Recurrence Of Heterotopic Ossification Research Articles

Analysis on the effect of surgical cleaning combined with external fixator for the treatment of post-traumatic heterotopic ossification of elbow joint

To evaluate the clinical efficacy of surgical treatment using a combined medial and lateral approach combined with an external fixator for the treatment of post-traumatic heterotopic ossification(HO) in patients with stiff elbow joints. Surgical release using the combined medial and lateral approach combined with external fixation for the treatment of HO and elbow stiffness in 26 patients from July 2010 to December 2013. The study group included 18 males and 8 females, with an average age 38.7 years (ranged 14 to 60 years). The time from injury to surgery averaged 9.3 (ranged 7 to 18) months. Before and after operation, the elbow range of motion and forearm rotation angle were measured, and the Mayo Elbow Performance Score (MEPS) was evaluated. The wound of all patients was well healed during the first period, except one patient who had chronic infection at the external fixation pin 3 weeks after operation. Then the external fixator was removed. All 26 patients were followed up, and the during ranged from 24 to 40 months, with an average of 34 months. HO recurrence occurred in 1 patient 8 months after operation. The range of motion, forearm rotation angle, and Mayo Elbow Performance Score of elbow joint in patients was significantly improved compared with that before surgery(P<0.05). Surgical release using the combined medial and lateral approach combined with an external fixator for the treatment of traumatic HO and elbow stiffness can effectively improve elbow function, resulting in a satisfactory effect.

Application of distal radius–positioned hinged external fixator in complete open release for severe elbow stiffness

Radical release for severe stiff elbows may lead to instability. Hinged external fixation is used to treat unstable elbows. We hypothesized that extensive open release combined with a distal radius-positioned hinged external fixator would have good performance and low complications rate in treating severe elbow stiffness. Thus, the efficacy and security of this technique were assessed in this study. We retrospectively reviewed 38 post-traumatic elbows with severe stiffness that underwent arthrolysis between February 2011 and February 2014. All patients were assessed as having elbow instability after complete arthrolysis. Ligament repair was combined with implantation of a hinged external fixator (fixed to the humerus and distal radius) to maintain elbow stability. Flexion arc, forearm rotation, Mayo Elbow Performance Score, elbow stability, and radiographs were evaluated preoperatively and postoperatively, and complications were documented. Mean follow-up was 31 months. Significant improvement was noted in flexion-extension arc (from 27° to 126°), forearm rotation (from 148° to 153°), and mean Mayo Elbow Performance Score (from 68 points to 96 points). Mean pronation arc decreased from 66° preoperatively to 6° at 1.5 months of follow-up and showed a transient reduction during first 6 months postoperatively. Pin-related infection occurred in 2 patients, which was cured with conservative treatment. Two patients had moderate instability after removal of the fixator and regained stability at the 12-month follow-up. At the last follow-up, complications included ulnar nerve paralysis in 3, recurrence of heterotopic ossification in 1, and moderate pain in 1. Complete open release combined with a distal radius-positioned hinged external fixator is an effective treatment for severe stiff elbows. This technique had a low complication rate.

Posttraumatic Elbow Stiffness: A Critical Analysis Review.

Open and arthroscopic release are both effective surgical treatments for posttraumatic elbow stiffness. Both static and dynamic bracing are effective for increasing elbow range of motion when heterotopic ossification is not present. Some loss of immediate postoperative range of motion is expected. Recurrence of heterotopic ossification around the elbow is rare. The occurrence of ulnar nerve palsy is rare and often requires transposition.

Management of recurrent heterotopic ossification around total alloplastic temporomandibular joint replacement

Temporomandibular joint (TMJ) replacement is the gold standard for reconstruction of the ankylosed joint, as it provides the facility for early function and a suitably large gap, both aimed at the prevention of recurrence. The recurrence of heterotopic ossification is traditionally managed by resection, a temporary spacer, and remake of the prosthesis, with placement at a second procedure, which adds to costs and morbidity. Atraumatic removal of the prosthesis, resection of the heterotopic tissue, replacement of the prosthesis into its previous position, and the packing of fat around the articulation represents a technique that both minimizes morbidity and reduces costs. This technique has been utilized in three cases, with early improvement in mobility, function, and pain. It is still too early to determine whether the outcomes obtained will be maintained in the long-term.

Link Between Clinical Predictors of Heterotopic Ossification and Histological Analysis in Combat-Injured Service Members.

Heterotopic ossification (HO) is a debilitating condition that occurs following traumatic injury and may restrict range of motion and delay rehabilitation. The timing and efficacy of surgical resection have varied widely, and there is a gap in knowledge between clinical predictors of HO recurrence and histological analysis. Thirty-three service members seen at Walter Reed National Military Medical Center for symptomatic HO were enrolled in an institutional review board-approved study. Participants took oxytetracycline on four scheduled days prior to HO resection to determine the mineral apposition rate (bone growth rate). Detailed histological analyses included scanning electron microscopy with backscattered electron imaging and light microscopy. Data indicated that the mineral apposition rate of trauma-induced HO was approximately 1.7 μm/day at the time of operative intervention, which was 1.7 times higher than the rate in non-pathological human bone. The mineral apposition rate and postoperative alkaline phosphatase values were demonstrated to be positively and significantly related (ρ = 0.509, p = 0.026, n = 19). When the analysis was limited to patients with no more than a two-year period from injury to excision (thereby removing outliers who had a longer time period than their counterparts) and traumatic brain injury and nonsteroidal anti-inflammatory drugs (known correlates with HO development) were controlled for in the statistical analysis, the mineral apposition rate and recurrence severity were significantly related (ρ = -0.572, p = 0.041, n = 11). Data demonstrated a link between benchtop research and bedside care, with the mineral apposition rate elevated in patients with HO and correlated with recurrence severity; however, a larger sample size and more clinical factors are needed to refine this model. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The efficacy of celecoxib in preventing heterotopic ossification recurrence after open arthrolysis for post-traumatic elbow stiffness in adults

Heterotopic ossification (HO) recurrence after joint surgery is always a disturbing problem for patients and surgeons. Our study was performed to assess the efficacy and safety of celecoxib in preventing the recurrence of HO after open arthrolysis for post-traumatic elbow stiffness. We retrospectively studied 152 patients with stiff elbows caused by post-traumatic HO. After surgery, 77 patients received celecoxib (200 mg once daily) for 28 days, whereas 75 did not. Radiographic evaluation was performed at 3, 6, and 9 months postoperatively. Univariate and multivariate analyses were performed to determine which factors affected HO recurrence. HO was both more common and more severe in the no-celecoxib group than in the celecoxib group at 3, 6, and 9 months after surgery. A significant difference was observed between the 2 groups in terms of postoperative extension (P = .030), flexion (P = .008), and pronation (P = .005); however, no significant difference in postoperative supination was noted (P = .622). Logistic regression analysis showed that taking celecoxib was the protective factor for HO recurrence, whereas overweight (body mass index > 25) and male gender were the risk factors. A short course of celecoxib aids in the prevention of HO recurrence after open arthrolysis for elbow stiffness in adults and could be an effective and safe option.

The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise

Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary. We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated. Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups (P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively. Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened.

Preventing and Treating Complications After Hip Arthroscopy.

Although arthroscopic procedures are less invasive than open surgical techniques, arthroscopy is not without complications. Complications of hip “scopes” may include traction-related nerve injuries, fluid extravasation, infection, osteonecrosis, and heterotopic ossification (HO). How to address and avoid these complications are the topics of this month’s “Case Connections” article. In the August 27, 2014 JBJS Case Connector , Uquillas and Youm report on a fifty-one-year-old man who presented with symptoms consistent with right-sided femoroacetabular impingement (FAI). Radiographs revealed mixed cam and pincer impingement, and MRI showed an acetabular labral tear, spurring of the acetabulum and femoral neck, a loose body, and chondral delamination. Surgeons used hip arthroscopy to address these multiple problems. Six months after the procedure, the patient had developed increasing lateral hip pain and tightness. At the eight-month follow-up, he reported a sharp spike in hip pain and showed mild impingement signs. Radiographs revealed HO near the greater trochanter, a finding validated by CT (Fig. 1). MRI revealed inflammation surrounding the area of heterotopic bone. Fig. 1 Three-dimensional CT reconstruction showing heterotopic ossification near the greater trochanter. After a year of ineffective anti-inflammatory medication and physical therapy, interventional radiologists performed an ultrasound-guided pulse lavage (1% lidocaine followed by saline solution) to irrigate and debride the 1.3 × 0.08 × 1.1-cm calcific deposit that had been observed on a preprocedure ultrasound. Dispersion of the deposition was noted during the procedure, which was followed by a steroid/anesthetic injection to provide immediate pain relief and treat inflammation. The …

Surgical resection of severe heterotopic ossification after open reduction and internal fixation of acetabular fractures: A case series of 18 patients

ObjectiveTo evaluate the clinical results of surgical resection of severe heterotopic ossification (HO) after the open reduction and internal fixation (ORIF) of acetabular fractures. MethodsA retrospective chart review was performed between October 2005 and November 2010 on patients undergoing severe HO resection following an acetabular fracture ORIF. Our primary outcome was functional status evaluated by the Harris hip score (HSS). HO resection and hip release was performed using a Kocher–Langenbeck approach in all cases, and a combined radiation and indomethacin regimen was used to prevent HO recurrence. Plain radiographs were also used to evaluate the hip joint for arthritic changes and HO recurrence. ResultsA total of 18 patients (17 males and 1 female) were included in our study analysis. The mean patient age was 36.8 (range: 22–54 years old) when HO resection surgery was performed. The mean time interval between acetabular fracture ORIF and HO resection was 9.9 months (range: 3–30 months): it was within 6 months in 7 patients, 6–12 months in 8 patients, and >12 months in 3 patients.The HO was graded as Brooker grade III in 8 patients and grade IV in 10 patients. The mean time interval between HO resection and the latest follow-up was 4.5 years (range: 2.1–7.8 years). The mean Harris hip score (HHS) was 84.5 (range: 38–100), with a clinical outcome rating of excellent in 9 patients, good in 3 patients, fair in 4 patients, and poor in 2 patients (good and excellent rating accounted for 66.7%). The mean hip joint motion arc was 194° (range: 90–260°).Complications included one intraoperative femoral neck fracture, 1 sciatic nerve injury, 2 femoral head avascular necrosis, and 6 mild HO recurrences (33.3%). There was 28.6% recurrence if HO resection was within 6 months and 36.4% if >6 months. There were no cases of severe HO recurrence, wound infections, deep vein thrombosis, or pulmonary embolism. ConclusionThe early surgical resection of severe HO after an acetabular fracture ORIF can provide satisfactory results, however the complication rate is relatively high.

Massive heterotopic ossification associated with late deficits in posterior wall of acetabulum after failed acetabular fracture operation

BackgroundHeterotopic ossification is a common postoperative complication of acetabular fracture. However, functionally significant heterotopic ossification with associated late bone defects in the posterior wall of the acetabulum is rare and challenging to treat. When heterotopic ossification is a late complication of failed acetabular fracture operation, it is disabling and may only be treated by THA. THA is highly susceptible to premature failure in young and active patients and may require numerous revisions.Case presentationThis article describes a 40-year-old man with massive heterotopic ossification associated with late bone defects in the posterior wall of the acetabulum after a failed acetabular fracture operation. The primary fracture type was a 62-A2.3 fracture according to the AO/OTA Classification.Surgical excision and anatomical reconstruction of the acetabular wall using heterotopic ossific bone were performed 10 months after the fracture repair. Postoperatively, indomethacin was administered for prophylaxis against recurrence of heterotopic ossification, and hip range of motion was progressively increased. At 5 years and 6 months follow-up, the patient’s pain was relieved and hip function had recovered. Though radiography and CT showed minimal subchondral cysts and mild joint-space narrowing, there was no evidence of graft resorption, progressive posttraumatic osteoarthritis or necrosis of the femoral head.ConclusionTo the authors’ knowledge, this is the first case of such a challenging condition. Although it is an extremely rare case, it provides an attractive option for avoiding THA, as the long-term follow-up shows a satisfactory outcome.

Heterotopic Ossification Excision Improves Kinetic and Kinematic Gait Parameters as Demonstrated by Computerized Motion Analysis

Heterotopic ossification (HO) is defined as formation of bone in abnormal locations. HO has been extensively reported in the orthopaedic literature, particularly following total hip arthroplasty, the operative treatment of acetabular fractures, and after spinal cord, traumatic brain, and burn injuries1-24. The hip is the most common site of HO. While many patients with HO are asymptomatic, more severe cases can result in pain and substantial limitations in joint range of motion. The Brooker classification, which is based on the appearance of HO on a single anteroposterior radiograph, remains the most commonly used classification system for HO, although other modified rating systems have been suggested3,7,25. In patients who undergo procedures that result in substantial risk of HO, prophylaxis can be considered; numerous studies have reported successful prophylaxis against HO formation in patients following total hip arthroplasty and open reduction and internal fixation for acetabular fractures2,9,15,16,20,21,24,26-30. The key to preventing HO is early prophylaxis in the inflammatory stage. In patients with symptomatic HO, surgical excision may be considered. Previous studies report improved range of motion following HO excision31-35. Because the incidence of HO recurrence after surgical excision is extremely high, postoperative prophylaxis with radiation or anti-inflammatory medications is recommended. To the best of our knowledge, this is the first case report of HO excision with documentation of both static and dynamic changes of hip range of motion with use of preoperative and postoperative three-dimensional (3D) computerized motion analysis. The patient and her parents were informed that data concerning the case would be submitted for publication, and they provided consent. An eight-year-old girl with duodenal atresia had developed duodenal perforation …

Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification

Heterotopic ossification (HO) is considered as a common extrinsic cause of elbow stiffness. The purpose of this study was to show the results of surgical treatment for post-traumatic elbow stiffness caused by HO in a large, consecutive series of patients in a single unit. We retrospectively reviewed 77 surgically treated patients with post-traumatic elbow stiffness caused by HO. Final motion arc and Mayo Elbow Performance Index (MEPI) were assessed as final results. Univariable and multivariable analyses were done to determine which factors had an effect on the final motion arc. The average arc of elbow motion increased from 45° preoperatively to 112°, with an improvement of 67° at the final follow-up evaluation. The mean MEPI score was 91.9. At the final evaluation, 65patients (84.4%) obtained a total motion arc of ≥100°. Recurrent HO was observed in 16 patients postoperatively, and 6 underwent repeated surgical release. The time from the initial injury to surgical release with a cutoff value of 19 months was the only independent factor affecting the final range of motion (ROM) in multivariable median regression analysis. With the numbers studied, no significant association was found between the final ROM and other clinical variables except for the recurrence of HO (93° vs 117°). From the results of our study, we can support the surgical treatment of elbow stiffness caused by post-traumatic HO regardless of preoperative ROM. However, recurrence of heterotopic bone and delay in surgery of more than 19 months are associated with less favorable results.

Impact of the Operative Delay and the Degree of Neurologic Sequelae on Recurrence of Excised Heterotopic Ossification in Patients With Traumatic Brain Injury

The timing of surgery with regard to recurrence risk after neurologic heterotopic ossification (HO) excision is still debated. This study investigated the association between recurrence risk after HO excision in traumatic brain injury (TBI) patients and (1) the operative delay and (2) the degree of neurologic sequelae (Garland status). A case-control study was performed. Patients who developed troublesome HO requiring surgery after TBI with (case, n = 16) or without recurrence (control, n = 64) were retrospectively included. Other matching criteria were sex and age at the time of surgery (± 4 years). The median delay for first HO surgery was 13.7 months (interquartile range: 9.0-37.1) for the case group and 13.2 months (interquartile range: 7.8-30.0) for the control group. No significant link was found between recurrence and operative delay (P = .54), even after inclusion of all matching factors (P = .53), or Garland status (P = .81). The inclusion of Garland status into the model did not change this result (P = .64). After TBI, no link was found between HO operative delay and recurrence. In spite of a common notion of a relationship between initial severity of TBI and HO development, no link was found between HO recurrence risk and the severity of sequelae.

A classification method for neurogenic heterotopic ossification of the hip

BackgroundExisting classifications for heterotopic ossification (HO) do not include all HO types; nor do they consider the anatomy of the involved joint or the neurological injury. Therefore, we performed this study to propose and evaluate a classification according to the location of neurogenic HO and the neurological injury.Materials and methodsWe studied the files of 24 patients/33 hips with brain or spinal cord injury and neurogenic HO of the hip treated with excision, indomethacin, and radiation therapy. We classified patients according to the Brooker classification scheme as well as ours. Four types of neurogenic HO were distinguished according to the anatomical location of HO: type 1, anterior; type 2, posterior; type 3, anteromedial; type 4, circumferential. Subtypes of each type were added based on the neurological injury: a, spinal cord; b, brain injury. Mean follow-up was 2.5 years (1–8 years).ResultsThe Brooker classification scheme was misleading—all hips were class III or IV, corresponding to ankylosis, even though only 14 hips had ankylosis. On the other hand, our classification was straightforward and easy to assign in all cases. It corresponded better to the location of the heterotopic bone, and allowed for preoperative planning of the appropriate surgical approach and evaluation of the prognosis; recurrence of neurogenic HO was significantly higher in patients with brain injury (subtype b), while blood loss was higher for patients with anteromedial (type 3) and circumferential (type 4) neurogenic HO.ConclusionsOur proposed classification may improve the management and evaluation of the prognosis for patients with neurogenic HO.

The Incidence of Heterotopic Ossification After Hip Arthroscopy

Background: Minimally invasive techniques to treat femoroacetabular impingement (FAI), snapping hip syndrome, and peritrochanteric space disorder (PSD) were developed to reduce complications and recovery time. Although a multitude of studies have reported on the incidence of heterotopic ossification (HO) after open procedures of the hip, there is little known about the rate of HO after hip arthroscopy. Hypotheses: The incidence of HO after hip arthroscopy is comparable with that after open surgical dislocation of the hip and can be reduced with the addition of indomethacin to an existing nonsteroidal anti-inflammatory medication prophylaxis protocol. Study Design: Cohort study; Level of evidence, 3. Methods: Between July 2008 and July 2010, 616 primary hip arthroscopies were performed to treat FAI and PSD. In July 2009, indomethacin was added in the acute postoperative period to an existing HO prophylactic protocol of naproxen administered for 30 days postoperatively. Postoperative radiographs were reviewed to detect the presence and classify the size and location of HO. Odds ratios and logistic regression explored predictor variables and their relationships with HO, with P < .05 defined as significant. Results: Twenty-nine (21 male, 8 female) of 616 (4.7%) hip procedures developed HO postoperatively. Brooker classification of HO was 18 grade I, 4 grade II, 6 grade III, and 1 grade IV. Mean follow-up was 13.2 months (range, 2.9-26.5 months). Rate of HO for cases with and without indomethacin for prophylaxis was 1.8% (6/339) and 8.3% (23/277), respectively. This difference was statistically significant (P < .05), and patients who underwent protocol 1 were 4.36 times more likely to develop HO postoperatively than those who had protocol 2. The majority of cases of HO (72.4%) occurred in male patients, and all cases occurred in the setting of osteoplasty performed for symptomatic FAI. We were not able to demonstrate statistically significant clinical risk factors that were predictive for the development of postoperative HO. However, the data clearly demonstrate that the performance of arthroscopic osteoplasty with a capsular cut in male patients represented the majority of cases, who are likely the group at highest risk. Seven cases (~1%) required revision procedures to excise HO. There were no cases of recurrence of HO after excision, whether it was performed open or arthroscopically. Conclusion: The addition of indomethacin is effective in reducing the incidence of HO after hip arthroscopy and should be especially considered in male patients who undergo osteoplasty for correction of symptomatic FAI.

Heterotopic ossification of the elbow after closed reduction and retrograde intramedullary nailing for radial neck fracture treated by anconeus interposition

Heterotopic ossification around the elbow can lead to considerable functional disability. We describe a case of a 42-year-old man who developed heterotopic ossification of his elbow after closed reduction of the elbow dislocation and radial neck fracture and retrograde intramedullary nailing for radial neck fracture. During the follow-up after initial surgery, movements of the elbow were gradually deteriorated and diagnosed as heterotopic ossification of the elbow. Implant removal, radial head excision along with heterotopic mass, and also interposition of the anconeus muscle resulted in improvement of his elbow mobility. At 18months of follow-up, patient had elbow flexion arc of 15°-110°, 70° of supination, and 50° of pronation without recurrence of heterotopic ossification. The uniqueness of this case lies in the treatment of heterotopic ossification of the elbow to prevent its recurrence, which was developed after retrograde intramedullary nailing for radial neck fracture following closed reduction.

The Impact of Preoperative Hip Heterotopic Ossification Extent on Recurrence in Patients with Head and Spinal Cord Injury: A Case Control Study

BackgroundThe preoperative Heterotopic Ossification (HO) extent is usually one of the main used criteria to predict the recurrence before excision. Brooker et al built a radiologic scale to assess this pre operative extent around the hip. The aim of this study is to investigate the relationship between the recurrence risk after hip HO excision in Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) patients and the preoperative extent of HO.Methodology/Principal FindingsA case control study including TBI or SCI patients following surgery for troublesome hip HO with (case, n = 19) or without (control, n = 76) recurrence. Matching criteria were: sex, pathology (SCI or TBI) and age at the time of surgery (+/−4.5 years). For each etiology (TBI and SCI), the residual cognitive and functional status (Garland classification), the preoperative extent (Brooker status), the modified radiological and functional status (GCG-BD classification), HO localization, side, mean age at the CNS damage, mean delay for the first HO surgery, and for the case series, the mean operative delay for recurrence after the first surgical intervention were noted.Conclusions/SignificanceThe median delay for first HO surgery was 38.6 months (range 4.5 to 414.5;) for the case subgroup and 17.6 months (range 5.7 to 339.6) for the control group. No significant link was found between recurrence and operative delay (p = 0.51); the location around the joint (0.07); the Brooker (p = 0.52) or GCG-BD status (p = 0.79). Including all the matching factors, no significant relationship was found between the recurrence HO risk and the preoperative extent of troublesome hip HO using Brooker status (OR = 1.56(95% CI: 0.47–5.19)) or GCG-BD status (OR class 3 versus 2 = 0.67(95% CI: 0.11–4.24) and OR class 4 versus 2 = 0.79(95%CI: 0.09–6.91)). Until the pathophysiology of HO development is understood, it will be difficult to create tools which can predict HO recurrence.

Safety and efficacy of radiation therapy as secondary prophylaxis for heterotopic ossification of non-hip joints

Prophylactic radiation therapy (RT) is an established adjuvant therapy for heterotopic ossification (HO) of the hip when delivered in the immediate pre- or postoperative setting. Its role in prevention of recurrence after excision of HO is supported by randomised trials for HO of the hip, but there is scant evidence to demonstrate the safety and efficacy of a similar approach in non-hip joints. In the current study, we evaluate radiological and functional outcomes after prophylactic RT for prevention of HO of the knee and upper extremity. With institutional review board (IRB) approval, patients treated at our institution with prophylactic RT for non-hip HO from 1998 to 2009 were identified. Records were reviewed, including pre- and postoperative records, operative reports and radiography. The primary objectives were to determine the safety of RT and rate of treatment failure, as defined by need for further surgical intervention. A total of 30 patients received prophylactic RT for HO of the elbow (n=21), MCP joint (n=1) and knee (n=8). Twenty-nine of the 30 patients were treated within 24-48h postoperatively, and one patient was treated within 24h preoperatively. Based on institutional policy, only patients considered to be at high risk of recurrence were selected to receive prophylactic RT. Patients were treated to a dose of 7Gy in one fraction, with two parallel opposed. Complications following treatment included two patients with postoperative wound infections, one patient with a ruptured triceps tendon and one patient with a fracture within the treatment field. Follow-up information was available for 26 of 30 patients, with a median follow-up time of 16months (range, 2-143months). Recurrent HO, requiring surgical re-excision, developed in 10.5% (n=2) of patients who were followed for upper extremity HO (n=19). For patients followed after RT for HO of the knee (n=7), there were no recurrences of HO that required further intervention. In this group of patients at high risk for developing further HO, prophylactic RT appears to be a safe adjunct to surgery and is effective in prevention of HO recurrence. Results are similar to published reports of HO of the hip and support the use of surgical excision and perioperative, prophylactic RT for HO of non-hip joints.

Surgical Resection of Heterotopic Bone About the Elbow: An Institutional Experience With Traumatic and Neurologic Etiologies

We evaluated the outcomes of patients with elbow heterotopic ossification (HO) who underwent surgical intervention. Our goal was to elucidate differences in outcome of surgical treatment between those patients with traumatic brain injury, direct elbow trauma, or combined etiologies. In addition, we used regression analysis to adjust for confounding factors (such as age, gender, preoperative range of motion [ROM], location of HO, chronicity of HO [ie, time from HO formation to surgery], and whether motor control was spastic or normal) on the relationship between surgical outcome and etiology. We reviewed 60 patients (64 elbows) surgically treated for heterotopic ossification. A total of 42 patients had trauma as the primary etiology, 15 had traumatic brain injury, and 7 had combined etiologies. All had pain or functional limitations at presentation. All patients had surgical resection of their HO. Functional and ROM outcomes were recorded. Mean preoperative arc of motion for the entire cohort was 57° (range, 0° to 150°). Mean postoperative arc for the entire cohort was 106° (range, 0° to 145°) at a mean follow-up of 44 months (range, 21-72 mo), demonstrating a significant gain. Average gain, in arc of motion was 49° (range, 10° to 140°). Gains in motion were not significantly different in any individual etiologic group. A total of 6% of cases were complicated by infection, 13% of cases had recurrence of HO, and 11% of cases required repeat surgery for infection or recurrence. Preoperative ROM was an important independent predictor of final range achieved and gain in ROM after surgical intervention. Recurrence rates were higher in patients with neurologic involvement. Postoperative stiffness was related to preoperative stiffness, delay of surgery longer than 12 months, and anterior location of the HO. Surgical excision of heterotopic bone about the elbow results in significant gains in ROM regardless of etiology. The likelihood of recurrence is higher in patients with central nervous system injuries than in patients with purely localized trauma.

Troublesome Heterotopic Ossification after Central Nervous System Damage: A Survey of 570 Surgeries

BackgroundHeterotopic ossification (HO) is a frequent complication after central nervous system (CNS) damage but has seldom been studied. We aimed to investigate features of HO for the first time in a large sample and the rate of early recurrence of HO in terms of the time of surgery.Methodology/Principal FindingsWe retrospectively analyzed data from an anonymous prospective survey of patients undergoing surgery between May 1993 and November 2009 in our institution for troublesome HO related to acquired neurological disease. Demographic and HO characteristics and neurological etiologies were recorded. For 357 consecutive patients, we collected data on 539 first surgeries for HO (129 surgeries for multiple sites). During the follow-up, recurrences requiring another surgery appeared in 31 cases (5.8% [31/539]; 95% confidence interval [CI]: 3.8%–7.8%; 27 patients). Most HO requiring surgery occurred after traumatic brain injury (199 patients [55.7%]), then spinal cord injury (86 [24.0%]), stroke (42 [11.8%]) and cerebral anoxia (30 [8.6%]). The hip was the primary site of HO (328 [60.9%]), then the elbow (115 [21.3%]), knee (77 [14.3%]) and shoulder (19 [3.5%]). For all patients, 181 of the surgeries were performed within the first year after the CNS damage, without recurrence of HO. Recurrence was not associated with etiology (p = 0.46), sex (p = 1.00), age at CNS damage (p = 0.2), multisite localization (p = 0.34), or delay to surgery (p = 0.7).Conclusions/SignificanceIn patients with CNS damage, troublesome HO and recurrence occurs most frequently after traumatic brain injury and appears frequently in the hip and elbow. Early surgery for HO is not a factor of recurrence.