Acta Chir Orthop Traumatol Cech. 2021; 88(4):253-259 | DOI: 10.55095/achot2021/039
Heterotopic Ossifications after Fractures of the Anterior Pelvic Segment: Overview of Morphology and Clinical CorrelationsOriginal papers
- 1 Centre for Integrated Studies of the Pelvis, Third Faculty of Medicine, Charles University, Prague
- 2 Department of Orthopaedics and Traumatology, Third Faculty of Medicine, Charles University, and University Hospital Královské Vinohrady, Prague
- 3 Department of Urology, Third Faculty of Medicine, Charles University, and University Hospital Královské Vinohrady, Prague
PURPOSE OF THE STUDY:
In certain patients after treated pelvic fractures, heterotopic ossifications can be observed in the area of the pubic bone, which protrude ventrally, and often also laterally and distally into surrounding soft tissues of the groin or even medially into the proximal thigh. These ossifications are shaped like sharp spikes of various lengths, which is why the authors refer to them as "spicules". In some patients, these ossifications are also associated with pain. The aim of this study was to provide an overview of the morphology of heterotopic ossifications of the anterior segment of the pelvis and to discuss the etiology of their origin, and further to determine the incidence, risk factors and clinical significance of these "spike-like" ossifications.
MATERIAL AND METHODS:
X-ray images of patients treated for pelvic injuries between 2009 and 2018, in whom radiological documentation was available at least 12 months after the injury or surgery were evaluated. Patients with acetabular fractures or combined pelvic and acetabular injuries were not included in the study. Possible risk factors studied included gender, severity of injury, type of fracture according to the AO / ASIF classification, concomitant bladder injury, method of treatment and type of osteosynthesis of the anterior segment of the pelvis. The categorial data concerning risk factors for the observed "spicule" type ossifications was statistically evaluated using the chi-square test at the 5% level of significance.
RESULTS:
The studied group consisted of 218 patients (121 women, 97 men) aged 13 to 92 years of age (mean age was 54 years, median age was 55 years). Heterotopic "spicule" type ossifications occurred in 21 patients (4 females, 17 males) aged 18 to 76 years (mean 39 years, median 41 years). Significant risk factors in the observed ossification group included male sex (p = 0.0004), severity of trauma (predominance of "spicules" was seen in multiple trauma patients, (p = 0.0024), unstable pelvic injury according to AO / ASIF classification (predominance of "spicules" in type B and C fractures over type A fractures, (p = 0.0013), concomitant bladder injury (p = 0.0009) and in patients undergoing surgical treatment of the fracture (p < 0.0001), where all the observed spicules were seen in patients undergoing anterior pelvic segment osteosynthesis. A statistically significant difference was also evident when comparing the osteosynthetic material used in the anterior segment (a increased incidence of ossifications was seen in patients undergoing plate fixation compared to patients in whom pubic screws were used, p = 0.0050).
DISCUSSION:
Heterotopic ossifications are described as relatively common consequences of pelvic fractures, but are not considered a major problem because they usually do not produce any clinical correlations. The causes of post-traumatic and postoperative ossifications in the pelvic area include the effects of high energy traumas, extensive surgical procedures, prolonged artificial lung ventilation, and post-infectious states after complications of surgical treatment.
CONCLUSIONS:
The study identified risk factors for heterotopic "spicule" type ossifications. The identified risk factors include male sex, severity of injury, unstable type of fracture, concomitant bladder injury, surgical treatment, and the use of massive implants. Only the effect of bladder injuries can be partially influenced by performing less invasive surgical techniques during combined pelvic and bladder injuries.
Keywords: pelvic fracture, pelvic injury, complications, heterotopic ossifications, multiple trauma, unstable pelvic trauma, urinary bladder injury
Published: August 15, 2021 Show citation
ACS | AIP | APA | ASA | Harvard | Chicago | Chicago Notes | IEEE | ISO690 | MLA | NLM | Turabian | Vancouver |
References
- Anthonissen J, Steffen CT, Alessandri B, Baranowski B, Rommens PM, Victor J, Hofmann A. Traumatic brain injury enhances the formation of heterotopic ossification around the hip: an animal model study. Arch Orthop Trauma Surg. 2020;140:1029-1035.
Go to original source...
Go to PubMed...
- Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. J Trauma. 2009;67:1033-1039.
- Calderazzi F, Nosenzo A, Galavotti C, Menozzi M, Pogliacomi F, Ceccarelli F. Apophyseal avulsion fractures of the pelvis: a review. Acta Biomed. 2018;89:470-476.
- Citak M, Grasmücke D, Salber J, Cruciger O, Meindl R, Schildhauer TA, Aach M. Heterotopic ossification mimicking infection in patients with traumatic spinal cord injury. Technol Health Care. 2016;24:87-91.
Go to original source...
Go to PubMed...
- Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW. The Injury Severity Score revisited. J Trauma. 1988;28: 69-77.
Go to original source...
Go to PubMed...
- DeBaun MR, Ziino C, LaPrade C, Pun S, Avedian RS, Bellino MJ. An anatomic classification for heterotopic ossification about the hip. J Orthop. 2020;21:228-231.
Go to original source...
Go to PubMed...
- Elhassan Y, Abdelhaq A, Piggott RP, Osman M, McElwain JP, Leonard M. Heterotopic ossification following acetabular fixation: incidence and risk factors, 10-year experience of a tertiary centre. Injury. 2016;47:1332-1336.
Go to original source...
Go to PubMed...
- Gänsslen A, Grechenig S, Nerlich M, Müller M, Grechenig W, Lindahl J.: Standard approaches to the acetabulum - part 3: intrapelvic approach. Acta Chir Orthop Traumatol Cech. 2016;83:293-299.
Go to original source...
Go to PubMed...
- Grotz, M.R.W., Allami, M.K., Harwood, P., Pape, H.C., Krettek, C., Giannuodis, P.V.: Open pelvic fractures: epidemiology, current concepts of management and outomes. Injury. 2005;36:1-13.
Go to original source...
Go to PubMed...
- Hayashi D, Gould ES, Ho C, Caruana DL, Komatsu DE, Yang J, Zhu C, Mufti M, Nicholson J. Severity of heterotopic ossification in patients following surgery for hip fracture: a retrospective observational study. BMC Musculoskelet Disord. 2019;20:348.
Go to original source...
Go to PubMed...
- Hendricks HT, Geurts AC, van Ginneken BC, Heeren AJ, Vos PE. Brain injury severity and autonomic dysregulation accurately predict heterotopic ossification in patients with traumatic brain injury. Clin Rehabil. 2007;21:545-553.
Go to original source...
Go to PubMed...
- Kellam JF, Meinberg EG, Agel J, Karam MD, Roberts CS. Fracture and dislocation classification compendium 2018. J Orthop Trauma. 2018;32(Suppl 1):S71-S81.
Go to original source...
Go to PubMed...
- Ledermann HP, Schweitzer ME, Morrison WB. Pelvic heterotopic ossification: MR imaging characteristics. Radiology. 2002;222:189-195.
Go to original source...
Go to PubMed...
- Lui SK, Ramalingam MB. A case of acquired heterotopic ossification following a complicated pelvic fracture. Am J Physical Med Rehab. 2017;96:e13.
Go to original source...
Go to PubMed...
- Ochenjele G, Reid KR, Castillo RC, Schoonover CD, Montalvo RN, Manson TT, Sciadini MF, Nascone JW, Carlini AR, OʼToole RV. Predictors of unplanned reoperation after operative treatment of pelvic ring injuries. J Orthop Trauma. 2018;32:e245-e250.
Go to original source...
Go to PubMed...
- Ohlmeier M, Suero EM, Aach M, Meindl R, Schildhauer TA, Citak M. Muscle localization of heterotopic ossification following spinal cord injury. Spine J. 2017;17:1519-1522.
Go to original source...
Go to PubMed...
- Pavelka T, Houcek P, Hora M, Hlavacova J, Linhart M. [Urogenital trauma associated with pelvic ring fractures.] (Article in Czech) Acta Chir Orthop Traumatol Cech. 2010;77:18-23.
Go to original source...
Go to PubMed...
- Stancak A, Kautzner J, Havlas V. [Anterior superior and anterior interior iliac spine fractures. comparison of the results of conservative and surgical treatment.] (Article in Czech) Acta Chir Orthop Traumatol Cech. 2016;83:38-42.
Go to original source...
Go to PubMed...
- Steer R, Balendra G, Matthews J, Wullschleger M, Reidy J. The use of anterior subcutaneous internal fixation (INFIX) for treatment of pelvic ring injuries in major trauma patients: complications and outcomes. SICOT J. 2019;5:22.
Go to original source...
Go to PubMed...
- Vaidya R, Martin AJ, Roth M, Tonnos F, Oliphant B, Carlson J. Midterm radiographic and functional outcomes of the anterior subcutaneous internal pelvic fixator (INFIX) for pelvic ring injuries. J Orthop Trauma. 2017;31:252-259.
Go to original source...
Go to PubMed...
- Wirth T. Avulsionsverletzungen der Hüftregion des Jugendlichen. Orthopade. 2016;45:213-218.
Go to original source...
Go to PubMed...
- Wu F-F, Gao H-L, Huang S, Wang G-R, Jiang X-S, Li J-Y, Shou Z-Q. [NSAIDs combined with radiotherapy to prevent heterotopic ossification after total hip arthroplasty.] (Article in Chinese) Zhongguo Gu Shang. 2018;31:538-542.
Go to PubMed...
- Zagaja GP, Cromie WJ. Heterotopic bone formation in association with pelvic fracture and urethral disruption. J Urol. 1999;161:1950-1953.
Go to original source...
Go to PubMed...