Physionotes 1
Heterotrophic Ossifications: Current concepts. (Pape et. al. 2004)
- No clear mechanism
- Multifactorial with several risk factors
- Trauma is a Constant Feature
- Risk factors for TBI
- Spasticity of Limbs (Garland et. al. 1988)
- Decebrate posture (Flin et al 2002)
- Diffuse Axonal Injury (Gennarelli et al 1988)
- Prolonged Immobilization (Mielants et al 1975)
- Respiratory ventilation (Newman et al 1987)
- Risk factors after THR
- Male (Ahrengart et al 1989)
- Previous history of HO (Ritter et al 1977)
- OA with pre-existing heterotrophic bone (DeLee et al 1976)
- Ankylosing spondylitis (Sundaram et al 1986)
- Diffuse idiopathic skeletal hyperostosis (Fahrer et al 1988)
- Clinical features
- Accelerated bone healing
- Biochemical changes – Serunm alkaline phosphatase levels, Prostaglandin E2 (PGE2)
- Radiological Changes
- X-ray: extent of ossification (6 weeks to 2 months)
- Three-phase bone scintigraphy
- Flow studies
- Blood pool image
- Bone scan
- Pathophysiology
- Mesenchymal stem cells – ability to generate cartilage, bone, muscle, tendon, ligament and fat.
- Stimulating Events – proteins presents in soft tissues.
- Interleukin-1ß
- Many others
- Poorly understood
- Stimulating factors related to injury
- Serum of TBI patients promoted mitogenesis and cell division in a rat osteoblast cell culture.
- Local tissue environment
- Microvascular changes → hypoxemia paraarticular soft tissue → Metabolic changes → HO
- Mechanical Ventilation → local PH from acid to alkaline → systemic alkalosis → HO
- Treatment
- PT (Ellerin et al 1999)
- Assisted ROM with gentle stretch and terminal resistance training not beyond Pain-free range of movements. (Evans et al 1991)
- Medical Management
- No conclusive evidence for etidronate
- Radiotherapy
- Prophylactic – effective in preventing HO in arthroplasty
- Surgical Incision
- Timings of Surgery
- Traumatic HO – 6 months
- SCI – 12 months
- TBI – 18 months
- Better neuromuscular control = better outcomes
- CPM is beneficial after surgery
- HO continues to be poorly understood. Prevention is better than cure.
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