Surgical Excision Of Heterotopic Ossification Research Articles

Complete elbow ankylosis secondary to heterotopic ossification: operative management leads to fair to excellent long-term outcomes

BackgroundHeterotopic ossification (HO) in the elbow, often caused by trauma or neurogenic factors, can lead to limited range of motion and physical impairment, while severe cases may result in debilitating loss of function. Complete bony ankylosis of the elbow, though rare, presents challenges in treatment due to complex anatomy and high recurrence rates, with limited literature on management and outcomes. This study retrospectively investigates cases of elbow ankylosis secondary to HO, assessing long-term functional outcomes following operative intervention and standardized rehabilitation. MethodsA retrospective case series was performed on patients who underwent surgical excision of heterotopic ossification of the elbow at our institution. Outcomes of interest were intraoperative flexion-extension arc, flexion-extension arc at final long-term postoperative follow-up, visual analog scale pain scores at long-term follow-up, and Mayo Elbow Performance Scores at long-term follow-up. Wilcoxon signed-rank test was performed to identify a statistically significant difference between arc of motion achieved intraoperatively and the arc of motion maintained at final long-term postoperative follow-up. ResultsBetween September 1999 and July 2021, 107 patients underwent operative resection for heterotopic ossification around the elbow, with 13 patients (16 elbows) exhibiting complete ankylosis at time of surgery. Patients were followed for a minimum of two years. Long-term outcomes demonstrated an average VAS pain score of 1.4 +/- 1.7, and an average MEPS of 85.9 +/-12.8, with 75% of cases maintaining at least 100 degrees of flexion-extension arc at final long-term postoperative follow-up. On average, the flexion-extension arc of motion at final follow-up was preserved at 95% of intraoperative levels. Patients did have an average residual flexion contracture of 18 +/- 9 degrees at final follow-up. ConclusionSurgical excision for complete elbow ankylosis secondary to heterotopic ossification presents challenges due to potential complications. Our study shows favorable long-term outcomes in pain scores, range of motion, and Mayo Elbow Performance Scores (MEPS). Despite reported complications in the literature, our series exhibited no adverse events, supporting operative excision as a standard treatment with overall fair to excellent outcomes. Further research, particularly involving multicenter, randomized, prospective studies, is warranted to refine protocols and understand predictors for improved outcomes in this patient population.

Surgical excision of heterotopic ossification associated with anti-N-methyl-d-aspartate receptor encephalitis: A case report.

Introduction and importanceHeterotopic ossification (HO) associated with Anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis is rare and the treatment strategy is unclear.Case presentationWe report the case of a 31-year-old female diagnosed with anti-NMDA receptor encephalitis from Osaka General Medical Center, Osaka, JAPAN that developed heterotopic ossification of the knees during prolonged coma. She was unable to walk because of pain and limited range of motion in both knees. Thirty months after the onset of the coma, surgical excision of the heterotopic bone in both knees was performed. The range of motion of both the knees improved markedly and she had no recurrence of heterotopic ossification on a three-year follow-up. Thus, this case can be used as a guide for surgeons with such patients.ConclusionsWe reported a case of heterotopic bone formation in the periarticular region of both bilateral knees in a patient who suffered a 2-month coma following anti-NMDA receptor encephalitis. Surgical excision of the heterotopic bones significantly improved the passive range of motion in both knees. Three years after the operation, the patient had no complaints about her knees, and there was no recurrence of HO.

Heterotopic Ossification after Direct Anterior Approach Total Hip Arthroplasty

AbstractPrevious studies have demonstrated varying rates of heterotopic ossification (HO) after total hip arthroplasty (THA) depending on which anatomical approach is utilized. The direct anterior approach (DAA) is considered to be a muscle-sparing approach to the hip, which may lead to decreased rates of HO formation. This study evaluated the incidence of HO formation after DAA THA. The current work is a retrospective review of patients who underwent DAA THA. Six-month postoperative radiographs were evaluated and HO grade was classified using the Brooker classification system. Baseline characteristic differences between the Brooker classification groups were analyzed, specifically looking at: age, sex, type of deep venous thrombosis prophylaxis utilized, and preoperative Bombelli arthritis type. The overall incidence of HO in this DAA group was 179/485 patients (36.9%). There were 14 patients (2.9%) with Brooker Type 3 HO and 1 patient (0.21%) with Brooker Type 4 HO. No surgical excision of HO was performed. Patients were significantly more likely to develop HO if they had Bombelli hypertrophic arthritis (p < 0.00003). Preoperative radiographic imaging suggesting Bombelli hypertrophic arthritis is predictive of HO formation, warranting consideration for HO prophylactic treatment. The radiographic incidence of HO in DAA THA was 36.9%, which is within the previously reported range of HO seen for lateral and posterior approaches to the hip. HO after total hip arthroplasty is likely due to soft tissue handling, hemostasis, and patient factors, rather than type of surgical approach.

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

Poster 58 Very Early Surgical Excision of Heterotopic Ossification during Inpatient Rehabilitation 7 Weeks After Diagnosis in a Patient with Left Acromioclavicular Fracture and Spinal Cord Injury: A Case Report

Poster 58 Very Early Surgical Excision of Heterotopic Ossification during Inpatient Rehabilitation 7 Weeks After Diagnosis in a Patient with Left Acromioclavicular Fracture and Spinal Cord Injury: A Case Report

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.

Survey

Background Complications caused by heterotopic ossification are a common concern after orthopaedic surgery of the elbow. Little effort has been directed at establishing best practices of management of heterotopic ossification in the elbow, in stark contrast to that in the hip. A survey was distributed to all orthopaedic residency programs in the United States to understand current management of heterotopic ossification in the elbow. Methods A survey was designed to query prophylaxis and surgical excision of heterotopic ossification in the elbow. Respondents were asked about their use of radiation therapy, nonsteroidal antiinflammatory drugs in the prophylaxis of heterotopic ossification or both, as well as the preference for delaying surgical excision of heterotopic ossification after specific index events. Levels of consensus were determined by one-way binomial tests. Responses were categorized as no consensus (50% or less), weak consensus (51--67%), moderate consensus (68--75%), and strong consensus (>75%) level practices. Results One third of the surveys were returned. A strong consensus (91%, P <0.001) indicated the use of prophylactic radiation therapy but there was no agreement on the appropriate dose. Indomethacin is the recommended nonsteroidal antiinflammatory drug (moderate consensus, 84%, P ¼0.009) but with disagreement about the treatment duration. Finally, there is very little agreement concerning the time-delay for surgical excision for all index events. Conclusions The community of orthopaedic surgeons agrees on the prophylaxis and surgical management of heterotopic ossification in the elbow. However, there is less agreement about the appropriate dose, duration, and surgical delay. These uncertainties reflect the dearth of research about the management practices for heterotopic ossification in the elbow.

F2.6 Functional outcomes after surgical excision of heterotopic ossification of the hip developed in ICU patients

F2.6 Functional outcomes after surgical excision of heterotopic ossification of the hip developed in ICU patients

Incidence and Risk Factors of Heterotopic Ossification Following Major Elbow Trauma

Heterotopic ossification is a common complication of Orthopaedic Trauma Association (OTA) type C distal humerus fractures and ulnohumeral fracture dislocations. The purpose of this study was to precisely define the incidence of heterotopic ossification following major elbow trauma and to identify risk factors for the development of clinically significant heterotopic ossification and for surgical excision of elbow heterotopic ossification.Current Procedural Terminology codes identified 156 patients who underwent operative intervention for a distal humerus fracture or an ulnohumeral fracture dislocation at 2 Level I trauma centers over 6 years. The incidence of elbow heterotopic ossification was recorded at >90 days following the definitive procedure. Risk factors for the development of class 3 or 4 heterotopic ossification and for surgical excision of heterotopic ossification were evaluated using separate multivariable logistic regression analyses. Brooker class 3 or 4 heterotopic ossification occurred following 18 (14%) of 125 distal humerus fractures, 15 (22%) of 69 OTA type C distal humerus fractures, and 11 (35%) of 31 ulnohumeral fracture dislocations. Surgical excision of heterotopic ossification was performed after 12 (10%) of 125 distal humerus fractures, 10 (14%) of 69 OTA type C distal humerus fractures, and 8 (26%) of 31 ulnohumeral fracture dislocations. Sustaining a severe elbow injury (P<.05) or a delay of fixation (P=.05) was found to be independent risk factors for Brooker class 3 or 4 heterotopic ossification. Severe elbow injury (P<.05) and male sex (P<.05) were associated with operative excision of heterotopic ossification.

Heterotopic Ossification Associated With Recombinant Human Bone Morphogenetic Protein-2 (Infuse) in Posterolateral Lumbar Spine Fusion

A case of heterotopic ossification in the lumbar spine associated with the off-label use of recombinant human bone morphogenetic protein-2 (rhBMP-2) is reported. To highlight a previously unreported complication of rhBMP-2 use and to review the literature pertinent to the topic. There is no report in the literature regarding a large mass of rhBMP-2-associated heterotopic ossification surrounding the paraspinal musculature. The clinical and radiographical features of this complication and treatment course are presented. The surgical excision of heterotopic ossification and removal of symptomatic instrumentation have resulted in the patient remaining asymptomatic at 1 year of follow-up examination. The reported case adds to the literature of off-label use of rhBMP-2 and the potential for the formation of heterotopic ossification with its use.

Surgical excision of heterotopic ossification of hip in a rare case of Moyamoya disease with extra articular ankylosis

We report a case of isolated ossification of iliopsoas with ankylosis of the left hip in a 27-year-old female. The patient was diagnosed to have Moyamoya disease, a rare chronic occlusive disorder of cerebrovascular circulation following an acute onset of hemiplegia. The patient presented 9 months later to us with ankylosis of left hip which was successfully treated by surgical excision of the heterotopic bone and there was no recurrence at the end of 5 years. A review of literature failed to reveal a similar case with isolated and complete ossification of iliopsoas muscle associated with Moyamoya disease which required surgical intervention. Surgical excision resulted in dramatic improvement in the quality of life. Surgical excision of neurogenic type of heterotopic ossification is a very successful procedure and timely intervention after maturity of mass is very important to prevent the onset of secondary complications and to avoid recurrence.

Heterotopic ossification following surgical treatment of avulsion fracture of the anterior inferior iliac spine

Avulsion fractures of the anterior inferior iliac spine are rare injuries of the pelvic ring and occur during sports activities. Hereby is presented a case of a 22-year-old professional football player who was diagnosed to have an avulsion fracture of the anterior inferior iliac spine on the right side four months after the initial injury and he was treated surgically with the excision of the avulsed fragment. The football player recovered completely and returned to his usual sports activities. Two years later, due to the pain in the hip an x-ray and MR image were made, which established the existence of crescent formation, a heterotopic bone, in the area of the anterior inferior iliac spine, which was surgically removed. Physical and medical therapy was conducted and after four months, the professional athlete was back playing football. Two years after the surgical excision of heterotopic ossification, the patient was completely asymptomatic with the same ROM without any thigh muscle hypotrophy, although isokinetic muscle testing did show some weakness of the thigh extensor muscles. An x-ray did not show any signs of heterotopic ossification.

Radiation Therapy for Heterotopic Ossification Prophylaxis Acutely After Elbow Trauma

Heterotopic ossification around the elbow can result in pain, loss of motion, and impaired function. We hypothesized that a single dose of radiation therapy could be administered safely and acutely after elbow trauma, could decrease the number of elbows that would require surgical excision of heterotopic ossification, and might improve clinical results. A prospective randomized study was conducted at three medical centers. Patients with an intra-articular distal humeral fracture or a fracture-dislocation of the elbow with proximal radial and/or ulnar fractures were enrolled. Patients were randomized to receive either single-fraction radiation therapy of 700 cGy immediately postoperatively (within seventy-two hours) or nothing (the control group). Clinical and radiographic assessment was performed at six weeks, three months, and six months postoperatively. All adverse events and complications were documented prospectively. This study was terminated prior to completion because of an unacceptably high number of adverse events reported in the treatment group. Data were available on forty-five of the forty-eight patients enrolled in this study. When the rate of complications was investigated, a significant difference was detected in the frequency of nonunion between the groups. Of the nine patients who had a nonunion, eight were in the treatment group. The nonunion rate was 38% (eight) of twenty-one patients in the treatment group, which was significantly different from the rate of 4% (one) of twenty-four patients in the control group (p = 0.007). There were no significant differences between the groups with regard to the prevalence of heterotopic ossification, postoperative range of motion, or Mayo Elbow Performance Score noted at the time of study termination. This study demonstrated that postoperative single-fraction radiation therapy, when used acutely after elbow trauma for prophylaxis against heterotopic ossification, may play a role in increasing the rate of nonunion at the site of the fracture or an olecranon osteotomy. The clinical efficacy of radiation therapy could not be determined on the basis of the sample size. Further research is needed to determine the role of limited-field radiation for prophylaxis against heterotopic ossification after elbow trauma.

Early Excision and Late Excision of Heterotopic Ossification after Traumatic Brain Injury Are Equivalent: A Systematic Review of the Literature

Heterotopic ossification (HO) is a common complication in patients with coma after brain injury. As the optimal timing of surgical resection is still controversial and unclear, a review of the literature was performed in order to determine the impact of early operation on recurrence rate and joint mobility. We identified all types of studies dealing with surgical excision of HO in patients after head injury in major medical and publishers' databases. Publication bias and statistical heterogeneity were assessed by funnel-plot asymmetry and Galbraith regression. We abstracted demographic and outcome information from manuscripts that tabulated individual patient data (IPD) to build univariate logistic and linear regression models. Means and proportions for random-effects meta-regression analysis were also obtained. Of 318 studies originally identified, 16 observational studies enrolling 255 patients (212 men, 329 affected joints, mean age of 30.6 [+/-SEM of 1.4] years) were included in the analysis. The reported overall recurrence rate in eleven studies was 38/192 (19.8%). Both IPD and meta-regression analysis failed to show a marked impact of the interval to resection on the probability of recurrence (odds ratio 1.00, 95% CI 0.98-1.03). The predicted probability of recurrence after 13, 21, and 30 months of waiting was 9%, 14%, and 19%, respectively. The length of coma period and patient's neurologic deficit were statistically significant negative predictors for both recurrence rate and functional outcome. Although no conclusive inferences can be drawn from the identified studies, the available data do not support the concept that early excision triggers later recurrence.

Excision of Heterotopic Ossification from the Knee

We retrospectively reviewed 17 consecutive patients with neurologic injuries (22 knees) who had excision of heterotopic ossification (22 knees, five bilateral) of the knees. Our primary research goal was to determine the change in range of motion at the knee after resection of heterotopic ossification in patients with neurologic injuries. Our secondary research goal was to determine the mobility gains measured regarding ambulatory and sitting functions for these patients. Diagnoses included traumatic brain injury (15 patients), anoxia (one patient), and spinal cord injury (one patient). The average age of the patients was 33 years (range, 19-51 years). Data were collected by an independent observer and included range of motion of the knee, ambulatory ability according to a five-level scale, and sitting ability according to a three-level scale. The average followup was 32 months. Range of motion improved by 65 degrees postoperatively. Extension improved from a preoperative mean of 16 degrees to a postoperative mean of 2 degrees . Flexion improved from a preoperative mean of 57 degrees to a postoperative mean of 107 degrees . Ambulatory and sitting function improved as a result of treatment. Surgical excision of heterotopic ossification of the knee is an effective procedure to increase joint mobility and function. Therapeutic study, Level IV (case series-no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Functional outcome following surgical excision of heterotopic ossification in patients with traumatic brain injury.

Increased osteogenesis, both in fracture healing and heterotopically, occurs in a significant percentage of patients with traumatic brain injury. Periarticular heterotopic ossification, especially in the hip and elbow joint, can cause functional loss of motion in patients with traumatic brain injury and interfere with activities of daily living. Seventeen patients with traumatic brain injury had periarticular heterotopic ossification resected in 20 joints (13 hips and seven elbows). Each joint was ankylosed prior to surgical resection (Brooker IV). In the immediate postoperative period, the average arc of motion was 85 degrees in the hips and 65 degrees in the elbows. At the final follow-up observation (average, 23 months), 17 of the 20 heterotopic ossification resected joints had maintained functional range of motion. Three joints in two patients reankylosed. Two additional patients had significant complications. In summary, surgical excision of periarticular heterotopic ossification in patients with traumatic brain injury can give satisfactory results, provided appropriate preoperative selection is done.