Heterotope Ossifikationen

Heterotope Ossifikationen sind ein bekanntes Phänomen in Orthopädie und Unfallchirurgie und Gegenstand aktueller Forschung. Im Folgenden präsentieren wir den derzeitigen Kenntnisstand zu Pathophysiologie, Diagnostik, Therapie und Prävention mit zwei Fallbeispielen und abschließender Erfolgskontrolle.

Kernaussagen

• Heterotope Ossifikationen (HO) sind ein weiterhin aktuelles Krankheitsbild mit z. T. ausgeprägtem klinischem Charakter.

• Schonendere Operationstechniken und optimierte perioperative Abläufe haben zu sinkenden Inzidenzen geführt.

• Schwere Fälle von HO beobachten wir bei septischen Fällen.

• Ungeklärt sind derzeit noch die exakte Pathogenese und Pathomechanik, vor allem bei noch ausstehenden Kontrollstudien.

• In schweren Fällen mit ausgeprägter Bewegungseinschränkung des betroffenen Gelenks sollte eine chirurgische Exzision in Verbindung mit einer lokalen Bestrahlung im Sinne einer Sekundärprophylaxe erfolgen.

• Der OP-Zeitpunkt zur HO-Abtragung sollte so gewählt werden, dass die aktive Verknöcherung abgeschlossen ist.

• Zur Beurteilung können eine Szintigrafie und Laborparameter herangezogen werden.

• Die Bestrahlung kann bis zu 24 h prä- und 96 h postoperativ erfolgen. Als Strahlendosis sollten minimal 6 Gy bis maximal 12 Gy gewählt werden.

• Es kann eine postoperative Ossifikationsprophylaxe für mindestens 14 Tage erfolgen.

• Bei neurogener HO können sonografische Screeninguntersuchungen zu einer frühzeitigen Erkennung und Behandlung des Krankheitsbildes führen.

Schlüsselwörter

Myositis ossificans - NSAID - Verknöcherung - Hüft-TEP - Bewegungsumfang

Publication History

Article published online:
04 June 2023

• Literatur

• 1 Brooker AF, Bowerman JW, Robinson RA. et al. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973; 55: 1629-1632 (PMID: 4217797)
• 2 Forsberg JA, Pepek JM, Wagner S. et al. Heterotopic ossification in high-energy wartime extremity injuries: prevalence and risk factors. J Bone Joint Surg Am 2009; 91: 1084-1091 DOI: 10.2106/JBJS.H.00792. (PMID: 19411456)
• 3 Schuh A, Zeiler G. Die modifizierte Brooker-Klassifikation zur Beurteilung heterotoper Ossifikationen in der Hüftendoprothetik. Zentralbl Chir 2005; 130: 293-296 DOI: 10.1055/s-2005-836783. (PMID: 16103951)
• 4 Arduini M, Mancini F, Farsetti P. et al. A new classification of peri-articular heterotopic ossification of the hip associated with neurological injury: 3D CT scan assessment and intra-operative findings. Bone Joint J 2015; 97-B: 899-904 DOI: 10.1302/0301-620X.97B7.35031. (PMID: 26130343)
• 5 DeBaun MR, Ziino C, LaPrade C. et al. An anatomic classification for heterotopic ossification about the hip. J Orthop 2020; 21: 228-231
• 6 Della Valle AG, Ruzo PS, Pavone V. et al. Heterotopic ossification after total hip arthroplasty: a critical analysis of the Brooker classification and proposal of a simplified rating system. J Arthroplasty 2002; 17: 870-875
• 7 Ilahi OA, Bennett JB, Gabel GT. et al. Classification of heterotopic ossification about the elbow. Orthopedics 2001; 24: 1075-1077
• 8 Mavrogenis AF, Guerra G, Staals EL. et al. A classification method for neurogenic heterotopic ossification of the hip. J Orthop Traumatol 2012; 13: 69-78 DOI: 10.1007/s10195-012-0193-z. (PMID: 22476356)
• 9 McAfee PC, Cunningham BW, Devine J. et al. Classification of heterotopic ossification (HO) in artificial disk replacement. J Spinal Disord Tech 2003; 16: 384-389 DOI: 10.1097/00024720-200308000-00010. (PMID: 12902954)
• 10 Brady RD, Shultz SR, McDonald SJ. et al. Neurological heterotopic ossification: current understanding and future directions. Bone 2018; 109: 35-42 DOI: 10.1016/j.bone.2017.05.015. (PMID: 28526267)
• 11 Ranganathan K, Loder S, Agarwal S. et al. Heterotopic ossification: basic-science principles and clinical correlates. J Bone Joint Surg Am 2015; 97: 1101-1111 DOI: 10.2106/JBJS.N.01056. (PMID: 26135077)
• 12 Lee KB, Cho YJ, Park JK. et al. Heterotopic ossification after primary total ankle arthroplasty. J Bone Joint Surg Am 2011; 93: 751-758 DOI: 10.2106/JBJS.J.00178. (PMID: 21508282)
• 13 Dowdell JE, Kim JS, Mikhail C. et al. The rate of heterotopic ossification following cervical disc arthroplasty: a systematic review and comparison of data. Spine 2020; 45: E1197-E1202 DOI: 10.1097/BRS.0000000000003524. (PMID: 32355139)
• 14 Sperling JW, Cofield RH, Rowland CM. Heterotopic ossification after total shoulder arthroplasty. J Arthroplasty 2000; 15: 179-182 DOI: 10.1016/s0883-5403(00)90154-2. (PMID: 10708082)
• 15 Salazar D, Golz A, Israel H. et al. Heterotopic ossification of the elbow treated with surgical resection: risk factors, bony ankylosis, and complications. Clinical Orthop Relat Res 2014; 472: 2269-2275
• 16 Ohlmeier M, Suero EM, Aach M. et al. Muscle localization of heterotopic ossification following spinal cord injury. Spine J 2017; 17: 1519-1522 DOI: 10.1016/j.spinee.2017.04.021. (PMID: 28456672)
• 17 Wittenberg RH, Peschke U, Bötel U. Heterotopic ossification after spinal cord injury. Epidemiology and risk factors. J Bone Joint Surg Br 1992; 74: 215-218 DOI: 10.1302/0301-620X.74B2.1544955. (PMID: 1544955)
• 18 Cipriano CA, Pill SG, Keenan MA. Heterotopic ossification following traumatic brain injury and spinal cord injury. J Am Acad Orthop Surg 2009; 17: 689-697 DOI: 10.5435/00124635-200911000-00003. (PMID: 19880679)
• 19 van Kuijk AA, Geurts ACH, van Kuppevelt HJM. Neurogenic heterotopic ossification in spinal cord injury. Spinal Cord 2002; 40: 313-326 DOI: 10.1038/sj.sc.3101309. (PMID: 12080459)
• 20 Zhu Y, Zhang F, Chen W. et al. Incidence and risk factors for heterotopic ossification after total hip arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2015; 135: 1307-1314 DOI: 10.1007/s00402-015-2277-8. (PMID: 26155968)
• 21 Firoozabadi R, O’Mara TJ, Swenson A. et al. Risk factors for the development of heterotopic ossification after acetabular fracture fixation. Clinical Orthop Relat Res 2014; 472: 3383-3388 DOI: 10.1007/s11999-014-3719-2. (PMID: 24906813)
• 22 Citak M, Suero EM, Backhaus M. et al. Risk factors for heterotopic ossification in patients with spinal cord injury: a case-control study of 264 patients. Spine 2012; 37: 1953-1957
• 23 Ritter MA, Vaughan RB. Ectopic ossification after total hip arthroplasty. Predisposing factors, frequency, and effect on results. J Bone Joint Surg Am 1977; 59: 345-351 (PMID: 403193)
• 24 Manrique J, Alijanipour P, Heller S. et al. Increased risk of heterotopic ossification following revision hip arthroplasty for periprosthetic joint infection. Arch Bone Joint Surg 2018; 6: 486-491 (PMID: 30637303)
• 25 Dey D, Wheatley BM, Cholok D. et al. The traumatic bone: trauma-induced heterotopic ossification. Transl Res 2017; 186: 95-111 DOI: 10.1016/j.trsl.2017.06.004. (PMID: 28668522)
• 26 Mills WJ, Tejwani N. Heterotopic ossification after knee dislocation: the predictive value of the injury severity score. J Orthop Trauma 2003; 17: 338-345 DOI: 10.1097/00005131-200305000-00004. (PMID: 12759638)
• 27 Whelan DB, Dold AP, Trajkovski T. et al. Risk factors for the development of heterotopic ossification after knee dislocation. Clin Orthop Relat Res 2014; 472: 2698-2704 DOI: 10.1007/s11999-014-3730-7. (PMID: 25002209)
• 28 Stannard JP, Wilson TC, Sheils TM. et al. Heterotopic ossification associated with knee dislocation. Arthroscopy 2002; 18: 835-839
• 29 Ohlmeier M, Krenn V, Thiesen DM. et al. Heterotopic ossification in orthopaedic and trauma surgery: a histopathological ossification score. Sci Rep 2019; 9: 18401 DOI: 10.1038/s41598-019-54986-2. (PMID: 31804584)
• 30 Bettiol P, Egan A, Cox C. et al. Pathological analysis of periprosthetic soft tissue and modes of failure in revision total joint arthroplasty patients. SAGE Open Med 2021; 9 DOI: 10.1177/20503121211047099. (PMID: 34589221)
• 31 Xu Y, Huang M, He W. et al. Heterotopic ossification: clinical features, basic researches, and mechanical stimulations. Frontiers in cell and developmental biology 2022; 10: 770931 DOI: 10.3389/fcell.2022.770931. (PMID: 35145964)
• 32 Zhao Y, Ouyang N, Chen L. et al. Stimulating factors and origins of precursor cells in traumatic heterotopic ossification around the temporomandibular joint in mice. Front Cell Dev Biol 2020; 8: 445 DOI: 10.3389/fcell.2020.00445. (PMID: 32626707)
• 33 Zhang X, Jie S, Liu T. et al. Acquired heterotopic ossification in hips and knees following encephalitis: case report and literature review. BMC Surg 2014; 14: 74 DOI: 10.1186/1471-2482-14-74. (PMID: 25280472)
• 34 Rosenberg AE. Pseudosarcomas of soft tissue. Arch Pathol Lab Med 2008; 132: 579-586 DOI: 10.5858/2008-132-579-POST. (PMID: 18384209)
• 35 Hoch B, Montag A. Reactive bone lesions mimicking neoplasms. Semin Diagn Pathol 2011; 28: 102-112 DOI: 10.1053/j.semdp.2011.02.011. (PMID: 21675381)
• 36 Mujtaba B, Taher A, Fiala MJ. et al. Heterotopic ossification: radiological and pathological review. Radiol Oncol 2019; 53: 275-284 DOI: 10.2478/raon-2019-0039. (PMID: 31553710)
• 37 Rosteius T, Suero EM, Grasmücke D. et al. The sensitivity of ultrasound screening examination in detecting heterotopic ossification following spinal cord injury. Spinal Cord 2017; 55: 71-73 DOI: 10.1038/sc.2016.93. (PMID: 27349610)
• 38 Popken F, König DP, Tantow M. et al. Ist eine perioperative sonographische Frühdiagnostik heterotoper Ossifikationen nach Alloarthroplastik des Hüftgelenks möglich?. Unfallchirurg 2003; 106: 28-31
• 39 Garland DE. A clinical perspective on common forms of acquired heterotopic ossification. Clin Orthop Relat Res 1991; (263) 13-29 (PMID: 1899635)
• 40 Citak M, Grasmücke D, Suero EM. et al. The roles of serum alkaline and bone alkaline phosphatase levels in predicting heterotopic ossification following spinal cord injury. Spinal Cord 2016; 54: 368-370 DOI: 10.1038/sc.2015.211. (PMID: 26643987)
• 41 Mollan RA. Serum alkaline phosphatase in heterotopic para-articular ossification after total hip replacement. J Bone Joint Surg Br 1979; 61-B: 432-434 DOI: 10.1302/0301-620X.61B4.115891. (PMID: 115891)
• 42 Collier BD, Hellman RS, Krasnow AZ. Bone SPECT. Semin Nucl Med 1987; 17: 247-266 DOI: 10.1016/s0001-2998(87)80037-5. (PMID: 3303342)
• 43 Ghanem MA, Dannoon S, Elgazzar AH. The added value of SPECT-CT in the detection of heterotopic ossification on bone scintigraphy. Skeletal Radiol 2020; 49: 291-298 DOI: 10.1007/s00256-019-03286-x. (PMID: 31363823)
• 44 Schmücking M, Niesen A, Przetak C. et al. F-18-Fluorid-PET in der Frühdiagnostik und zur Verlaufskontrolle der heterotopen Ossifikation vor und nach Strahlentherapie bei querschnittgelähmten Patienten. Strahlenther Onkol 2002; 178: 97
• 45 Citak M, Grasmücke D, Salber J. et al. Heterotopic ossification mimicking infection in patients with traumatic spinal cord injury. Technol Health Care 2016; 24: 87-91
• 46 Mühlhofer H, Renz N, Zahar A. et al. Diagnostik der periprothetischen Infektion Entwicklung eines evidenzbasierten Algorithmus der Arbeitsgruppe implantatassoziierte Infektion der Arbeitsgemeinschaft Endoprothetik. Orthopade 2021; 50: 312-325
• 47 Abdel Karim M, Andrawis J, Bengoa F. et al. Hip and Knee Section, Diagnosis, Algorithm: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34: S339-S350
• 48 Rumi MN, Deol GS, Singapuri KP. et al. The origin of osteoprogenitor cells responsible for heterotopic ossification following hip surgery: an animal model in the rabbit. J Orthop Res 2005; 23: 34-40 DOI: 10.1016/j.orthres.2004.05.003. (PMID: 15607872)
• 49 Molligan J, Mitchell R, Schon L. et al. Influence of bone and muscle injuries on the osteogenic potential of muscle progenitors: contribution of tissue environment to heterotopic ossification. Stem Cells Transl Med 2016; 5: 745-753 DOI: 10.5966/sctm.2015-0082. (PMID: 27112178)
• 50 La Li, Jiang Y, Lin H. et al. Muscle injury promotes heterotopic ossification by stimulating local bone morphogenetic protein-7 production. J Orthop Trans 2019; 18: 142-153 DOI: 10.1016/j.jot.2019.06.001. (PMID: 31508317)
• 51 Genêt F, Kulina I, Vaquette C. et al. Neurological heterotopic ossification following spinal cord injury is triggered by macrophage-mediated inflammation in muscle. J Pathol 2015; 236: 229-240 DOI: 10.1002/path.4519. (PMID: 25712044)
• 52 Sakellariou VI, Grigoriou E, Mavrogenis AF. et al. Heterotopic ossification following traumatic brain injury and spinal cord injury: insight into the etiology and pathophysiology. J Musculoskelet Neuronal Interact 2012; 12: 230-240
• 53 Tseng H-W, Kulina I, Salga M. et al. Neurogenic heterotopic ossifications develop independently of granulocyte colony-stimulating factor and neutrophils. J Bone Miner Res 2020; 35: 2242-2251 DOI: 10.1002/jbmr.4118. (PMID: 32568412)
• 54 Vasileiadis GI, Amanatullah DF, Crenshaw JR. et al. Effect of heterotopic ossification on hip range of motion and clinical outcome. J Arthroplasty 2015; 30: 461-464 DOI: 10.1016/j.arth.2014.09.019. (PMID: 25449585)
• 55 Migliorini F, Trivellas A, Eschweiler J. et al. NSAIDs for prophylaxis for heterotopic ossification after total hip arthroplasty: a bayesian network meta-analysis. Calcif Tissue Int 2021; 108: 196-206 DOI: 10.1007/s00223-020-00763-7. (PMID: 33044630)
• 56 Joice M, Vasileiadis GI, Amanatullah DF. Non-steroidal anti-inflammatory drugs for heterotopic ossification prophylaxis after total hip arthroplasty: a systematic review and meta-analysis. Bone Joint J 2018; 100-B: 915-922 DOI: 10.1302/0301-620X.100B7.BJJ-2017-1467.R1. (PMID: 29954195)
• 57 Cai L, Wang Z, Luo X. et al. Optimal strategies for the prevention of heterotopic ossification after total hip arthroplasty: a network meta-analysis. Int J Surg 2019; 62: 74-85 DOI: 10.1016/j.ijsu.2018.12.011. (PMID: 30615954)
• 58 Juarez JK, Wenke JC, Rivera JC. Treatments and preventative measures for trauma-induced heterotopic ossification: a review. Clin Transl Sci 2018; 11: 365-370 DOI: 10.1111/cts.12552. (PMID: 29697199)
• 59 Müseler AC, Grasmücke D, Jansen O. et al. In-hospital outcomes following single-dose radiation therapy in the treatment of heterotopic ossification of the hip following spinal cord injury-an analysis of 444 cases. Spinal Cord 2017; 55: 244-246 DOI: 10.1038/sc.2016.112. (PMID: 27431658)
• 60 Gregoritch SJ, Chadha M, Pelligrini VD. et al. Randomized trial comparing preoperative versus postoperative irradiation for prevention of Heterotopic ossification following prosthetic total hip replacement: preliminary results. Int J Radiat Oncol Biol Phys 1994; 30: 55-62 DOI: 10.1016/0360-3016(94)90519-3. (PMID: 8083129)
• 61 Seegenschmiedt M, Keilholz L, Martus P. et al. Prevention of heterotopic ossification about the hip: final results of two randomized trials in 410 patients using either preoperative or postoperative radiation therapy. Int J Radiat Oncol Biol Phys 1997; 39: 161-171 DOI: 10.1016/s0360-3016(97)00285-x. (PMID: 9300751)
• 62 Rumi MN, Deol GS, Bergandi JA. et al. Optimal timing of preoperative radiation for prophylaxis against heterotopic ossification. A rabbit hip model. J Bone Joint Surg Am 2005; 87: 366-373 DOI: 10.2106/JBJS.C.00974. (PMID: 15687161)
• 63 Pohl F, Hassel S, Nohe A. et al. Radiation-induced suppression of the Bmp2 signal transduction pathway in the pluripotent mesenchymal cell line C2C12: an in vitro model for prevention of heterotopic ossification by radiotherapy. Radiat Res 2003; 159: 345-350 DOI: 10.1667/0033-7587(2003)159[0345:risotb]2.0.co;2. (PMID: 12600237)
• 64 Kölbl O, Barthel T, Krödel A. et al. Prävention von heterotopen Ossifikationen nach Totalendoprothese des Hüftgelenks. Dtsch Arztebl Ausg A 2003; 100: A2944-2954
• 65 Seegenschmiedt MH, Makoski H-B, Micke O. Radiation prophylaxis for heterotopic ossification about the hip joint—a multicenter study. Int J Radiat Oncol Biol Phys 2001; 51: 756-765 DOI: 10.1016/s0360-3016(01)01640-6. (PMID: 11697322)
• 66 Healy WL, Lo TC, DeSimone AA. et al. Single-dose irradiation for the prevention of heterotopic ossification after total hip arthroplasty. A comparison of doses of five hundred and fifty and seven hundred centigray. J Bone Joint Surg Am 1995; 77: 590-595 DOI: 10.2106/00004623-199504000-00013. (PMID: 7713977)
• 67 Ong C, Hall M, Youm T. Surgical technique: arthroscopic treatment of heterotopic ossification of the hip after prior hip arthroscopy. Clin Orthop Relat Res 2013; 471: 1277-1282 DOI: 10.1007/s11999-012-2627-6. (PMID: 23054520)
• 68 Bachman DR, Fitzsimmons JS, O’Driscoll SW. Safety of arthroscopic versus open or combined heterotopic ossification removal around the elbow. Arthroscopy 2020; 36: 422-430 DOI: 10.1016/j.arthro.2019.09.010. (PMID: 31870750)
• 69 Garland DE. Surgical approaches for resection of heterotopic ossification in traumatic brain-injured adults. Clin Orthop Relat Res 1991; (263) 59-70 (PMID: 1899638)
• 70 Pavey GJ, Formby PM, Hoyt BW. et al. Intrawound antibiotic powder decreases frequency of deep infection and severity of heterotopic ossification in combat lower extremity amputations. Clin Orthop Rel Res 2019; 477: 802-810 DOI: 10.1007/s11999.0000000000000090. (PMID: 30811369)
• 71 l’Escalopier N de, Salga M, Gatin L. et al. Resection of heterotopic ossification around the hip after trauma. EFORT Open Rev 2019; 4: 263-268 DOI: 10.1302/2058-5241.4.180098. (PMID: 31210967)
• 72 Almangour W, Schnitzler A, Salga M. et al. Recurrence of heterotopic ossification after removal in patients with traumatic brain injury: a systematic review. Ann Phys Rehabil Med 2016; 59: 263-269
• 73 Genêt F, Jourdan C, Lautridou C. et al. The impact of preoperative hip heterotopic ossification extent on recurrence in patients with head and spinal cord injury: a case control study. PloS One 2011; 6: e23129 DOI: 10.1371/journal.pone.0023129. (PMID: 21853078)
• 74 Genêt F, Jourdan C, Schnitzler A. et al. Troublesome heterotopic ossification after central nervous system damage: a survey of 570 surgeries. PloS One 2011; 6: e16632 DOI: 10.1371/journal.pone.0016632. (PMID: 21304993)
• 75 Hoyt BW, Pavey GJ, Potter BK. et al. Heterotopic ossification and lessons learned from fifteen years at war: a review of therapy, novel research, and future directions for military and civilian orthopaedic trauma. Bone 2018; 109: 3-11
• 76 Aziz A, Choudhari R, Alexander AJ. et al. Heterotopic ossification post COVID-19: Report of two cases. Radiol Case Rep 2021; 16: 404-409 DOI: 10.1016/j.radcr.2020.12.002. (PMID: 33354272)
• 77 Benkhaled S, Da Gomes Silveira Cauduro C, Alexiou J. et al. Heterotopic ossification and severe COVID-19 infection. QJM 2022; 115: 201-203
• 78 Stoira E, Elzi L, Puligheddu C. et al. High prevalence of heterotopic ossification in critically ill patients with severe COVID-19. Clin Microbiol Infect 2021; 27: 1049-1050
• 79 Peters J, Köhler H-C, Oltmanns K. et al. Heterotope Ossifikationen nach Langzeitbeatmung bei Covid-19 Erkrankung. Rehabilitation 2021; 60: 231-234
• 80 Meyers C, Lisiecki J, Miller S. et al. Heterotopic ossification: a comprehensive review. JBMR Plus 2019; 3: e10172 DOI: 10.1002/jbm4.10172. (PMID: 31044187)
• 81 Amanatullah DF, Masini MA, Roger DJ. et al. Greater inadvertent muscle damage in direct anterior approach when compared with the direct superior approach for total hip arthroplasty. Bone Joint J 2016; 98-B: 1036-1042
• 82 Korth MJS, Ezzibdeh R, Arora P. et al. Excellent clinical and radiographic outcomes with direct superior total hip arthroplasty with a minimum of two-year follow up. Surg Technol Int 2021; 37: 342-346