower prevalence of HO than the NSAIDs group or radiotherapy group, but the statistical difference between them is not significant. NSAIDs is still the first choice to prevent HO after THA.</p>

Meta analysis of efficacy and safety of non-steroidal anti-inflammatory drugs in preventing heterotopic ossification after hip arthroscopy / 中华创伤杂志

Objective To evaluate the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) in preventing heterotopic ossification after hip arthroscopy.Methods Literature search was conducted in PubMed,Embase,Cochrane Library,CNKI and Wanfang data with time range from January 1973 to November 2017.Clinical case control articles on NSAIDs in preventing heterotopic ossification after hip arthroscopy were screened based on the inclusion and exclusion criteria.Meta analysis was done using RevMan 5.3 software to investigate the incidence of complications such as heterotopic ossification and gastrointestinal bleeding after hip arthroscopy in patients taking NSAIDs orally.Results Six articles were included in the study,with a total of 754 cases and 536 controls.NSAIDs reduced the incidence of heterotopic ossification after hip arthroscopy (RR =0.09,95％ CI 0.03-0.27,P ＜ 0.05).Selective COX-2 inhibitor celecoxib (RR =0.17,95％ CI 0.03-0.91,P ＜ 0.05) and PG synthase inhibitor of naproxen (RR =0.17,95％ CI 0.09-0.32,P ＜ 0.05) were also effective in preventing heterotopic ossification.There was no significant difference in the incidence of gastrointestinal complications between the cases and controls after NSAIDs prophylaxis (RR =2.17,95％ CI 0.92-5.12,P ＞ 0.05).Conclusion NSAIDs can effectively reduce the incidence of heterotopic ossification after hip arthroscopy and does not increase the incidence of postoperative gastrointestinal complications.Therefore,it is effective and safe to use NSAIDs to prevent the occurrence of heterotopic ossification after hip arthroscopy.

Zoning laminectomy for the treatment of ossification of thoracic ligamentum flavum / 中华骨科杂志

Objective To investigate the safety and effect of zoning laminectomy for the ossification of thoracic ligamentum flavum.Methods From November 2011 to December 2014,34 patients (15 males,19 females;41-76 years old,average 55.0±8.1) with ossification of thoracic ligamentum flavum (OLF) were treated by zoning laminectomy.The course of disease ranged from 1 month to 123 months (average 16.5 months).According to the anatomical characteristics and the pathological ossification process of the thoracic ligamentum flavum,we proposed the concept of "zoning",which divided each segmental thoracic OLF into three zones:"safety zone","middle zone" and "risk zone".From the features of anatomy of LF and process of OLF development,we found there is no or less cerebrospinal fluid between spinal cord and the tip of each ossified nodular masses in severe OLF,any procedures using instruments in this area have the potential to cause irreversible spinal cord injury,we defined this area as "risk zone",the "null" area of each lamina and lateral and dorsal side of nodular masses as "safety zone",and the other area as "middle zone".From "safety zone" to "risk zone" the spinal canal decreased gradually,different zone needs different surgical strategy:This surgical procedure first removed the "null" area of superior and inferior lamina and dorsal side of each segmental OLF.Next,partially or totally resected the "middle zone",exploring the lateral side of nodular masses,and the "risk zone" was exposed and isolated.Finally,dissected the lateral side of nodular masses,and then the "risk zone" was floated and resected with a directly decompressing the spinal cord.Preoperative and postoperative modified Japanese Orthopedic Association (JOA) score and neurologic functional recovery ratio were used to evaluate the surgical outcomes.Results Of the total 83 decompressed OLF segments,5 (6.0％) located in the upper thoracic spine (T1-T4),8 (9.6％) in the midthoracic spine (T5-T8),and 70 (84.4％) in the lower thoracic spine (Tg-L 1).The followed up ranged from 4 to 40 months,with an average of 21.7±9.9 months.The mean JOA score increased significant from 5.3±2.0 preoperatively to 8.8±1.8 at the final follow-up (t=1 1.566,P=0.001).Postoperative average JOA neurologic functional recovery rates were 63.2％±24.7％,including excellent in 15 cases,good in 11 cases and fair in 8 cases.The excellent and good rate was 76.5％.Twelve cases had transient CSF leakage because of dural defect.The dural defect was only treated by tightly suturing the paraspinal muscles,the subcutaneous tissue,and the skin layers.The CSF leakage lasted for 6 to 8 days after operation.Two cases with wound infection were treated with debridement and antibiotics and healed completely.One case with thoracic spinal cord transient incomplete paralysis due to a post-operative epidural hematoma was treated with an emergency operation and got recovered neurological function.Conclusion Zoning laminectomy has the advantages of safe manipulation and thorough decompression,which is an effective choice for the surgical treatment of thoracic OLF.

The evaluation of osteogenic potency of ligament cells in thoracic ossification of the ligamentum flavum and relevant transcriptome high-throughput sequencing analysis / 中华骨科杂志

Objective To investigate the osteogenic differentiation potency of ligament cells in thoracic ossification of the ligamentum flavum (TOLF) and analyze further by using transcriptome high-throughput sequencing.Methods Clinically,the patients with non-TOLF and TOLF (n=10 in each group) who underwent surgery in our hospital from October 2015 to April 2016 were included in this study.The primary ligament cells that derived from the two groups were separately cultured and induced osteogenesis with 15％ strength of cyclic mechanical stress for 12h and 24h using a device called Flexcell FX-4000.The ALP activity was determined to evaluate the osteogenesis using quantitative analysis and ALP staining assay.Real-time PCR and westernblotting were used to detect the mRNA and protein expression of osteogenic-related genes including ALP,BMP-2 and Osteocalcin.Then,three patients in each group were included in the study of transcriptome high-throughput sequencing and bioinformatics analysis using Illumina HiSeqTM 2500 sequencing platform to compare further.Results The morphology of the cells that derived from two groups was basically similar,all presented an elongate spindle-shape.To evaluate the ostogenesis,ALP activity assays including quantitative and staining assays were performed.Under microscope,the ALP staining in the TOLF group was higher than non-TOLF group and increased with the longer duration of stress induction.The result of semi-quantitative analysis showed the stained area and positive cells in TOLF group were more than non-TOLF group significantly at 0 h,and were increased with the induction.The results of quantitative analysis showed ALP activity in the TOLF group was significantly higher than non-TOLF group and were increased with the induction significantly all the time.But no significant change in ALP staining or quantitative analysis was found in non-TOLF.The results of real-time PCR indicated that the expression of ostegenic markers above in the TOLF group was more than non-TOLF group significantly except the expression of OCN at 0 h.The expression of the three ostegenic markers in TOLF group was increased with the stress induction for 12 h and 24 h significantly except the expression of BMP-2 and OCN at 12 h.The results of western-blotting indicated that the expression of the three ostegenic markers above in the TOLF group was more than non-TOLF group significantly except the expression of ALP at 0 h.The expression of the three ostegenic markers in TOLF group was increased with the stress induction for 12 h and 24 h,but only the expression of ALP at 24 h was significant.And no significant change in the expression of mRNA and protein was found in non-TOLF group.In the transcriptome analysis,671 genes of TOLF group were up-regulated and 314 genes were found to be down-regulated compared to the control group.In addition,22 significant GO terms associated with upregulated genes were found to be closely related to ossification.Conclusion TOLF ligament cells have high osteogenic differentiation potency,which could express obvious osteogenesis-related gene spectrum,and differentially expressed genes including L1RL1 、PTHLH、DKK1 、BMP6、SPP1 and FGF1 may be related with the osteogenic potency of ligament cells in thoracic ossification.

Heterotopic mesenteric ossification in a child: Case report / Osificación mesentérica heterotópica en un niño: informe del caso / Ossificação mesentérica heterotópica num menino: relatório do caso

The term heterotopic ossification refers to bone formation in normally non-ossifying tissue. It represents a benign, localized, self-limiting and well-circumscribed lesion, and the phenomenon is rather unusual in the immediate vicinity of bones. Likewise, it is very rare in soft tissues such as the gastrointestinal tract, where it is also known as heterotopic mesenteric ossification (HMO). Intra-abdominal heterotopic ossification (IHO) is also known as intra-abdominal myositis ossificans, mesenteritis ossificans, heterotopic mesenteric ossification, and heterotopic ossification of the intestinal mesentery. It is extremely rare and only approximately 30 cases have been reported in the literature since it was first described in 1983. This paper presents the case of a male 14 year-old patient diagnosed with mesenteric ossification who was treated by the pediatric surgeons. Additionally, the authors present a review of the medical literature regarding this condition.

El término osificación heterotópica se refiere a la neoformación de tejido óseo en sitios donde normalmente el tejido no se osifica. Es una condición benigna, localizada, bien definida y autolimitada; ocurre con mayor frecuencia en la vecindad inmediata de los huesos. Es muy raro que se presente en los tejidos blandos del tracto gastrointestinal, donde es conocida como osificación heterotópica del mesenterio (OHM). La osificación heterotópica intraabdominal (OHI) es además conocida como miositis osificante, mesenteritis osificante, osificación heterotópica del mesenterio y osificación heterotópica del mesenterio intestinal. Es una condición extremadamente rara, con solo 30 casos aproximadamente reportados en la literatura desde su primera descripción en 1983. Este artículo presenta el caso de un niño de 14 años con diagnóstico de mesenteritis osificante que fue tratado por un grupo de cirujanos pediátricos. Además, se presenta una revisión de la literatura médica sobre esta extraña condición.

O termo ossificação heterotópica se refere à neoformação de tecido ósseo em lugares onde normalmente o tecido não se ossifica. É uma condição benigna, localizada, bem definida e autolimitada; ocorre com maior frequência na vizinhança imediata dos ossos. É muito raro que se apresente nos tecidos macios do trato gastrointestinal, onde é conhecida como ossificação heterotópica do mesentério (OHM). A ossificação heterotópica intra-abdominal (OHI) é ademais conhecida como miosite ossificante, mesenterites ossificante, ossificação heterotópica do mesentério e ossificação heterotópica do mesentério intestinal. É uma condição extremamente rara, com só 30 casos aproximadamente reportados na literatura desde sua primeira descrição em 1983. Este artigo apresenta o caso de um menino de 14 anos com diagnóstico de mesenterites ossificante que foi tratado por um grupo de cirurgiões pediátricos. Ademais, apresenta-se uma revisão da literatura médica sobre esta estranha condição.

Reoperation for cervical myelopathy duo to progressing ossification of the posterior longitudinal ligaments in patients with expansive laminoplasty / 北京大学学报(医学版)

Objective:To retrospectively analyze the clinical data of the patients with reoperation for cervical myelopathy due to progressing ossification of the posterior longitudinal ligaments,with previous open-door expansive laminoplasty,and to evaluate the outcomes.Methods:From May 2006 to July 2012,a retrospective study was performed on a consecutive series of 17 patients with previous open-door expansive laminoplasty,who had received the reoperation for cervical myelopathy due to progressing ossi-fication of the posterior longitudinal ligaments.The reoperation was performed based on the clinical mani-festations and segments of responsibility.The anterior approaches were performed in 12 cases,and the posterior approaches in 5 cases.The correlation between the clinical factors and Japanese Orthopedic As-sociation (JOA)scores or the JOA recovery rate was evaluated by Pearson or Spearman correlation test. The pre-and post-operative JOA scores were analyzed by repeated measures ANOVA and the JOA recovery rates were compared with paired t test.Results:The mean follow-up was 137.5 months (range 60-348 months).There were no serious complications after surgical procedures.There was one case that had C5 palsy in the first operation and had recovery after one week.Another case had C5 palsy in the reoperation with posterior approach,which had recovery at the end of 6 months post-operation.Three cases had the cerebrospinal fluid leakage of the reoperation,with two cases in the anterior approaches and one case in the posterior approach.There was no significant correlation between the clinical variables and JOA scores or JOA recovery rates.The JOA scores of the patients in the first operation were improved from 9.4 ±4.1 to 12.8 ±2.8 (P<0.01),and the JOA recovery rate was 45.6%.The JOA scores of the reoperation were improved from 10.2 ±2.8 to 12.7 ±2.4 (P<0.05)at the end of 6 months and 14.3 ±1.9 (P<0.01)by the last follow-up.There were significant differences between the JOA recovery rates by the last follow-up (63 .2%)and at the end of 6 months (39 .3%)of the reoperation or 45 .6%of the first opera-tion (P<0.01).Conclusion:The reoperation for cervical myelopathy duo to progressing ossification of the posterior longitudinal ligaments can significantly promote the recovery of the spinal cord,based on the clinical manifestations combined with segments of responsibility of the imaging.

Treatment of the old terrible triad of the elbow without operative history / 北京大学学报(医学版)

Objective:To introduce the surgical techniques and treating results of the old “terrible triad”of the elbow.Methods:A retrospective analysis of 1 1 cases of old “terrible triad”of the elbow treated by the author from March 2009 to February 2014 were performed,with 9 males and 2 females;mean age was (31.82 ±8.66)years (17-45 years).The average time after injury was (6.36 ±2.50) weeks (4-12 weeks),with 7 cases on the left and 4 right.The combined injury included 2 cases with distal radius fractures,1 with ankle fractures,fractures of the distal radius and the head injury (minor epidural hematoma,no surgery),and 1 with Pilon fractures and L4 fractures (fixed at local hospital). All the patients had elbow stiffness and joint dislocation,and 2 patients had symptoms of ulnar nerve. Mason classification of radial head fractures:2 cases were type Ⅰ,5 were type Ⅱ,4 were type Ⅲ. Classification of the coronoid process:Regan &Morrey:1 was type Ⅰ,10 were type Ⅱ;according to O’Driscoll classification,all the fractures were tip fracture,one was the first subtype,10 were the second subtype.The elbow were released,the coronoid process were fixed by lasso suture combined with Kirschner wires.Radial head fractures were resected in 1 case,and replaced in 1 case,3 cases with no treatment,6 cases with osteotomy and 3.0 mm headless compression screw (HCS)fixation.The lateral collateral ligament complex and the common extensor tendon were repaired to the humeral lateral epicon-dyles,No.2 Ethibon was used in 2 cases through bone holes,and suture anchorsin the other 9 cases.All the patients were fixed by Stryker DJDⅡhinged external fixator to protect the bone and soft tissue.Re-sults:The average follow-up time was (38.36 ±21.92)months (19-77 months).All the patients had no obvious pain,instability and ulnar nerve symptoms in the last follow-up.The average elbow flexion was 134.09°±12.41°(100°-140°),average extension was -15.91°±14.46°(-40°-0°),range of flexion and extension was 118.18°±23.80°(70°-140°).Average pronation was 70.91°±26.63° (20°-90°),supination was 70.91°±26.63°(20°-100°).The range of motion (ROM)of forearm rotation was 150.91°±43.00°(40°-180°).Average Mayo elbow performance score (MEPS)was 96.36 ±5.04 (85 -100).X-ray showed that no degenerative changes.Five patients had heterotopic os-sifications,according to Hastings and Graham grading:1 case was grade Ⅰ,3 cases were grade ⅡA, 1 case was ⅡB.Conclusion:The old “terrible triad”of elbow with no operative history is difficult to treat.The elbow’s functions and stabilization can be recovered by thorough elbow release,repair of coro-noid process and anterior capsule,radial head fractures,lateral collateral ligament and the common ex-tensor tendon insertion,combined with hinged external fixator.Joint stiffness and heterotopic ossification are common complications.