Introduction
Formation of lamellar bone within the soft tissue surrounding a joint is called Heterotopic ossification (HO). Generally seen in cases with long history of spinal cord injury (SCI), traumatic to brain causing injury, burns, and direct trauma.1, 2 Varghese in his study stated that the incidence of Heterotopic ossification after developing stroke was 0.5–1.2%. The aetiopathogenesis of this still remains unclear. It been said that the major factors for developing Heterotopic ossification are immobilization and forcible manipulation of joints to achieve range of motion.3, 4 Major contributing factors like fracture, spasticity, deep venous thrombosis infection, and development of pressure ulcers.5, 6 It is mainly categorised into traumatic and neurogenic. Traumatic which generally develops after direct muscle trauma or surgery or any irregular manipulations. Neurogenic generally develops after neurological lesions, like trauma to brain or any spinal cord injury (SCI).7 In post-stroke hemiplegia conditions occurrence of Heterotopic ossification is rare; very few cases were reported in the literature. Development of Heterotopic ossification in all the joints was not reported previously. We are presenting the case of a 50 yr man who had stroke and developed Heterotopic ossification in all his joints.
Case Report
Ten months before, a 50-year-old male was brought to the emergency department due to unbearable headache with previous history of seizures and was admitted. The patient followed by generalized seizure and loss his consciousness for about an hour at that time the Glasgow Coma Scale [GCS]: 5/15. He was intubated and mechanically ventilation was given at the time of unconsciousness. CT Brain was being done and which showed a subarachnoid bleed I both the cerebral hemisphere. Then he was shifted to ICU and was there for about 2 months. He was regularly monitored and all the care was taken. pt came out of ventilator after 2 months and at that time his gcs was 9/15. follow up Neurological examination showed that the patient developed rt hemiplegia. He was transferred to the observation department and was discharged later on 20th day with GCS 13/15. Two month later, he was brought back to emergency department with drowsiness, vomiting and speech and gait impairment and his condition was deteriorating along with that, spasticity of the right wrist and finger flexors was grade 3 according to the modified Ashworth scale (MAS) and spasticity of the gastrocnemius was grade 3. Active and passive range of motion of all the non-paretic knee was restricted (range 40–90°). In addition, there was swelling and warmth on the both knee. His treatment was complicated with The rehabilitation of the patient mainly comprised exercise and transfer activities, balance and gait training for 2 months by the time he got discharged he developed a grade 2 pressure sore, which treated with regular dressing and got resolved respectively and discharged. Regular physiotheraphy was done in the rehabilitation clinic with regular followup was done for about a month. After a week and her clinical observation spasticity developed in hip flexors, adductors and knee flexors and the rom was very difficult to perform and even a slight moment gave pt a very severe pain ;Laboratory examination revealed a WBC count of 6800mm3, ESR of 40mmh1 and serum ALP level of 147 IU L1. The patient was evaluated with the x-rays Heterotopic Ossificans was identified in all the major joints [Figure 1]. C T was done to obtain differential diagnosis, and it clarified the development of the heterotrophic Ossificans. The pt was given Warfarin were administered. The whole episode compromised the daily activity of the patient and moment In his limbs so he was transferred to the training and physiotheraphy which was not useful that the stage some functional recovery was achieved for about 5 to 20 degree of moment in all the joints on his last visit.
Discussion
In post-stroke hemiplegia Heterotopic ossification is very rare, the reporting of such type of cases is very low in the literature.2 Heterotopic ossification aetiopathogenesis is not clear till date in such cases. Few authors proposed that the aetiopathogenesis is may be due to neuronal control mechanisms.8 Some stated that the main responsible for this metabolic control by a potential neurotransmitter meight be the cause. Few say that conditions like Heterotopic ossification, Charcot joint, osteoporosis, are conditions that are controlled by same mechanism.9 Some say that factors that can stimulate are related to neurogenic Heterotopic ossification such as : prolonged comatose stage, mechanical ventilation, increased muscle tone, and limited movement in the involved extremity.10, 11 Some authors stated in such patients immobilization, passive ROM exercises, transfer activities and repeated micro-traumas might be the cause.3, 4, 5, 9, 11 few of the recent literature has shown that Heterotopic ossification may be traumatic.12 Michelsson et al.3, 4 said that immobilization and forcible mobilization are the most important causes of developing Heterotopic Ossificans In our patient, passive range of moment was done in both limbs equally, But non of it explains why HO developed in the non-affected side. The major regions like hips, shoulders, pelvis, elbows and knees are generally involved so as in our case.13 If the patient has hemiplegia, general site of HO is the hip, where commonly flexor (anterior) or adductor (medial) compartments13, 14, 15, 16, 17 are affecred. Nakajo and Endo18 in their study stated that HO developed in few of their patients with hemiplegia, most of then occured around the hip, knee and elbow. In our cases, HO is atypical due to late development at 6 months’ after developing stroke, generally the onset of HO ranges from 4–12 weeks, mostly occurred by 2 months19 HO in neurologic disorders generally develops over affected side limbs. Garland et al.5 in his study stated that hemiparesis is the region where HO occurs. Whereas On the other hand, Kocaaga et al.20 stated and reported the development of HO in nonparetic knee. In our case, either neurogenic or traumatic or both factors together may have role in developing HO in un effected side other than affected side. It is hence important to keep in mind that the HO may develop both in affecting and non affecting side hence proper observation and early treatment is necessary to prevent HO formation, There are few studies which are against ROM in treatment protocol,3, 21, 22, 14, 23 gentle rom which comes within the pain-free range should be done to patients.
