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Heterotopic ossification is also described in association with severe head injury (in association with coma and long-term mechanical ventilation) [6]. In ARDS osteoarthropathia hypertrophicans occurs infrequently and is probably even less frequent since newer methods of mechanical ventilation and prone positioning have been introduced into intensive care medicine, shortening the need for mechanical ventilation.
References 1. Willems MCM, Voets AJ, Welten RJTJ (1998) Two unusual complications of prone-dependency in severe ARDS. Intensive Care Med 24: 276±277 2. Bamberger E (1889) Sitzungsbericht der k. k. Gesellschaft der ¾rzte in Wien, 8. März 1889. Wien Klin Wschr II: 226 3. Marie P (1890) De l'ostØo-arthropathie hypertrophiante pneumique. Revue de MØdicine 10: 1±36 4. Ricklin P (1955) Über die OstØoarthropathie hypertrophiante pneumique (Bamberger-Marie). Ergebnisse der Chirurgie und Orthopädie 39: 295±326 5. Deller A, Wiedeck H, Konrad F, Schmitz JE (1987) ARDS nach Fruchtwasserembolie. Anaesthesist 36: 34±38 6. Spielman G, Gennarelli TA, Rogers CR (1983) Disodium etronidate: its role in preventing heterotopic ossification in severe head injury. Arch Phys Med Rehabil 64: 539±542
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A. Deller ( ) × B. Heuer Dept. of Anaesthesia and Intensive Care Medicine, Krankenhaus der Barmherzigen Brüder, Nordallee 1, D-54292 Trier, Germany Tel.: +49 65 12 08 28 01 Fax: +49 65 12 08 28 19 H. Wiedeck Universitätsklinik für Anästhesiologie, Universitätsklinikum Ulm, Steinhövelstraûe 9, D-89075 Ulm
M. C. M. Willems
Reply Received: 16 October 1998 Accepted: 16 October 1998 Sir: Deller, Heuer and Wiedeck comment on findings of heterotropic calcifications in a patient on mechanical ventilation, in prone position. The authors state that position is not a causal relationship but that severe ARDS (and hypoxia) is. In our opinion, osteoarthropathia hypertroficans is a different disease with a different, if unknown, pathogenesis. Bamberger and Marie described the syndrome as hypertrophy of the bones in patients with chronic lung disease. We, on the other hand, observed calcification of muscle and other tissue in a patient who was healthy beforehand and was mechanically ventilated for 3±4 weeks. In two of the four cases presented by Deller, Heuer and Wiedeck, severe trauma is the underlying cause of illness. Trauma patients are known to show heterotropic calcification that has a different pathogenesis, trauma induced and not due to hypoxia.
In the first case described by the authors, a young female had been on mechanical ventilation for a substantial period of time, like our patient, when soft tissue calcification started at the fingers. Later this was also seen between humerus and scapulae, comparable to that of our patient. However, the only calcification we observed in our patient was in the shoulder region, which was fiercely stretched and immobilised by the position we put her in. Therefore, we believe that the calcification which grew on this site was myositis ossificans. In conclusion, we do not believe that all calcification can be categorized under the name Marie-Bamberger. The cause of all calcification in seriously ill patients remains unknown. In the case of our patient we believe that position is the most important etiologic factor. M. C. M. Willems Department of Surgery, Hospital Atrium Heerlen, P. O. Box 4446, 6401 Cx Heerlen, The Netherlands Tel. + 3 14 55 76 66 66 Fax + 3 14 55 76 60 55
