Douglas E. Garland

A clinical perspective on common forms of acquired heterotopic ossification.

The clinical courses of heterotopic ossification (HO) as a consequence of trauma and central nervous system insults have many similarities as well as dissimilarities. Detection is commonly noted at two months. The incidence of clinically significant HO is 10%-20%. Approximately 10% of the HO is massive and causes severe restriction in joint motion or ankylosis. The most common sign and symptom are decreased range of motion and pain. The locations are the proximal limbs and joints. Sites of HO about a joint may vary according to the etiology of the HO. Roentgenographic evolution of HO occurs during a six-month period in the majority of patients. Treatment modalities include diphosphonates, indomethacin, radiation, range of motion exercises, and surgical excision. Surgical timing differs according to etiology: traumatic HO may be resected at six months; spinal cord injury HO is excised at one year; and traumatic brain injury HO is removed at 1.5 years. A small number of patients have progression of HO with medicinal treatment and recurrence after resection. The patients seem recalcitrant to present treatment methods regardless of the HO etiology.

Resection of heterotopic ossification in the adult with head trauma.

Lesions of heterotopic ossification were excised from thirty-seven joints in twenty-three adults who had had injuries to the brain. The lesions were excised from twenty-three elbows, twelve hips, and two shoulders. Patients were retrospectively divided into five categories according to the neural residua (cognitive and physical deficits). The patients in Class I (minimum cognitive and physical disability) and patients in Class II (minimum cognitive disability and moderate physical disability) who had fair or good selective control of the affected extremity had the best prognosis for maintaining the range of motion resulting from resecting the lesion and improving function postoperatively. They also had a low incidence of recurrence of the lesion. Seven of the nine elbows and eight of the eight hips in patients in these classes had successful results. All three of the patients in Class V (severe cognitive and physical deficits) who had a lesion of the hip and all eight of the patients in Class V with poor selective control had a poor result. In the twenty-five joints for which adequate follow-up radiographs were available to determine if the lesion recurred, fourteen recurrences were identified (56 per cent). Eleven of these patients were considered to have a poor result. Nine of the fourteen recurrences occurred in patients in Class V. Radiographic evidence of the maturity of the lesion and a normal level of alkaline phosphatase were of limited importance in predicting a low rate of recurrence. The over-all complications included four superficial infections and no instances of osteomyelitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical observations on fractures and heterotopic ossification in the spinal cord and traumatic brain injured populations.

Fracture care and osteogeneic response deviate significantly from normal in patients with traumatic brain injury (TBI) or spinal cord injury (SCI). In TBI open reduction and internal fixation (ORIF) are recommended whenever possible to improve mobilization in the face of spasticity and the formation of heterotopic ossification (HO). In the patient with SCI, immobility and paralysis negatively alter healing. A fracture above the level of SCI, although not altered in healing, when treated by ORIF will facilitate transfer training and self care. Lower extremity fractures in SCI have a high incidence malunion, delayed union, or nonunion and are best treated by internal fixation. HO occurs in 11% of TBI patients, with the hip, shoulder, and elbow being common sites. Trauma dramatically increases the incidence of HO. In SCI, the incidence of HO is 20%, with most occurring in the hip region. A genetic predisposition to form HO is suspected but not proven.

Regional Osteoporosis in Women Who Have a Complete Spinal Cord Injury

Background: Regional bone loss in patients who have a spinal cord injury has been evaluated in males. In addition, there have been reports on groups of patients of both genders who had an acute or chronic complete or incomplete spinal cord injury. Regional bone loss in females who have a complete spinal cord injury has not been reported, to our knowledge. Methods: In a study of thirty-one women who had a chronic, complete spinal cord injury, we assessed bone mineral density in relation to age, weight, and time since the injury. The results were compared with the bone mineral density in seventeen healthy, able-bodied women who had been age-matched by group (thirty years old and less, thirty-one to fifty years old, and more than fifty years old). Dual-energy x-ray absorptiometry was used to measure the bone mineral density of the lumbar spine, hip, and knee; Z-scores for the hip and spine were calculated. Results: The mean bone mineral density in the spine in the youngest, middle, and oldest spinal-cord-injury groups was 98%, 108%, and 115% of the densities in the respective age-matched control groups (p < 0.0001), and the mean bone mineral density in the oldest spinal-cord-injury group was equal to that in the youngest control group. This gain in bone mineral density in the spine was reflected by the spine Z-scores, as the mean score in the oldest injured group averaged more than one standard deviation above both the norm and the mean score in the control group. The mean loss of bone mineral density in the knee in the youngest, middle, and oldest spinal-cord-injury groups was 38%, 41%, and 47% compared with the densities in the corresponding control age-groups (p < 0.0001). Furthermore, the oldest injured group had a mean reduction of knee bone mineral density of 54% compared with the youngest control group. The mean loss of bone mineral density in the hips of the injured patients was 18%, 25%, and 25% compared with the densities in the control subjects in the respective age-groups (p < 0.0001). Conclusions: The bone mineral density in the spine either was maintained or was increased in relation to the time since the injury. This finding is unlike that seen in healthy women, in whom bone mineral density decreases with age. The bone mineral density in the hips of the injured patients initially decreased approximately 25%; thereafter, the rate of loss was similar to that in the control group. The bone mineral density in the knees of the injured patients rapidly decreased 40% to 45% and then further decreased only minimally. Clinical Relevance: The results provide a partial explanation of the fracture patterns seen after spinal cord injuries. Vertebral fractures rarely occur, whereas the knee is at risk for fracture soon after the spinal cord injury. The potential for fracture of the hip also occurs soon after the spinal cord injury. This risk increases with age and the amount of time since the spinal cord injury.

Resection of heterotopic ossification in patients with spinal cord injuries.

Nineteen spinal cord injury (SCI) patients were treated with resection of heterotopic ossification (HO) in 24 hips. The average follow-up period after surgery was 6.1 years. The mean time to surgery after injury was 50.6 months. The indication for surgery in all patients was improvement in hip motion to allow sitting. The average preoperative motion in flexion and extension was 11.5 degrees. The average intraoperative motion was 82.7 degrees. The average postoperative motion at the follow-up evaluation was 35.2 degrees. Fourteen of 19 patients (74%) had sufficient motion at the follow-up evaluation for sitting. Unlimited sitting tolerance was achieved in seven patients (37%), and seven patients (37%) had improved sitting posture with some time limitations. The average arc of motion in those patients able to sit at the follow-up evaluation was 41.5 degrees. Normal bone scans, alkaline phosphatase levels, and the mature roentgenographic appearance of HO were unreliable predictors of recurrence. The preoperative range of motion was the best predictor of improved postoperative range of motion since patients with retained motion did better than those with severe ankylosis. All six hips with severe recurrence had 0 degree of preoperative motion. The average degree of preoperative motion for all remaining hips was 15.3 degrees. The best predictor of recurrence was the roentgenographic grade of HO. Nineteen of 22 hips (86%) with a mild to severe recurrence had large amounts of bone preoperatively (Grades 3-5). Complications excluding recurrence occurred in 19 of 24 hips (79%) and included superficial wound infections in nine of 24 hips (38%) and deep persistent infections (osteomyelitis) in eight of 24 hips (33%).(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of Surgically Treated Supracondylar Fractures of the Femur

Surgical treatment of supracondylar fractures of the femur has become commonplace. A variety of surgical implants are available. In carefully chosen patients treated with appropriate surgical technique, early motion and good knee function can be obtained with open reduction and internal fixation. However, the morbidity (and mortality) are substantial following complications of open reduction and internal fixation of supracondylar fractures of the femur. We present a series of 30 consecutive patients referred to Rancho Los Amigos Medical Center for complications following open reduction and internal fixation of supracondylar femur fractures. Three patients with septic pseudarthrosis underwent above-knee amputations. Two of these three patients died of systemic sepsis. Fourteen additional patients were treated for nonunions, with 13 patients achieving union at an average time of 36.5 months from the date of injury. Six patients underwent quadricepsplasties for residual knee stiffness. Only 16 patients were returned to their preinjury ambulatory status.

Stiff-legged gait in hemiplegia: surgical correction.

Selective tenotomy of one or two heads of the quadriceps based on electromyographic criteria improved knee flexion in hemiplegic patients who walked with a unilateral stiff-legged gait. The improvement was greatest in eight patients in whom the rectus femoris was released, either with or without release of the vastus intermedius, with activity in pre-swing stance and initial swing confined to those heads of the quadriceps; in these patients knee flexion improved an average of 20 degrees. Knee flexion improved an average of only 8 degrees in five patients in who activity was present in one head of the quadriceps that was not surgically released. No improvement in knee flexion occurred in seven of eight patients in whom activity was present in two or more of the quadriceps heads that were not surgically released.

Surgical Stabilization of the Cervical Spine A Comparative Analysis of Anterior and Posterior Spine Fusions

Two hundred twenty-two cervical spine stabilization procedures in 212 patients are reviewed. In 114 posterior cervical fusions, 88 anterior fusions, and ten combined procedures, no deaths occurred. Surgical complication rates were similar, but more severe complications were noted with anterior cervical fusions, including tracheoesophageal problems and transient neurologic loss. Six cases of graft dislodgement requiring reoperation also occurred. In long-term follow-up evaluations, 36 anterior fusion patients developed progressive kyphotic deformity averaging 22 degrees between surgery and the time solid fusion was obtained. Degenerative changes above and below the fusion mass were detected in 36 of 59 patients treated by anterior surgery. Posterior cervical fusion patients were noted to have no significant late change in alignment, and degenerative changes were infrequent. However, 73 of 98 patients had significant extension of fusion mass beyond the originally intended levels of stabilization. Because anterior cervical spine fusion was associated with significant complications of graft dislodgement and tracheoesophageal trauma, as well as postsurgical progressive deformity, the authors recommend posterior wiring and fusion as the procedure of choice to treat cervical spine instability and permit halo-free postsurgical rehabilitation. When anterior neural decompression and fusion is necessary, concomitant posterior wiring and fusion or halo vest immobilization may be necessary to maintain reduction and prevent kyphotic angulation, because posterior ligamentous disruption is not always grossly evident on radiographic examination.

Electromyographic gait analysis before and after operative treatment for hemiplegic equinus and equinovarus deformity.

Gait electromyograms were obtained before and after tendon transfer, lengthening, or release in twenty-seven hemiplegic patients with equinus or equinovarus deformities. Abnormal patterns of muscle activity almost always were present preoperatively in the gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, flexor digitorum longus, peroneus brevis, and tibialis anterior muscles in these patients. The surgical procedures to correct the foot deformities altered the gross patterns of activity of most of the muscles operated on by very little. Of particular importance to the surgeon was the finding that the pattern of activity of the muscles whose tendon was transferred, lengthened, or released was not altered after operation. This finding makes the preoperative gait electromyogram a useful means of determining the appropriate surgical plan, since it is an indication of the type of muscle activity to expect postoperatively.

Surgical approaches for resection of heterotopic ossification in traumatic brain-injured adults.

The site of heterotopic ossification (HO) at the elbow or the hip dictates the surgical approach for resection. Three approaches are used for HO resection at the elbow: (1) a posterolateral approach for posterolateral HO; (2) an anterolateral approach for anterior HO; and (3) a medical approach for medial or posteromedial HO or anterior transfer of the ulnar nerve. Two approaches are recommended for resection of HO at the hip: (1) an anterior approach for anterior or inferomedial HO and (2) a posterior approach for posterior HO. Posterior HO is often associated with a hip-flexion contracture, and an anterior soft-tissue release may be necessary as well. Physical examination indicates the prognosis for functional improvement as well as recurrence. Patients with a near normal neurologic recovery have minimal to no HO recurrence with improved limb function and increased joint motion, whereas a poor neurologic recovery and persistent spasticity are associated with recurrence of HO and no functional limb improvement. Standard roentgenograms aid in selecting the appropriate surgical approach. Radiation, indomethacin, and diphosphonates have been administered for prophylaxis. Physical therapy is necessary until range of motion stabilizes.