Post-laparotomy heterotopic ossification of the xiphoid process: A case report

BACKGROUND Heterotopic ossification(HO)represents all types of extraskeletal ossification in the body.It occurs in various areas,including the skin,subcutaneous tissue,muscle,and joints.Surgical excision is recommended for symptomatic HO.Postoperative radiotherapy,oral nonsteroidal anti-inflammatory drugs,and topical sealants,such as bone wax,have been recommended as preventive measures.As HO is rare in occurrence,these recommendations are based on personal experiences,and there is a lack of information on individualized treatments depending on its location.CASE SUMMARY A 62-year-old male was admitted for symptomatic HO along a laparotomy scar.Surgical excision was performed for an 11 cm-sized ossification originating from the xiphoid process,and bone wax was applied to the excisional margin.However,the surgical wound failed to heal.After several weeks of saline-soaked gauze dressing,delayed wound closure was performed.The patient was finally discharged eight weeks after the excision.Because HO can occur in various areas of the body,a treatment strategy that may be effective for some may not be for others.Bone wax has been used as a topical sealant over excisional margins in the shoulder,elbow,and temporomandibular joints.However,in our case,its application on an abdominal surgical wound delayed its primary healing intention.The valuable lesson was that,when choosing a treatment method for HO based on available research data,its location must be considered.CONCLUSION Complete excision should be the priority treatment option for symptomatic HO along the laparotomy scar.Bone wax application is not recommended.Core Tip:Heterotopic ossification(HO)represents all types of extraskeletal ossification,and occurs in various areas,including the skin,muscle,and joints.There are some suggested treatment and preventive approaches for symptomatic HO,which include surgical excision and preventive measures such as postoperative radiotherapy,oral nonsteroidal anti-inflam-matory drugs,and topical sealants(bone wax).However,these recommendations are based on personal experiences limited to HO in certain locations.It is important to individualize our treatment approaches depending on its location.For symptomatic HO along the laparotomy scar,complete surgical excision should be the priority treatment option,and bone wax application is not recommended.

Post-traumatic heterotopic ossification in front of the ankle joint for 23 years:A case report and review of literature

BACKGROUND Heterotopic ossification(HO)refers to the formation of new bone in non-skeletal tissues such as muscles,tendons or other soft tissues.Severe muscle and soft tissue injury often lead to the formation of HO.However,anterior HO of the ankle is rarely reported.CASE SUMMARY We report a patient with massive HO in front of the ankle joint for 23 years.In 1998,the patient was injured by a falling object on the right lower extremity,which gradually formed a massive heterotopic bone change in the right calf and dorsum of the foot.The patient did not develop gradual ankle function limitations until nearly 36 mo ago,and underwent resection of HO.Even after 23 years and resection of HO,the ankle joint was still able to move.CONCLUSION It is recommended that the orthopedist should be aware of HO and distinguish it from bone tumor.

Heterotopic ossification beneath the upper abdominal incision after radical gastrectomy:Two case reports

BACKGROUND Heterotopic ossification(HO)is a rare clinical phenomenon that refers to bone formation in nonossifying tissues.CASE SUMMARY This report presents two cases of HO beneath the upper abdominal median incision after radical gastrectomy.The first patient had postoperative pain below the incision area.There were no signs of anastomotic leakage,and the wound healed.Computed tomography(CT)findings 2 wk postoperatively were negative for HO,but the 6-wk CT showed HO beneath the incision.The patient refused reoperation,and after conservative therapy,the pain was gradually relieved after 2 wk.In the second case,postoperative recovery was uneventful,and HO was only detected on routine follow-up CT after 4 mo.An anti-adhesion membrane was applied beneath the peritoneum in both patients.Our findings suggest that HO beneath the abdominal incision might form at approximately 1 mo postoperatively.It may cause intractable pain;however,reoperation is usually not required.CONCLUSION In our cases,we suspect that HO may be related to the use of foreign materials beneath the peritoneum,which needs to be further investigated.

Bilateral hip heterotopic ossification with sciatic nerve compression on a paediatric patient–An individualized surgical approach: A case report

BACKGROUND Neurogenic heterotopic ossification is an acquired serious complication described in patients with central nervous system disorders and defined by bone formation in non-osseous tissue.CASE SUMMARY We present an unusual case of a 13-yr-old boy presenting with hip pain and severe gait impairment 5 mo after the diagnosis of hemiplegia following a spontaneous intracerebral haemorrhage.Computed tomography revealed bilateral heterotopic ossification of both the paretic and the non-paretic limbs,with entrapment of the sciatic nerve.The choice of surgical or nonsurgical management of such patients depends on the timing of diagnosis,the symptoms,and the extent of maturation of the ossified lesions.Surgical resection remains the only treatment with proven,evidence-based effectiveness.The choice of surgical approach largely depends on the location of the ossified lesions.CONCLUSION We believe the plane of dissection presented is a satisfactory option for resection of a posteromedial mass and sciatic nerve release.

Non-Traumatic Intracranial Heterotopic Ossification: A Case from Turkey

Heterotopic ossification (HO) is the abnormal, non-neoplastic presence of lamellar bone in soft tissue. The ectopic formation of lamellar bone in non-osseus tissues secondary to traumatic injuries of the spinal cord or the brain is defined as Neurogenic HO. The pathophysiology of HO is not clear. But several theories like overactive humoral mechanisms after fracture healing, imbalance of pro-osteoinductive and anti-osteoinductive mediators located on the soft tissues and gene mutations in such as bone morphogenetic proteins-4 (BMP-4) are proposed. Casualty factors leading to increased risk of HO include older age, blast mechanism of injury, location of injury and traumatic brain injury. The aim of this paper is to demonstrate a case of HO located in the brain without history of trauma or any other risk factors.

Elevated Cobalt, Chromium and Molybdenum Levels in Peripheral Blood Have No Effect on the Development of Heterotopic Ossifications after Metal-on-Metal Total Hip Arthroplasty

Metal debris from metal-on-metal (MoM) total hip arthroplasties (THA) has been suspected to cause periprosthetic heterotopic ossifications (HO). We determined the influence of disseminated cobalt, chromium and molybdenum on the development of HO. Native blood samples from patients with 86 high-carbon and 16 low-carbon Co28Cr6Mo articulations were analysed by high-resolution inductively coupled plasma mass-spectrometry (HR ICP-MS). The results revealed that high-carbon metal-on-metal articulations showed lower metal blood levels (Co 1.03 to 1.60 μg/l, Cr 0.77 to 0.88 μg/l, Mo 0.45 to 0.56 μg/l) whereas low-carbon articulations achieved higher metal blood levels (Co 2.59 to 6.85 μg/l, Cr 1.25 to 3.55 μg/l, Mo 0.45 to 0.64 μg/l), but no correlation between metal ion blood level or carbon content and the development of HO could be found in these MoM articulations. Hence, metal debris from MoM articulation does not stimulate heterotopic bone formation despite other well-known local reactions.

Incidence and risk factors analysis of heterotopic ossification after cervical disc replacement

Background Cervical disc replacement （CDR） as a substitute for traditional fusion surgery has been widely used in treating degenerative cervical disc diseases.The objectives of this study were to assess the clinical and radiological findings for patients with heterotopic ossification （HO） following CDR and to detect the risk factors of HO after CDR.Methods A total of 125 patients with symptomatic cervical single-or double-level disc diseases,who underwent CDR procedure with Discover prosthesis in Department of Spine Surgery,Changzheng Orthopedics Hospital from March 2009 to March 2011,were enrolled in this retrospective study.Occurrence of HO was defined by the McAfee classification on cervical lateral X-rays in this study.Prosthesis vertebral ratio （PVR） was used to determine the matching degree between the cervical disc prosthesis and cervical vertebra.Logistic regression analyses were performed to determine the risk factors of HO.Variables evaluated for their association with HO occurrence included age,gender,high-intensity signal in spinal cord,preoperative range of motion （ROM）,postoperative ROM,operation level number,and PVR.Results Mean follow-up time was （26.4±5.8） months.All the patients had significant symptoms and neurological function improvements during the follow-up period.The ROM of the operated segment from the preoperative period to the last follow-up was relatively well maintained.The rate of HO in this cohort of patients,who underwent Discover disc,was 27.92％ per surgical level and 24.8％ per patient by the last follow-up.There were 19 patients （19.79％） with HO in the single-level group while 12 patients （41.38％） in the double-level group.Conclusions We identified preoperative high-intensity signal in spinal cord,postoperative ROM of surgical level,number of operation level,and PVR as significant risk factors for postoperative HO occurrence.

A Systems Biology Approach for Studying Heterotopic Ossification： Proteomic Analysis of Clinical Serum and Tissue Samples

Heterotopic ossification （HO） refers to the abnormal formation of bone in soft tissue. Although some of the underlying processes of HO have been described, there are currently no clinical tests using validated biomarkers for predicting HO formation. As such, the diagnosis is made radiographically after HO has formed. To identify potential and novel biomarkers for HO, we used isobaric tags for relative and absolute quantitation （iTRAQ） and high-throughput antibody arrays to produce a semi-quantitative proteomics survey of serum and tissue from subjects with （HO ＋） and without （HO-） heterotopic ossification. The resulting data were then analyzed using a systems biology approach. We found that serum samples from subjects experiencing traumatic injuries with resulting HO have a different proteomic expression controls. Subsequent quantitative ELISA identified profile compared to those from the matched five blood serum proteins that were differentially regulated between the HO-- and HO- groups. Compared to HO- samples, the amount of insulin-like growth factor I （IGF1） was up-regulated in HO＋ samples, whereas a lower amount of osteopontin （OPN）, myeloperoxidase （MPO）, runt-related transcription factor 2 （RUNX2）,and growth differentiation factor 2 or bone morphogenetic protein 9 （BMP-9） was found in HO ＋ samples （Welch two sample t-test; P 〈 0.05）. These proteins, in combination with potential serum biomarkers previously reported, are key candidates for a serum diagnostic panel that may enable early detection of HO prior to radiographic and clinical manifestations.

HETEROTOPIC OSSIFICATION IN ADENOCARCINOMA OF THE COLON

Heterotopic ossification occurring in large-bowel carcinoma and/or its metastasis is a rare entity. There had been only 33 cases reported in the literature by 1992. Isolated wound recurrence after surgery for colorectal carcinomas is also relatively uncommon. Hughes et al studied the surgery results of 1 603 patients with large-bowel cancer and found 11 patients (0.7%) having recurrent tumor in the abdominal wall scar. The finding of malignant epithelial cells and benign bone trabeculae in adenocarcinoma of the colon and its incisional recurrence is an exceedingly rare phenomenon. Herein, an unusual case of colonic carcinoma with an isolated abdominal wall scar recurrence was presented, in which heterotopic ossification was associated with primary and metastatic adenocarcinomas.

Development of an experimental method for well-controlled blast induced traumatic limb fracture in rats

Heterotopic ossification(HO)is a consequence of traumatic bone and tissue damage,which occurs in 65%of military casualties with blast-associated amputations.However,the mechanisms behind blast-induced HO remain unclear.Animal models are used to study blast-induced HO,but developing such models is challenging,particularly in how to use a pure blast wave(primary blast)to induce limb fracture that then requires an amputation.Several studies,including our recent study,have developed platforms to induce limb fractures in rats with blast loading or a mixture of blast and impact loading.However,these models are limited by the survivability of the animal and repeatability of the model.In this study,we developed an improved platform,aiming to improve the animal's survivability and injury repeatability as well as focusing on primary blast only.The platform exposed only one limb of the rat to a blast wave while providing proper protection to the rest of the rat's body.We obtained very consistent fracture outcome in the tibia(location and pattern)in cadaveric rats with a large range of size and weight.Importantly,the rats did not obviously move during the test,where movement is a potential cause of uncontrolled injury.We further conducted parametric studies by varying the features of the design of the platform.These factors,such as how the limb is fixed and how the cavity through which the limb is placed is sealed,significantly affect the resulting injury.This platform and test setups enable well-controlled limb fracture induced directly by pure blast wave,which is the fundamental step towards a complete in vivo animal model for blast-induced HO induced by primary blast alone,excluding secondary and tertiary blast injury.In addition,the platform design and the findings presented here,particularly regarding the proper protection of the animal,have implications for future studies investigating localized blast injuries,such as blast induced brain and lung injuries.

Pulsed lavage in joint arthroplasty: A systematic review and metaanalysis

BACKGROUND Knee and hip osteoarthritis affects millions of people around the world and is expected to rise even more in frequency as the population ages.Joint arthroplasty is the surgical management of choice in these articulations.Heterotopic ossi-fication and radiolucent lines formation are two frequent problems faced in hip and knee replacements respectively.Some studies show that the usage of pulsed lavage may prevent their formation.AIM To compare pulsed lavage to standard lavage in joint arthroplasty.METHODS PubMed,Cochrane,and Google Scholar(page 1-20)were searched till December 2023.Only comparative studies were included.The clinical outcomes evaluated were the heterotopic ossification formation in hip replacements,radiolucent lines formation,and functional knee scores in knee replacements.RESULTS Four studies met the inclusion criteria and were included in this meta-analysis.Pulsed lavage was shown to reduce the formation of radiolucent lines(P=0.001).However,no difference was seen in the remaining outcomes CONCLUSION Pulsed lavage reduced the formation of radiolucent lines in knee replacements.No difference was seen in the remaining outcomes.Furthermore,the clinical significance of these radiolucent lines is poorly understood.Better conducted randomized controlled studies and cost-effectivity studies are needed to reinforce these findings.

Port-site metastasis of unsuspected gallbladder carcinoma with ossification after laparoscopic cholecystectomy:A case report

BACKGROUND Unsuspected gallbladder carcinoma(UGC)refers to cholecystectomy due to benign gallbladder disease,which is pathologically confirmed as gallbladder cancer during or after surgery.Port-site metastasis(PSM)of UGC following laparoscopic cholecystectomy is rare,especially after several years.CASE SUMMARY A 55-year-old man presenting with acute cholecystitis and gallstones was treated by laparoscopic cholecystectomy in July 2008.Histological analysis revealed unexpected papillary adenocarcinoma of the gallbladder with gallstones,which indicated that the tumor had spread to the muscular space(pT1b).Radical resection of gallbladder carcinoma was performed 10 d later.In January 2018,the patient was admitted to our hospital for a mass in the upper abdominal wall after surgery for gallbladder cancer 10 years ago.Laparoscopic exploration and complete resection of the abdominal wall tumor were successfully performed.Pathological diagnosis showed metastatic or invasive,moderately differentiated adenocarcinoma in fibrous tissue with massive ossification.Immunohistochemistry and medical history were consistent with invasion or metastasis of gallbladder carcinoma.His general condition was well at follow-up of 31 mo.No recurrence was found by ultrasound and epigastric enhanced computed tomography.CONCLUSION PSM of gallbladder cancer is often accompanied by peritoneal metastasis,which indicates poor prognosis.Once PSM occurs after surgery,laparoscopic exploration is recommended to rule out abdominal metastasis to avoid unnecessary surgery.

Intervertebral bridging ossification after kyphoplasty in a Parkinson’s patient with Kummell’s disease:A case report

BACKGROUND The short-term therapeutic efficacy of kyphoplasty on Kummell’s disease is obvious.However,postoperative refracture and adjacent vertebral fracture occur occasionally and are difficult to treat.Parkinson's disease(PD)is a pathological disorder associated with heterotopic ossification.In a patient with PD,an intervertebral bridge was formed in a short period of time after postoperative refracture and adjacent vertebral fracture,providing new stability.CASE SUMMARY A 78-year-old woman had been suffering from PD for more than 10 years.Three months before operation,she developed lower back pain and discomfort.The visual analog scale(VAS)score was 9 points.Preoperative magnetic resonance imaging indicated collapse of the L2 vertebra.Kyphoplasty was performed and significantly decreased the severity of intractable pain.The patient’s VAS score for pain improved from 9 to 2.Fifty days postoperatively,the patient suddenly developed severe back pain,and the VAS score was 9 points.X-ray showed L2 vertebral body collapse,slight forward bone cement displacement,L1 vertebral compression fracture,and severe L1 collapse.The patient was given calcium acetate capsules 0.6 g po qd and alfacalcidol 0.5ug po qd,and bed rest and brace protection were ordered.After conservative treatment for 2 mo,the patient's back pain was alleviated,and the VAS score improved from 9 to 2.Computed tomography at the 7-mo follow-up indicated extensive callus formation around the T12-L2 vertebrae and intervertebral bridging ossification,providing new stability.CONCLUSION Kyphoplasty is currently a conventional treatment for Kummell's disease,with definite short-term effects.However,complications still occur in the long term,and these complications are difficult to address;thus,the treatment needs to be selected carefully.To avoid refracture,an interlaced structure of bone cement with trabeculae should be created to the greatest extent possible during the injection of bone cement.Surgical intervention may not be urgently needed when a patient with PD experiences refracture and adjacent vertebral fracture,as a strong bridge may help stabilize the vertebrae and relieve pain.

Preemptive targeted muscle reinnervation:the single incision approach should be avoided in trans‑tibial traumatic amputation

Dear Editor,Chronic pain is a significant concern after major lower limb amputations that often preclude prosthetic fitting,decrease ambulation,and impact the quality of life[1,2].In the last decade,targeted muscle reinnervation(TMR)has been proposed as a surgical strategy for treating or preventing symptomatic neuromas and phantomlimb phenomena in major amputees[1].This technique involves the transfer of an amputated mixed-motor and sensory nerve to a nearby recipient motor nerve[1,2].Unlike most surgical strategies that aim to hide or protect the neuroma,TMR gives the amputated nerves“somewhere to go and something to do”[2].In a randomized clinical trial on neuroma and phantom pain,Dumanian et al.[1]demonstrated that TMR reduces amputationrelated chronic pain at 1-year post-intervention when compared with the excision and muscle-burying technique,which remains the current gold standard.Valerio et al.[2]also proposed applying TMR at the time of major limb amputation for preventing chronic pain and found that TMR patients experienced less residual limb pain(RLP)and phantom limb pain(PLP)when compared with untreated amputee controls.

Nontraumatic Myositis Ossificans in a Muscle of Mastication

Myositis ossificans (MO) is an extraskeletal tumor-like lesion with bone formation, and is relatively rare in the head and neck region. We report herein a clinicopathological analysis of MO associated with a muscle of mastication. The patient was a 70-year-old Japanese woman who presented with a tumorous mass in the right parotid area and no history of trauma. The surgically excised tumorous lesion consisted of proliferating fibroblastic cells with no atypia in the central portion, and a formation of trabecular osteoid and/or bony tissue in the peripheral portion as the so-called “zonal phenomenon”. The final histological diagnosis was MO, and the lesion was located in the posterior belly of the digastric muscle on computer tomography. A review of the literature showed that many cases of MO predominantly affected the medial pterygoid and masseter muscle and showed a history of previous trauma. The present case represents a rare case of nontraumatic MO in the uncommon location of the posterior belly of the digastric muscle.

Cervical disc arthroplasty with ProDisc-C artificial disc： 5-year radiographic follow-up results

Background Cervical disc arthroplasty is an alternative surgery to standard cervical decompression and fusion for disc degeneration. Different types of cervical disc prosthesis are used in China. The aim of this study was to evaluate the radiographic outcomes of cervical arthroplasty using the ProDisc-C prosthesis.

影响人工耳蜗植入术效果的相关疾病

人工耳蜗植入（cochlear implantation，CI）的适应证非常严格，患者的选择有赖于术前耳科学、听力学检查，中耳、内耳的影像学检查及智力、交流能力等综合评估。最初手术仅局限于成人语后聋患者，随着CI的发展，手术适应证不断放宽，一些曾被视为手术禁忌证，如耳蜗骨化、内耳畸形及听神经病等患者也接受CI，并取得满意的效果。

FIBRODYSPLASIA OSSIFICANS PROGRESSIVA IN CHILDREN:FIVE CASES AND REVIEW OF THE LITERATURE

ObjectiveTo describe the clinical manifestations and radiographic characteristics of fibrodysplasia ossificans progressiva (FOP). MethodsThe radiographs and lesion photographs of five patients aged between 23 months and 17 years diagnosed as FOP were presented and the literatures were reviewed. ResultsClinical features were shortened great toes at birth, episodic soft tissue swellings, pain in the subcutaneous tissues of neck, back, shoulders, and extremities, hard lumps at back and spine, and restricted mobility of neck and arms. Radiological findings included short digit with hallus valgus, scoliosis, exostoses on many bones, and ossification of ligament. The characteristic subcutaneous soft tissues included masses or ossifications of neck, back, extremities, and shoulders. ConclusionThe short terminal phalanges of the thumbs and intermittently progressive heterotopic ossifications of the striated muscles and soft tissues suggest that FOP should promptly get early genetic consultation.