Incidence Of Heterotopic Ossification Research Articles

Operative treatment of anterior heterotopic bone formation of the elbow in a patient with severe haemophilia A

There is no statistical data on the incidence of heterotopic ossification among patients with haemophilia, and a few reports documenting this entity in haemophilia are available. Although post-traumatic heterotopic ossification about the elbow is a well-recognized complication, we are not aware of any previously reported case in haemophiliacs. An 8-year-old boy with severe haemophilia A presented with fixed elbow in 80 degrees of flexion. Radiographs disclosed a mature anterior heterotopic ossification in the form of complete ulnohumeral bony bridge. Surgical excision of the heterotopic bone was performed. A full elbow range of motion was obtained after long-term physiotherapy. We conclude that this surgery is safe and successful in haemophilic patients, if performed at the right time under optimal situation.

Acetabular fractures

Evidence from one quasi randomized controlled trial suggests that the incidence of heterotopic ossification (Brooker class III or IV) may be less for those receiving radiation therapies versus indomethacin following surgical repair of acetabular fracture but the difference was not statistically significant. It is possible that this study was underpowered to detect a difference. Among patients with concomitant long-bone fractures, however, indomethacin use was associated with over a three-fold increase in nonunion of the long bone.

Prevention of heterotopic ossification in high-risk patients with total hip arthroplasty: the experience of a combined therapeutic protocol

The combination of radiotherapy and indomethacin for the prevention of heterotopic ossification (HO) in high-risk patients undergoing total hip arthroplasty (THA) has not been reported. The aim of the present study was to present the experience of our department with this combined therapeutic protocol. Fifty-four patients who underwent THA received a single dose of 7 Gy of postoperative radiotherapy and 75 mg of indomethacin for 15 days. Patients were analyzed for clinical and radiographical evidence of HO development at 1 year postoperatively. The overall radiographical incidence of HO was 20.4% (95% CI 10.6-33.5%), while only 1 patient with clinically significant HO was seen. Patients with secondary arthritis due to congenital hip disease had a statistically significantly higher incidence of HO compared with those with osteoarthrosis. The clinical assessment with the Merle d'Aubigné score showed that patients with radiographic documentation of HO had a lower mean score compared with those with no evidence of HO. No treatment-related side effects were seen. Combined radiotherapy and indomethacin was effective in preventing heterotopic ossification after total hip arthroplasty. The evaluation of this efficacy compared with radiotherapy or NSAIDs alone should be the future target of larger randomized designs.

Clinical Significance of Heterotopic Ossification in Cervical Disc Replacement: A Prospective Multicenter Clinical Trial

Heterotopic ossification (HO) is a well-known complication in joint replacements, but its occurrence and clinical effect on cervical artificial discs has not yet been studied. The purpose of this study was to investigate the incidence of HO in cervical disc replacement, to identify any associated risk factors for HO, and to examine the relationship of HO with clinical outcomes. The patient data for this observational study were obtained from the original Bryan Disc Study by the European Consortium. Occurrence of HO was defined by the McAfee classification on the cervical lateral x-rays at 12 months after surgery. Secondary outcome measurements included Odom's criteria and the Medical Outcomes Study Short-Form 36-Item Health Survey. Sixteen (17.8%) of the 90 studied patients experienced HO, and 6 (6.7%) of these patients experienced Grade 3 and 4 HO. Ten patients' (11%) artificial discs were shown to have movement of less than 2 degrees on flexion and extension cervical x-ray at 12 months, with 4 of these patients having HO of Grade 3 or 4. Male sex (chi2 = 4.1; P = 0.0407) and older patients (P = 0.023; odds ratio = 1.10; 95% confidence interval = 1.01-1.19) were associated with development of HO. There is a strong association of the occurrence of HO with subsequent loss of movement of the implanted cervical artificial disc. We have found that sex and age are two possible risk factors in the development of HO after cervical disc replacement.

Clinical Significance of Heterotopic Ossification in Cervical Disc Replacement: A Prospective Multicenter Clinical Trial

ABSTRACTOBJECTIVE:Heterotopic ossification (HO) is a well-known complication in joint replacements, but its occurrence and clinical effect on cervical artificial discs has not yet been studied. The purpose of this study was to investigate the incidence of HO in cervical disc replacement, to identify any associated risk factors for HO, and to examine the relationship of HO with clinical outcomes.METHODS:The patient data for this observational study were obtained from the original Bryan Disc Study by the European Consortium. Occurrence of HO was defined by the McAfee classification on the cervical lateral x-rays at 12 months after surgery. Secondary outcome measurements included Odom's criteria and the Medical Outcomes Study Short-Form 36-Item Health Survey.RESULTS:Sixteen (17.8%) of the 90 studied patients experienced HO, and 6 (6.7%) of these patients experienced Grade 3 and 4 HO. Ten patients' (11%) artificial discs were shown to have movement of less than 2 degrees on flexion and extension cervical x-ray at 12 months, with 4 of these patients having HO of Grade 3 or 4. Male sex (χ2 = 4.1; P = 0.0407) and older patients (P = 0.023; odds ratio = 1.10; 95% confidence interval = 1.01–1.19) were associated with development of HO.CONCLUSION:There is a strong association of the occurrence of HO with subsequent loss of movement of the implanted cervical artificial disc. We have found that sex and age are two possible risk factors in the development of HO after cervical disc replacement.

Klinisches Outcome nach Roboter-assistierter versus konventionell implantierter Hüftendoprothetik: Prospektive, kontrollierte Untersuchung von 71 Patienten

Robotic assisted total hip arthroplasty remains controversial, since wider exposure of the proximal femur and placement of the leg in maximal hip adduction and external rotation using a rigid leg-holder apparatus may impair significantly the hip abductors. Consequently, it is the purpose of this study to analyse and report both clinical outcome and hip abductor function following robotic assisted versus conventional total hip arthroplasty. 36 robotic-assisted (CASPAR, Orto-Maquet, Rastatt, Germany) and 35 conventional cementless total hip arthroplasties were followed on average for 18 months regarding incidence of complications, Harris hip score, the scoring system according to Merle d'Aubigné and Postel, hip abductor function (using a spring-balance), and incidence of Trendelenburg's sign (according to the Kuhfuss-classification). Statistical analysis was performed in case of continuous data using the t test and the Mann-Whitney test, respectively, and in case of categorical data using Fisher's exact test and the chi-squared test, respectively. The level of significance was set as p < 0.05. Average duration of surgery (CASPAR: 100.6 min; conventional: 51.5 min; p < 0.0001) as well as average loss of haemoglobin (CASPAR: 4.5 mg/dL; conventional: 3.3 mg/dL; p = 0.0002) differed significantly, whereas the incidence of complications (CASPAR: two dislocations, one sciatic paresis, one deep infection; conventional: one dislocation, two fissures), revision rate (CASPAR: 5.6 %; conventional: 2.9 %), and incidence of heterotopic ossifications (CASPAR: 30.6 %; conventional: 17.1 %) was comparable following both procedures (p > 0.05). Improvement of the Harris hip score also was comparable in both groups (CASPAR: 40.9 to 86.1 points; conventional: 39.5 to 88.0 points; p = 0.21), whereas improvement of the score according to Merle d'Aubigné and Postel was significantly greater following the manual procedure (CASPAR: 10.1 to 16.0 points; conventional: 8.3 to 16.6 points; p < 0.0001). Differences between the two groups were also significant regarding hip abductor function (CASPAR: 76.1 %; conventional: 93.8 % of the contralateral hip; p < 0.0001) and incidence of Trendelenburg's sign (CASPAR: 61.1 %; conventional: 25.7 %; p = 0.0014). The significant functional impairment following robotic assisted THA should be taken critically into consideration prior to initiating such procedure.

Limited range of motion caused by heterotopic ossifications in primary total knee arthroplasty: a retrospective study of 27/191 cases

Heterotopic ossification (HO) following primary total knee arthroplasty is a rare complication and may be symptomatic if massive enough. Especially the range of motion (ROM) is essential for the function and durability of the implant. The aim of the study was to evaluate the influence of HO on ROM using clinical and radiological parameters. We reviewed 191 primary total knee arthroplasties according to the clinical preoperative and postoperative parameters of the Knee Society Score with special interest paid to the ROM. Standardized radiographs were taken at three levels and the implant position compared. The patients were divided into group 1 (with HO) and group 2 (without HO). The clinical and radiological parameters were compared. We found an incidence of HO in 14.1% (n = 27). Group 1 showed a decreased ROM postoperatively (p = 0.003) and worse flexion contracture (p = 0.04) compared with group 2. The evaluated radiological parameters showed no significant difference between the two groups. We found a significant limitation of ROM because of HO in our study. We found no correlation between HO and component alignment or component position. Local irritation has to be considered the main reason for limited ROM.

P3. The incidence of heterotopic ossification in total disk replacements: a prospective randomized FDA study in 257 consecutive patients

P3. The incidence of heterotopic ossification in total disk replacements: a prospective randomized FDA study in 257 consecutive patients

87. Clinical significance of heterotopic ossification in cervical disc replacement: a prospective multicenter clinical trial

BACKGROUND CONTEXT: Heterotopic ossification (HO) is a well-known complication after joint replacements such as hip and knee replacements. In lumbar total disc replacement, heterotopic ossification has an occurrence rate of 1.4% to 15.2%. Cervical total disc replacements have been performed and investigated widely in recent years, but the significance and incidence of HO associated with cervical total disc replacement is not known at present time.

The incidence of heterotopic ossification after total knee arthroplasty

Five hundred consecutive patients undergoing primary cemented knee arthroplasties were prospectively followed up and evaluated for the presence of heterotopic ossification. Of the patients studied, 95% had osteoarthritis and 5% had inflammation. A radiographic grading system was devised based on the size and location of the heterotopic bone. The overall incidence of heterotopic ossification in this group was 15%. The patients who developed HO tended to be heavier than the average and were more likely to be men. This is the most comprehensive prospective study of the incidence of HO in primary cemented knee arthroplasty. Other than a small subset of the patients (4 of 500), HO does not appear to have a major influence on the outcome of knee arthroplasty.

Incidence of heterotopic ossification following total hip arthroplasty in patients with prior stroke.

This study reviewed the incidence of heterotopic ossification and the functional limitations in a cohort of consecutive patients with prior stroke who underwent primary total hip arthroplasty (THA). Thirty-one primary THAs were performed in 22 patients who had a cerebrovascular accident prior to THA. Mean follow-up 35 months. The overall incidence of heterotopic ossification was 36%, with significant Brooker class III and IV heterotopic ossification reported in 22% of patients. The data suggest that prior cerebrovascular accident may pose an increased risk of significant heterotopic ossification following primary THA. Consideration of prophylaxis in this subset of patients may be warranted.

Prevention and Treatment Of Heterotopic Ossification After Spinal Cord Injury

Background/Objectives: Heterotopic ossification (HO) is a frequent, irreversible complication afterspinal cord injury (SCI). The objective of this article is to explain the etiology of HO; present new advances in prevention, diagnosis, and management of this complication; and provide a suggested algorithm for clinical management.Etiology: Although still hypothetical, trauma and overexpression of bone morphogenic protein(s) in traumatized soft tissue appear to play important roles as initiating factors of HO.Prevention: Preventive use of nonsteroidal antiinflammatory agents (NSAIDs) reduces the incidence of HO by a magnitude of 2 to 3.Management: Early determination of serum creatine phosphokinase may have a diagnostic value in predicting the onset and severity of HO, and an NSAID may be added to etidronate therapy in the initial inflammatory phase of HO formation until C-reactive protein Ieveis return to normal range. Surgery is indicated in a subset of patients, and a regimenthat includes radiation therapy may prevent postoperative recurrence.Conclusion: Significant progress has been made in the early prevention and management of HO. Further studies are needed to elucidate the etiology.

Heterotopic ossification after total knee arthroplasty

The incidence of heterotopic ossification (HO) after total knee arthroplasty (TKA) and its effect on the postoperative range of motion (ROM) were assessed in 63 primary TKAs. Twenty-five of 63 knees (39%) showed postoperative HO, most of which were found in the region anterior to the distal femur. The incidence of HO was significantly higher ( P < .05) in the osteoarthritic knees than in the rheumatoid knees. Significant positive correlation was seen between the preoperative grade of osteophyte formation and the incidence of postoperative HO. The ROM in the knees with HO was not significantly different than that in the knees without HO at 1 year after surgery. Thus, we concluded that HO after TKA is a self-limiting condition and its pathogenesis is completely different from that of myositis ossificance.

Deep vein thrombosis and heterotopic ossification in spinal cord injury: a 3 year experience at the Swiss Paraplegic Centre Nottwil.

Retrospective review of patient data. (i) To determine the incidence and time of deep vein thrombosis (DVT) under low molecular weight heparin (LMWH) prophylaxis in spinal cord injury (SCI), (ii) to determine the incidence and time of heterotopic ossification (HO) and (iii) to assess a possible aetiologic relationship in the pathogenesis of DVT and HO. Swiss Paraplegic Centre, Nottwil. We analyzed the incidence of DVT and HO in 1209 SCI patients (275 first rehabilitations) at the Swiss Paraplegic Centre Nottwil from 1998 to 2000. Clinical files and laboratory data were scrutinised for particularities preceding DVT and HO. The incidence of DVT was 6.55% for first rehabilitation compared to only 1.59% in all patients hospitalised. DVT was complicated by pulmonary embolism (PE) in 1.45% and 0.47% respectively. Incidence of HO was 8% for first rehabilitation and 1.82% for all patients hospitalised. In first rehabilitation patients the peak for DVT occurred around day 30 contrary to HO with a peak around day 120. In single patients HO was identified by MRI as a rapidly progressing process. Laboratory profiles were inflammatory in both HO and DVT. Increased physical activity preceding HO was observed in four patients. In two patients acute HO was complicated by ipsilateral DVT. Prophylaxis with LMWH and elastic stockings significantly reduces the frequency of DVT during first rehabilitation in SCI. DVT and HO are both associated with laboratory parameters of non-infectious inflammation. The later onset of HO coinciding with ongoing mobilisation, argues for a different pathogenetic mechanism. Acute HO of the hip region appears to favour ipsilateral DVT by well known thrombogenic mechanisms.

Heterotopic ossification after revision total knee arthroplasty.

A consecutive series of revision total knee arthroplasties done at two centers was evaluated for the presence of heterotopic ossification on radiographs taken before and after revision using the classification system of Harwin et al. Knee Society scores were obtained preoperatively and at annual intervals postoperatively. The patients' demographics and clinical scores were correlated with the incidence and grade of heterotopic ossification. Minimum 2-year followup was obtained in 135 of 151 patients who had revision total knee arthroplasty during this period (89%). The incidence of heterotopic ossification before revision surgery was 23%, which increased to 56% at most recent followup (mean, 30 months; range, 24-48 months). The only risk factor identified for the development of heterotopic ossification was the presence of infection (76%), which was significantly higher than the 47% incidence of heterotopic ossification in patients who did not have an infection. The average postoperative Knee Society score was lower in patients with heterotopic ossification compared with patients without heterotopic ossification (129 points versus 148 points). Patients with heterotopic ossification had significantly lower functional scores particularly on stair climbing but did not have a significantly decreased range of motion. Parameters not associated with subsequent development of heterotopic ossification included gender (males), patient size (body mass index), surgical time, operative approach, or number of prior knee procedures.

Heterotopic ossification associated with knee dislocation

Purpose: The purpose of this study was to determine the prevalence of heterotopic ossification following knee dislocation. Type of Study: Prospective clinical evaluation and a retrospective chart review. Methods: This study evaluated 57 knees in 55 patients who sustained high-energy blunt trauma with resultant knee dislocations. Radiographs were reviewed by 2 of the authors (J.P.S., T.C.W.), and the incidence of heterotopic ossification (HO) was documented. Additionally, patients were classified regarding the degree of HO on a scale from 0 to 4. One is punctate calcification, 2 is HO involving less than 50% of the joint space; 3 is HO involving more than 50%; and 4 is ankylosis of the joint. Results: Thirteen patients with 15 knee dislocations developed HO. The incidence of HO was 26%. Seven knees demonstrated severe HO (grade 3 or 4) which represented an incidence of 12% of all knee dislocations. Injury severity score for both groups was 18, documenting that the patients in this study represent multiple trauma patients. There was no significant difference in the incidence of HO based on mechanism of injury with the current number enrolled in the study. However, 60% (3 of 5) of patients involved in a motor vehicle versus pedestrian accident developed HO. There was a significant increase in the incidence of arthrofibrosis in patients with severe HO (P <.05). Patients with significant HO had a mean flexion of 97°, compared with flexion of 117° in patients with no or mild HO. This difference was borderline significant (P =.058). There was no difference between the groups in mean extension. There was a significant increase in knee HO in patients with HO at another anatomic site (P =.01). Conclusions: HO is a common problem following knee dislocation. Of the 7 knees with severe HO, 5 developed HO medially, 4 developed HO posteriorly, 3 developed HO laterally, and only 1 had involvement anteriorly. A similar distribution was present in the patients with mild HO, with posterior and medial ossification being the most common. Five of the 7 severe HO cases involved at least 3 of the 4 sides (anterior, posterior, medial, or lateral) of the knee. Patients were evaluated for the presence of head injury and any relationship to the development of HO around the knee. There was no increased incidence of HO around the knee in our 10 patients with severe head injuries when compared with those with no head injury. There was also no increased incidence of HO in knee dislocations associated with periarticular fractures.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 8 (October), 2002: pp 835–839

The effect of pulsed irrigation on the incidence of heterotopic ossification after total hip arthroplasty

Abstract: Heterotopic ossification (HO) is a common complication of total hip arthroplasty (THA). Pulsed lavage is being used with increasing frequency for THA. A prospective randomized, double-blind trial was initiated to determine if pulsed lavage affected the incidence of HO. A total of 94 THAs in 91 patients were analyzed. No significant difference in the incidence of HO was found between the 2 groups. Hypertrophic osteoarthritis was found to be a significant risk factor for HO. The findings suggest that the osteogenic precursor cells thought to be involved in the pathogenesis of HO possibly are derived from within the local soft tissues in the proximity of the hip joint.

Heterotopic ossification after total hip arthroplasty.

We studied 178 patients undergoing total hip arthroplasty (66 men and 112 women) retrospectively, with regard to the incidence and severity of heterotopic ossification and the significance of postoperative prophylaxis with non-steroid anti-inflammatory drugs. The overall incidence of heterotopic ossification was 32% 1 year after surgery. The factors increasing the incidence were male gender, previous arthroplasty of the contralateral hip joint, previous surgery on the hip, absence of preoperative treatment with non-steroidal anti-inflammatory drugs and an operating time of more than 100 min. The incidence of heterotopic ossification was lower in the patients of O blood group.

A prospective evaluation of the timing of postoperative radiotherapy for preventing heterotopic ossification following traumatic acetabular fractures

Purpose: Preoperative and immediate postoperative irradiation of traumatic acetabular fractures (TAF), although known to reduce heterotopic ossification (HO), can cause significant organizational and logistic difficulties. We sought to determine an acceptable time interval between surgery and radiation without compromising control, as well as to update our large experience and to further validate our treatment philosophy. Methods and Materials: Beginning in June 1995, we began a prospective study, irradiating 152 patients on postoperative days 1, 2, or 3. There were also 17 patients delayed further secondary to medical difficulties. Results: All patients treated since June 1995 received 700 cGy/1 fx. Fifty-eight patients received radiation within 24 hours of surgery, 41 within 2 days, 53 within 3 days, 13 within 4 days, and 4 were delayed further. Delaying irradiation for up to 4 days postoperatively caused no statistical increase in HO ( p = 0.625). Of 263 patients in our retrospective cohort, HO occurred in 5.3% of patients who received irradiation versus 60% of patients who did not. Conclusion: In our prospective study, we noted no perceptible increase in HO with up to a 3-day interval between surgery and radiotherapy. This allows a more structured treatment schedule and allows the patient more time to heal and recover. Updated results from our overall series continue to demonstrate that adjuvant radiation decreases the incidence and severity of HO after TAF.

Orthopedic problems in Lesch-Nyhan syndrome.

Lesch-Nyhan syndrome is an X-linked disorder of purine metabolism. The orthopedic problems and results of treatment of nine Lesch-Nyhan patients are reviewed. Associated orthopedic problems included hip subluxation or dislocation (nine of 18 hips), fractures (three), autoamputation, infections (three), minor scoliosis, and contractures. Lesch-Nyhan patients can safely undergo orthopedic procedures and the results of surgery are satisfactory and similar to those of patients with spastic cerebral palsy. All of the seven operated-on hips maintained good reduction at 6-year mean follow-up. With adequate cast technique, fractures and hip subluxation/dislocation may be treated successfully. The treating orthopedist should be aware of the increased incidence of heterotopic ossification in this population, as well as the potential for serious complications such as hardware failure or femur fracture, if appropriate immobilization is not used.