Mesa Redonda: Osificaciones Heterotpicas

Identifying risk factors for heterotopic ossification after traumatic brain injury Description of a hypothesis and research proposal J.D. Martina, MD, Physiatrist, P. van Kampen, MD Rehabilitation Centre Groot Klimmendaal Department for Acquired Brain Injury Patients Arnhem, the Netherlands
Heterotopic Ossification (HO) is a common skeletal complication in patients with brain injury (BI) which can lead to severe functional disability and may interfere with the rehabilitation treatment. Detection of HO is often delayed until the clinical manifestations have already caused irreversible joint contractures. Identification of risk factors and early detection of HO may help prevent a more severe handicap. The etiology and pathogenesis of HO remain unexplained despite many scientific investigations. Prolonged immobilization, metabolic and hormonal abnormalities and the role of prostaglandin have been associated with the appearance of HO. Animal studies do suggest that denervation of muscle leads to a proliferative response by various cell types in the muscle, mainly fibroblasts. The basic defect in HO is the inappropriate differentiation of fibroblasts to bone-forming cells. Early edema of connective tissue proceeds to tissue with foci of calcification and then to maturation of calcification and ossification. Stretch forces seem to be implicated in the proliferation process of fibroblasts in the soft tissues. The cell differentiation from fibroblasts into osteoblasts is a fundamental factor for the onset of HO. This cell differentiation may be stimulated by predisposing factors such as pH changes in soft tissues, edema, free oxygen radicals and immunologic agents. In our clinical practice we have noticed that most patients with impaired Range of Motion (ROM) due to HO, also have suffered a systemic infection while being treated at the intensive care unit. Most of them underwent mechanical ventilation. Although the incidence of this combination of factors: Traumatic Brain Injury, Systemic Infection and Mechanical Ventilation has not been reported in the literature, we strongly suspect that a systemic infection could possibly trigger the onset of HO. So far we know, this etiologic relationship has never been established in the literature. Through a case study report we will illustrate our hypothesis and suggest a therapeutic approach. To better characterize the risk factors implicated in HO, a three-year prospective study at the Brain Injury Rehabilitation Unit of Rehabilitation Centre Groot Klimmendaal in Arnhem, the Netherlands, will be conducted.

Tratamiento quirrgico de las calcificaciones heterotpicas Dr. Ricardo Yohena- IREP BsAs. Argentina
Uno de los inconvenientes que presentan los pacientes para su rehabilitacin es la fijacin de la cadera producida por calcificaciones heterotpicas. Las alteraciones metablicas inducidas localmente por la inflamacin crnica producen depsitos de calcio con limitacin de los movimientos de cadera o su fijacin. Los tratamientos mdicos realizados con corticoides, si bien disminuyen los depsitos de calcio no impiden la rigidez articular a largo plazo. Los tratamientos quirrgicos mediante la reseccin del fmur, eliminan los depsitos clcicos con el hueso, pero no impiden la impactacin del extremo proximal del fmur con la cavidad cotiloidea, aumentando la inflamacin y el depsito de calcio. En la actualidad aplicamos un colgajo muscular en la cavidad neoformada, disminuyendo notoriamente el deposito de calcio por la detersin biolgica que l mismo produce, se presenta el mecanismo de formacin de las calcificaciones heterotpicas y la tcnica quirrgica empleada en la actualidad para este tipo de patologas.