Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies

Bony encasement of the ulnar nerve secondary to heterotopic ossification of the elbow: an evaluation of long-term outcomes

BACKGROUND

Ulnar neuropathy at the elbow caused by heterotopic ossification (HO) is a rare condition. This retrospective study aims to report on 32 consecutive cases of ulnar nerve encasement caused by elbow HO and evaluate long-term outcomes of operative management and a standardized postoperative rehabilitation regimen.

METHODS

A retrospective case series was conducted on 32 elbows (27 patients) that underwent operative management of bony ulnar nerve encasement. All procedures were performed in the inpatient setting at an Academic Level 1 Trauma Center from September 1999 to July 2021 by one of 3 fellowship-trained shoulder and elbow. Postoperatively, all patients received formal physical therapy, HO prophylaxis (30 received indomethacin, 2 received radiation), and a structured continuous passive motion machine regimen. Patient demographics, age, gender, type of injury, history of tobacco use, and medical comorbidities were obtained to include in the analysis. Long-term follow-up examinations were performed to evaluate elbow flexion-extension arc of motion, Mayo Elbow Performance Score, and visual analog scale pain scores.

RESULTS

Thirty-two elbows with complete bony ulnar nerve encasement secondary to HO were identified (14 from burns, 15 from trauma, 3 closed head injuries). Following surgery, the mean flexion-extension arc of motion improved significantly, increasing from 21° to 100° at long-term follow-up (average 8.7 years, range 2-17 years), with statistically significant improvements in preoperative vs. long-term postoperative elbow extension (P < .001), flexion (P < .001), and total arc of motion (P < .001). There was a statistically significant improvement in pre- vs. postprocedure ulnar nerve function, as demonstrated by a decrease in average McGowan grade (1.2-0.7; P = .002). Additionally, 63% of patients with preoperative ulnar neuropathy symptoms (20/32) had either complete resolution or subjective improvement after surgery. The mean time from injury to surgery was 518 days (range 65-943 days). Age, gender, time to surgery, and medical comorbidities were not associated with outcomes. The complication rate was 9% (3/32). Patients had an average flexion-extension arc of motion of 97° and average Mayo Elbow Performance Score of 80 ("good") at long-term follow-up.

CONCLUSIONS

The combination of operative management, postoperative HO prophylaxis, and a regimented rehabilitation program has proven to be a durable solution for treating and ensuring good long-term functional outcomes for patients with elbow HO and bony ulnar nerve encasement. This treatment approach leads to superior range of motion, improved or resolved ulnar neuropathy, and good to excellent long-term functional outcomes.

Primary Versus Secondary Radiotherapy for Heterotopic Ossification Prevention About the Elbow

OBJECTIVES

To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow.

DESIGN

Retrospective chart review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundred and twenty-nine patients who received prophylactic radiotherapy (XRT) over a 15-year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow-up after XRT. Fifty-four patients were ultimately included.

INTERVENTION

All patients were treated with a single dose of 7 Gy. Ninety-eight percentage of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery.

MAIN OUTCOMES MEASUREMENTS

The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint.

RESULTS

Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT and 11.1% required surgery to resect the heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT and 5.5% required resection surgery. No secondary malignancies were identified.

CONCLUSIONS

Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow-up is required to better characterize populations at high risk for development of HO and secondary malignancy.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Neurogenic heterotopic ossification in the upper limb

Neurogenic heterotopic ossifications (NHOs) are periarticular ectopic ossifications that frequently develop after a central nervous system injury, most often a traumatic one. They limit range of motion and cause pain, interfering with limb positioning and function, whether active or passive. Highly described in the lower limbs, NHOs can also develop in the upper limb, with specific characteristics depending on their location. This article provides a summary of the diagnostic and therapeutic management of NHOs in the upper limb, based on the current literature.

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Introduction  Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods  We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results  Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion  There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence  Level III.

Global Excision of Severe Heterotopic Ossification of the Shoulder: A Case Report

CASE

A 21-year-old man sustained a closed glenohumeral fracture/dislocation as a pedestrian struck by a motor vehicle. He was treated nonoperatively and developed severe post-traumatic heterotopic ossification (HO) with near-complete shoulder ankylosis. We present our technique for safe surgical excision.

CONCLUSIONS

Excision led to improvements in motion and quality of life at 1 year postoperatively. Recommendations for successful HO excision around the shoulder include excision after at least 180 days, appropriate preoperative imaging to include cross-sectional imaging and a 3D model, intraoperative fluoroscopy, well-serviced instruments, preparation for iatrogenic fracture and/or neurovascular injury, meticulous hemostasis, postoperative HO prophylaxis, immediate postoperative therapy, and involvement of a multidisciplinary team.

The column procedure preserves elbow stability on biomechanical testing

PURPOSE

The effect of open release of a post-traumatic elbow contracture on the stability of the joint has not been so far studied in vivo. Resection of elbow joint capsule, the key element of surgery, was reported to have no effect on the stability of cadaveric elbows. The joint capsule is yet known to participate in maintaining elbow stability as one of secondary stabilizers.

METHODS

We assessed elbow joint laxity in 39 patients who underwent an open contracture release via the 'column procedure' described by B. Morrey and P. Mansat within the preceeding three to nine months. The measurements were taken with an apparatus designed particularly for this experiment according to the predetermined protocol. A preliminary part of the experiment showed that there was no significant difference between laxity of two elbow joints in healthy volunteers. Laxity of the operated elbows could be then compared with the contralateral joints.

RESULTS

Mean absolute difference of laxity between healthy and operated elbows was 1.55° (0.1°-4.1°, SD = 1.1) being significantly lower than 2°, p = 0.0056. The difference of the joint laxity between the operated and healthy elbows did not differ statistically significantly by more than 0.6° from the difference of the laxity of two healthy elbows and, therefore, is not clinically noticeable.

CONCLUSIONS

Our experiment confirmed that the 'column procedure' is a safe procedure which does not compromise the stability of the elbow joint.

Loss of pronation-supination in patients with heterotopic ossification around the elbow

BACKGROUND

Heterotopic ossification (HO) is a well-recognized cause of limited flexion-extension, but it can also limit pronation-supination. There is a paucity of literature concerning restriction of pronation-supination due to HO.

METHODS

We conducted a retrospective review of patients who had undergone elbow surgery for HO removal between January 1, 2003, and September 27, 2013. Computed tomography scans were reviewed to determine the presence of HO restricting forearm rotation and were rated independently by 4 observers. Each elbow was given 1 of 4 scores according to the likelihood that HO was restricting forearm rotation. Agreement was achieved when 3 or 4 observers thought that HO definitely or probably caused a loss of pronation-supination.

RESULTS

Of 132 post-traumatic patients undergoing HO excision for restricted elbow motion, 61 (46%) also lacked a functional arc of pronation and supination (50° and 50°, respectively). Of these 61 patients, 32 (53%) were considered to have lost forearm rotation because of HO. The remaining 29 patients (47%) were thought to have restricted forearm rotation for reasons unrelated to HO.

DISCUSSION

In this study, loss of pronation-supination affected almost half of the patients (61 of 132 [46%]) undergoing HO excision around the elbow. Of these 61 patients, 32 (52%) had HO extending into the proximal forearm and affecting rotation. From our data, one can expect that about one-quarter (24% of patients in this study, or 32 of 132) with post-traumatic HO of the elbow will have a significant functional loss of pronation-supination due to HO extending into the forearm.

The Neuro-Orthopaedic Approach

Upper motor neuron disease or injury can lead to muscle spasticity or nonfunction throughout the body. Imbalance in muscle forces predisposes patients to development of functional deficiencies, contractures, pain, and poor hygiene. The approach to neuro-orthopaedic patients is by necessity multidisciplinary, because a variety of nonsurgical and surgical options are available. In evaluating each patient, surgeons must consider the extent and quality of any deformity, potential for improvement in function, the ability to alleviate pain, and potential for improvement in hygiene and cosmesis. Surgical techniques include tendon lengthenings, releases, transfers, osteotomies, and bony fusions.

Surgical release for tubercular elbow stiffness

Background

For decades, tuberculosis (TB) has posed a great threat to people worldwide. Bone and joint TB is one of the most common types of extrapulmonary TB, with elbow TB comprising a small proportion of these cases. The treatment for elbow stiffness associated with TB has been rarely reported.

Patients and methods

We retrospectively analyzed six patients (four females and two males) with tubercular elbow stiffness during a 7-year period. All of them received open arthrolysis and hinged external fixation to restore functional extension, flexion, supination and pronation. Mayo Elbow Performance Score (MEPS) and range of motion (ROM) were evaluated preoperatively and at final follow-up.

Results

At final follow-up after surgery, we evaluated the average active ROM, which was 111.7° (90°–135°). The average extension was 11.7° (0°–30°), while the average flexion was 123.3° (115°–135°). At the same time, the average supination was increased to 70° (40°–90°) and the average pronation was increased to 68.3° (45°–80°). The MEPS was elevated to 92.5 (85–100). Three patients displayed complications and were treated and cured with dressing changes and antibiotics.

Conclusion

Open arthrolysis and hinged external fixation are useful for the treatment of non-traumatic elbow stiffness with TB.

Appropriate excision time of heterotopic ossification in elbow caused by trauma

OBJECTIVE

The aim of this study was to investigate the optimal timing for the resection of heterotopic ossification (HO) of the elbow.

METHODS

We 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.

RESULTS

The 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).

CONCLUSIONS

Early 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 EVIDENCE

Level III, therapeutic study.

Heterotopic Ossification Following Upper Extremity Injury

Heterotopic ossification (HO) presents a substantial barrier to rehabilitation for patients with severe burns or trauma. Although surgical excision is a mainstay of management for this condition, this is unable to address the chronic sequelae of HO, including chronic pain, joint contractures, nerve dysfunction, and open wounds. Current therapeutic modalities are aimed at excision and the prevention of recurrence using nonsteroidal antiinflammatory drugs (NSAIDs) or radiation therapy. Research is now focused on identifying alternative strategies to prevent the initial occurrence of HO through NSAIDs and novel inhibitors of the bone morphogenetic protein signaling pathway.

Does Excision of Heterotopic Ossification of the Elbow Result in Satisfactory Patient-Rated Outcomes?

Introduction

Treatment of heterotopic ossification (HO) of the elbow is challenging and fraught with complications. Patients who sustain direct trauma to the elbow joint, the central nervous system, and thermal burns are at increased risk for development of HO. There is a paucity of studies and reports on patient’s self-evaluation after the excision of the heterotopic ossification.

Materials and Methods

This retrospective study assessed outcomes after excision of heterotopic ossification around the elbow in a cohort of ten patients operated from 2012 to 2015. The outcome assessment was done by the Mayo Elbow Performance index (MEPI) and the American Shoulder and Elbow Surgeons-Elbow score (ASES-E scores).

Results

The mean follow-up was 18.11 months after the operation. The Mayo Elbow Performance Score was excellent in two elbows, good in six and fair in two. The mean gain in flexion-extension arc after excision of HO was 80 degrees. All of the patients had residual flexion deformity postoperatively. Eight of the nine patients were able to do activities requiring flexion at final follow-up.

Conclusion

Excision of HO around the elbow is associated with satisfactory patient-rated outcomes in spite of failure to regain full range of motion.

Posttraumatic stiff elbow

Posttraumatic stiff elbow is a frequent and disabling complication and poses serious challenges for its management. In this review forty studies were included to know about the magnitude of the problem, causes, pathology, prevention, and treatment of posttraumatic stiff elbow. These studies show that simple measures such as internal fixation, immobilization in extension, and early motion of elbow joint are the most important steps that can prevent elbow stiffness. It also supports conservative treatment in selected cases. There are no clear guidelines about the choice between the numerous procedures described in literature. However, this review article disproves two major beliefs-heterotopic ossification is a bad prognostic feature, and passive mobilization of elbow causes elbow stiffness.

A Unique Surgical Technique for Tracheostomy in Heterotopic Ossification: A Case Report

OBJECTIVE

To describe a technique for tracheostomy in heterotopic ossification that has not yet been described in the literature.

METHODS

We report a case of difficult tracheostomy while using conventional techniques in a 68-year-old patient who underwent mitral valve replacement requiring warfarin therapy three months prior. Imaging revealed heterotopic ossification overlying the trachea. A literature review was performed to identify similar cases or techniques.

RESULTS

Extensive surgical planning was pursued after the initial attempted tracheostomy failed, and the airway was eventually accessed using a lighted intubation stylet for guidance and a drill. Heterotopic ossification has been described after orthopedic and abdominal surgeries. We identified one case report in the literature of tracheostomy performed in the setting of heterotopic ossification by an unspecified mechanism. There are few reported cases of tracheobronchial calcification in cardiac patients receiving warfarin therapy; however, these patients had characteristic imaging findings that were not consistent with those of our patient.

CONCLUSIONS

We illustrate a safe and effective technique for tracheostomy in heterotopic ossification that has not been reported. Coordination with the anesthesia service was paramount for a successful operation.

Recurrence of heterotopic ossification after removal in patients with traumatic brain injury: A systematic review

OBJECTIVE

A systematic review of the literature to determine whether in patients with neurological heterotopic ossification (NHO) after traumatic brain injury, the extent of the neurological sequelae, the timing of surgery and the extent of the initial NHO affect the risk of NHO recurrence.

DATA SOURCES

We searched MEDLINE via PubMed and Cochrane library for articles published up to June 2015. Results were compared with epidemiological studies using data from the BANKHO database of 357 patients with central nervous system (CNS) lesions who underwent 539 interventions for troublesome HO.

RESULTS

A large number of studies were published in the 1980s and 1990s, most showing poor quality despite being performed by experienced surgical teams. Accordingly, results were contradictory and practices heterogeneous. Results with the BANKHO data showed troublesome NHO recurrence not associated with aetiology, sex, age at time of CNS lesion, multisite HO, or "early" surgery (before 6months). Equally, recurrence was not associated with neurological sequelae or disease extent around the joint.

CONCLUSIONS

The recurrence of NHO is not affected by delayed surgery, neurological sequelae or disease extent around the joint. Surgical excision of NHO should be performed as soon as comorbid factors are under control and the NHO is sufficiently constituted for excision.

Management of Adult Elbow Fracture Dislocations

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.

What Risk Factors Predict Recurrence of Heterotopic Ossification After Excision in Combat-related Amputations?

BACKGROUND

Heterotopic ossification (HO) is common after combat-related amputations and surgical excision remains the only definitive treatment for persistently symptomatic HO. There is no consensus in the literature regarding the timing of surgery, and recurrence frequency, reexcision, and complications have not been reported in large numbers of patients.

QUESTIONS/PURPOSES

(1) What are the rates of symptomatic recurrence resulting in reexcision and other complications resulting in reoperation in patients with HO? (2) Is either radiographic or symptomatic recurrence dependent on timing and type of initial surgery, the experience of the surgeon in performing the procedure, the severity of preexcision HO, the presence of concomitant neurologic injury, or the use of postoperative HO prophylaxis?

METHODS

Between March 2005 and March 2013 our institution treated 994 patients with 1377 combat-related major extremity amputations; of those, 172 amputations underwent subsequent excision of symptomatic HO. The mechanism of injury resulting in nearly all amputations (n = 168) was blast-related trauma. We reviewed medical records and radiographs to collect initial grade of HO, radiographic recurrence, complete compared with partial excision, concomitant neurologic injury, timing to initial surgery, surgeon experience, and use of postexcision prophylaxis with our primary study outcome being a return to the operating room (OR) for repeat excision of symptomatic HO. All 172 combat-related amputations were considered for this study irrespective of followup, which was noted to be robust, with 157 (91%) amputations having at least 6 months clinical followup by an orthopaedic surgeon or physiatrist (median, 20 months; range, 0-88 months).

RESULTS

Eleven of 172 patients (6.5%) underwent reexcision of HO, and 67 complications resulting in return to the OR occurred in 53 patients (31%) of patients. Multivariate analysis of our primary outcome measure showed more frequent symptomatic recurrences requiring reexcision when initial excision was performed as a partial excision (p = 0.03; odds ratio [OR], 5.0; 95% confidence interval [CI], 1.2-29.6) or when the initial excision was performed within 180 days of injury (p = 0.047; OR, 4.1; 95% CI, 1.02-16.6). There was no association between symptomatic recurrence and HO grade, central nervous system injury, experience of the attending surgeon, or postoperative prophylaxis. Radiographic recurrence was observed when partial excisions (eight of 30 [27%]) were done compared with complete excisions (five of 77 [7%]; p = 0.008).

CONCLUSIONS

HO is common after combat-related amputations, and patients undergoing surgical excision of HO for this indication often have complications that result in repeat surgical procedures. Partial excisions of immature lesions more often resulted in both symptomatic and radiographic recurrence. The likelihood of a patient undergoing reexcision can be minimized by performing a complete excision at least 180 days from injury to surgery with no evidence of a reduced risk of reexcision by waiting longer than 270 days.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Novel mouse model of spinal cord injury-induced heterotopic ossification

Heterotopic ossification (HO) develops in about 20% to 30% of patients with spinal cord injury (SCI) and significantly impairs their rehabilitation. There is no effective prevention or treatment for this condition at this time. Our current understanding of its etiology and pathophysiology is limited partially due to the lack of clinically relevant animal models. In this study, we report a novel mouse model of SCI-induced HO by administering a subthreshold dose of bone morphogenetic protein (BMP)-2 to muscles in mice after SCI. Micro-computed tomography scanning showed that an intramuscular injection of 0.25 micrograms of BMP-2 causes significant HO in mice with SCI but not in control (sham surgery) mice. Our analysis of gene expression showed significantly increased BMP signaling in quadriceps following SCI, suggesting that BMP signaling may play a role in SCI-induced HO. Administering 0.25 micrograms of BMP-2 to the front arms of the mice with SCI also results in the development of significant HO but not in control mice. This suggests that SCI causes a systematic osteogenic effect, which is not limited to paralyzed limbs. This novel mouse model will serve as a powerful tool in exploring the molecular mechanisms of SCI-induced HO, which may lead to novel treatment for this disease.

Does Blast Medium Affect Heterotopic Ossification in a Blast-amputation Model?

BACKGROUND

Heterotopic ossification (HO) develops after nearly 2/3 of traumatic blast amputations in the contemporary battlefield. This phenomenon has potentially devastating consequences for servicemen and women and its pathophysiology warrants further investigation using a previously developed animal blast model.

QUESTIONS/PURPOSES

We asked, what is the (1) severity (quantity) and (2) type (location) of HO bone formation after a hindlimb blast amputation with two distinct blast media. We hypothesized that a more "war-relevant" blast medium could be a more accurate model and potentially intensify the development of HO.

METHODS

Using a Sprague-Dawley rat model, the pathophysiology of ectopic bone formation in a traumatic hindlimb blast amputation was evaluated. Twenty-four animals underwent blast amputations and closure based on a previously established experimental model. Half the amputations were subjected to blasted sand and the other 1/2 to blasted water. Serial orthogonal radiography was performed on each animal until euthanasia at 24 weeks to track the development of HO. Heterotopic bone severity and type were assessed by three independent graders at each time using a novel grading scale to assess quantity and quality of HO.

RESULTS

All animals had radiographic evidence of HO develop. No differences were observed in ectopic bone development between sand and water blasting regarding severity or type at any time. Animals that received water and sand blasting had moderate HO develop at 24 weeks (median, 2.0 and 2.5 weeks, respectively; range, 1-3 weeks; difference of medians, 0.5; p=0.67). At the time of euthanasia, 10 animals that were water blasted had Type 3 HO compared with 11 in the sand-blasted group (p=1.00).

CONCLUSIONS

Our study showed a clear development of HO after hindlimb blast amputation in a Sprague-Dawley rat model; however, no difference was observed in HO development based on the type of blast media. This suggests it is the blast mechanism that induces ectopic bone development, regardless of the blasted medium. The grading scale we developed for our animal-model study provided a reliable means of assessing HO severity and type.

CLINICAL RELEVANCE

We anticipate that future investigations will elucidate similarities between service members' wartime extremity injuries and the animal model used in our study, and with focused future research this model may have beneficial therapeutic implications as the pathophysiology of HO development is further understood.

Open surgical release for contractures of the elbow

Compared with arthroscopic release, open release is more commonly used for the treatment of stiff elbow. Flexion is recovered by releasing posterior tethering soft-tissue structures and by removing anterior impingement between the coronoid and/or radial head and the distal humerus. Extension is improved by releasing anterior soft-tissue tethers and by removing impingement between the olecranon tip and the olecranon fossa. Open elbow release is most commonly performed via ligament-sparing approaches. Ulnar nerve identification and transposition is recommended in the presence of nerve dysfunction or when correction of significant loss of elbow flexion is anticipated. Long-term improvement in flexion and extension can be expected with proper patient selection. Less predictable results are obtained in adolescent patients and in those with underlying traumatic brain injury.

Heterotopic ossification of the elbow treated with surgical resection: risk factors, bony ankylosis, and complications

BACKGROUND

Heterotopic ossification is the most common extrinsic cause of elbow contracture and may lead to clinically important stiffness, and rarely, complete bony ankylosis. Surgery sometimes is performed to treat this problem, and published reports differ regarding the factors that are associated with success or failure after this operation and whether the procedure is effective for patients with elbow ankylosis.

QUESTIONS/PURPOSES

We wished (1) to identify potential patient characteristics and modifiable risk factors that are associated with improvements in ROM after surgery for heterotopic ossification of the elbow; (2) to compare ROM gains between patients with complete ankylosis and partially restricted ROM; and (3) to characterize the complications of elbows treated by surgical release and excision of heterotopic ossification followed by a standardized rehabilitation program.

METHODS

We reviewed the records of all patients treated operatively for heterotopic ossification of the elbow from September 1999 to February 2012 at one institution by one surgeon. General indications for the surgery were clinically symptomatic or debilitating heterotopic ossification of the elbow. Each patient received prophylaxis postoperatively consisting of indomethacin (or single-shot radiation for patients with sensitivity to antiinflammatory medications). All patients received a physical therapy regimen and used a continuous passive motion machine for 6 weeks. Patient demographics, mechanism of injury, time between injury and surgery, and medical history were reviewed for comparison. Followup was at a mean of 13 months (range, 3-106 months); no patients were lost to followup. Thirty-nine patients (46 elbows) with heterotopic ossification treated with excision were identified: 10 patients (16 elbows) had burns, 28 patients (29 elbows) had trauma, and one patient (one elbow) had a closed head injury. Eight of the 39 patients (12 of 46 elbows [26%]) had complete ankylosis at the time of surgery.

RESULTS

Hypertension, obesity, and absence of intraoperative anterior ulnar nerve transposition were associated with an adverse effect on change from preoperative to final arc of motion. The group with ankylosis had greater preoperative to postoperative gain in arc compared with the group with partial restriction (96°, 95% CI, 84°-107° and 59°, 95% CI, 46°-72°, respectively). For the entire cohort there was an overall improvement in mean flexion-extension arc of motion from 35° to 103° at final followup (p < 0.001; 95% CI, 57°-80°), with a 17% rate of complications (three patients [three elbows] with heterotopic ossification, three patients [three elbows] with nerve palsies, one patient [one elbow] with deep wound infection, and one patient [one elbow] with an unstable elbow).

CONCLUSIONS

Patients with partially and completely restricted ROM showed substantial improvement in postoperative ROM. Hypertension, obesity, and absence of intraoperative anterior ulnar nerve transposition were negative predictors of outcome in our series. Surgery combined with postoperative prophylaxis and a regimented rehabilitation program are feasible modalities to treat patients with heterotopic ossification of the elbow.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

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.

A novel mouse model of trauma induced heterotopic ossification

Severe soft tissue trauma is associated with heterotopic ossification (HO), the abnormal deposition of bone at extra-skeletal sites. The pathophysiology of the development of trauma-induced HO remains largely unknown due in part to the lack of appropriate animal models. In this study, we sought to develop a new trauma-induced HO mouse model using muscle impact injury combined with low dose BMP-2. BMP-2 at doses ranging from 0 to 2 µg was injected into quadriceps muscles of adult male C57/BL6 mice. Animals then received a one-time quadriceps impaction injury to mimic the trauma associated with severe injuries. HO was monitored using in vivo microCT scanning at 1, 2, 4, and 8 weeks after treatment. After trauma, the expression of BMP-2, -4, BMP receptor 1, SOX9 and RUNX2 were increased in muscle. Although little or no HO was observed in mice receiving 1 µg BMP-2, combining this dose with muscle trauma produced an abundance of HO. At higher doses of BMP-2, trauma did not augment mineral deposition. These results suggest that BMP-2 signaling can sensitize muscle to trauma-induced HO. They also provide the basis for a new model to study the pathogenesis of trauma-induced HO.

Prevention and treatment of elbow stiffness: a 5-year update

Elbow stiffness is a challenging and common problem faced by upper extremity surgeons. Although functional improvements can be made with both nonsurgical and surgical management strategies, physicians must remain vigilant with efforts to prevent stiffness before it starts. Recent advancements in the biology and pathology of elbow contracture have led to improved understanding of this difficult problem, and they may lead to future breakthroughs in the prevention and treatment of elbow stiffness. This article serves as an update to our previous review of elbow stiffness, focusing on recent advancements in the past 5 years, as well as updating our current algorithm for treatment.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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, 65 patients (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°).

CONCLUSIONS

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.

Clinical results of the excision of heterotopic bone around the elbow: a systematic review

BACKGROUND

Heterotopic ossification (HO) of the elbow can occur following direct trauma, brain injury, or burns. Development of elbow HO is sporadic, making levels 1-3 clinical evidence difficult to establish. We systematically reviewed literature regarding management and outcomes of surgically treated elbow HO.

METHODS

A systematic review of the literature regarding elbow HO was performed to compare imaging modalities, surgical timing, surgical approaches, and methods of prophylaxis in outcomes of patients treated with excision.

RESULTS

Our systematic review included 24 level 3 or 4 studies investigating 384 post-trauma (158), brain injury (105), or burn (94) patients with elbows complicated by HO that were treated with surgical excision. Average patient age was 36.9 years and there was a 65/35 M/F ratio. For all etiologies, preoperatively elbow flexion/extension averaged 53/83; postoperatively elbow flexion/extension significantly improved to 22/123. Regardless of the etiology, surgical excision of elbow HO significantly improved functional range of motion. Neither total body surface area (TBSA) burned for burn patients or Garland classification for brain-injured patients correlated with outcome. Overall complication rate was 22.6% and included HO recurrence (11.9%), ulnar nerve injury, infection, and delayed wound healing.

CONCLUSION

Surgical treatment of elbow HO leads to improved functional outcome, whether the etiology of bone formation was direct elbow trauma, brain injury, or thermal injury.

Surgical release of elbow stiffness after internal fixation of intercondylar fracture of the distal humerus

BACKGROUND

Loss of motion is common after intercondylar fracture of the distal humerus despite proper management. The purpose of the current study was to report the results of contracture release for stiffness that developed after open reduction and internal fixation (ORIF) of distal humeral intercondylar fractures.

METHODS

Twenty-four consecutive patients with a stiff elbow after ORIF of intercondylar fractures (20 AO type C2 and 4 type C3 fractures) were managed with contracture release at a median of 13 months. The surgical indication was total arc of motion of less than 100° despite physical therapy for more than 6 months. Plates and screws for ORIF were removed concomitantly in 16 patients. Each patient was evaluated by final arc of motion and Mayo Elbow Performance Score (MEPS).

RESULTS

The main lesions causing stiffness were heterotopic ossification or excessive callus in 13 patients and capsular fibrosis in 11. The mean total range of motion (ROM) was improved from 60.2° preoperatively to 104.8° postoperatively. At the final follow-up, 17 of the 24 elbows (71.8%) obtained a total ROM of more than 100°. The mean MEPS improved from 69 points preoperatively to 87 points at the final follow-up (P < .05). Refracture occurred during ROM exercise in 4 patients who had undergone concomitant implant removal during the contracture release.

CONCLUSION

Surgical release of a stiff elbow that develops after ORIF of intercondylar fractures can result in satisfactory restoration of ROM in most patients. However, potential risk of refracture after release should be considered when implants are concomitantly removed.

Risk factors for development of heterotopic ossification of the elbow after fracture fixation

BACKGROUND

Postoperative heterotopic ossification (HO) about the elbow may occur after surgical fixation of fractures and can contribute to dysfunction. Factors associated with HO formation after surgical fixation of elbow trauma are not well understood.

METHODS

All patients who underwent surgery for elbow trauma at our institution from October 2001 through August 2010 were retrospectively reviewed. Patients with prior injury or deformity to the involved elbow were excluded. Demographic data; fracture type; surgical treatment; and presence, location, and size of HO were recorded. The Fisher exact test, χ(2) test, and multivariate logistic regression were used with an α value of .05 used for significance.

RESULTS

A total of 159 patients were identified, with 89 (37 men and 52 women) meeting inclusion and exclusion criteria. The mean age was 54.4 years (range, 18-90 years), and the mean follow-up time was 180 days. Age, male gender, lateral collateral ligament repair, and dual-incision approach were not associated with increased ectopic bone formation. Distal humeral fractures were a significant predictor of heterotopic bone. In patients in whom HO ultimately developed, it was visible on radiographs obtained 2 weeks postoperatively in 86% of cases.

CONCLUSION

This investigation found predictors for the development of HO after surgical fixation of intra-articular elbow fractures. Furthermore, HO went on to develop at the time of final follow-up in only 14% of patients without HO on radiographs obtained 2 weeks postoperatively. This may suggest that absence of HO on radiographs obtained 2 weeks postoperatively may predict a more favorable outcome.

Ankylosis of temporomandibular joint after the traumatic brain injury: a report of two cases

Mouth opening limitation after the neurosurgical procedures is a common complication and usually resolves within 3 months. If limited mouth opening remains unresolved on the long term, an intra-articular ankylosis of temporomandibular joint may develop eventually. The possible mechanisms base on the myositis and atrophy of the masticatory muscles for these craniotomies are often involved in the temporalis. This article reports two unusual cases with the intra-articular ankylosis of temporomandibular joint after the traumatic brain injury, who received a modified surgical treatment for joint ankylosis. Therefore, the early diagnosis and intervention are important to minimize these complications.