Intra- and periarticular heterotopic ossification in the knee after a low-velocity gunshot wound treated with retrograde intramedullary nailing of the femur

Incidence and Risk Factors of Heterotopic Ossification in the Knee After Reamed Tibial Nailing

INTRODUCTION

Heterotopic ossification (HO) in the knee after tibial intramedullary nailing (IMN) has yet to be thoroughly investigated. Our aim was to assess frequency and associated factors for HO in the knee after tibial IMN.

METHODS

This is a retrospective review at a single level 1 urban trauma center of 213 patients who underwent reamed tibial IMN. Plain radiographs were reviewed postoperatively and on final follow-up (≥6 weeks). Chart review was performed for surgical approach (suprapatellar versus infrapatellar), demographics, injury characteristics, and clinical follow-up. The primary outcome was frequency of HO.

RESULTS

HO on final follow-up (mean: 41.43 weeks) was recorded in 15% cases. Postsurgical retroinfrapatellar reaming debris (odds ratio [OR], 4.73), Injury Severity Score (OR, 1.05), intensive care unit admission (OR, 2.89), chest injury (OR, 3.4), and ipsilateral retrograde femoral IMN (OR, 5.08) showed a notable association with HO development. No association was observed in HO formation between surgical approach, knee pain, or range-of-motion deficits.

DISCUSSION

Radiographic evidence of HO in the knee after reamed tibial IMN is not uncommon and is associated with retained reaming debris, Injury Severity Score, chest injury, intensive care unit admission, and ipsilateral retrograde femoral nailing. No differences were noted in HO formation between approaches. HO was not associated with knee pain or range-of-motion deficits.

Heterotopic ossification in the knee following retrograde nailing of a femur fracture

BACKGROUND

Heterotopic ossification (HO) is a pathologic bone formation in extra skeletal tissue and articular space. This was an objection to nailing of femur fractures across the knee; however, this has not been the case in many thousands of cases. Nonetheless, we present a patient in who placement of a retrograde nail resulted in calcification in the knee requiring excision.

CASE PRESENTATION

A 42-year-old male presented to the clinic complaining of pain, popping, clicking, and mocking in the right knee, especially in the patellar region. Nine months prior he suffered an ipsilateral femur fracture that was treated with a retrograde intramedullary nail. X-ray and CT scan were used to confirm the presentation of a heterotopic bone mass in the Hoffa area of the right knee. The patient underwent an arthrotomy for excision of the bone mass. The bone mass was excised, but bone in the ACL was not removed. The patient experienced pain relief and improved range of motion following excision.

CONCLUSION

Intraarticular heterotopic ossification is an infrequent event. We present a case of heterotopic ossification in the knee following retrograde nailing. The patient experienced improved symptoms and range of motion after excision of the intraarticular heterotopic bone mass.

Early resection of ectopic bone in patients with heterotopic ossification about the hip after trauma

OBJECTIVES

Heterotopic ossification (HO) is a common complication in patients who have sustained high-energy trauma to the hip region. Traditionally, resection is performed after ectopic bone maturation. We hypothesized that early HO resection in patients with hip ankylosis after trauma can be performed with little chance of recurrence.

DESIGN

Retrospective clinical cohort.

SETTING

Level I Trauma Center PATIENTS/PARTICIPANTS: 14 patients with resection of HO about the hip performed by the senior author during a six-year period.

INTERVENTION

Early resection of Brooker Class III or IV HO.

MAIN OUTCOME MEASUREMENTS

The original injuries, risk factors for HO, post-traumatic clinical course including the workup for HO, times from fixation to resection, surgical approach, and complications were recorded. Records were reviewed to document pre and postoperative hip motions. Pre and post-operative x-rays and CT scans were reviewed to classify the HO and localize the ectopic mass.

RESULTS

Mean injury to resection interval was 6.8-months. Nine of 14 (64%) patients were followed for a mean of 32.9-months post-resection. Indications for resection included pain, stiffness, and evolving sciatic nerve lesions. Risk factors were male gender, brain injury, and extended iliofemoral and Kocher-Langenbeck surgical approaches. Complications included gluteal vein laceration, draining wounds, and recurrence. Mean flexion-extension arc of motion was 18° (range = 0-70°) preoperatively, 100° (range = 85-125°) intra-operatively, and 94° (range = 20-110°) at final follow-up. HO recurred in nine patients; functionally significant in one.

CONCLUSION

Early resection of HO around the hip may be performed with little chance of symptomatic recurrence.

LEVEL OF EVIDENCE

This is a Level IV retrospective case series.

Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up

OBJECTIVE

To evaluate the clinical and radiographic results associated with the use of a percutaneous suprapatellar (SP) portal and accompanying instrumentation for tibial intramedullary nail (IMN) insertion using a semiextended approach.

DESIGN

Prospective, nonrandomized, nonconsecutive study.

SETTING

Level 1 trauma center.

PATIENTS AND METHODS

From June 2007 to January 2011, 56 fractures (55 patients) underwent intramedullary nailing of a tibia fracture with a semiextended approach through a SP portal. Radiographic and clinical follow-up examinations were performed at a minimum of 1 year after the index procedure. Measurements included bone healing, tibial alignment, knee range of motion, pain drawings, pain scoring (visual analogue scale), functional outcome (Lysholm and SF-36 scoring), evaluation of prenail and postnail insertion arthroscopic images of the patella-femoral (PF) joint (subgroup of study patients), and 1-year follow-up magnetic resonance imaging (MRI) scans (STIR and T2 gradient echo) of the knee to evaluate the PF joint cartilage. MRI scans were reviewed by an independent bone radiologist, whereas arthroscopic images were evaluated by an independent sports medicine fellowship-trained orthopaedic surgeon.

RESULTS

Thirty-six patients (37 fractures) were available for follow-up at a minimum of 1 year (range: 12-49 months) after the index procedure. All but 2 fractures healed after the index procedure (94.6%). There was 1 radiographic malunion (2.7%). The mean Lysholm knee score was 82.14. Mean SF-36 physical and mental scores were 40.8 and 46.0, respectively. Mean arc of knee motion was 124.4 degrees for the affected extremity compared with 127.2 degrees for the contralateral knee. One patient (2.7%) complained of mild pain at the scar, but no patient complained of anterior knee pain either at the PF joint or at the anterior proximal tibia. In 13 of 15 patients undergoing an arthroscopic assessment of the PF joint, prenail and postnail insertion, no cartilage changes, or pressure points were seen either at the patella or at the trochlea groove. Two patients had grade II chondromalacia of the trochlea immediately after the procedure, but these did not correspond with either MRI scans or clinical findings at 1 year. When the remainder of the 1-year MRI scans were reviewed, 1 knee (2.7%) in a patient that did not have an arthroscopic examination was found to have grade II chondromalacia in the PF joint, but this did not correlate with the clinical examination, which was normal.

CONCLUSIONS

This is the first paper to critically document clinical and radiographic results using the percutaneous SP portal with the semiextended approach for IMN of the tibia. Our 1 year results indicate that the procedure resulted in excellent tibial alignment, union, and knee range of motion, with rare sequelae in the PF joint based on immediate arthroscopy and 1-year MRI scans and clinical examinations. Even more interesting was the absence of anterior tibial pain often found when a tibial nail is inserted in a standard fashion.

Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up

OBJECTIVE

To evaluate the clinical and radiographic results associated with the use of a percutaneous suprapatellar (SP) portal and accompanying instrumentation for tibial intramedullary nail (IMN) insertion using a semiextended approach.

DESIGN

Prospective, nonrandomized, nonconsecutive study.

SETTING

Level 1 trauma center.

PATIENTS AND METHODS

From June 2007 to January 2011, 56 fractures (55 patients) underwent intramedullary nailing of a tibia fracture with a semiextended approach through a SP portal. Radiographic and clinical follow-up examinations were performed at a minimum of 1 year after the index procedure. Measurements included bone healing, tibial alignment, knee range of motion, pain drawings, pain scoring (visual analogue scale), functional outcome (Lysholm and SF-36 scoring), evaluation of prenail and postnail insertion arthroscopic images of the patella-femoral (PF) joint (subgroup of study patients), and 1-year follow-up magnetic resonance imaging (MRI) scans (STIR and T2 gradient echo) of the knee to evaluate the PF joint cartilage. MRI scans were reviewed by an independent bone radiologist, whereas arthroscopic images were evaluated by an independent sports medicine fellowship-trained orthopaedic surgeon.

RESULTS

Thirty-six patients (37 fractures) were available for follow-up at a minimum of 1 year (range: 12-49 months) after the index procedure. All but 2 fractures healed after the index procedure (94.6%). There was 1 radiographic malunion (2.7%). The mean Lysholm knee score was 82.14. Mean SF-36 physical and mental scores were 40.8 and 46.0, respectively. Mean arc of knee motion was 124.4 degrees for the affected extremity compared with 127.2 degrees for the contralateral knee. One patient (2.7%) complained of mild pain at the scar, but no patient complained of anterior knee pain either at the PF joint or at the anterior proximal tibia. In 13 of 15 patients undergoing an arthroscopic assessment of the PF joint, prenail and postnail insertion, no cartilage changes, or pressure points were seen either at the patella or at the trochlea groove. Two patients had grade II chondromalacia of the trochlea immediately after the procedure, but these did not correspond with either MRI scans or clinical findings at 1 year. When the remainder of the 1-year MRI scans were reviewed, 1 knee (2.7%) in a patient that did not have an arthroscopic examination was found to have grade II chondromalacia in the PF joint, but this did not correlate with the clinical examination, which was normal.

CONCLUSIONS

This is the first paper to critically document clinical and radiographic results using the percutaneous SP portal with the semiextended approach for IMN of the tibia. Our 1 year results indicate that the procedure resulted in excellent tibial alignment, union, and knee range of motion, with rare sequelae in the PF joint based on immediate arthroscopy and 1-year MRI scans and clinical examinations. Even more interesting was the absence of anterior tibial pain often found when a tibial nail is inserted in a standard fashion.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.