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Scientific Articles   |    
Neurovascular Entrapment Due to Combat-Related Heterotopic Ossification in the Lower Extremity
Elizabeth M. Polfer, MD1; Jonathan A. Forsberg, MD2; Mark E. Fleming, DO1; Benjamin K. Potter, MD3
1 Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address for E.M. Polfer: Elizabeth.m.polfer.mil@health.mil. E-mail address for M.E. Fleming: Mark.Fleming@med.navy.mil
2 Regenerative Medicine, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910, E-mail address: Jonathan.forsberg@med.navy.mil
3 Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889. E-mail address: Benjamin.k.potter.mil@health.mil
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  • Disclosure statement for author(s): PDF

All of the authors are employees of the U.S. Government and this work was prepared as part of their official duties. As such, there is no copyright to transfer. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, or the U.S. Government. Nothing in the presentation implies any Federal/DOD/DON endorsement.

Investigation performed at Walter Reed National Military Medical Center, Bethesda, Maryland



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Dec 18;95(24):e195 1-6. doi: 10.2106/JBJS.M.00212
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Abstract

Background: 

Heterotopic ossification is the ectopic formation of mature lamellar bone in nonosseous tissue. The prevalence of heterotopic ossification following combat injuries is much higher than civilian data would suggest. In certain cases, the aberrant bone formation can envelop major neurovascular structures in the lower extremity, leading to symptomatic neurovascular entrapment.

Methods: 

We describe five consecutive cases of heterotopic ossification leading to symptomatic neurovascular entrapment in the lower extremity as a result of blast trauma and present our method of patient assessment, preoperative planning, and surgical excision.

Results: 

Heterotopic bone was successfully excised without neurovascular injury in all patients. At a mean of twenty months (range, eight to forty-five months) postoperatively, all patients demonstrated continued improvement of their pre-excision function. All patients who had neuropathic pain had a decrease in the pain. Those with decreased joint motion regained motion once their wounds were stable. Sensory deficits resolved before motor deficits did. There was no recurrence of clinically relevant heterotopic ossification in this series.

Conclusions: 

Excision of heterotopic bone, particularly with concurrent neurovascular entrapment, can be associated with major short-term and long-term complications. With use of our treatment algorithm, involving careful preoperative planning and meticulous operative excision, heterotopic bone entrapping major neurovascular structures following severe extremity trauma can be safely excised with subsequent clinical improvement.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    References

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    Kemal Gökkuş, M.D (1); Selahattin Ozyurek, M.D. (2); Sagtas Ergin, M.D. (3); Ahmet Turan Aydın, M.D., Prof. (1)
    Posted on March 12, 2014
    Comments on this study
    (1) Orthopaedics and Trauma Deparment, Antalya Memorial Hospital, (2) Department of Orthopaedics and Traumatology, Aksaz Military Hospital, Marmaris, (3) Radiodiagnostic Department, Antalya Memorial H

    We thank the authors for this well-founded and well-documented article. We were impressed by the utilization of CT for construction of a three-dimensional(3-D) resin model that was used for both preoperative planning and intraoperative reference. We would like to express our comments to the authors on their study.

    Heterotopic ossification (HO) is the pathological new formation of mature lamellar bone in nonosseous or soft tissues. HO has been extensively studied and develops most commonly after traumatic brain and spinal cord injuries (neurogenic heterotropic ossification), electrical and thermal burns, acetabular and elbow fractures, and total hip arthroplasty procedures [2].

    Following most traumatic injuries in the civilian population, the formation of heterotopic ossification is relatively rare in the absence of head injury. The incidence following brain injury has been reported to vary between 11% and 22%. [3]. The most common joints to be affected are the hip, elbow and shoulder. After such an injury, an accelerated rate of fracture healing has also been reported with the formation of exuberant callus at fracture sites [4].

    The severity of brain trauma has an influence on the extent of HO near the hip joint and also on the rehabilitation process [5]. Brain injury is also considered to play a possible role in the development of HO [2]. Rates of heterotopic ossification formation exceed 50% only in the setting of femoral shaft fractures with concomitant head injury, although reported rates following acetabular and elbow fractures vary substantially[3].

    However we noticed in the authors’ series that all patients were injured by a high-energy blast and all had concomitant mild traumatic brain injury. Thus, it means the cases can be described as neurogenic heterotopic ossification leading to symptomatic neurovascular entrapment in the lower extremity as a result of blast trauma.

    A scan of literature showed us there were a few articles about gunshot wound and high velocity blast injury related heterotopic ossification which causes neurovascular entrapment. Federico et al.[6] reported three cases with heterotopic ossification around the hip; two of them had the story of mechanical ventilation regimen at their treatment period. Those three cases had no neurovascular entrapment.

    Potter BK et al.[7] performed an excellent cohort study (330 patients with 373 combat related amputations) and reported increased prevalence of heterotopic ossification; they also emphasized the importance of Raman spectroscopy at early detection of the heterotopic ossification. In their study, they also reported the cases which had neurovascular entrapment.

    Morasch et al.[8] reported a case of heterotopic ossification within a missile track around the hip without any brain injury. This case had no neurovascular entrapment. We agree with the authors about the rarity of cases that related with neurovascular entrapment. Thus, combinations of gunshot wound at the hip, sciatic nerve entrapment, heterotopic ossification without the existence of mechanical ventilation regimen at their treatment story or heterotopic ossification without the existence any degree of brain injury were very rare.

    But in October 2013, we published a case entitled ‘‘Myositis ossificans circumscripta, secondary to high-velocity gunshot and fragment wound that causes sciatica.’’[9] The patient had no brain injury. Despite the similarity of two cases (case 1, case 5) of the author and our case with regard to nerve entrapment (sciatic nerve ) due to combat related heterotopic ossification,our case presented without brain injury. This feature gave our case a special value in the recent literature.

    We would like stress the rarity of our published case which addressed the non-neurogenic myositis ossificans secondary to high velocity gunshot and fragment wound that causes sciatica. Also we would like stress the contribution to the literature with one patient who had non-neurogenic myositis ossificans secondary to high velocity gunshot and fragment wound that causes sciatica.

    References

    1. Polfer EM, Forsberg JA, Fleming ME, Potter BK. Neurovascular entrapment due to combat-related heterotopic ossification in the lower extremity. J Bone Joint Surg Am. 2013 Dec 18;95(24):e1951-6. doi: 10.2106/JBJS.M.00212.
    2. Federico MD, Andersen RC, Ledford CL, et al. Heterotopic ossification secondary to high-velocity gunshot and fragment wounds about the hip: a report of three cases. J Trauma 2009;67:E29–32.
    3. Potter BK, Forsberg JA, Davis TA, et al. Heterotopic ossification following combat-related trauma. J Bone Joint Surg Am 2010;92(Suppl 2):74–89.
    4. Pape HC, Lehman U, van Griensven M, Gaensslen A, von Glinski S, Krettek C. Heterotopic ossifications in patients after severe blunt trauma with and without head trauma: incidence and patterns of distribution. J Orthop Trauma. 2001;15:229–237.
    5. Ebinger T, Roesch M, Kiefer H, Kinzl L, Schulte M. Influence of etiology in heterotopic bone formation of the hip. J Trauma. 2000;48: 1058–1062.
    6. Federico MD, Andersen RC, Ledford CL Potter BK, Gajewski DA, Frisch HM. Heterotopic ossification secondary to high-velocity gunshot and fragment wounds about the hip: a report of three cases. J Trauma 2009;67:E29–32
    7. Potter BK, Forsberg JA, Davis TA, Evans KN, Hawksworth JS, Tadaki D, Brown TS, Crane NJ, Burns TC, O'Brien FP, Elster EA.Heterotopic ossification following combat-related trauma. J Bone Joint Surg Am. 2010 Dec;92 Suppl 2:74-89. doi: 10.2106/JBJS.J.00776.
    8. Morasch MD, Shoup M, Marshall WJ, Maull KI. Heterotopic bone formation within a missile track. J Accid Emerg Med 1996;13:227–9.
    9. Gokkus K, Sagtas E, Suslu FE, Aydin AT. Myositis ossificans circumscripta, secondary to high-velocity gunshot and fragment wound that causes sciatica. BMJ Case Rep. 2013 Oct 17;2013. pii: bcr2013201362. doi: 10.1136/bcr-2013-201362.

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