Resection Of Heterotopic Ossification Research Articles

Appropriate excision time of heterotopic ossification in elbow caused by trauma

ObjectiveThe aim of this study was to investigate the optimal timing for the resection of heterotopic ossification (HO) of the elbow. MethodsWe retrospectively reviewed 42 patients who were treated operatively for heterotopic ossification of the elbow from March 2010 to December 2014 at our institution. The patients were divided into early (before 12 months) and late (after 12 months) excision groups. In the early excision group (17 patients), the average time from the initial injury to HO excision was 7.4 (3–11) months, and in the late excision group (25 patients), the average time was 33.5 (12–240) months. Every patient was evaluated by range of motion (ROM), the Mayo Elbow Performance Score (MEPS), postoperative complications and HO recurrence. ResultsThe preoperative mean ROM in the late excision group was greater than that of the early excision group, suggesting that the ROM is expected to increase even without surgery. Both early and late surgery increased ROM and MEPS, but early surgery improved ROM and MEPS more than late surgery did (p < .05). ConclusionsEarly excision of HO can provide better elbow function, as indicated by ROM and MEPS. Considering that there were no notable differences in postoperative ROM and MEPS, HO recurrence, or postoperative complications, we concluded that early excision is safe and that the time from an elbow injury to surgery may be shortened. Level of EvidenceLevel III, therapeutic study.

Comprehensive Treatment Strategy for Chronic Low Back Pain in a Patient with Bilateral Transfemoral Amputations Integrating Changes in Prosthetic Socket Design

ABSTRACT Introduction Wounded service members with amputations undergo a complex rehabilitation regimen that can often become complicated by skin breakdown, heterotopic ossification (HO), and pain of the residual limb, contralateral limb, or low back. These complications can impact prosthetic socket fit, decreasing one's functional independence, and potentially negatively impact quality of life. The purpose of this report is to present a case involving the treatment of HO along with prosthetic socket modifications, with the intention to address low back pain (LBP), in a patient with bilateral transfemoral amputations. Materials and Methods The patient experienced traumatic bilateral amputations as a result of an improvised explosive device blast. He was initially fit with ischial containment sockets to provide stability and enhance early mobility. He became a community ambulator but was experiencing LBP and issues with HO. After extensive HO resection, a multidisciplinary discussion took place to determine the best way to diminish LBP by improving spinopelvic alignment while restoring function. It was decided to refit the patient with subischial containment sockets. Subjective questionnaires and three-dimensional gait analysis were used to quantify results. Results After HO resection and prosthetic socket modifications, the patient's complaints of LBP decreased, along with subjective improvements in the Oswestry Disability Index and Short Musculoskeletal Functional Assessment. During upright standing, anterior pelvic tilt decreased from 27.6° to 18.1°. During walking, excursion of the trunk relative to the pelvis decreased in all planes after changing prosthetic socket design to subischial and completing 6 months of rehabilitation: from 24.0° to 17.6° in the frontal plane, 12.4° to 7.8° in the sagittal plane, and 23.1° to 19.1° in the transverse plane. Conclusions A multidisciplinary team approach to the care of patients with bilateral transfemoral amputations can help to improve functional outcomes. For this patient with nonradicular, mechanical LBP, a subischial prosthetic socket design that minimized intrusion on the pelvis had a significant influence on static and dynamic sagittal spinopelvic alignment and overall outcomes. In the end, contributions by orthopedic and plastic surgeons, pain management strategies by a physical medicine and rehabilitation physician, rehabilitation by a physical therapist, and prosthetic modifications all played a role in reduction of this patient's LBP. Among the numerous interventions provided to this patient, including surgical revisions, prosthetic socket design, prosthetic alignment, and physical therapy, it is hypothesized that the change in prosthetic socket design from ischial containment to subischial had a significant, long-lasting impact on LBP and function.

Disuse osteoporosis in heterotopic ossification resection complicated with femoral neck fracture: A case report

Disuse osteoporosis in heterotopic ossification resection complicated with femoral neck fracture: A case report

Results from the surgical resection of severe heterotopic ossification of the hip: a case series of 26 patients

Surgical resection of heterotopic ossification (HO) around the hip joint is often challenging. The aim of this study is to evaluate the clinical and radiological outcomes following surgical resection of Brooker's type III and IV HO of the hip. We retrospectively reviewed clinical and radiological data, between November 2006 and January 2013, of all patients who underwent surgical resection of severe HO of the hip. Brooker's grading, range of motion and the Harris Hip Score before and after surgery were recorded in all cases. The combined radiation (700cGy preoperatively) and indomethacin regimen was used to prevent heterotopic ossification recurrence. Twenty-six patients (22 males and 4 females) were included in our study. Mean patient age was 47.38years (range 24-72). The HO was graded as Brooker grade III in 3 patients (11.5%) and Brooker grade IV in 23 patients (88.5%). Mean time interval between HO development and resection was 40.8months (range 13-156months). All patients had CT scans prior to surgery. Mean follow-up was 31.4months (range 24-40months). There was no severe HO recurrence. Complications included one intraoperative injury of a femoral artery branch, one intraoperative femoral neck fracture treated with intramedullary nailing, one sciatic nerve injury and one superficial infection treated conservatively. Surgical resection of severe HO of the hip along with preoperative radiation and indomethacin provides excellent results; however, the complication rate is relatively high. Careful evaluation of the preoperative CT scan and wide exposure are required in order to identify all the involved neurovascular structures.

Functional Outcomes of Operative Management of Scapula Fractures in a Geriatric Cohort.

To analyze functional outcomes, motion, and strength in patients 65 years of age and older who underwent operative management of a scapula fracture. Retrospective review of prospective database. A single level-1 teaching trauma center. Two hundred fifty patients with scapula fractures were operated between January 2002 and March 2014. A review identified 16 geriatric patients 65 years of age and older. All patients underwent operative treatment of a scapular fracture. Disabilities of the Arm, Shoulder, and Hand (DASH), Short-Form Health Survey versions 1 and 2 (SF-36), Range of Motion (ROM), and Strength assessment at final follow-up 1 year or greater. Outcomes were attained on 15/16 patients at a mean follow-up of 40 months (range = 12-114). All fractures were united. Three patients experienced minor perioperative complications (temporary delirium in 2 patients, urinary tract infection in 1). One patient required subsequent removal of an intraarticular screw, and 1 patient required resection of heterotopic ossification and requested implant removal. The mean ROM expressed as a percent of contralateral ROM ranged from 78% to 96%. The mean strength expressed as a percent of contralateral strength ranged from 76% to 92%. The mean DASH score was 8.4. SF-36 scores were comparable with the normal population. All patients returned to activities. Operative treatment for displaced fractures in patients 65 years of age and older is safe and can yield good functional results and return to function. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Heterotopic Ossification in Primary Total Hip Arthroplasty Using the Direct Anterior vs Direct Lateral Approach

BackgroundThe formation and severity of heterotopic ossification (HO) may be influenced by type of surgical approach. Our hypothesis was that because of differences in soft tissue dissection, differences exist in HO formation in primary total hip arthroplasty using direct anterior (DA) vs direct lateral (DL) approach. MethodsA total of 1482 consecutive patients with DL (736) or DA (746) approach and similar perioperative care protocol during 2009-2011 were retrospectively studied. No patient received prophylactic radiotherapy. Preoperative and 6-month postoperative radiographs were reviewed based on Brooker classification. ResultsThe incidence of overall HO was higher in DL (36.1%) vs DA group (19.4%, P < .001) but high-grade HO (Brooker ≥3) was not significantly different among the groups (3.9% for DL and 3.0% for DA groups). No patient required further surgery for HO resection. ConclusionThe type of approach (DA vs DL) did not seem to have a major influence on the short-term incidence of high-grade HO based on this radiographic analysis.

Surgical Excision of Heterotopic Ossification Leads to Re-Emergence of Mesenchymal Stem Cell Populations Responsible for Recurrence.

Trauma‐induced heterotopic ossification (HO) occurs after severe musculoskeletal injuries and burns, and presents a significant barrier to patient rehabilitation. Interestingly, the incidence of HO significantly increases with repeated operations and after resection of previous HO. Treatment of established heterotopic ossification is challenging because surgical excision is often incomplete, with evidence of persistent heterotopic bone. As a result, patients may continue to report the signs or symptoms of HO, including chronic pain, nonhealing wounds, and joint restriction. In this study, we designed a model of recurrent HO that occurs after surgical excision of mature HO in a mouse model of hind‐limb Achilles’ tendon transection with dorsal burn injury. We first demonstrated that key signaling mediators of HO, including bone morphogenetic protein signaling, are diminished in mature bone. However, upon surgical excision, we have noted upregulation of downstream mediators of osteogenic differentiation, including pSMAD 1/5. Additionally, surgical excision resulted in re‐emergence of a mesenchymal cell population marked by expression of platelet‐derived growth factor receptor‐α (PDGFRα) and present in the initial developing HO lesion but absent in mature HO. In the recurrent lesion, these PDGFRα+ mesenchymal cells are also highly proliferative, similar to the initial developing HO lesion. These findings indicate that surgical excision of HO results in recurrence through similar mesenchymal cell populations and signaling mechanisms that are present in the initial developing HO lesion. These results are consistent with findings in patients that new foci of ectopic bone can develop in excision sites and are likely related to de novo formation rather than extension of unresected bone. Stem Cells Translational Medicine 2017;6:799–806

Physical and rehabilitation medicine management of heterotopic ossification in brain injury

The aim of this work is to determine the epidemiological and characteristics and the therapeutic modalities of heterotopic ossification in brain injury. Retrospective study conducted between January 2010 and January 2016, including patients hospitalized for management of sequelae of an isolated head injury or associated with multiple trauma, and in whom the diagnosis of of heterotopic ossification (HO) was increased. A review of epidemiological data (including age, sex, occupation, type of neurological injury, discovering circumstances of HO), clinical data, the therapeutic choice and evolutivity. Twenty-nine patients with HO were included in the study, 22 adults and 7 children. A male predominance was noted with a sex ratio of 3/1. Mean Glasgow Outcome scale following the trauma was 6/15. Muscle retractions were noted in 23 patients, mainly affecting the upper limb muscles of the wrist and hands and leg sural triceps. Forty-three HO were found in 29 patients. The main locations of HO were respectively hips, knees and elbows. All patients had rehabilitation and working life skills adapted to the evolutionary stage of the brain trauma. Drug treatment included non-steroidal anti-inflammatory and analgesic. HO resection was performed in 15 patients having significant functional limitation or a painful nerve compression. Six adults were able to resume their old job and three children were able to resume normal schooling. The recruitment of our patients has been among the severe trauma patients explaining the high incidence of heterotopic ossifications (HO). The hip is the location most frequently found which is comparable to the literature data. This work highlights the importance of early detection and multidisciplinary management of HO in brain injury patients. These HO will determine the functional prognosis and the social and professional reintegration of the brain injury patient.

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.

Radiation Therapy for Recurrent Heterotopic Ossification Prophylaxis After Partial Metatarsal Amputation

The formation of heterotopic ossification is a relatively common, yet rarely discussed, cause of re-ulceration after previous partial metatarsal amputation. Excessive bone growth at the amputation site has the potential to create an unwanted prominence on the weightbearing surface of the foot, intuitively increasing plantar pressure and placing the neuropathic patient at greater risk of re-ulceration and limb loss. The aim of the present study was to assess the efficacy of single-dose radiation therapy in preventing recurrent heterotopic ossification. The inclusion criteria consisted of a history of clinically relevant heterotopic ossification formation after partial metatarsal amputation with subsequent partial metatarsal amputation for heterotopic ossification resection, followed by prophylactic single-dose radiation therapy. Eleven consecutive patients meeting the inclusion criteria were identified for the present study. Before the intervention, 10 (91%) patients demonstrated formation of mid- to high-grade heterotopic ossification, and 9 (82%) patients exhibited an associated neuropathic ulceration. On follow-up at least 6 weeks after intervention, 2 (18%) patients exhibited low-grade heterotopic ossification reformation that was not clinically relevant and 9 (82%) did not show signs of heterotopic recurrence. Single-dose radiation therapy can help prevent the formation of heterotopic ossification in high-risk patients, acting as an effective adjunct to surgery in minimizing the risk of re-ulceration and re-amputation in the neuropathic patient.

Acquired heterotopic ossification in hips and knees following encephalitis: case report and literature review

BackgroundHeterotopic ossification (HO) is a rare and potentially detrimental complication of soft-tissue trauma, amputations, central nervous system injury (traumatic brain injuries, spinal cord lesions, tumors, encephalitis), vasculopathies, arthroplasties and burn injury, characterized by lamellar bone growth in non-osseous tissues such as the muscle and the joint capsule. Heterotopic ossification associated with encephalitis is rare and the occurrence of excessive, symptomatic heterotopic ossification around bilateral hips and bilateral knees is rarely described in the literature.Case presentationWe present a 47-year-old man with heterotopic ossification in the bilateral hips and bilateral knees that prevented him from walking after being attacked by encephalitis as the case study. He developed severe pain and significantly impaired range of motion of bilateral hips and bilateral knees. Research so far revealed that the management of heterotopic ossification is controversial. After requiring revision surgery resection of heterotopic ossification, reconstruction of the medial collateral ligament and adjunctive pharmacotherapy of 200 mg Celecoxib for 8 weeks after operation, he regained mobility of his joints. On review of X-ray, there was no recurrence of HO and no loosening of rivets which were used in the reconstruction of medial collateral ligament.ConclusionHeterotopic ossification in the bilateral hip joints and bilateral knee joints associated with encephalitis have never been reported previously. Daily functions of heterotopic ossification patients can be hampered by pain, inflammation, reduced mobility, the loss of normal posture and other complications. Further studies of presumptive root causes, the early diagnosis, preventability and optimal therapeutic measures for heterotopic ossification following encephalitis are required. Different patient should be managed with different appropriated protocol based on the risk of individual patient and the institutional experience.

Improvements in elbow motion after resection of heterotopic bone: a systematic review.

Complex elbow trauma, severe burn, or a closed head injury render patients at risk for developing heterotopic ossification around the elbow. When heterotopic ossification restricts elbow motion, some patients request surgical resection. We performed a systematic review of the literature to analyze improvement in elbow motion after resection of heterotopic ossification around the elbow. We found that, on average, etiology had little impact on outcome after resection of heterotopic ossification. Resection of heterotopic bone generally leads to improvement of elbow function.

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.

Heterotopic ossification in the reaming tract of a percutaneous antegrade femoral nail: a case report

IntroductionHeterotopic ossification is a rare complication of musculoskeletal injuries, characterized by bone growth in soft tissues. Percutaneous antegrade intramedullary nailing represents the ‘gold standard’ for the treatment of femur shaft fractures. Minor bone growth is frequently seen around the proximal end of reamed femoral nails (so-called ‘callus caps’), which are asymptomatic and lack a therapeutic implication. The occurrence of excessive, symptomatic heterotopic ossification around the entry site of an antegrade femoral nail is rarely described in the literature.Case presentationWe present the case of a 28-year-old Caucasian woman who developed extensive heterotopic ossification around the reaming seeds of a reamed femoral nail. She developed severe pain and significantly impaired range of motion of the hip joint, requiring revision surgery for heterotopic ossification resection and adjunctive local irradiation. She recovered full function of the hip and remained asymptomatic at her two-year follow-up appointment.ConclusionsSevere heterotopic ossification represents a rare but potentially detrimental complication after percutaneous femoral nailing of femur shaft fractures. Diligent care during the reaming procedure, including placement of a trocar to protect from osteogenic seeding of the soft tissues, may help decrease the risk of developing heterotopic ossification after reamed antegrade femoral nailing.

Heterotopic Ossification Resection After Open Periarticular Combat-Related Elbow Fractures

A retrospective review was performed to evaluate the outcomes and complications following heterotopic ossification (HO) resection and lysis of adhesion procedures for posttraumatic contracture, after combat-related open elbow fractures. From 2004 to 2011, HO resection was performed on 30 blast-injured elbows at a mean 10 months after injury. Injuries included 8 (27%) Gustilo-Anderson type II fractures, 8 (27%) type III-A, 10 (33%) III-B, and 4 (13%) III-C. Mean preoperative flexion-extension range of motion (ROM) was 36.4°, compared with mean postoperative ROM of 83.6°. Mean gain of motion was 47.2°. Traumatic brain injury, need for flap, and nerve injury did not appear to have a significant effect on preoperative or postoperative ROM. Complications included one fracture, six recurrent contractures, and one nerve injury. The results and complications of HO resection for elbow contracture following high-energy, open injuries from blast trauma are generally comparable to those reported for HO resection following lower energy, closed injuries.

Heterotopic ossification of the shoulder in patients with traumatic brain injury

We retrospectively reviewed 10 consecutive patients (11 shoulders) with traumatic brain injury who underwent surgical resection of heterotopic ossification (HO) of the shoulder. Our primary research goal was to determine the change in range of motion (ROM) at the shoulder after resection of heterotopic ossification in patients with traumatic brain injury. Secondary research goals were to determine simple functional outcome gains related to activities of daily living and to determine complications in this patient cohort. Data were collected retrospectively and included measured ROM of the shoulder and observed ability to perform daily activities. The average age of the patients was 33 years (range, 20 -45). Sagittal plane motion (flexion/extension) increased by 85.0°, coronal plane motion (adduction/abduction) increased by 59.1°, and axial plane motion (internal/external rotation) increased by 66.8° (P<.001). Nine patients increased independence with improved functional status (7 patients able to perform all 3 activities of feeding, grooming, and toiletry) (P<.001). Surgical resection of heterotopic ossification of the shoulder is an effective procedure to increase joint mobility and improve function.

Immature Heterotopic Ossification in the Iliacus Muscle in Spinal Cord Injury - A Case Report -

Heterotopic ossification (HO) is a frequent complication associated with spinal cord injury and can lead to significant problems during rehabilitation. Surgical resection of HO could be applied to patients who do not respond to conservative treatment. To reduce the risk of recurrence after the operation, radiation therapy and NSAID or bisphosphonate administration may be utilized. We report the case of a 48-year-old male with a T3-sparing spinal cord injury who underwent successful treatment of immature HO in the iliacus muscle with a combination of surgical resection, radiation therapy, and NSAID administration.

Resection of Heterotopic Ossification of the Elbow: A Comparison of Ankylosis and Partial Restriction

This study tests the hypothesis that the results of release of elbow stiffness related to heterotopic ossification (HO) are comparable whether there is partial or complete restriction (ankylosis) of flexion and extension. Eighteen patients who had surgical release of complete bony ankylosis between the humerus and ulna were retrospectively compared to 27 matched patients who had surgical release of partial restriction of elbow flexion and extension related to HO. Patients were evaluated a minimum of 10 months after surgery, using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Broberg and Morrey rating system. An average of 22 months after surgery (range, 10 to 62 mo), the arc of flexion and extension averaged 95 degrees in the ankylosis cohort and 93 degrees in the partial HO cohort. Forearm rotation averaged 131 degrees versus 134 degrees ; the mean Disabilities of the Arm, Shoulder, and Hand score was 28 versus 30 points; and the mean Broberg and Morrey score was 81 versus 84 points, respectively. After controlling for other factors, patients with elbow stiffness related to HO can recover comparable motion after surgical release at short-term follow-up whether they have complete ankylosis or only partial restriction of motion. Therapeutic III.

Functional results of the parallel-plate technique for complex distal humerus fractures

We evaluated functional results of patients treated with open reduction and internal fixation with the parallel-plate technique for complex distal humerus fractures. Twenty-one patients (14 males, 7 females; mean age 47 years; range 16 to 85) underwent open reduction with olecranon osteotomy and internal fixation with the parallel-plate technique for distal humerus fractures accompanied by highly intra-articular or metaphyseal comminution (n=10), intra-articular comminution and osteoporosis (n=7), and intra-articular and metaphyseal comminution with bone loss (n=4). According to the AO classification, there were 12 C3, six C2, and three C1 type fractures. Eight patients had open fractures. The mean time to surgery was six days (range 1 to 17 days). Functional results were evaluated using the Mayo elbow performance score, Jupiter elbow score, and DASH (Disabilities of the Arm, Shoulder and Hand) score. The mean follow-up was 28 months (range 12 to 48 months). The mean total range of motion was 90.2+/-31.1 degrees, flexion was 118.1+/-17.4 degrees, and extension was 27.8+/-17.4 degrees. The mean Mayo elbow performance score and DASH score were 86.1+/-12.6 and 7.6+/-9.5, respectively. According to the Jupiter elbow scores, the results were excellent in seven patients, good in 11 patients, moderate in two patients, and poor in one patient. Radiographically, solid union was achieved in all the patients. Heterotopic ossification of varying degrees was seen in seven patients, two of whom underwent resection of heterotopic ossification due to severe limitation of movement. Debridement was performed in one patient due to the development of deep infection. Chondrolysis of the elbow occurred in one patient. Patients with open fractures had significantly lower range of motion than those with closed fractures (p<0.05), but the Mayo elbow performance score and DASH score did not differ significantly in this respect (p>0.05). Functional results are satisfactory in distal humerus fractures treated with stable osteosynthesis and parallel-plate technique that allow early active motion.

Poster 42: Early, Directed Surgical Resection of Heterotopic Ossification Following Extensive Trauma: A Case Report

Setting: Regional trauma center. Patient: 22-year-old man with severe crush injury to both lower limbs following a motor vehicle accident. Case Description: The patient presented with multiple injuries, including compartment syndrome and ischemic necrosis of his thigh musculature bilaterally, requiring fasciotomies, muscle debridement, and eventual right hemipelvectomy. On transfer to the rehabilitation unit on hospital day 58, he had functional hip range of motion (ROM) in the remaining left lower limb, but later developed rapid loss of hip flexion and adduction. Radiographs revealed heterotopic ossification (HO) appearing to bridge the hip joint posteriorly. Triple-phase bone scan confirmed the presence of active HO extending from the left superior pubic ramus to the distal femoral diaphysis. Despite standard physical and pharmacotherapy, progressive loss of hip ROM in the remaining limb ultimately precluded his ability to sit upright and safely use power mobility. Given the severe limitations imposed on his rehabilitation, we considered early, selective resection of the bridging heterotopic bone to regain sufficient hip flexion to allow adequate seating. He underwent partial excision of the HO with 1 dose of postoperative radiation on hospital day 100. Assessment/Results: He achieved postsurgical hip flexion of 80° with neutral internal rotation. This resulted in good seated positioning, and he was discharged home by day 122, independent in wheelchair mobility. Triple phase bone scan 3 months later showed no evidence of recurrent HO. Discussion: Limited conflicting literature exists addressing optimal surgical timing for refractory HO. The prevailing recommendation is to delay surgery until maturity of the heterotopic bone, possibly 12 months postdiagnosis. In this case, early resection resulted in appropriate seating and wheelchair driving, and averted unacceptably prolonged immobilization. Conclusions: Resection of HO before full maturity can be beneficial or essential in achieving good, short-term functional outcome.