Extracorporeal shockwave therapy (ESWT) has been reported to be a safe and effective method for decreasing pain and relieving range of motion (ROM) limitations caused by neurogenic heterotopic ossification (NHO), though there has been no report that it might cause hematoma if applied to NHO. We hereby report a case of massive hematoma after ESWT, specifically the radial shockwave therapy (RSWT) device at both hips in a 49-year-old female patient with NHO. She had developed NHO after extensive subarachnoid hemorrhage. We had applied RSWT according to the previous report. The pain and the ROM limitations were gradually improved. Six weeks later, she reported pain and ROM limitations on the right hip. From a medial aspect, swelling and bruising of the right thigh could be seen. Magnetic resonance imaging and ultrasonography suggested a large hematoma between right hip adductor muscles. The symptoms disappeared after conservative treatment for one month, and subsequent follow-up imaging studies demonstrated resolution of the hematoma.
Citations
Heterotopic ossification (HO) is frequently seen on rehabilitation units after spinal cord injuries, fractures, brain injuries, and limb amputations. Currently, there is no effective treatment for HO other than prophylaxis with anti-inflammatory medications, irradiation, and bisphosphonate administration. These prophylactic treatments are not effective for managing ectopic bone once it has formed. Here we describe three cases of established neurogenic HO treated with radiation therapy (RT). All patients had decreased serum alkaline phosphatase (ALP) and bone-specific ALP levels with decreased pain but increased range of motion immediately after RT. Post-treatment X-rays revealed no further growth of the HO. All patients maintained clinical and laboratory improvements 4 or 6 months after the RT. Our results suggest that RT is safe and effective in decreasing pain and activity of neurogenic HO.
Citations
Neurogenic heterotopic ossification (NHO) is a process of benign bone formation and growth in soft tissues surrounding major synovial joints and is associated with central nervous system (CNS) injuries. It is a common complication in major CNS injuries, such as traumatic brain injury, spinal cord injury, and stroke. Here, we report the case of a 72-year-old male, who experienced a traumatic brain injury and painful chronic NHO around the left hip joint. Three applications of extracorporeal shock wave therapy (ESWT) were administered to the area of NHO, which resulted in pain relief and an improvement in the loss of motion in the left hip joint. Improvements were also noted in walking performance and activities of daily living, although the size of NHO remained unchanged. Therapeutic effects of ESWT lasted for 12 weeks.
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Early diagnosis and treatment of heterotopic ossification (HO) is essential to the prevention of complications. It is difficult to diagnose HO in its initial phase because non-specific clinical manifestations, laboratory findings and imaging findings of immature HO may mimic other diseases such as cellulitis, osteomyelitis, thrombophlebitis, deep vein thrombosis and local infection with abscess. We experienced two cases of HO, which were misdiagnosed as pyomyositis at first by clinical signs and MRI findings indicating the deep infection; the extensive intramuscular ossification appeared later on. We observed an increase of C-reactive protein and creatine kinase followed by the elevation of alkaline phosphatase with abnormal triphasic bone scan. The trajectory of these biomarkers was analyzed to get more insight into the early stages of HO along with the imaging findings. Although our cases cannot be generalized as typical of immature HO, they clearly demonstrate that the change of specific biomarkers with a careful history taking and physical examination should be noted to detect HO as early as possible while avoiding confusion with other mimicking conditions.
Citations
Method: The medical records of 201 patients with spinal cord injury were reviewed. Duplex ultrasound and/or venography were used for the diagnosis of deep vein thrombosis and 3 phase bone scan and/or plain radiologic studies were used for the diagnosis of heterotopic ossification.
Results: Whereas the incidence of heterotopic ossification and deep vein thrombosis in this population were 10.0% and 4.5%, respectively, 55.5% of the individuals with deep vein thrombosis developed heterotopic ossification. The overall incidence of coexistence of deep vein thrombosis and heterotopic ossification was 2.5%. The significant difference between the occurrence of heterotopic ossification and deep vein thrombosis in this SCI population reached statistical significance (Fisher's exact test p＜0.005).
Conclusion: The results of this study suggest that there exists an association between the occurrence of deep vein thrombosis and heterotopic ossification following SCI. (J Korean Acad Rehab Med 2003; 27: 349-354)
Heterotopic ossification(HO) is a formation of ectopic bone around joints in the soft tissues. It often occurs after the central nervous system injuries, burns, and joint replacements. It causes an important morbidity in the rehabilitation population. The etiology, pathogenesis, prophylaxis, and treatment of HO are still unclear even though there have been many investigation on the prevention of HO among the patients with spinal cord injury. The prevention effect of EHDP on HO formation still remains controversial. A randomized clinical trial was performed to assess the prevention effect of EHDP on HO formation in 73 patients (control group: 40 cases, study group: 33 cases) as a prospective study. EHDP was given to the study group for 12 weeks; 20 mg /kg /day for 2 weeks followed by 10 mg/kg/day for 10 weeks. The patients were followed up with the serial physical examinations, serum alkaline phosphatase levels, and plane radiographs for one year period after the injury.
The results revealed that HO developed in eight cases(20.0%) among the control group and two cases(9.1%) among the study group. There was no significant difference in the incidence of HO between two groups(p＞0.05). The mean duration from the injury to the detection of HO was 113 days. Twelve of 15 HO sites(80.0%) were detected within the 6 months after injury. Seven patients developed the HO in one site, two in two sites, and one in three sites. The sites of HO were 6 in hips, 4 in knees, 2 in shoulders, 2 in pelvis, and one in elbow. The results of this study do not support the prevention effect of EHDP on HO formation among the patients with spinal cord injury.
Heterotopic ossification(H.O.) is a common complication in spinal cord injured patients. The majority of heterotopic ossification in spinal cord injury occurs around hip joints. Fracture of femur is also a quite common complication in spinal cord injured patient, however H.O. associated with femur fracture at the hip was rarely reported.
The author experienced femur neck fracture in a spinal cord injured patient with preexisting H.O. The proper management of femur neck fracture and the prevention of H.O. were reviewed and discussed.
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