임상진료 지침을 이용한 이소성 골화증의 조기 진단 및 치료

접수일 : 2014 년 4 월 12 일 , 게재승인일 : 2014 년 5 월 28 일 책임저자 _: 임재영 _, 경기도 성남시 분당구 구미로 ₁₇₃ 번길 ₈₂

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임상진료 지침을 이용한 이소성 골화증의 조기 진단 및 치료

󰠏 증례 보고 󰠏

분당서울대학교병원 재활의학과

김정길ㆍ이유경ㆍ임재영

Early Diagnosis and Management to Minimize Heterotopic Ossification Under a Clinical Pathway

󰠏 A Case Report 󰠏

Jeong-Gil Kim, M.D., Yookyung Lee, M.D. and Jae-Young Lim, M.D., Ph.D.

Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

It is crucial to diagnose heterotopic ossification (HO) at an early stage because the HO can restrict the range of joint motions and eventually result in the functional deceleration.

After having a number of diagnostic confusion in the initial presentation of the HO, we established a clinical pathway for the acute swelling during the rehabilitation after hip frac- ture which is a work-up process to diagnose the HO at the earliest stage as possible, including the biomarkers plus the imaging study. A 79 year old woman who had an HO on the right hip where she had a bipolar hemiarthroplasty was managed under the clinical pathway. As a result, her HO became distinctly smaller than the HO of other similar cases that we previously experienced. In brief, an early di- agnosis and a proper management of the HO using clinical pathway can minimize the formation, and prevent its complications. (Clinical Pain 2014;13:37-41)

Key Words: Heterotopic Ossification, Clinical pathway, Biomarkers

INTRODUCTION

Heterotopic ossification (HO) is a condition charac- terized by the presence of mature lamellar bone in the soft tissues surrounding a major joint. It is associated with frac-

ture, dislocation, surgery, severe burn and several medical conditions, including spinal cord injuries, traumatic brain injuries.

In addition, HO is a well-known complication after open hip surgery such as total hip replacement, open reduction and internal fixation of hip and pelvic fractures, and joint sparing reconstructive surgery.

It is difficult to discover the initial state of HO which mimics many other diseases such as cellulitis, osteomyelitis, thrombophlebitis, deep vein thrombosis and local infection with abscess.

Besides, the early diagnosis of HO is not easy due to non- specific presenting signs and symptoms such as fever, swelling, erythema, and decreased joint motion. In many cases, missed early diagnosis of HO remains found already in mature state. This could be related to functional deceler- ation and it is hard to manage and rehabilitate. Therefore, we eventually developed a clinical pathway to make an ear- ly diagnosis and proper management for HO.

This is a case report with the clinical pathway for the acute swelling during the rehabilitation after hip fracture which is a work-up process to diagnose the HO at the ear- liest stage as possible, using the biomarker and the imaging study.

CASE REPORT

A 79 year old woman complained of pain, swelling and

heating sense on the right hip where she had a bipolar hem-

iarthroplasty at 20 days after surgery. She could walk by

herself in indoor but accidentally fell down during trans-

ferring to toilet at dawn and felt pain in her right hip. Then,

she was diagnosed with an intertrochanteric fracture of

right side and had a bipolar hemiarthroplasty at the follow-

ing day. She had a complex past medical history which of

having a coil embolization after subarachnoid hemorrhage

6 years ago and left total mastectomy due to breast cancer

1 year ago. She had been taking a hypertensive medication

and insulin therapy due to diabetes mellitus. In addition,

Table 1. Initial Physical Examination at Transfer Day Manual Muscle Power

(Right/Left)

Range of Motion (Right/Left)

Hip Flexor III/V Hip Flexion 75/120

Hip Extensor II/V Hip Extension 0/15

Hip Adductor II/V Hip Adduction 15/45

Hip Abductor III/V Hip Abduction 0/30

Knee Flexor IV/V Knee Flexion 90/135

Knee Extensor IV/V Knee Extension 10/5 Ankle Dorsiflexor V/V Ankle Dorsiflexion 20/20 Ankle Plantar flexor V/V Ankle Plantar Flexion 50/50 First Toe Extensor V/V

Muscle power was graded by MRC (Medical Research Council) grading scale.

Fig. 1. Clinical pathway for heterotopic ossification. HO: Heterotopic ossification, CBC: Complete blood count, CRP: C-reactive pro- tein, ALP: Alkaline phosphatase, CK: Creatine kinase, OP: Operation, AP: Anterior-posterior.

she was suffering from liver cirrhosis and bronchial asthma for a long time. Because of underlying diseases, post-oper- ative management was prolonged and the patient was trans- ferred for rehabilitation at 8

post-operative day (POD).

She took the screening evaluation for HO such as blood test, plan x-ray film and physical examination on transfer day according to the clinical pathway (Table 1) (Fig. 1, 2, 3). The results of the blood test were normal range; ALP, 83 IU/L (reference value: 30∼115 IU/L), CRP 0.51 mg/L (0∼0.5 mg/L). There was not definitely abnormal finding at a simple radiograph of POD 8 except post-operative

findings.

She complained of progressive swelling and pain on sur- gical site at 20

POD. We evaluated the HO work up such as bone scan, computerized tomography (CT) -angiography and blood test including complete blood count (CBC), C-reactive protein (CRP), alkaline phosphatase (ALP) and creatine kinase (CK) (Fig. 1). At that time, HO was sus- pected noticing the intramuscular fluid collection (about 250 cc) on CT with increasing CRP 0.46 to 1.17 mg/L and ALP 222 IU/L, which was higher value than that of screen- ing test (83 IU/L) (Fig. 3, 4A).

We aspirated the fluid over two times under ultrasono-

graphic guidance and began to administrate non-steroidal

anti-inflammatory drug (NSAID). Bone scan revealed in-

creased uptake at a different site from post-operative

change on right hip joint and a lumpy HO appeared around

lesser trochanter in serial follow up x-ray films (Fig. 2,

4B). We also took careful control of her passive range of

motion of her lower limb. We continued a close monitoring

of the manifestation of the HO with a regular follow up

according to a clinical pathway including the plain film and

biomarkers (Fig. 1, 2, 3). In about 6 weeks, the HO became

distinctly smaller than the HO’s in other similar cases that

we previously experienced and did not restrict the range of

motion of the lower limb (Fig. 2). She could walk with a

walker and the pain became negligible eventually.

Fig. 2. Serial hip x-ray shows a maturation and disappearance of heterotopic ossification around the right hip joint after proper manage- ment with the clinical pathway.

DISCUSSION

This case report shows earlier diagnosis and a proper management of the HO using clinical pathway can mini- mize the formation, and successfully prevent its compli- cations.

The incidence of HO in patients with a total hip arthro- plasty (THA) ranges between 16 to 58.3%.

Nearly 3∼

7.6% of people who develop HO following a THA will be severely disabled.

It is known that male and patient who have a hypertrophic osteoarthritis, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis and having specific surgical method such as lateral approach and total ce- mented implants have a greater risk for the development of HO.

The establishment of clinical pathway, therefore, is important to diagnose as early as possible and prevent

the development of HO after major hip surgery for patient who has a high risk.

HO can be suspected if there is a pain, limited range of motion, redness and swelling around the joint. These clin- ical signs and symptoms may appear as early as 3 weeks, or as late as 12 weeks after neurogenic and/or traumatic insult.

It can be confirmed when it shows in simple x-ray but it is hard to find at 3∼4 weeks of early stage and it is usually found at 4∼6 weeks.

Three phase bone scan can help to diagnose within 2 weeks and ultrasonography (USG) is one of the useful diagnostic tool, in recent years.

In addition, it is reported the blood test including CBC,

CRP, CK and ALP can help to find the initial stage of HO.

There are some studies that shows elevated ALP and CRP

levels are associated with HO.

The ALP level may be

elevated in the early stages of bone formation, this returns

to normal as the bone becomes mature.

The authors apply

Fig. 4 (A) CT-Angiography shows intramuscular fluid collection around the right hip joint (white arrows)., (B) Bone scan reveals hot uptake on the right hip joint (black arrow).

Fig. 3. Serum ALP levels increased with pain and swelling initially. Then serum CRP, CK followed by the ALP at the time of confirmation of heterotopic ossification radiographically.

ALP: Alkaline phosphatase, CRP: C-reactive protein, CK: Creatine kinase.

to all patients who are having rehabilitation after hip sur- gery and strive for finding the HO using a diagnostic se- quence considering this critical course of HO.

The major complication of HO is a limited range of mo- tion and functional deceleration following joint contracture.

Early range of motion exercise is known to protect the joint contracture.

The etiology and pathophysiology are not yet completely understood. But it is believed to develop through stimulation by cellular mediators and altered neu- rovascular signaling.

Recently, NSAIDs and radiotherapy is reported to have an effect to prevent the HO after hip surgery.

Our clinical pathway also can prevent the de- velopment of HO using early and regular range of motion exercise and administrating the NSAIDs. But, the patient was not administrated the bisphosphonate because of the abovementioned poor medical conditions including low glomerular filtration rate due to the lingering diabetic mel- litus and complained gastrointestinal trouble such as severe diarrhea at that time.

Using initial evaluation including the physical examina-

tion, blood test and x-ray on lesion site and swelling work

up with HO-specific biomarkers and sensitive imaging

study, we could easily filtered HO in early phase. And

proper management with NSAIDs, ROM exercise and aspi-

ration of collecting fluid if it exists could minimize the

complication of HO. Finally, regular evaluation after con-

firming HO could provide an adequate management ac-

cording the stage of maturation.

After having a number of diagnostic confusion in the ini- tial presentation of the HO, we established a clinical path- way for the acute swelling during the rehabilitation after hip fracture. Clinicians should be concerned about mini- mizing or preventing HO in patients after major hip surgery. A clinical pathway of diagnosis and prevention for HO can be helpful in early detection and proper manage- ment of HO.

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