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Kacem MS, Aloui A, Bahroun S, Abdennadher A, Bouaziz A, Teissier P. Heterotopic ossification of the shoulder after arthroscopic rotator cuff repair: A case report. Int J Surg Case Rep 2023; 112:108916. [PMID: 37826980 PMCID: PMC10667768 DOI: 10.1016/j.ijscr.2023.108916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 10/14/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Heterotopic ossification (HO) often arises in response to trauma, prior surgical procedures, neurological injuries, or burns. However, its presentation as a complication of shoulder arthroscopy is uncommon and can sometimes lead to functional impairment. In our study, we report a case of HO complicating rotator cuff repair, along with details of the surgical treatment and subsequent progression. CASE PRESENTATION We report the case of a 45-year-old man with no medical history, who had undergone a rotator cuff arthroscopic repair of his left shoulder. Despite initial improvements, he developed intense pain and stiffness of the operated shoulder. X-rays revealed an extensive HO. Surgical revision and excision of the ossification, followed by high-dose indomethacin in combination with proton pump inhibitors and specialized physiotherapy, resulted in remarkable improvement in shoulder function. CLINICAL DISCUSSION Studies investigating HO in shoulder arthroplasty have unveiled a diverse range of formation rates, spanning from 15 % to 62 %. Nonetheless, it's noteworthy that the prevalence of HO around the shoulder remains less common in comparison to other anatomical sites, especially in the context of arthroscopic surgical procedures. The exact mechanism and pathophysiology that leads to HO formation remains unknown. It is believed to stem from a combination of multiple factors and is associated with various contributors. Arthroscopic intervention, coupled with high-dose Indomethacin, offers an effective approach for managing HO. CONCLUSION While HO remains an uncommon complication after shoulder arthroscopy, it is crucial for clinicians to consider it in patients experiencing post-surgery stiffness and pain.
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Affiliation(s)
- Mohamed Samih Kacem
- Mohamed Kassab national Institute of Orthopaedics, Workors street, Manouba, Tunisia
| | - Ala Aloui
- Mohamed Kassab national Institute of Orthopaedics, Workors street, Manouba, Tunisia.
| | - Sami Bahroun
- Mohamed Kassab national Institute of Orthopaedics, Workors street, Manouba, Tunisia
| | | | - Anis Bouaziz
- Mohamed Kassab national Institute of Orthopaedics, Workors street, Manouba, Tunisia
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Dragonas CG, Mamarelis G, Shahid S, Tsekes D. A Systematic Review of Heterotopic Ossification Following Shoulder Arthroplasty: Is There a Clinical Value? Cureus 2023; 15:e47374. [PMID: 38021631 PMCID: PMC10657507 DOI: 10.7759/cureus.47374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
This systematic review aims to assess the contemporary literature on the incidence rate, functional scores, and clinical outcomes of heterotopic ossification (HO) following shoulder arthroplasty. We conducted a thorough literature search on EMBASE, MEDLINE, and Ortho Search to identify studies that directly compared patients with and without HO following hemiarthroplasty, anatomic total shoulder arthroplasty (aTSA), or reverse total shoulder arthroplasty (rTSA). We included studies with a minimum follow-up period of one year published from January 2000 to March 2023. We excluded case reports, editorials, and reviews. We performed the systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of the 297 studies initially identified, seven met our inclusion criteria. These studies evaluated a total of 1,134 arthroplasties (212 hemiarthroplasties, 376 aTSAs, and 546 rTSAs). The mean follow-up period was 30.52 (12-120) months and the mean age was 68.69 (20-92). The overall incidence rate of HO was 26.8% (304/1,134). Male gender was associated with a higher incidence rate of HO in three studies. No statistically significant difference was noted in symptoms at follow-up or in Constant-Murley score at two years of follow-up (HO vs. non-HO: 70 vs. 75, p = 0.081). Only one study reported a significant difference in the post-arthroplasty range of motion, specifically in forward elevation (121° vs. 133°, p = 0.0087) and external rotation (19° vs. 25°, p-value = 0.0266). We conclude that HO after shoulder arthroplasty does not display a significant impact on postoperative symptoms or functional outcomes in the majority of patients. To fully comprehend its effect, further research and consensus among experts is necessary.
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Affiliation(s)
- Christos G Dragonas
- Trauma and Orthopaedics, The Princess Alexandra Hospital NHS Trust, Harlow, GBR
| | | | - Shahan Shahid
- Trauma and Orthopaedics, King's College Hospital NHS Foundation Trust, London, GBR
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Severe Heterotopic Ossification with Proximal Entrapment of the Ulnar Nerve following Primary Anterior Shoulder Dislocation. Case Rep Orthop 2020; 2020:8883758. [PMID: 33083076 PMCID: PMC7558775 DOI: 10.1155/2020/8883758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 09/15/2020] [Accepted: 09/24/2020] [Indexed: 11/30/2022] Open
Abstract
Heterotopic ossifications (HO) in the shoulder are rare. The effectiveness of conservative treatment is limited, and therefore, symptomatic cases are usually treated surgically. However, there are no guidelines for the surgical treatment of HO. Herein, we report the case of a 45-year-old man with severe HO and proximal entrapment of the ulnar nerve following primary anterior shoulder dislocation without concomitant injuries (e.g., fracture and rotator cuff tears). Surgical intervention was indicated, including resection of HO and neurolysis of the brachial plexus. Nine months after surgery, the patient presented with restored shoulder function, pain relief, and good patient satisfaction. The case shows that the ulnar nerve can also be impaired due to HO following shoulder dislocation.
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Cirino CM, Chan JJ, Patterson DC, Jia R, Poeran J, Parsons BO, Cagle PJ. Risk factors for heterotopic ossification in operatively treated proximal humeral fractures. Bone Joint J 2020; 102-B:539-544. [PMID: 32228071 DOI: 10.1302/0301-620x.102b4.bjj-2019-1510.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Heterotopic ossification (HO) is a potentially devastating complication of the surgical treatment of a proximal humeral fracture. The literature on the rate and risk factors for the development of HO under these circumstances is lacking. The aim of this study was to determine the incidence and risk factors for the development of HO in these patients. METHODS A retrospective analysis of 170 patients who underwent operative treatment for a proximal humeral fracture between 2005 and 2016, in a single institution, was undertaken. The mean follow-up was 18.2 months (1.5 to 140). The presence of HO was identified on follow-up radiographs. RESULTS The incidence of HO was 15% (n = 26). Our multivariate model revealed that male sex (odds ratio (OR) 3.57, 95% confidence interval (CI) 1.30 to 9.80 compared to female) and dislocation as the initial injury (OR 5.01, 95% CI 1.31 to 19.22) were significantly associated with the formation of HO (p < 0.05) while no significant associations were seen for the age of the patient, the characteristics of the injury, or the type of operative treatment. CONCLUSION This retrospective radiological study is the first to investigate the association between the method of surgical treatment for a proximal humeral fracture and the formation of HO postoperatively. We found that male sex and dislocation as the initial injury were risk factors for HO formation, whereas the method of surgical treatment, the age of the patient, and the pattern of the fracture were not predictive of HO formation. While additional studies are needed, these findings can help to identify those at an increased risk for HO formation under these circumstances. Cite this article: Bone Joint J 2020;102-B(4):539-544.
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Affiliation(s)
- Carl M Cirino
- Leni and Peter W. May Departmentof Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jimmy J Chan
- Leni and Peter W. May Departmentof Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diana C Patterson
- Leni and Peter W. May Departmentof Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel Jia
- Center for Clinical and Outcomes Research, Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jashvant Poeran
- Center for Clinical and Outcomes Research, Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bradford O Parsons
- Leni and Peter W. May Departmentof Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paul J Cagle
- Leni and Peter W. May Departmentof Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Polfer EM, Nappo KE, Giuliani JR, Nesti LJ. Global Excision of Severe Heterotopic Ossification of the Shoulder: A Case Report. JBJS Case Connect 2020; 10:e0080. [PMID: 32224653 DOI: 10.2106/jbjs.cc.18.00080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth M Polfer
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kyle E Nappo
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jeffrey R Giuliani
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Leon J Nesti
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
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Hallock J, Field LD. Surgical Management of Shoulder Heterotopic Ossification. Arthrosc Tech 2019; 8:e1057-e1062. [PMID: 31737484 PMCID: PMC6848966 DOI: 10.1016/j.eats.2019.05.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/13/2019] [Indexed: 02/03/2023] Open
Abstract
The formation of heterotopic ossification around the shoulder is a rare but potentially debilitating condition. It is found most commonly around the hip and is usually associated with an inciting event such as trauma, burn, previous surgery, or traumatic brain/spinal cord injury. The formation of shoulder heterotopic ossification following arthroscopic surgery is very uncommon, with few data pertaining to it in the current literature. Formation of heterotopic ossification in the shoulder after arthroscopic surgery typically occurs around the acromioclavicular joint and in the subacromial space. This location may lead to chronic pain and decreased mobility. The purpose of this article is to describe an arthroscopic technique for excision of heterotopic ossification.
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Affiliation(s)
| | - Larry D. Field
- Address correspondence to Larry D. Field, M.D., Mississippi Sports Medicine and Orthopaedic Center, 1325 E Fortification St, Jackson, MS 39202, U.S.A.
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Mulligan A, Tytherleigh-Strong G. Heterotopic ossification after superior capsular reconstruction. J Shoulder Elbow Surg 2018; 27:e380-e386. [PMID: 30446233 DOI: 10.1016/j.jse.2018.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 08/13/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023]
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Supraspinatus Intramuscular Calcified Hematoma or Necrosis Associated with Tendon Tear. Case Rep Orthop 2015; 2015:496313. [PMID: 26380138 PMCID: PMC4563087 DOI: 10.1155/2015/496313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/12/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction. Rotator cuff intramuscular calcification is a rare condition usually caused by heterotopic ossification and myositis ossificans. Case Presentation. We describe a patient with voluminous calcified mass entrapped in supraspinatus muscle associated with corresponding tendon tear. Histological examination corresponded to a calcified hematoma or necrosis. Patient was surgically managed with open excision of the calcified hematoma and rotator cuff arthroscopic repair. At 6 months, supraspinatus muscle was healed, and functional outcome was good. Discussion and Conclusion. We hypothesized that supraspinatus intramuscular calcified hematoma was responsible for mechanical stress on the tendon. This association has never been described.
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