CONCURRENT EXISTENCE OF HETEROTOPIC OSSIFICATION AND THROMBOPHLEBITIS To the Editor: Yarkony et al (Am J Med 1989; 87: 342-344) detailed the necessary steps required to distinguish between heterotopic ossification and deep vein thrombosis (DVT) in patients with spinal cord injuries and unilateral leg swelling. They did not, unfortunately, offer advice on how to approach the simultaneous presence of both diagnoses. The following case serves to depict the management dilemma that arises when heterotopic bone and ipsilatera1 lower extremity thrombophlebitis exist concurrently. A 60-year-old man who had a left-sided subarachnoid hemorrhage presented during inpatient rehabilitation hospitalization with pain and limited range of motion in the hip region of the flaccid, hemiplegic lower extremity. Radiography revealed heterotopic ossification of the proximal femur. Pharmacologic management with disodium etidronate as well as aggressive range of motion of the hip with physiotherapy was begun to prevent impending joint ankylosis. Ten weeks later, the patient presented with diffuse swelling and pain in the same extremity. Contrast venography corroborated the clinical suspicion of extensive obstruction of the deep venous system in the leg and thigh. Anticoagulation therapy was considered; however, the risk of bleeding in and around the mass of ectopic bone in a patient requiring aggressive hip range of motion therapy, in our opinion, precluded its use. There was no neurosurgical contraindication to anticoagulation therapy at that time. A Greenfield vena caval filter was placed to prevent clot propagation, and the patient was discharged home without further thromboembolic problems to date. Whether to treat acute thrombophlebitis with blood thinners in the presence of significant heterotopic ossification is a difficult management decision. Pathologic and surgical experiences with ectopic ossification reveal characteristic hypervascularity [1,2], with significant bleeding commonly associated with its surgical resection [1,3]. The ectopic bone is often an 318



The American


irregularly shaped mass imbedded between fascial and muscle planes [4,5]. Depending on its exact location, the ectopic bone and surrounding soft tissue are theoretically subject to frequent local trauma with repetitive range of motion of the affected joint. Moreover, the joint range of motion in cases of impending ankylosis, as in the case described, needs to be performed aggressively to maintain a pseudoarthrosis and thus preserve acceptable extremity positioning for sitting or hygiene activities [4]. Clearly, the simultaneous presence of heterotopic ossification and thrombophlebitis must occur not uncommonly, as both are frequent, early complications of spinal cord injury, hip arthroplasty, and, less often, other neurologic diagnoses such as stroke. Surprisingly, to our knowledge there have been no published reports of bleeding complications in patients initially receiving anticoagulation therapy for DVT, but later correctly diagnosed as having only heterotopic ossification. Nonetheless, in those cases of established heterotopic bone formation and suspected or diagnosed DVT, we suggest careful analysis of the potential bleeding risks. This analysis should be based on the relative size of the ectopic mass, its location in relation to the stressed joint, and the anticipated aggressiveness of enforced range of motion. The comparative maturity of newly forming bone may be an additional factor, as evidence suggests immature bone is relatively hypervascular [2]. KENNETH SILVER,M.D. Johns Hopkins University School of Medicine Baltimore, Maryland 21239 1. Hardy AG, Dtckson JW: PathologIcal ossiflcatlon in traumatic paraplegia. J Bone Joint Surg [Br] 1963; 45: 76-87. 2. Metal MA. Garber JE. Stlnson JT: Ectoolc bone formation anchildren and adolescents with hkad Injuryes: Its management. J Pedlatr Orthop 1987: 7: 83-

90. 3. Hsu JD. Saklmura I, Stauffer ES Heterotoplc owficatlon around the hip ]olnt in spinal cord I”lured patients. Clln Orthop Rel Res 1975; 112 165169. 4. Stover SL, Hataway CJ. Zelger HE, Heterotoplc osslficatton In splnai cord-injured patients Arch Phys Med Rehabll 1975: 56. 199-204. 5. Nicholas JJ, Ectopvz bone form&on in patients wth spinal cord qury. Arch Phys Med Rehabil 1973, 54: 354-359. SubmItted

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29, 1989, and accepted December 6, 1989


SYNCOPE AND HUMAN IMMUNODEFICIENCY VIRUS DISEASE IN THE ELDERLY To the Editor: We were intrigued by the case presented by Ratner (Am J Med 1988; 85: 742) on acquired immunodeficiency syndrome (AIDS) presenting as syncope and would like to comment on several points pertaining to the two major issues highlighted in the report: (1) syncope and human immunodeficiency virus (HIV) disease in the elderly; (2) conditions representing difficult diagnostic and management problems in this population. From a geriatrician’s perspective, the salient features of this case were as follows: syncope (occurring during bowel movements) in a 76year-old man; probable volume depletion with hypokalemia secondary to watery diarrhea; documented supraventricular tachycardia (SVT) with mild hypotension; antecedent weight loss presumed secondary to depressive features; an unclassified cognitive impairment of unknown duration; and a past history of blood transfusions during aortic valve surgery. Syncope in the elderly is often the initial manifestation of numerous disorders [I]. The fact that this patient’s syncope presented on more than one occasion, in conjunction with bowel movements, is not surprising in view of the wellknown observation that Valsalva maneuvers in the elderly can cause sustained symptomatic hypotensive episodes [2]. In this population, the usual counterbalancing vascular responses are delayed and blunted. This suggests that defecation itself may have been the cause of the syncope. Furthermore, as in this patient, the risk of syncope is potentiated in volume-depleted elderly persons. The documented (concurrent?) arrhythmia was presumed to be the cause of this patient’s syncope. However, electrocardiographic abnormalities are commonly seen in this population. Continuous ambulatory electrocardiographic monitoring reveals frequent bursts of SVT often without associated clinical symptoms in 4% to 70% of the elderly [3]. The manifestations of dysautonomit syndromes are varied, and

Concurrent existence of heterotopic ossification and thrombophlebitis.

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