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Thread: Heterotopic ossification question...

  1. #1
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    Question Heterotopic ossification question...

    Hi, have received a report re MRI of hips undertaken to check on my HO but my appointment with specialist is a few weeks away & was looking to get a heads up beforehand, so was hoping someone could decipher my report please & translate into plain english for me if possible...

    History: Heterotopic ossification about right hip.

    Technique: Coronal & axial T1 & fatsat T2 sequences were obtained at both hips & sagittal T1 and fatsat T2 sequences were obtained of the right hip.

    Findings: There is heterotopic ossification within the obturator externus, iliopsoas, quadratus femoris & adductor magnus muscles about the right hip. There is intermediate signal on T2 surrounding the ossification in the obtrurator externus muscle. There is no intermediate signal identified surrounding the ossification in the other muscles. Fatty marrow is present within the ossification at the posterior aspect of the intertrochanteric region of the femur at the quadratus femoris attachment. No other muscle or tendon abnormality identified about the right hip. No other muscle or tendon abnormality identified about the right hip.

    There is ossification within the left iliopsoas muscle adjacent to the tendon. There is no oedema surrounding this. No other ossification identified about the left hip. A small area of subchondral reactive change is present in the anterior aspect of the left acetabular roof. No subchondral reactive change identified in the right acetabular roof. No hip joint effusion.

    No abnormality involving the sacroiliac joints or symphysis. No bone marrow abnormality identified. There is 3cm diameter fibroid in the posterior aspect of the uterus.


    Any help is appreciated

    klj
    The important thing in life is to have great aim, and the determination to attain it.

  2. #2
    hello klj as far as ho in the hips i really not familiar with that i myself have ho on the left knee im still waiting for my doctors visit to see the ho in my left knee the only problem with that, is that i can only bend my knee back to a certain degree i heard there is a meds to stop growing of ho on hips or on knee joint these are the two most common places for ho, well keep me informed after yous see your doctor thansk good luck

  3. #3
    I have asked Dr. Young to comment. It sounds like you have pretty extensive HO. How limited is your movement? Are you on medications for this? Did you have radiation therapy when it started?

    (KLD)

  4. #4
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    Unhappy

    Thanks for the above replies.

    No, I haven't got meds or had radiation for this

    About 9yrs ago I started getting pain in my left hip & went to GP for help. X-ray showed HO on one side was given meds from specialist (I use that word loosely) from the spinal unit but after results from blood test later on was told to stop by the spinal unit as not HO.
    Over the next year pain came & went, then in 2002 after a physio session I noticed my right hip was swollen (10cm bigger than the other) went to hospital to get tested for dvt but ultra sound was clear & sent home, told must of torn my hamstring no further instructions given.
    Leg still swells on & off to date & is always bigger than the other. A few months after the first time it felt like I was sitting differently. Had an MRI for my lower back later on for unrelated issue & was noted in results that there appeared to be "holes" (how it was described to me) in my muscles, the ones responsible for holding your hip in the correct position. I feel as a result of my hip rotating I changed my sitting position to compensate which has then caused a curve in my back. Asked to see a musculosketetal (after talking to a friend who's a physiotherapist) who said short of biopsy from the muscle to see the cause, I had to get use to it. My good GP left & was taken over by another. Have been back 2x to the musculosketel since then & he hasn't offered anything new to help. Have asked doctor several times over the years about pain was told it was nerve pain & nothing can be done. Kept asking, kept getting the same response.

    Researched further through other peoples post re HO on here & went to doctor with a list of demands so to speak to get to the bottom of my pain & rule different things out. For HO first on the list was to get a referral to an orthopedic surgeon who could organise a scintigraphy & a MRI, which I had last Wednesday & hence my question post above. NZ doesn't have dedicated specialists who know a lot about sci's & associated conditions so it pays sometimes to be armed with more knowledge than your doctor but then there's no one (other than through CareCure) who you can ask questions & get help from

    I have pretty much constant pain now in my right hip (no longer can tell if the left hurts) after shower I have a cold pack on it & at night have heat rub on the area. I have Panadol 2caps 2x daily & Burofen 400mg 2x daily morning & night to help ease it but have developed a fairly high pain tolerance level now. Some days its too much pain wise & makes everything else harder. My knee & leg rotates inwards & others find it different to try & get a straight alignment or do the stretch of rotating the leg outwards, also difficult when doing various other strethes to keep knee from bend inwards. Apart from that I have pretty good range as just push through the pain & have read exercise is important, there are some that are just to sore but I do try. I have stretches 3-4x a wk, stand most days, fes on quads, cycle & vibratrain a couple times each wk. I just want it sorted! Any help is really appreciated

    klj
    The important thing in life is to have great aim, and the determination to attain it.

  5. #5

    A review of Heterotopic Ossification

    HETEROTOPIC OSSIFICATION
    Wise Young, Ph.D., M.D.
    25 August 2008


    Heterotopic ossification (HO) is a abnormal bone formation outside of the skeleton. It usually occurs in muscle but can also appear in tendon and tendon sheath and fat. It usually presents as a localized inflammatory mass in muscle, usually in the lower limbs. The limb may be warm and swollen. Fever may be present. If sensation is present, the area of swelling is tender and painful. Range of motion may be present. HO of the hip or knee may be associated with effusion at the knee. Blood tests may show elevated creatine kinase (indicative of muscle damage), inflammatory C-reactive protein, and occasionally elevated alkaline phosphatase; none of these, however, are specific to HO.

    HO syndromes. Myositis ossificans traumatica occurs after blunt injury, surgery, or burns. Nontraumatic myositis ossificans is when no trauma has occurred. Panniculitis ossificans is in subcutaneous fat. Rider’s bones are in leg adductor muscles and Shooter’s bones are in deltoid muscle. Münchmeyer disease or fibrodysplasia ossificans progressiva (FOP) is a very rare disease characterized by ossification of fascial planes, muscles, tendons, and ligaments. Albright hereditary osteodystrophy, progressive hteroplasia, and primary osteoma cutis are other genetic disease that manifest HO. In general HO can be classified into three types: FOP, traumatic, and neurogenic.

    Risk of HO. Many neurological diseases are associated with HO, including spinal cord injury, brain injury, tetanus, poliomyelitis, Guillain-Barre syndrome, and even prolonged pharmacological paralysis during mechanical ventilation. Other bone-forming disorders increase the risk for HO, including diffuse idiopathic skeletal hyperostosis, ankyosing spondylitis, and Paget disease. A prior history of HO increases the risk of further occurrences. HO is a common complication of arthroplasty procedures with a 20-30% risk, approaching 100% if the patient had a previous HO in a previous arthroplasty site or if the patient has spinal cord injury. Males are twice as likely to develop HO than females. It is rare in young children.

    Incidence. In spinal cord injury, the incidence ranges from a low of 3.4% to a high of 47% (e.g. 62 of 131 patients with SCI admitted to the Hot Spring Rehabilitation Center). Most reports indicate an incidence of 20-30% with severe functional limitations in 3-8%. Peak incidence is 4-12 weeks after spinal cord and can be develop as late as 5 months after trauma. Later onset have been reported but is very rare. Between 10-35% of patients with spinal cord injury have significantly reduced range of motion (ROM) of the affected joint; 3% of an ankylosed joint due to HO. In spinal cord injury, if HO occurs, it is always below the injury level The incidence of HO after severe head injury range from 11-76%. In one study by Garland, et al., HO affected 100 joints in 57 of 496 patients.

    Causes of HO. HO results from osteoprogenitor cells that are present in soft tissues. With proper stimulation, these cells produce osteoblasts, which begins osteoid formation, eventually forming heterotopic bone. Several bone growth factors, i.e. bone morphogenetic proteins (BMP), can cause HO when injected into soft tissues. The genetic disease FOP involves mutations of two sites, one in the region of the noggin gene (NOG) which inhibits BMP’s. The second site is on the long arm of chromosome 4, in the region of a known BMP-signalling pathway gene. People with FOP have an overproduction of BMP.

    Pathophysiology. HO starts with spindle cell formation within a week of a traumatic event. Primitive osteoid dvelops in the periphery of the lesion with 7-10 days. Primitive cartilage and woven bone can be seen at 2-5 weeks after trauma. At 6 weeks, mature lamellar bone can be observed. Thus, HO can form relatively quickly after a traumatic event. The most common site s the hip, following total hip arthroplasty, spinal cord injury, or brain injury. In head injury, the next most common sites are shoulder and elbows but not knees. In spinal cord injury, the next most common site is the knee.

    Diagnosis. HO usually manifests as a painful palpable mass that becomes non-tender and smaller and firmer to touch. In spinal cord injury, patients frequently have leg pain and swelling without any history of trauma to the leg. It may be difficult to differentiate HO from deep venous thrombosis (DVT), since both may present with leg pain, swelling, and erythema (redness). In fact, the two often occur together since the mass effect of HO may encourage DVT. The preferred imaging method is x-ray, either plain or CT but cannot detect HO during the first 2 weeks. Bone scanning may detect early formation. Ultrasound may be useful as a screening tool in the hip region and can be applied at the same time as a DVT exam. In inexperienced centers, a CT scan provides a definitive diagnosis of a calcified mass in soft tissue. A biopsy may be necessary if there is any reason to suspect neoplasm. A false negative is common because until mineralization is present. Therefore, followup CT or x-ray showing characteristic progression in 2-3 weeks will confirm the diagnosis. Magnetic resonance is not definitive, usually showing a heterogenous high T2 signal in soft tissue mass with gadolinium enhancement during the early phase and a low-intensity rim with high T1 and T2 intensification in the central portion, probably representing marrow fat. Percutaneous biopsy is contraindicated because it may yield a small sample that is potentially confusing to inexperienced pathologists. The presence of high cellular activity coupled with new bone formation may be mistakened for osteoblastic neoplasm, such a osteosarcoma. Open biopsy may exacerbate the HO, causing it to progress. If a biopsy is carried out after a resection, it may cause a recurrence of the condition. The recommended approach is:
    • Plain x-ray. One may see a faint band of calcification at early stages of swelling.
    • CT-scan. At later stages, both non-contrast CT scan and x-ray should ossified mass.
    • Technetium-99m methylene diphosphonate bone scan should show marked uptake.
    • MRI should show a central heterogeneous high T2 signal with low signal surrounding.
    • Ultrasound scan shows heterogeneous central hypo- and peripheral hyper-echogenic mass.

    Treatment. Four classes of therapies are used for HO.
    • Anti-inflammatory drugs such as indomethacin (75 mg/day) and the COX-2 inhibitor rofecoxib (25 mg/day) reduces the risk of HO by 2-3x.
    • Physical therapy. Controversy surrounds the benefits and extent of physical therapy to be used, once the HO has occurred. It is generally acknowledged that lack of range of motion and movement may lead to further loss of joint function. On the other hand, some people believe that physical therapy may aggravate the condition.
    • Surgical excision. Once the HO has developed to the extent of interfering with function, surgery is the only option. Most operations involve wedge resection.
    • Radiation therapy has been used but the dose, frequency, and timing has not yet been determined. The rationale is that mesenchymal stem cells that contribute osteoprogenitor cells are radiosensitive. Radiation is used more in Europe. The risk of local induction of malignancy have not been determined.
    • Bisphosphonates may reduce bone formation. Etidronate sodium (Didronel) is given 20 mg/kg PO p24h followed by 10 mg/kg q24h for 10 weeks.

    Pitfalls to avoid.
    • Surgical excision may aggravate HO. If surgery is done, the tissues must be minimally manipulated and care must be taken to achieve rigorous hemostasis. Be wary of lesions that cross tissue planes. Relief of pain is seldom achieved. For this reason, surgery should not be carried out until the lesion is matured and there is significant functional limitation. Traditionally, surgeons have delayed surgery by 18 months after brain injury. However, such case studies suggest that very early removal may be more effective.
    • Non-steroidal anti-inflammatory drugs may have significant side-effects. Long-term aspirin and indomethacin may not be well-tolerated and COX-2 inhibitors is likely to replace indomethacin use.
    • Do not be afraid of physical therapy. While animal studies suggest that excessive stretching and can aggravate HO, there is no evidence that this is the case in humans. Lack of physical therapy has much worse consequences including restricted range of motion, muscle atrophy, and other consequences of inactivity.

    References

    1. Moore DS (2007). Heterotopic Ossification. Emedicine. http://www.emedicine.com/radio/topic336.htm
    2. Campagnolo DI (2006). Heterotopic Ossification in Spinal Cord Injury. Emedicine. http://www.emedicine.com/pmr/TOPIC52.HTM
    3. Bruno-Petrina A (2008). Posttraumatic Heterotopic Ossification Emedicine. http://www.emedicine.com/pmr/TOPIC112.HTM
    4. McLean C, Hargrove R, Wood JB (2006). Traumatic Heterotopic Ossification. Emedicine http://www.emedicine.com/orthoped/TOPIC401.HTM
    5. Banovac K, Speed J (2008). Heterotopic Ossification. Emedicine. http://www.emedicine.com/pmr/TOPIC51.HTM

  6. #6
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    Thanks Wise for your post. I had read your previously postings re HO on CareCure & also the eMedicine article when researching - great to see its "real" as is often hard to determine what is correct & what's not on the web.

    Regarding my case, do you have any suggestions on where to go/what to do next..?

    klj
    The important thing in life is to have great aim, and the determination to attain it.

  7. #7
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    Exclamation

    Hi all, was hoping someone could advise a good medication for pain associated with HO? I'm taking panadol & burofen but the past week the pain has been considerably bad & is intense (I'd have to rate it as one of the worse to date). Can't get comfortable lying or sitting. Tried hot/cold packs & anti-inflammatory cream... Any help is appreciated

    klj
    The important thing in life is to have great aim, and the determination to attain it.

  8. #8
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    Unhappy Please help...

    Also, is a deep tissue massage a good idea or would this inflame the area more? Plus is it ok to continue with fes, passive stretches, passive cycling & standing? Or is it best to rest?
    Whole leg is in pain even hurts when some is lightly touching it. Feels like its frozen inside but burning with a slicing pain (I describe it as little pixies with frozen ice picks trying to climb up my leg while planting burning wooden stakes to mark the way up - weird huh)
    The important thing in life is to have great aim, and the determination to attain it.

  9. #9
    I'm curious if my daughter has HO. About 3 to 4 months after her injury I noticed her tail bone sticks out and feels crunchy to the touch and seems misshaped. We have talked to several doctors and they seem to blow it off saying it is because her hips are tight and that she is thin. I'm convinced it is more that just tightness and her being slender. Recently we changed doctors and I brought it up again. She mentioned that it could possibly be HO. I've given her previous scan to review, but haven't heard back yet. I've been concerned as is her therapist that her tail bone is broken as I don't understand why if feels crunchy (hard to explain any other way). I also noticed it looks a little bumpy, like a small piece of bone is protruding.

    Her range on motion is very different on her left (left has much more return) than her right and now wondering if maybe she has HO elsewhere contributing to the difference in the ROM on her left and right side.

    Does this sound like heterotopic ossification? I would appreciate any input.

  10. #10
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    Question Treat HO Deposits

    I have a question for Dr Young, or anyone who may have done this. Have you heard of using pulse ultrasound to treat HO deposits? Most of my research only shows using it as prevention.

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