Predicting Heterotopic Ossification Early After Burn Injuries

Schneider, Jeffrey C.; Simko, L C; Goldstein, Richard; Shie, Vivian L.; Chernack, Betty; Lévi, Benjamin; Jayakumar, Prakash; Kowalske, Karen; Herndon, David N.; Gibran, Nicole S.; Ryan, Colleen M.

doi:10.1097/sla.0000000000001841

Cited by 33 publications

(19 citation statements)

References 29 publications

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“…[7] The incidence of HO ranges from 0.2% to 5.6% in burn injury patients. [8–12] In this mass casualty incident, the incidence of elbow HO in the burn patients treated in our institution was 3.6% (2/56).…”

Section: Discussionmentioning

confidence: 90%

Surgical treatment of postburn heterotopic ossification around the elbow

Chen

et al. 2019

Medicine

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Rationale: Heterotopic ossification (HO), which is defined as the formation of new bone in tissues that do not normally ossify, is an infrequent yet debilitating complication of burns. Herein, we report three patients who suffered from elbow HO after burn injury due to a dust explosion event. This is a case report that includes the most cases involved in a single mass casualty incident in the presented literature. Patient concerns: Case 1: A 28-year-old man presented with second-to-third degree 88% total body surface area (TBSA) burns after the explosion event. He complained of decreased progressive bilateral elbow range of motion (ROM) for 1.5 months after the burn injury. Case 2: A 28-year-old woman presented with second-to-third degree 50% TBSA burns and complained of decreased progressive bilateral elbow ROM with intolerable pain on elbow extension for 1 month after the burn injury. Case 3: A 22-year-old man presented with second-to-third degree 90% TBSA burns and complained of significantly decreased left elbow ROM with intolerable pain 5 months after the burn injury. Diagnosis: The follow-up radiograph of the symptomatic elbow of these three patients revealed heterotopic ossification formation. Three-dimensional reconstruction computed tomography performed preoperatively showed that HO mainly affected the humeroulnar joint. Interventions: We treated all three patients with surgical elbow HO resection and ulnar nerve transposition, followed by immediate passive ROM exercise since postoperative day 1 and continuous physical therapy. Outcomes: In case 1, the documented ROM gain on the last follow-up (18.5 months after surgery) was 30° in the right elbow and 118° in the left elbow. In case 2, the follow-up time was 21 months and the documented ROM gain on the last follow-up was 120° in the right elbow and 90° in the left elbow. In case 3, the follow-up time was 20 months and the documented left elbow ROM gain on the last follow-up was 40°. Lessons: We discuss our experience of treating postburn HO and review the recent literature. The postburn HO treatment results of early surgical excision combined with immediate postoperative physical therapy were satisfactory.

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Section: Discussionmentioning

confidence: 90%

Surgical treatment of postburn heterotopic ossification around the elbow

Chen

et al. 2019

Medicine

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“…Risk factors can be etiologically specific: the degree of spasticity in spinal cord injury (SCI) patients, need for prolonged mechanical ventilation in patients with severe burns, and surgical approach for orthopedic procedures all prove to be prominent predictive factors for HO development [11,87–89]. A number of these factors have been incorporated into scoring systems used to predict HO development with successful results in burn patients [90]. In most cases, however, these predictive factors are insufficient to dictate treatment algorithms, highlighting the need for early and accurate diagnosis before lesions are formed.…”

Section: The Evolving Practice Of Diagnosis and Treatmentmentioning

confidence: 99%

Heterotopic ossification and the elucidation of pathologic differentiation

Cholok

Chung

Ranganathan

et al. 2018

Bone

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Tissue regeneration following acute or persistent inflammation can manifest a spectrum of phenotypes ranging from the adaptive to the pathologic. Heterotopic Ossification (HO), the endochondral formation of bone within soft-tissue structures following severe injury serves as a prominent example of pathologic differentiation; and remains a persistent clinical issue incurring significant patient morbidity and expense to adequately diagnose and treat. The pathogenesis of HO provides an intriguing opportunity to better characterize the cellular and cell-signaling contributors to aberrant differentiation. Indeed, recent work has continued to resolve the unique cellular lineages, and causative pathways responsible for ectopic bone development yielding promising avenues for the development of novel therapeutic strategies shown to be successful in analogous animal models of HO development. This review details advances in the understanding of HO in the context of inciting inflammation, and explains how these advances inform the current standards of diagnosis and treatment.

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“…Records were reviewed, and all individuals were assigned a risk score for the development of HO using a previously validated scoring system. 15 The HO Risk Scoring System, derived using the Burn Model Systems National Database and externally validated, assigns point values based on burn size and deep wounds to the upper extremities, trunk, and head and neck. All subjects with a HO risk score of ≥7 were included.…”

Section: Retrospective Review Of Human Experiencementioning

confidence: 99%

“…The authors found that burn size, and need for autografting to the arms, head or neck, and trunk were predictors of HO development. 15 Estrogens and androgens have been well characterized for their role in postnatal bone development, especially in the obstetrics and gynecology literature in the context of postmenopausal decreases in trabecular and cortical bone after loss of these steroids 16,17 corroborated by mouse models of orchiectomy/ovariectomy. 18,19 It is this association between steroids and their pro-osteogenic 20 and metabolic effects that serves as the rationale for extended oxandrolone therapy in burn patients who are at risk for osteo-and sarcopenia during their hospital course and recovery.…”

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confidence: 99%

Investigation into Possible Association of Oxandrolone and Heterotopic Ossification Following Burn Injury

Thorpe

Ozgurel

Simko

et al. 2019

Journal of Burn Care &Amp; Research

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Oxandrolone, a testosterone analog, is used to counteract the catabolic effects of burn injury. Recent animal studies suggest a possible hormonal association with heterotopic ossification (HO) development postburn. This work examines oxandrolone administration and HO development by exploring historical clinical data bridging the introduction of oxandrolone into clinical practice. Additionally, we examine associations between oxandrolone administration and HO in a standardized mouse model of burn/trauma-related HO. Acutely burned adults admitted between 2000 and 2014, survived through discharge, and had a HO risk factor of 7 or higher were selected for analysis from a single burn center. Oxandrolone administration, clinical and demographic data, and elbow HO were recorded and were analyzed with logistic regression. Associations of oxandrolone with HO were examined in a mouse model. Mice were administered oxandrolone or vehicle control following burn/tenotomy to examine any potential effect of oxandrolone on HO and were analyzed by Student's t test. Subjects who received oxandrolone had a higher incidence of elbow HO than those that did not receive oxandrolone. However, when controlling for oxandrolone administration, oxandrolone duration, postburn day oxandrolone initiation, HO risk score category, age, sex, race, burn size, and year of injury, there was no significant difference between rates of elbow HO between the two populations. In agreement with the review, in the mouse model, while there was a trend toward the oxandrolone group developing a greater volume of HO, this did not reach statistical significance.

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Predicting Heterotopic Ossification Early After Burn Injuries

Abstract: This HO risk scoring system identifies high-risk burn patients suitable for diagnostic testing and interventional HO prophylaxis trials.

Cited by 33 publications

References 29 publications

Surgical treatment of postburn heterotopic ossification around the elbow

Surgical treatment of postburn heterotopic ossification around the elbow

Heterotopic ossification and the elucidation of pathologic differentiation

Investigation into Possible Association of Oxandrolone and Heterotopic Ossification Following Burn Injury

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