Early diagnosis of heterotopic ossification among patients admitted to a neurological Post-Intensive Care Rehabilitation Unit.

BACKGROUND: Heterotopic ossification (HO) is defined as the formation of endochondral bone within soft tissue. Non-genetic forms, mainly corresponding to a consequence of bone, brain or spinal cord injury, are the most common. HO leads to important functional limitations and alteration of quality of life. To our knowledge, the time between brain, bone, or spinal cord injury and clinical suspicion of HO has never been studied. By admitting patients with severe neurological disorders, we hypothesized that the prevalence of HO in neurological post-intensive care rehabilitation units (PICRU) might be significant as these patients have recognized risk factors for HO. AIM: This study aimed to investigate HO among patients admitted to a neurological PICRU with two objectives: 1) to describe the prevalence of HO in PICRU; 2) to assess the time between neurological disorder, clinical suspicion of HO and radiological diagnosis. DESIGN: A monocentric retrospective cohort study. SETTING: PICRU in our public university teaching hospital. This inpatient referral department is specifically dedicated to the early discharge from Intensive Care Units (ICU) of patients with severe neurological impairment who need rehabilitation. POPULATION: We study all patients admitted between April 2016 and January 2019. One hundred twenty-five subjects were admitted for a rehabilitation program after neuro-trauma or stroke. We included all first-time stays in PICRU lasting 7 days or longer. METHODS: Retrospective data extraction using administrative data from an electronic patient management program was done to select eligible subjects. Included subjects were then identified by a retrospective review of electronic inpatient medical records after patient discharge. Data of interest were collected from these same medical records. RESULTS: Forty-four HO were diagnosed in 24 subjects (24/125; 19%), with a median number of 2 [1; 2] HO per subject. Neurological trauma was the main reason for admission to ICU (89/125; 71%) and half of patients had a traumatic brain injury (TBI) (67/125; 54%). The diagnosis of HO was made in PICRU in 75% of cases. Clinical suspicion of HO (autonomic dysfunction, local inflammatory signs, pain, or reduced joint range of motion) was made 6 [5; 7] weeks after admission to ICU. Radiological confirmation of clinical suspicion or fortuitous diagnosis by imaging (50% of the cases) occurred 8 [7; 12] weeks after admission to ICU. The median time of clinical suspicion or radiological diagnosis was 1 week after admission to PICRU. CONCLUSIONS: HO is a sub-acute complication which develops in patients admitted to ICU for severe central nervous system disorders as clinical suspicion or radiological confirmation of diagnosis was made within the first week after admission in neurological PICRU (i.e. 6 to 8 weeks after ICU admission). CLINICAL REHABILITATION IMPACT: As treatment for HO may at least partially improves rehabilitation and quality of life, we recommend a systematic screening in PICRU patients for HO by clinical examination supplemented by imaging in case of suspicion.

Post-stroke bilateral heterotopic ossification: An acute problem with long-lasting consequences.

Heterotopic ossification (HO) is a complication of injury to the central nervous system in which production of lamellar bone within the soft tissues occurs resulting in pain, reduced range of motion (ROM) and loss of functional capacity. Heterotopic ossification is rarely seen in stroke patients and mostly affects the paretic side. In this article, we present a case of established bilateral HO of the hips soon after stroke onset. A 77-year-old female patient with a five-month history of stroke presented to our rehabilitation clinic. Physical examination revealed sensorimotor aphasia, right-sided hemiplegia, bilateral painful limited ROM of the hips and left knee contracture. An anteroposterior X-ray of the pelvis revealed previously undiagnosed bilateral HO of the hips. The patient and her relatives declined operative interventions. The patient was discussed in the departmental meeting and it was agreed that she would not be able to partake in an active inpatient rehabilitation program. She was discharged with a home exercise plan. This case highlights the importance of HO, of both the paretic and non-paretic side, being included in the differential diagnosis of post-stroke patients presenting with joint pain and reduced ROM, both acutely and in the long-term. This may aid the timely diagnosis and management of HO, a pathology which has detrimental effects on functionality.

Nonsurgical Management of Heterotopic Ossification in a Runner.

A 51-year-old man was referred to physical therapy with right calf and anterior lateral lower-leg pain that had begun 3 weeks prior. Radiographs ordered by his physician identified calcific changes within the mid-posterior lower leg. Computed tomography was ordered to further characterize the lesion and identified heterotopic ossification in the right soleus. The patient refrained from running for 3 weeks and had complete resolution of pain. Following 5 weeks of physical therapy, the patient was able to increase his distance and remain pain free. J Orthop Sports Phys Ther 2019;49(9):676. doi:10.2519/jospt.2019.8491.

Stylohyoid Syndrome.

A 26-year-old male presented with an ache deep to the angle of the left mandible and moderate, constant pain with swallowing, symptoms that had begun 3 years earlier. He was diagnosed with Eagle syndrome, characterized by cervical oropharynx pain due to an elongated styloid process. The patient consulted a physical therapist, who instructed the patient on a home exercise program based on imaging and examination findings. Six weeks later, the patient reported that he was able to swallow with only minimal, intermittent discomfort. J Orthop Sports Phys Ther 2019;49(8):621. doi:10.2519/jospt.2019.8759.

Cochlear implantation in patients with ossified cochleas.

PURPOSE: The timing of CI for postmeningitic deafness is controversial and differential outcomes have been reported. To review and share our surgical and auditory outcomes. MATERIALS AND METHODS: 17 patients with ossified cochleas who received CI were enrolled. Clinical data including the cause of cochlear ossification, preoperative examination, onset of deafness, age at implantation, surgical findings, and relevant auditory outcomes was analysed. RESULTS: Cochlear ossification was observed in 53% of patients with HRCT, whereas the corresponding value for MRI was 59%. Patients in both stage I and II received complete insertion of the electrode array, however, stage III patients only received partial insertion. 1 patient in stage II received bilateral CI. Hearing tests showed increased average hearing threshold for stage III patients than those in stage I and II (P < 0.05). CAP scores were much lower for stage III patients than those in stage I and II (P < 0.05). Postlingual deafness patients showed higher SIR scores than prelingual deafness children (P < 0.05). CONCLUSIONS: HRCT and MRI have comparable value in predicting the occurrence of ossification in cochleas. We recommend fast surgical intervention in the patients with bilateral profound postmeningitic deafness. If possible, bilateral cochlear implantation is recommended.

Our 35 years' experience on postburn heterotopic ossification: A three-step treatment.

Our retrospective study of burn patients presents a three-step treatment of heterotopic ossification: excision surgery, early rehabilitation, and analgesia. We included patients admitted to the department for treatment of postburn heterotopic ossification between January 1, 1979, and September 30, 2015. The mean age at the time of the burn was 43.3 years. Men accounted for the majority of burn patients who developed an osteoma (70.8%). The mean total skin area burned was 38.4%. No osteoma justifying surgery was found for any patient with a total burned skin area less than 19%. The burned zones were related to the osteoma development in 94.3% of cases. On average, the surgery took place 10.8 months after the burn. The osteotomy was accompanied by surgical treatment of a contracture in 37.1% of patients. Most of the osteomata were found at the elbows (30), followed by the shoulders (3), and finally the knees (2). Rehabilitation began on D0 after the surgery, except if a flap or a thin-skin graft was used. Regarding analgesia, opiates were prescribed systematically during the immediate postoperative period. Elbow range of motion on flexion improved by a mean of 84.1°. During the postoperative period, we found 2 recurrences of osteoma and 1 elbow hematoma in two separate patients. There were no postoperative infections or neurological sequelae. Our retrospective French study confirmed results found in the international literature. The three-step treatment - excision surgery, early rehabilitation, and antalgia - seems to be the best means of treating osteoma with satisfactory results. Surgery is indicated only in the case of functional impairment and not simply based on imaging.

Occurrence and predictive factors of heterotopic ossification in severe acquired brain injured patients during rehabilitation stay: cross-sectional survey.

OBJECTIVES: To report occurrence and identify patient's features and risk factors of heterotopic ossifications in patients with severe acquired brain injury in intensive rehabilitation centres. DESIGN: Multicentre cross-sectional survey. SETTING: A total of 48 severe acquired brain injury rehabilitation institutes. PARTICIPANTS: Traumatic and non-traumatic severe brain-injured patients ( N = 689) in rehabilitation centres on 28 May 2016. MAIN OUTCOME MEASURE: Occurrence of heterotopic ossifications diagnosed by standard radiological and/or sonographic evaluation on the basis of clinical suspicion. RESULTS: Heterotopic ossification occurred around one or more joints in 94/689 patients (13.6%) with a significantly higher prevalence in young males. Occurrence did not significantly differ in relation to aetiology (16.3% traumatic, 19.2% anoxic, 11.7% vascular and 11.5% other). Prevalence was significantly higher in patients with diffuse (23.3%) rather than focal brain lesions (12.4%) or unspecified lesions (11.2%; chi-square = 7.81, df = 2, P = 0.020); longer duration of coma ( P = 0.0016) and ventilation support ( P = 0.0145); paroxysmal sympathetic hyperactivity (22.6% versus 11.6%; chi-square = 10.81, df = 1, P = 0.001); and spasticity (22.7% versus 10.1%; chi-square = 18.63, df = 1, P < 0.0001). A longer interval between acute brain injury and admission to rehabilitation centre was significantly associated with higher frequency of heterotopic ossifications. CONCLUSION: Occurrence of heterotopic ossifications is frequent in patients with severe traumatic and non-traumatic brain-injury in rehabilitation centres. Our study confirms male gender, young age, paroxysmal sympathetic hyperactivity, spasticity, longer duration of coma and ventilation and longer interval between brain injury onset and admission to rehabilitation centre as possible risk factors. Further studies are necessary to investigate the role of early appropriate rehabilitation pathways to reduce occurrence of heterotopic ossifications.

Osificación heterotópica neurógena. Veinte años después de una lesión medular traumática / Neurogenic heterotopic ossification. Twenty years after a traumatic spinal cord injury

Paciente con lesión medular cervical C8-D1 postraumática desde hace 22 años, ASIA B, que inicia de forma aguda un cuadro de eritema e induración en la cara anterointerna del muslo derecho. La exploración y las pruebas complementarias concluyen que se trata de una osificación heterotópica neurógena (OHN), aunque no presenta factores de riesgo para su desarrollo. Se inicia tratamiento con prednisona y etidronato disódico con mejoría clínica y radiológica, aunque en el último control de imagen persiste la calcificación. La OHN es una complicación común en el lesionado medular traumático durante la fase aguda o subaguda. Sin embargo, apenas se han descrito casos años después de la lesión, y los que se han publicado hacen referencia a la presencia de algún factor de riesgo predisponente. En el caso que se describe, la dificultad para un correcto diagnóstico condicionó un tratamiento tardío, aunque la evolución clínica fue favorable (AU)

The case of a patient with a post-traumatic C8-D1 spinal cord ASIA B injury that occurred 22 years ago is presented. The patient initiated with acute erythema and induration at the anteromedial aspect of the right thigh. Examination and complementary tests confirmed the diagnosis of neurogenic heterotopic ossification (NHO). However, the patient did not have risk factors for NHO development. Treatment was started with prednisone and etidronate disodium with clinical and radiological improvement. Nonetheless, calcification persisted in the last imaging control. NHO is a common complication in the acute or subacute phase of post-traumatic spinal cord injuries. However, cases have been rarely reported in the years following the injury. Those found in the literature include predisposing risk factors. In our case, the difficulty to reach a correct diagnosis led to late treatment. Even so, the outcome was favorable (AU)

Heterotopic ossification of the elbows in a major petrol burn.

A case of a young man who developed heterotopic ossification (HO) in his elbows following an accident where he sustained petrol burns to over 60% of his body. His injuries necessitated intubation, escharotomies and a protracted intensive care unit stay that was complicated by septicaemia. Several weeks after the injury, he was diagnosed with HO in his right elbow, followed by the left elbow a week later. He was commenced on an non-steroidal anti-inflammatory drug, a long-term course of a bisphosphonate and regular physiotherapy. He is now waiting for the HO bone to mature before having definitive excision of his lesions in 12-18 months time.

Neurogenic heterotopic ossification: epidemiology and morphology on conventional radiographs in an early neurological rehabilitation population.

OBJECTIVE: To retrospectively evaluate neurogenic heterotopic ossification in an early neurological rehabilitation population (phases B and C) with respect to epidemiology and morphology on conventional radiographs. MATERIALS AND METHODS: Over a 4-year period, 1,463 patients treated at a clinic for early neurological rehabilitation were evaluated for clinical symptoms of neurogenic heterotopic ossification. In case of clinical suspicion, plain radiographs of the expected sites were obtained. If heterotopic ossification was detected, the initial and subsequent radiographs were retrospectively analyzed for sites, size, and morphology. Immature lesions were categorized as small (<10 mm) or large (10-100 mm). RESULTS: The prevalence rate of neurogenic heterotopic ossification was 2.05%. The condition was most common in young male adults. The hip was the most common site accounting for more than half of the cases. Two or more ossifications were seen in 56.7% of the affected patients with approximately two-thirds showing bilateral symmetric involvement of corresponding joint regions. The size of ossifications strongly varied interindividually. Small immature lesions demonstrated less progression in size than large lesions during maturation (P < 0.05). CONCLUSION: Standard radiographs, as a fast and inexpensive technique, allow the expected size progression of heterotopic ossifications during maturation to be estimated, which is relevant in terms of therapeutic decisions, patient mobilization, and neurological rehabilitation.

Fiebre alta asociada a osificación heterotópica en un lesionado medular / High fever with heterotopic ossification in a patient with spinal cord injury

Paciente de 27 años que 9 semanas después de una paraplejía postraumática aguda T5, grado A de ASIA, presenta un cuadro febril de hasta 40°C con buen estado general. En la exploración clínica sólo encontramos como posible foco un área de edema sin aumento de temperatura en la región proximal de la extremidad inferior izquierda (MII). Las pruebas complementarias realizadas aportan como hallazgos una elevación de la proteína C reactiva (PCR), sin leucocitosis ni aumento de las fosfatasas alcalinas (PA). En la gammagrafía ósea encontramos un foco de hipercaptación indicativo de osificación heterotópica paratrocantéreo izquierdo, la resonancia magnetica (RM) sólo aporta un foco de edema inespecífico, el eco-Doppler venoso es normal. Tras dos ciclos de tratamiento con AINE y bisfosfonatos se normalizaron los datos analíticos. La osificación heterotópica es común en pacientes con lesión medular, pero no es habitual que vaya asociada a cifras tan elevadas de fiebre, ni elevación de las fosfatasas alcalinas. La PCR y gammagrafía ósea sirvieron como marcadores de la enfermedad y de su resolución. El ibuprofeno y el etidronato sódico fueron nuestros fármacos de elección resolviéndose el cuadro con buena adaptación funcional acorde con la lesión. En casos de mala evolución es fundamental el diagnóstico y el tratamiento precoces (AU)

A 27-year old patient who presented with a fever of up to 40°C with good overall condition nine weeks after an acute T5 posttraumatic paraplegia (grade A on the ASIA Scale). In the physical examination, the only significant finding has been an area of edema with no increase in temperature in the proximal lower left limb (LLL). The complementary blood tests revealed an elevation in the C-reactive protein (CRP) levels without leukocytosis or increase in alkaline phosphatase (AP). The bone scintigraphy revealed an area of hyperuptake that is suggestive of the presence of left trochanteric heterotopic ossification. The MRI only showed a nonspecific area of edema, and a venous Doppler ultrasound did not reveal any abnormal findings. After two cycles of treatment with NSAIDs and bisphosphonates, the blood test returned to normal levels. Heterotopic ossification is a common finding in patients with spinal cord injury. However, its association with high fever or such a high alkaline phosphatase level is unusual. The CRP level and bone scintigraphy were used as biomarkers of disease and of its resolution. The treatment of choice consisted of ibuprofen and sodium etidronate, which resulted in complete resolution with good functional adaptation. In the event of poor evolution of the disease, both early diagnosis and treatment are essential (AU)

[Cochlear implantation in the ossified cochlear].

OBJECTIVE: To explore the problems and describe clinical experiences associated with multichannel cochlear implantation in patients with cochlear ossification. METHODS: Seven cochlear implant cases with bilateral cochlear ossification from 1996 to 2006 in Beijing Tongren Hospital were retrospectively reviewed, 4 of which were the consequence of meningitis. Three patients' cochlear were completely ossified, 1 patient's tympanic scala was completely ossified, 1 patient's cochlear was partially ossified, and 2 patients' cochlear were partially fibrotic. This article addressed the components of the preoperative evaluation, surgical decision-making, and specific techniques for cochlear implant array insertion in all kinds of ossified cochlea. RESULTS: Gusher was found in 1 case but less serious than that with inner ear malformations. The electrodes were inserted in the cochleostomy in full length in 4 cases, 1 case gave up, and the cochlear implant array were partially inserted in the remains. No serious complications occurred after implantation. All patients had auditory sensations. The impedance of the electrodes, the T level, C level and the hearing threshold were slightly higher than that of the normal cochlear implantation. CONCLUSIONS: The key influencing factor of ossified cochlear patients were the degree of the disease and whether the electrode implanted completely or not. So, the profound sensorineural hearing loss patients after meningitis should be paid more attention. Patients with ossified cochlear could be benefit from cochlear implantation.

Heterotopic ossification as an unusual complication after Guillain-Barré syndrome: a case report.

Heterotopic ossification (HO) is the abnormal development of bone within soft tissue. It is frequently encountered after traumatic brain injury or spinal cord injury, rather than lower motoneuron disease. It has been reported as a rare complication in Guillain-Barré syndrome (GBS). We present the case of a 31-year-old woman who suffered from pain and swelling with limitation of the passive range of motion on right hip joint, and who had been diagnosed with GBS about 1 year previously. She was wheelchair-bound and had incomplete tetraplegia with flaccidity. She was diagnosed as HO based on the radiologic imaging study. She did not reveal any encephalopathy-related symptoms or signs, and hypercalcemia, and/or related metabolic derangement during 1.5-year follow-up period. Owing to the paucity of other causative factors, we presumed that the long-time hypomobility, even though not accompanied by hypercalcemia, played a major role for the development of HO. Early active rehabilitative management was initiated. The outcome is not promising because of her long-standing paralyzed state; however, it was possible to prevent the aggravation of HO.