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Kontokostopoulos AP, Gkiatas I, Vasileiadis GI, Flevas D, Tsirigkakis SE, Kosmas D, Kostas-Agnantis I, Pakos E, Gelalis I, Korompilias A. Heterotopic Ossification around the Elbow Revisited. Life (Basel) 2023; 13:2358. [PMID: 38137958 PMCID: PMC10744911 DOI: 10.3390/life13122358] [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: 10/10/2023] [Revised: 10/31/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Heterotopic ossification (HO) is the process of ectopic bone formation in the periarticular soft tissues and is usually formed in the elbow, hip and knee joint as a complication of trauma, burns, brain injury or surgical procedures. The development of HO around the elbow joint can cause a severe limitation of range of motion (ROM) and may affect daily activities of the patient. Treatment of ectopic bone formation around the elbow is a challenge for many surgeons. Non-operative treatment usually fails to restore the ROM of the elbow joint; thus, surgery is necessary to restore the function of the joint. In the past, many surgeons suggested that a delayed excision of HO, until maturation of the ectopic bone, is the best option in order to avoid any possible recurrence. However, many authors now suggest that this delay may lead to complications such as muscular atrophy and formation of soft tissue contractures that can cause a greater impairment of elbow function; thus, early excision is a better option and can better restore the elbow ROM. We performed a literature research of articles that investigated which is the best time of HO excision and we also evaluated if the tethering effect of HO can lead to a greater impairment of the elbow function. We found numerous studies suggesting that a limitation in ROM of the elbow can appear from the tethering of the ectopic bone formation and not only from primary HO. Concerning the HO excision, there were no significant differences between patients who underwent delayed and early excision, concerning the recurrence rate of HO around the elbow. Patients who underwent early excision had better restoration of elbow ROM; thus, early excision, combined with a rehabilitation program, is reported to be the best option for these patients.
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Affiliation(s)
- Aristeidis-Panagiotis Kontokostopoulos
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Ioannis Gkiatas
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - George I. Vasileiadis
- Department of Physical Medicine and Rehabilitation, School of Medicine, University Hospital of Ioannina, 451 10 Ioannina, Greece;
| | - Dimitrios Flevas
- Arthroscopy & Orthopaedic Surgery Department, Metropolitan Hospital, Neo Faliro, 185 47 Pireas, Greece;
| | - Spyridon E. Tsirigkakis
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Dimitrios Kosmas
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Ioannis Kostas-Agnantis
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Emilios Pakos
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Ioannis Gelalis
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
| | - Anastasios Korompilias
- Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (I.G.); (S.E.T.); (D.K.); (I.K.-A.); (E.P.); (I.G.); (A.K.)
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Abstract
Heterotopic ossification (HO) refers to benign ectopic bone formation in soft tissue and is common following trauma surgery. HO bone can restrict movement and progress into ankylosis that may necessitate surgical intervention. This article discusses the current literature on the pathophysiology, prophylaxis, treatment, and epidemiology of postoperative HO following orthopedic trauma.
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Affiliation(s)
- Jad Lawand
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA.
| | - Zachary Loeffelholz
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Bilal Khurshid
- Texas College of Osteopathic Medicine, Fort Worth, Texas, USA
| | - Eric Barcak
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
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Kim BS, Jung KJ, Kim KB, Park SS. Treating AO Type C2-3 Distal Humerus Fractures With the Anconeus Flap Transolecranon Approach. Orthopedics 2022; 45:e326-e334. [PMID: 35947456 DOI: 10.3928/01477447-20220805-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We evaluated the outcomes of precontoured locking plate fixation with the anconeus flap transolecranon (AFT) approach to treating AO type C2-3 comminuted intra-articular distal humerus (IDH) fractures among active patients. Thirty-six patients (age <65 years) with IDH fractures treated with precontoured distal humerus locking plate fixation were divided into 2 groups: group 1 (n=18; transolecranon [TO] approach) and group 2 (n=18; AFT approach). The radiographic examination included assessments of implant failure, fracture site union, and olecranon osteotomy site union. Clinical examination included assessments of operating time, range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disability of the Arm, Shoulder and Hand (DASH) score, and complications. The mean follow-up time was 25.2 months (range, 18-79 months). The mean operating time was 134.3 minutes and was significantly longer for group 2 (AFT; 141.2 minutes) than for group 1 (TO; 124.2 minutes). The mean olecranon osteotomy site union time was significantly longer in group 2 (7.4 weeks) than in group 2 (4.0 weeks). Olecranon osteotomy site resorption occurred among 6 of 18 patients only in group 2. No significant difference in ROM (flexion, 130°; extension, -0.7°), MEPS (85.7 points), DASH score (20.0 points), or frequency of major complications (TO, 5; AFT, 6) was observed between the groups. Our results showed no advantage of the AFT approach over the TO approach, despite preserving the anconeus. Prospective randomized trials will be necessary to compare the AFT and TO approaches for treating comminuted IDH fractures. [Orthopedics. 2022;45(6):e326-e334.].
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Henstenburg JM, Sherman M, Ilyas AM. Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis. J Hand Microsurg 2021; 13:189-195. [PMID: 34511838 DOI: 10.1055/s-0040-1721880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
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.
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Affiliation(s)
- Jeffrey M Henstenburg
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Matthew Sherman
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Asif M Ilyas
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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Jayamaraju D, Sarkar AS, Patra SK, Palanivelayutham SK, Rajasekaran S. A Surgical Protocol for Management of Post Traumatic Heterotopic Ossification of Elbow. Indian J Orthop 2021; 55:898-906. [PMID: 34194645 PMCID: PMC8192647 DOI: 10.1007/s43465-021-00381-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Open excision remains the gold standard of treatment for posttraumatic heterotopic ossification (HO) of the elbow. The purpose of this study is to evaluate the functional outcome of early surgical excision done by adhering to a proposed surgical protocol with exclusive posttraumatic HO of the elbow. METHODS A retrospective study was conducted with 31 patients (25 males and 6 females) with a mean follow-up of 40.5 ± 27.44 months. Excision was done according to our surgical protocol based on the location of HO, associated fractures, stability, need for ulnar nerve transposition, previous operative scar. Improvement in elbow function, Mayo elbow performance score (MEPS) preoperatively and at final follow-up was compared, and statistical analysis was done. RESULTS Mean flexion-extension arc, supination-pronation arc and MEPS improved by 74.68° ± 29.32°, 26.13° ± 32.93°, 30.48 ± 11.57, respectively. Flexion arc deteriorated by 10.81° ± 10.42° from intraoperative to final follow-up. Improvement at final follow-up was significant in all the cases (P < 0.05). 19 patients had limited HO, and 12 had global HO. Their mean flexion-extension arc increase was 77.63° ± 29.12° and 70° ± 30.3° respectively, and the final mean MEPS score was 96.05 ± 5.16 and 88.75 ± 11.51, respectively. Nine patients had no initial fracture (Group 1), 13 had some fracture (Group 2), nine had a fracture-dislocation of the elbow (Group 3). Their flexion-extension improvement, final MEPS were 88.33° ± 30.82°, 98.33 ± 5, (Group 1); 81.15° ± 16.73°, 92.31 ± 9.27 (Group 2) and 51.67° ± 31.32°, 89.44 ± 9.5 (Group 3), respectively. We had two complications (6.45%). CONCLUSION The surgical protocol described here enabled us to achieve good functional results and was in concordance with similar studies done previously. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00381-x.
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Affiliation(s)
| | - Aniruddha Sinha Sarkar
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals, Coimbatore, India
| | - Sudipta Kumar Patra
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals, Coimbatore, India
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Dass D, Amol Singh R, Chojnowski A. Management of recurrent digital heterotopic ossification with radiotherapy: a case report. J Hand Surg Eur Vol 2021; 46:542-544. [PMID: 33256522 DOI: 10.1177/1753193420976261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Debashis Dass
- Hand Unit, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Rohit Amol Singh
- Hand Unit, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
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Cole PA, Dugarte AJ, Talbot M, Routt MLC. Early resection of ectopic bone in patients with heterotopic ossification about the hip after trauma. Injury 2020; 51:705-710. [PMID: 32035630 DOI: 10.1016/j.injury.2020.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/18/2019] [Accepted: 01/19/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Peter A Cole
- University of Minnesota, Regions Hospital, Department of Orthopaedic Surgery, St. Paul, MN, United States.
| | - Anthony J Dugarte
- University of Minnesota, Regions Hospital, Department of Orthopaedic Surgery, St. Paul, MN, United States
| | - Max Talbot
- Canadian Armed Forces, 1 Canadian Field Hospital, 147 Flanders Row, Garrison Petawawa, Onatrio, K8H 2X3, Canada
| | - Milton L Chip Routt
- Department of Orthopaedic Surgery, UT Health McGovern Medical School, Houston, TX, United States.
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Bachman DR, Fitzsimmons JS, O'Driscoll SW. Safety of Arthroscopic Versus Open or Combined Heterotopic Ossification Removal Around the Elbow. Arthroscopy 2020; 36:422-430. [PMID: 31870750 DOI: 10.1016/j.arthro.2019.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 08/29/2019] [Accepted: 09/02/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the complications of arthroscopic heterotopic ossification (HO) excision and compare them with those of open removal of HO or a combined open-arthroscopic approach. METHODS We performed a retrospective review of elbow HO removal cases performed by a single surgeon from 1997 to 2014. In all cases studied, the intention was to restore range of motion owing to the presence of HO causing functional impairment. The arthroscopic, open, and combined treatment groups were compared. RESULTS The study cohort consisted of 223 surgical procedures performed on 213 elbows in 211 patients. Fifty major complications occurred in 46 cases (21%): 17 hematomas (8%) treated by irrigation and debridement, 8 cases of HO requiring reoperation (4%), 7 deep infections (3%), 4 contractures (2%), 3 cases of delayed-onset ulnar neuritis (1%), 2 cases of distal humeral avascular necrosis (1%), 2 tendon ruptures (1%), 2 cases of instability requiring reconstruction (1%), 2 postoperative fractures (1%), 1 intraoperative fracture (<0.5%), 1 case of worsening of pre-existing neuropathic pain (<0.5%), and 1 permanent partial posterior interosseous nerve injury (<0.5%). Of these 46 cases, the major complications occurred in 6 of the 41 (15%) performed arthroscopically, in 36 of the 158 (23%) performed open and in 4 of the 21 (17%) with combined (i.e. open + arthroscopic) HO removal. Preventive strategies, introduced to prevent hematomas and delayed-onset ulnar neuritis, reduced the rate of major complications from 35% during the period from 1997 to 2005 to 10% during the period from 2006 to 2014 (P < .0001). Moreover, the rate of reoperations was reduced from 34% to 10% in the same periods (P < .0001). Minor complications occurred in 36 cases (16%), including 17 cases of transient nerve palsy, 9 cases of superficial infection or delayed wound healing, 6 cases of mild instability, and 4 cases of hematoma resolved by aspiration. CONCLUSIONS The use of arthroscopy-or a combination of arthroscopic and open techniques-to remove HO around the elbow by a surgeon skilled in both arthroscopic and open elbow surgery does not increase the risk of major complications or need for reoperation compared with traditional open surgery. Preventive strategies, such as avoiding raising skin flaps by using multiple separate incisions for open and prophylactic ulnar nerve decompression in arthroscopic cases, were developed during the study period. These strategies were monitored prospectively and found to be effective in preventing two-thirds of the major complications needing reoperation with both open and arthroscopic HO removal. LEVEL OF EVIDENCE Level III, retrospective comparative study of prospectively collected data.
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Affiliation(s)
- Daniel R Bachman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Shawn W O'Driscoll
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, 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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Haglin JM, Kugelman DN, Christiano A, Konda SR, Paksima N, Egol KA. Open surgical elbow contracture release after trauma: results and recommendations. J Shoulder Elbow Surg 2018; 27:418-426. [PMID: 29290605 DOI: 10.1016/j.jse.2017.10.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/08/2017] [Accepted: 10/18/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Post-traumatic elbow contracture is a debilitating complication after elbow trauma. The purpose of this study was to characterize the affected patient population, operative management, and outcomes after operative elbow contracture release for treatment of post-traumatic elbow contracture. METHODS A retrospective record review was conducted to identify all patients who underwent post-traumatic elbow contracture release performed by 1 of 3 surgeons at one academic medical center. Patient demographics, injuries, operative details, outcomes, and complications were recorded. RESULTS The study included 103 patients who met inclusion criteria. At the time of contracture release, patients were a mean age of 45.2 ± 15.6 years. Contracture release resulted in a significant mean increase to elbow extension/flexion arc of motion of 52° ± 18° (P < .0005). Not including recurrence of contracture, a subsequent complication occurred in 10 patients (10%). Radiographic recurrence of heterotopic ossification (HO) occurred in 14 patients (14%) after release. Ten patients (11%) elected to undergo a secondary operation to gain more motion. CONCLUSION Soft tissue and bony elbow contracture release is effective. Patients with post-traumatic elbow contracture can make significant gains to their arc of motion after contracture release surgery and can expect to recover a functional elbow arc of motion. Patients with severe preoperative contracture may benefit from concomitant ulnar nerve decompression. HO prophylaxis did not affect the rate of HO recurrence or ultimate elbow range of motion. However, patients must be counseled that contracture may reoccur, and some patients may require or elect to have more than one procedure to achieve functional motion.
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Affiliation(s)
- Jack M Haglin
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA
| | - David N Kugelman
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Anthony Christiano
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Sanjit R Konda
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA; Trauma Division, Orthopaedic Department, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Nader Paksima
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA; Trauma Division, Orthopaedic Department, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Kenneth A Egol
- Trauma Division, Orthopaedic Department, NYU Hospital for Joint Diseases, New York, NY, USA; Trauma Division, Orthopaedic Department, Jamaica Hospital Medical Center, Queens, NY, USA.
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Appropriate excision time of heterotopic ossification in elbow caused by trauma. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:27-31. [PMID: 29290538 PMCID: PMC6136303 DOI: 10.1016/j.aott.2017.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/23/2017] [Accepted: 11/24/2017] [Indexed: 02/05/2023]
Abstract
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.
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Cui HM, Yu YL, He Y, Cheng Y, Liu JZ, Zheng W, Chen S, Fan CY. Management of elbow stiffness after postoperative treatment of terrible triad elbow injury: maintaining mobility and stability using a combined protocol. INTERNATIONAL ORTHOPAEDICS 2017; 42:609-618. [DOI: 10.1007/s00264-017-3721-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 12/10/2017] [Indexed: 12/19/2022]
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Sun C, Zhou X, Yao C, Poonit K, Fan C, Yan H. The timing of open surgical release of post-traumatic elbow stiffness: A systematic review. Medicine (Baltimore) 2017; 96:e9121. [PMID: 29245348 PMCID: PMC5728963 DOI: 10.1097/md.0000000000009121] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Open release of post-traumatic elbow stiffness is effective in restoring elbow function, but there is no guideline on the optimal time point of surgical release so far. The purpose of this article was to summarize the current available literature reporting on the timing of open release of post-traumatic elbow stiffness. METHODS The PubMed, Cochrane Library, and EMBASE were searched with a set of predefined inclusion and exclusion criteria. Manual searches for references were performed to find potential relevant studies. Two authors separately extracted data from all the articles selected. RESULTS 27 articles published between 1989 and 2017 were included with an overall enrollment of 836 patients. We divided all included studies into 3 groups according to the timing of surgical release: group 1 (6-10 months after injury), group 2 (11-20 months after injury), and group 3(>20 months after injury). The mean postoperative Mayo Elbow Performance Score (MEPS) and recurrence rate were similar among the 3 groups; however, the mean gain in arc of motion in group 1 was the highest with the lowest complication rate among the 3 groups. CONCLUSION There was a trend toward a shorter waiting time from injury to open arthrolysis from 12 months to 6 months. The shorter waiting period of 6 to 10 months yielded better results. Therefore, early surgical release of stiff elbows is recommended for a shorter rehabilitation time and earlier return to work. LEVEL OF EVIDENCE Level IV, Systematic Review.
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Affiliation(s)
- Chao Sun
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou
| | - Xijie Zhou
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou
| | - Chenglun Yao
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou
| | - Keshav Poonit
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hede Yan
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou
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Chen S, Liu J, Cai J, Zheng W, Li Z, Chen W, Fan C. Results and outcome predictors after open release of complete ankylosis of the elbow caused by heterotopic ossification. INTERNATIONAL ORTHOPAEDICS 2017; 41:1627-1632. [DOI: 10.1007/s00264-016-3395-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/27/2016] [Indexed: 10/20/2022]
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Bowman SH, Barfield WR, Slone HS, Shealy GJ, Walton ZJ. The clinical implications of heterotopic ossification in patients treated with radial head replacement for trauma: A case series and review of the literature. J Orthop 2016; 13:272-7. [PMID: 27408502 DOI: 10.1016/j.jor.2016.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/11/2016] [Accepted: 06/08/2016] [Indexed: 11/28/2022] Open
Abstract
Radial head arthroplasty (RHA) is an acceptable treatment for comminuted radial head fractures (RHF). Fourteen patients with no postop HO prophylaxis were treated with RHA for comminuted RHF. A 50% incidence in HO was seen following RHA with a statistically increased risk (p ≤ 0.05) of reoperation compared to those without HO. Decreased ROM was seen on the affected side (p ≤ 0.05); patients without HO showed no statistical difference (p ≥ 0.05) in ROM or grip strength. HO following RHA increases patient risk for reoperation and decreases ROM. We recommend HO prophylaxis with NSAIDs and/or radiotherapy if no direct patient contraindications are found.
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Affiliation(s)
- Seth H Bowman
- Medical University of South Carolina, Charleston, SC, United States
| | | | - Harris S Slone
- Medical University of South Carolina, Charleston, SC, United States
| | - Gerald J Shealy
- Medical University of South Carolina, Charleston, SC, United States
| | - Zeke J Walton
- Medical University of South Carolina, Charleston, SC, United States
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Willis AR, Samad AA, Prado GT, Gabisan GG. Heterotopic Ossification and Entrapment of the Tibial Nerve Within the Tarsal Tunnel: A Case Report. J Foot Ankle Surg 2016; 55:1106-9. [PMID: 27079305 DOI: 10.1053/j.jfas.2016.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Indexed: 02/03/2023]
Abstract
Heterotopic ossification has been reported to occur after musculoskeletal trauma (including orthopedic procedures). This has been known to cause nerve entrapment syndromes and persistent pain, limiting joint mobility. We present a case of a 19-year old female collegiate athlete who had previously undergone ankle arthroscopy and arthrotomy to remove 2 ossicles. At approximately 1 year postoperatively, the patient developed pain when planting and pivoting her foot. Imaging revealed a radiodense lesion at the posteromedial ankle consistent with heterotopic ossification and entrapment of the tibial nerve within the tarsal tunnel. The patient underwent surgical resection and postoperative indomethacin prophylaxis. At the 1-year follow-up visit, the patient remained asymptomatic, without evidence of recurrence of the heterotopic ossification. In our review of the published data, we found no previously reported cases of heterotopic ossification causing entrapment of the tibial nerve within the tarsal tunnel. In the present case report, we describe this rare case and the postulated etiologies and pathophysiology of this disease process. In addition, we discuss the clinical signs and symptoms and recommended imaging modalities and treatment.
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Affiliation(s)
- Alexander R Willis
- Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, Monmouth Medical Center, Long Branch, NJ.
| | - Adil A Samad
- Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, Monmouth Medical Center, Long Branch, NJ
| | - Gail T Prado
- Resident Physician, Department of Pathology, Monmouth Medical Center, Long Branch, NJ
| | - Glenn G Gabisan
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Monmouth Medical Center, Long Branch, NJ
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Winkler S, Wagner F, Weber M, Matussek J, Craiovan B, Heers G, Springorum HR, Grifka J, Renkawitz T. Current therapeutic strategies of heterotopic ossification--a survey amongst orthopaedic and trauma departments in Germany. BMC Musculoskelet Disord 2015; 16:313. [PMID: 26494270 PMCID: PMC4619196 DOI: 10.1186/s12891-015-0764-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 10/08/2015] [Indexed: 11/30/2022] Open
Abstract
Background Heterotopic ossification (HO) is a complication after tissue trauma, fracture and surgery (i.e. total hip arthroplasty). Prophylaxis is the most effective therapy. If HO formations become symptomatic and limit patients’ quality of life, revision surgery is indicated and is usually combined with a perioperative oral prophylaxis (NSAIDs) and/or irradiation. However, a long-term use of NSAIDs can induce gastro-intestinal or cardiac side-effects and possible bony non-unions during fracture healing. Subject of this study was to assess the current status of HO prophylaxis after injuries or fractures and to evaluate current indications and strategies for excision of symptomatic HO. Methods Between 2013 and 2014, a questionnaire was sent to 119 orthopaedic and trauma surgery departments in Germany. Participation was voluntary and all acquired data was given anonymously. Results The cumulative feedback rate was 71 %. Trauma and orthopaedic surgery departments in Germany recommend oral HO prophylaxis after acetabulum and femoral neck fractures, elbow dislocation, and fracture or dislocation of the radial head. Pain upon movement and an increasing loss of range of motion in the affected joint are considered to be clear indications for HO surgery. A partial removal of ROM-limiting HO formations was also considered important. The vast majority of all departments include perioperative oral HO prophylaxis and/or irradiation if surgical HO removal is planned. The choice and duration of NSAIDs is highly variable. Conclusion HO is of clinical significance in current traumatology and orthopaedics. Certain fractures and injuries are prone to HO, and prophylactic measures should be taken. The respondents in this survey assessed current therapeutic strategies for HO formations similarly. These concepts are in line with the literature. However, the duration of perioperative oral HO prophylaxis varied greatly among the specialist centres. This is significant as a long-term use of NSAIDs fosters a potential risk for the patients’ safety and could influence the clinical outcome. National and international guidelines need to be developed to further reduce HO rates and improve patients’ safety in trauma and orthopaedic surgery.
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Affiliation(s)
- Sebastian Winkler
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
| | - Ferdinand Wagner
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
| | - Markus Weber
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
| | - Jan Matussek
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
| | - Benjamin Craiovan
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
| | - Guido Heers
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
| | - Hans Robert Springorum
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
| | - Joachim Grifka
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
| | - Tobias Renkawitz
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
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Corrective and reconstructive surgery in patients with postburn heterotopic ossification and bony ankylosis: an evidence-based approach. J Burn Care Res 2015; 36:57-69. [PMID: 25159555 DOI: 10.1097/bcr.0000000000000116] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Articular heterotopic ossification (HO) and subsequent bony ankylosis (BA) are infrequent yet devastating complications of severe burn injuries. These conditions are diagnosed clinically and confirmed by imaging. Patients then begin active physical therapy until cleared for surgery, which remains the standard of care. This study critically reviews the existing literature on the diagnosis, treatment, and surgical outcomes of HO/BA in severely burned patients and provides an evidence-based treatment algorithm. A comprehensive search for all the studies addressing HO and BA after burn injury was conducted using PubMed and Google Scholar from 1957 to 2013. Fifty-one studies on postburn HO/BA have been published, reporting incidences from 0.1 to 35.3%. Most patients suffered from third-degree, thermal burns, with a mean TBSA of 49 ± 14%. The mean time from burn until diagnosis was 7 ± 11 months. Seventy-nine percent of the affected joints were elbows and 84% had adjacent and/or overlying burns. Ninety-one percent of joints had solely extra-articular HO. Ninety percent of HO/BA cases were treated with anatomic excision, and all achieved appreciable increases in range of motion with infrequent recurrence. Perioperative radiotherapy was used infrequently. Surgical articular reconstruction is the standard of care for postburn HO/BA severe enough to limit joint movement and/or function. Early detection and initiation of physical therapy are paramount in preventing progression to complete BA. Increased awareness and more rapid means of detecting postburn articular changes may permit earlier discontinuation of passive range of motion exercises, thereby halting the initiation and progression of HO.
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Pavey GJ, Polfer EM, Nappo KE, Tintle SM, Forsberg JA, Potter BK. What Risk Factors Predict Recurrence of Heterotopic Ossification After Excision in Combat-related Amputations? Clin Orthop Relat Res 2015; 473:2814-24. [PMID: 25832006 PMCID: PMC4523520 DOI: 10.1007/s11999-015-4266-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Gabriel J. Pavey
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA
| | - Elizabeth M. Polfer
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Kyle E. Nappo
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA
| | - Scott M. Tintle
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Jonathan A. Forsberg
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Benjamin K. Potter
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor–Ortho, Bethesda, MD 20889 USA ,Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
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21
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Chen S, Yu SY, Yan H, Cai JY, Ouyang Y, Ruan HJ, Fan CY. The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise. J Shoulder Elbow Surg 2015; 24:1165-71. [PMID: 26189802 DOI: 10.1016/j.jse.2015.05.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/28/2015] [Accepted: 05/04/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Shuai Chen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shi-yang Yu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hede Yan
- Division of Plastic and Hand Surgery, Department of Orthopaedics, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiang-yu Cai
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuanming Ouyang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hong-jiang Ruan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cun-yi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Ranganathan K, Loder S, Agarwal S, Wong VW, Forsberg J, Davis TA, Wang S, James AW, Levi B, Levi B. Heterotopic Ossification: Basic-Science Principles and Clinical Correlates. J Bone Joint Surg Am 2015; 97:1101-11. [PMID: 26135077 PMCID: PMC6948799 DOI: 10.2106/jbjs.n.01056] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Heterotopic ossification occurs most commonly after joint arthroplasty, spinal cord injury, traumatic brain injury, blast trauma, elbow and acetabular fractures, and thermal injury.➤ The conversion of progenitor cells to osteogenic precursor cells as a result of cell-mediated interactions with the local tissue environment is affected by oxygen tension, pH, availability of micronutrients, and mechanical stimuli, and leads to heterotopic ossification.➤ Radiation and certain nonsteroidal anti-inflammatory medications are important methods of prophylaxis against heterotopic ossification.➤ Well-planned surgical excision can improve patient outcomes regardless of the joint involved or the initial cause of injury.➤ Future therapeutic strategies are focused on targeted inhibition of local factors and signaling pathways that catalyze ectopic bone formation.
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Affiliation(s)
- Kavitha Ranganathan
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shawn Loder
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Shailesh Agarwal
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Victor W. Wong
- Department of Surgery, Johns Hopkins School of Medicine, 4924 Campbell Boulevard, Baltimore, MD 21236
| | - Jonathan Forsberg
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Thomas A. Davis
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD 20910
| | - Stewart Wang
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Aaron W. James
- Department of Pathology & Laboratory Medicine, University of California at Los Angeles, DGSOM, 200 Medical Plaza, Los Angeles, CA 90095
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, 1500 East Medical Center Drive, Taubman Center, XPC 5340, Ann Arbor, MI 48109-0219. E-mail address for B. Levi:
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Aibinder WR, Sperling JW. Heterotopic bone with rotator cuff tear: a case report and review of the literature. J Shoulder Elbow Surg 2015; 24:e190-4. [PMID: 25953487 DOI: 10.1016/j.jse.2015.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/12/2015] [Accepted: 03/18/2015] [Indexed: 02/01/2023]
Affiliation(s)
| | - John W Sperling
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, USA.
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Genêt F, Ruet A, Almangour W, Gatin L, Denormandie P, Schnitzler A. Beliefs relating to recurrence of heterotopic ossification following excision in patients with spinal cord injury: a review. Spinal Cord 2015; 53:340-4. [DOI: 10.1038/sc.2015.20] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/15/2014] [Accepted: 01/12/2015] [Indexed: 11/09/2022]
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Abstract
Heterotopic ossification (HO) is a clinical condition of ectopic bone formation in soft tissue. This clinical entity has been associated with genetic disorders, traumatic injuries, and musculoskeletal surgeries. In this regard, functional impairments secondary to scar contractures seen in burn injuries may be exacerbated with underlying HO. The appropriate prevention or management of this complication is crucial to optimize outcome in burn patients. This clinical study reviews the incidence of HO in our burned patients, diagnostic methods, therapeutic approaches including surgical timing and techniques.
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Perosky JE, Peterson JR, Eboda ON, Morris MD, Wang SC, Levi B, Kozloff KM. Early detection of heterotopic ossification using near-infrared optical imaging reveals dynamic turnover and progression of mineralization following Achilles tenotomy and burn injury. J Orthop Res 2014; 32:1416-23. [PMID: 25087685 PMCID: PMC4408934 DOI: 10.1002/jor.22697] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 06/24/2014] [Indexed: 02/04/2023]
Abstract
Heterotopic ossification (HO) is the abnormal formation of bone in soft tissue. Current diagnostics have low sensitivity or specificity to incremental progression of mineralization, especially at early time points. Without accurate and reliable early diagnosis and intervention, HO progression often results in incapacitating conditions of limited range of motion, nerve entrapment, and pain. We hypothesized that non-invasive near-infrared (NIR) optical imaging can detect HO at early time points and monitor heterotopic bone turnover longitudinally. C57BL6 mice received an Achilles tenotomy on their left hind limb in combination with a dorsal burn or sham procedure. A calcium-chelating tetracycline derivative (IRDye 680RD BoneTag) was injected bi-weekly and imaged via NIR to measure accumulative fluorescence for 11 wk and compared to in vivo microCT images. Percent retention of fluorescence was calculated longitudinally to assess temporal bone resorption. NIR detected HO as early as five days and revealed a temporal response in HO formation and turnover. MicroCT could not detect HO until 5 wk. Confocal microscopy confirmed fluorophore localization to areas of HO. These findings demonstrate the ability of a near-infrared optical imaging strategy to accurately and reliably detect and monitor HO in a murine model.
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Affiliation(s)
| | | | | | | | | | - Benjamin Levi
- Department of Plastic Surgery, University of Michigan
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Popovic M, Agarwal A, Zhang L, Yip C, Kreder HJ, Nousiainen MT, Jenkinson R, Tsao M, Lam H, Milakovic M, Wong E, Chow E. Radiotherapy for the prophylaxis of heterotopic ossification: a systematic review and meta-analysis of published data. Radiother Oncol 2014; 113:10-7. [PMID: 25220370 DOI: 10.1016/j.radonc.2014.08.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/08/2014] [Accepted: 08/12/2014] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Following surgery, the formation of heterotopic ossification (HTO) can limit mobility and impair quality of life. Radiotherapy has been proven to provide efficacious prophylaxis against HTO, especially in high-risk settings. PURPOSE The current review aims to determine the factors influencing HTO formation in patients receiving prophylactic radiotherapy. METHODS A systematic search of the literature was conducted on Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials. Studies were included if they reported the percentage of sites developing heterotopic ossification after receiving a specified dose of prophylactic radiotherapy. Weighted linear regression analysis was conducted for continuous or categorical predictors. RESULTS Extracted from 61 articles, a total of 5464 treatment sites were included, spanning 85 separate study arms. Most sites were from the hip (97.7%), from United States patients (55.2%), and had radiation prescribed postoperatively (61.6%) at a dose of 700cGy (61.0%). After adjusting for radiation site, there was no statistically significant relationship between the percentage of sites developing HTO and radiation dose (p=0.1) or whether radiation was administered preoperatively or postoperatively (p=0.1). Sites with previous HTO formation were more likely to develop recurrent HTO than those without previous HTO formation (p=0.04). There was a statistically significant negative relationship between the HTO development and the cohort mean year of treatment (p=0.007). CONCLUSION Decreases in rates of HTO over time in this patient population may be a function of more efficacious surgical regimens and prophylactic radiotherapy.
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Affiliation(s)
- Marko Popovic
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Arnav Agarwal
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Liying Zhang
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Cheryl Yip
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Hans J Kreder
- Division of Orthopaedics, Sunnybrook Health Science Centre, Toronto, Canada
| | | | - Richard Jenkinson
- Division of Orthopaedics, Sunnybrook Health Science Centre, Toronto, Canada
| | - May Tsao
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Henry Lam
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Milica Milakovic
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Erin Wong
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Edward Chow
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada.
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Salazar D, Golz A, Israel H, Marra G. Heterotopic ossification of the elbow treated with surgical resection: risk factors, bony ankylosis, and complications. Clin Orthop Relat Res 2014; 472:2269-75. [PMID: 24711127 PMCID: PMC4048438 DOI: 10.1007/s11999-014-3591-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 03/18/2014] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Dane Salazar
- />Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, 2160 South First Avenue, Maywood, IL 60153 USA
| | - Andrew Golz
- />Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, 2160 South First Avenue, Maywood, IL 60153 USA
| | - Heidi Israel
- />Department of Orthopaedic Surgery, St. Louis University, St Louis, MO USA
| | - Guido Marra
- />Department of Orthopaedic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL USA
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Veltman ES, Lindenhovius ALC, Kloen P. Improvements in elbow motion after resection of heterotopic bone: a systematic review. Strategies Trauma Limb Reconstr 2014; 9:65-71. [PMID: 24934800 PMCID: PMC4122684 DOI: 10.1007/s11751-014-0192-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 06/04/2014] [Indexed: 10/31/2022] Open
Abstract
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.
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Affiliation(s)
- Ewout S Veltman
- Department of Orthopedic Surgery, Secretariaat Orthopedie, G4-221, Academic Medical Center Amsterdam, Meibergdreef 9, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands,
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Min HW, Liu KM, Han XZ, Gu R. Management of multijoint stiffness of bilateral upper limbs secondary to heterotopic ossification: Case report and literature review. ACTA ACUST UNITED AC 2014; 51:497-502. [DOI: 10.1682/jrrd.2013.03.0073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 10/10/2013] [Indexed: 11/05/2022]
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Ploumis A, Belbasis L, Ntzani E, Tsekeris P, Xenakis T. Radiotherapy for prevention of heterotopic ossification of the elbow: a systematic review of the literature. J Shoulder Elbow Surg 2013; 22:1580-8. [PMID: 24138821 DOI: 10.1016/j.jse.2013.07.045] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 07/02/2013] [Accepted: 07/16/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification is a pathological process characterized by abnormal formation of bone in nonskeletal tissue. Radiotherapy for heterotopic ossification of the elbow is questionable because of possible adverse effects. METHODS A systematic review of the literature was conducted in MEDLINE, Scopus, ISI Web of Science, National Institute for Health and Clinical Excellence, National Guideline Clearinghouse, System for Information on Grey Literature in Europe, ClinicalTrials.gov, Cochrane Central Register of Clinical Trials, and Cochrane Database of Systematic Reviews up to April 2012. All published articles assessing interventions including radiotherapy for prevention of heterotopic ossification in the elbow of adult patients were considered. Information was recorded by the first two authors, and disagreements in interpretation were resolved by consensus. RESULTS In total, 27 studies using radiotherapy for elbow heterotopic ossification were identified (1 randomized clinical trial, 1 case-control study, and 25 case reports and case series) in the literature. Most of them used a single dose of 7.0 Gy. The randomized clinical trial was stopped early because of severe adverse effects (pseudarthrosis) caused by radiation. The case-control study showed that radiotherapy did not effectively prevent recurrence of heterotopic ossification. The case reports and case series mentioned only sparse adverse events. CONCLUSION The use of radiation therapy for prevention of heterotopic ossification of the elbow is supported by weak evidence.
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Affiliation(s)
- Avraam Ploumis
- Department of Orthopaedics and Rehabilitation, University of Ioannina Medical School, Ioannina, Greece.
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Koh KH, Lim TK, Lee HI, Park MJ. Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification. J Shoulder Elbow Surg 2013; 22:1128-34. [PMID: 23796381 DOI: 10.1016/j.jse.2013.04.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 04/07/2013] [Accepted: 04/17/2013] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea
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Lee EK, Namdari S, Hosalkar HS, Keenan MA, Baldwin KD. Clinical results of the excision of heterotopic bone around the elbow: a systematic review. J Shoulder Elbow Surg 2013; 22:716-22. [PMID: 23380078 DOI: 10.1016/j.jse.2012.11.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/19/2012] [Accepted: 11/21/2012] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Eric K Lee
- School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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[Post-traumatic proximal radioulnar synostosis. Surgical technique and review of the literature]. Unfallchirurg 2013; 115:451-6. [PMID: 21604034 DOI: 10.1007/s00113-011-2000-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Synostosis of the radioulnar joint can appear after severe fractures of the elbow, which leads to distinctive limitation in forearm rotation. We describe a surgical technique according to Morrey in a case of a young girl with resection osteotomy of the proximal radius without excision of the synostosis. Different therapeutic options for post-traumatic proximal radioulnar synostosis are discussed on the basis of the current literature.
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Insights into posttraumatic heterotopic ossification in extremity war injuries. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e31828780c8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES To determine the prevalence and identify the risk factors for heterotopic ossification (HO) formation in high-grade open fractures sustained during combat and to report on the results of HO excision. DESIGN Retrospective. SETTING United States Army level-1 trauma center. PATIENTS/PARTICIPANTS Seventy-six consecutive patients with 91 combat-related open Gustilo and Anderson type II and higher fractures were identified from March 1, 2003, through January 30, 2005. Fifty-nine patients with 71 fractures met criteria for study inclusion. MAIN OUTCOME MEASUREMENTS Fractures were categorized into HO-present and HO-absent groups based on radiographic imaging. Risk factors such as injury mechanism, injury severity score (ISS), Gustilo and Anderson type, injury location, closed head injury, burn, and infection were compared between the groups. RESULTS HO was present in 27 of 71 open fractures (38.1%). Variables associated with HO formation included ISS (p = 0.02) and injury location although infection and use of negative pressure therapy were not. Ten of 27 fractures with HO underwent excision. HO did not occur or was mild in 25 tibiae. CONCLUSIONS HO is a common sequela of high-grade open fractures sustained in combat. High ISS and injury location to the shoulder, hip, and femur are risk factors for HO formation. The most common regions for HO excision were the elbow, forearm, and hip with mixed results. Importantly, HO did not seem to be a complication of open high-grade tibia fractures. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Heterotopic ossification (HO) can be defined as the pathologic formation of bone in extraskeletal tissues. There has been a substantial amount of recent research on the pathophysiology, prophylaxis, and treatment of HO and traumatic conditions associated with the development of HO. This research has advanced our understanding of this disease and helped to clarify evidence-based approaches to both the prophylaxis and treatment of HO. This article reviews the literature on these topics with a focus on their application in orthopaedic trauma.
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Impact of the Operative Delay and the Degree of Neurologic Sequelae on Recurrence of Excised Heterotopic Ossification in Patients With Traumatic Brain Injury. J Head Trauma Rehabil 2012; 27:443-8. [DOI: 10.1097/htr.0b013e31822b54ba] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adult post-traumatic radioulnar synostosis. Orthop Traumatol Surg Res 2012; 98:709-14. [PMID: 23000035 DOI: 10.1016/j.otsr.2012.04.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Revised: 03/10/2012] [Accepted: 04/27/2012] [Indexed: 02/02/2023]
Abstract
Post-traumatic radioulnar synostosis is a rare complication of forearm fracture. Resulting in loss of forearm axial rotation, it is functionally very disabling. The surgical indication, timing of operation, surgical technique, interest and type of adjuvant treatment are all issues with which physicians managing radioulnar synostosis must deal. No therapeutic consensus yet exists, but a wide variety of surgical techniques and adjuvant treatments are suggested. A literature review sought to identify risk factors for synostosis, with a view to prevention and determining a suitable therapeutic attitude in the light of existing data.
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Park MJ, Chang MJ, Lee YB, Kang HJ. Surgical Release for Posttraumatic Loss of Elbow Flexion. JBJS Essent Surg Tech 2011; 1:e16. [PMID: 31321121 DOI: 10.2106/jbjs.st.k.00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction We describe a surgical release for patients who have a lack of elbow flexion limiting the ability to perform activities of daily living after trauma. Step 1 Mobilize the Ulnar Nerve Mobilize the ulnar nerve through the cubital tunnel with the accompanying superior ulnar collateral vessels. Step 2 Dissect the Triceps and Resect the Posterior Aspect of the Capsule Dissect the triceps from the distal part of the humerus and resect the posterior aspect of the capsule to expose the olecranon tip and fossa. Step 3 Resect the Posterior Band of the Medial Collateral Ligament Release the posterior band of the medial collateral ligament while continually checking the flexion arc until >130° of flexion can be achieved. Step 4 Resect the Anterior Aspect of the Capsule Perform an anterior approach if there is persistent flexion contracture or any impingement restricting full flexion. Step 5 Lengthen the Triceps If Indicated Consider triceps lengthening if you cannot achieve >130° of passive flexion with two fingers. Step 6 Transpose the Ulnar Nerve Anteriorly Locate the released ulnar nerve over the medial humeral epicondyle on the fascia overlying the common flexor-pronator muscles. Step 7 Postoperative Management Physical therapy consists of active-assisted and gentle passive flexion and extension exercises of the elbow, usually for two to six months. Results Forty-two patients with <100° of elbow flexion as an extrinsic contracture following trauma had a surgical release of the elbow at a median of ten months postinjury. What to Watch For IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea. E-mail address for M.J. Park:
| | - Moon Jong Chang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea. E-mail address for M.J. Park:
| | - Yong Beom Lee
- Department of Orthopedic Surgery, Sacred Heart Hospital, Hallym University College of Medicine, 896 Pyungchon-dong, Dongan-gu, Anyang, Republic of Korea
| | - Hong Je Kang
- Department of Orthopaedic Surgery, Wonkwang University Hospital, 344-2 Shinyong-dong, Iksan, Jeollabuk-do, Republic of Korea
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Genêt F, Jourdan C, Lautridou C, Chehensse C, Minooee K, Denormandie P, Schnitzler A. The impact of preoperative hip heterotopic ossification extent on recurrence in patients with head and spinal cord injury: a case control study. PLoS One 2011; 6:e23129. [PMID: 21853078 PMCID: PMC3154269 DOI: 10.1371/journal.pone.0023129] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 07/12/2011] [Indexed: 11/28/2022] Open
Abstract
Background The preoperative Heterotopic Ossification (HO) extent is usually one of the main used criteria to predict the recurrence before excision. Brooker et al built a radiologic scale to assess this pre operative extent around the hip. The aim of this study is to investigate the relationship between the recurrence risk after hip HO excision in Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) patients and the preoperative extent of HO. Methodology/Principal Findings A case control study including TBI or SCI patients following surgery for troublesome hip HO with (case, n = 19) or without (control, n = 76) recurrence. Matching criteria were: sex, pathology (SCI or TBI) and age at the time of surgery (+/−4.5 years). For each etiology (TBI and SCI), the residual cognitive and functional status (Garland classification), the preoperative extent (Brooker status), the modified radiological and functional status (GCG-BD classification), HO localization, side, mean age at the CNS damage, mean delay for the first HO surgery, and for the case series, the mean operative delay for recurrence after the first surgical intervention were noted. Conclusions/Significance The median delay for first HO surgery was 38.6 months (range 4.5 to 414.5;) for the case subgroup and 17.6 months (range 5.7 to 339.6) for the control group. No significant link was found between recurrence and operative delay (p = 0.51); the location around the joint (0.07); the Brooker (p = 0.52) or GCG-BD status (p = 0.79). Including all the matching factors, no significant relationship was found between the recurrence HO risk and the preoperative extent of troublesome hip HO using Brooker status (OR = 1.56(95% CI: 0.47–5.19)) or GCG-BD status (OR class 3 versus 2 = 0.67(95% CI: 0.11–4.24) and OR class 4 versus 2 = 0.79(95%CI: 0.09–6.91)). Until the pathophysiology of HO development is understood, it will be difficult to create tools which can predict HO recurrence.
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Affiliation(s)
- François Genêt
- Service de Médecine Physique et de Réadaptation, CHU R.Poincaré, Garches, France.
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Baldwin K, Hosalkar HS, Donegan DJ, Rendon N, Ramsey M, Keenan MAE. Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies. J Hand Surg Am 2011; 36:798-803. [PMID: 21458925 DOI: 10.1016/j.jhsa.2011.01.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 01/11/2011] [Accepted: 01/11/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE We evaluated the outcomes of patients with elbow heterotopic ossification (HO) who underwent surgical intervention. Our goal was to elucidate differences in outcome of surgical treatment between those patients with traumatic brain injury, direct elbow trauma, or combined etiologies. In addition, we used regression analysis to adjust for confounding factors (such as age, gender, preoperative range of motion [ROM], location of HO, chronicity of HO [ie, time from HO formation to surgery], and whether motor control was spastic or normal) on the relationship between surgical outcome and etiology. METHODS We reviewed 60 patients (64 elbows) surgically treated for heterotopic ossification. A total of 42 patients had trauma as the primary etiology, 15 had traumatic brain injury, and 7 had combined etiologies. All had pain or functional limitations at presentation. All patients had surgical resection of their HO. Functional and ROM outcomes were recorded. RESULTS Mean preoperative arc of motion for the entire cohort was 57° (range, 0° to 150°). Mean postoperative arc for the entire cohort was 106° (range, 0° to 145°) at a mean follow-up of 44 months (range, 21-72 mo), demonstrating a significant gain. Average gain, in arc of motion was 49° (range, 10° to 140°). Gains in motion were not significantly different in any individual etiologic group. A total of 6% of cases were complicated by infection, 13% of cases had recurrence of HO, and 11% of cases required repeat surgery for infection or recurrence. Preoperative ROM was an important independent predictor of final range achieved and gain in ROM after surgical intervention. Recurrence rates were higher in patients with neurologic involvement. Postoperative stiffness was related to preoperative stiffness, delay of surgery longer than 12 months, and anterior location of the HO. CONCLUSIONS Surgical excision of heterotopic bone about the elbow results in significant gains in ROM regardless of etiology. The likelihood of recurrence is higher in patients with central nervous system injuries than in patients with purely localized trauma.
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Affiliation(s)
- Keith Baldwin
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Heterotopic ossifications following implant surgery—epidemiology, therapeutical approaches and current concepts. Semin Immunopathol 2011; 33:273-86. [DOI: 10.1007/s00281-011-0240-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 01/01/2011] [Indexed: 10/18/2022]
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Potter BK, Forsberg JA, Davis TA, Evans KN, Hawksworth JS, Tadaki D, Brown TS, Crane NJ, Burns TC, O'Brien FP, Elster EA. Heterotopic ossification following combat-related trauma. J Bone Joint Surg Am 2010; 92 Suppl 2:74-89. [PMID: 21123594 DOI: 10.2106/jbjs.j.00776] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Benjamin K Potter
- Walter Reed National Military Medical Center, Washington, DC 20307, USA.
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Treatment of heterotopic ossification of the elbow following burn injury: recommendations for surgical excision and perioperative prophylaxis using radiation therapy. J Shoulder Elbow Surg 2010; 19:1269-75. [PMID: 20850996 DOI: 10.1016/j.jse.2010.05.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 05/25/2010] [Accepted: 05/25/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is reported to occur in 0.1-3.3% of elbows after a severe burn, and can significantly limit elbow motion and upper extremity function. METHODS The study included 9 patients (11 elbows) treated by the senior author (TW). The surgical technique consisted of making multiple small surgical approaches to remove heterotopic ossification (without raising cutaneous flaps) and concomitantly releasing the elbow capsule and skin contracture. Perioperative radiation therapy was performed to decrease heterotopic ossification recurrence. Outcome measures included postoperative elbow range of motion and Mayo Elbow Performance Score. RESULTS The average amount of body surface area burned was 54% (range, 10-86%) and mean time from injury to elbow surgery was 416 days (range, 175-860). All elbows had some degree of direct involvement with the thermal injury. Preoperative arc of motion averaged 39° in flexion/extension and 78° in supination/pronation. Four elbows had complete ankylosis in the flexion/extension plane and 1 had only 5° of motion. At last follow-up, arc of motion in flexion/extension averaged 116° and 139° in supination/pronation, an improvement of 77° and 61°, respectively. One recurrence of HO required re-excision. CONCLUSION We recommend this multiple-approach surgical technique for treatment of heterotopic ossification and elbow contracture after burn injury, along with perioperative radiation therapy to decrease recurrence. Our surgical approach and treatment resulted in significant gains in elbow motion and upper extremity function with few complications.
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Park MJ, Chang MJ, Lee YB, Kang HJ. Surgical release for posttraumatic loss of elbow flexion. J Bone Joint Surg Am 2010; 92:2692-9. [PMID: 21084579 DOI: 10.2106/jbjs.i.01367] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several surgical approaches have been suggested for the treatment of posttraumatic elbow stiffness; however, the optimal approach to elbows with considerable loss of flexion has not been well described. We investigated the pathologic lesions causing posttraumatic loss of elbow flexion and analyzed the results of surgical release. METHODS Forty-two patients with <100° of elbow flexion due to an extrinsic contracture following trauma underwent surgical release at a median of ten months after injury. To achieve maximum flexion, release of the posterior band of the medial collateral ligament was mandatory in all patients, and only four patients required additional anterior procedures. The ulnar nerve was transposed anteriorly in forty patients, including three who had had a previous transposition. To evaluate the results, we compared preoperative and postoperative elbow motion, Mayo Elbow Performance Index (MEPI) scores, and radiographs. RESULTS Intraoperatively, heterotopic ossification was observed in forty patients. It was located predominantly in the posteromedial aspect of the capsule. Heterotopic bone was more commonly found during surgery than it was identified preoperatively on radiographs. Mean flexion increased significantly from 89° preoperatively to 124° (range, 90° to 140°) at a mean of thirty-nine months postoperatively. The mean size of the flexion contracture decreased from 34° preoperatively to 9° (range, 0° to 30°) postoperatively. Overall, ≥120° of final flexion and a total arc of ≥100° were regained by 88% of the patients. The mean MEPI score improved significantly from 73 points preoperatively to 94 points (range, 72 to 100 points) postoperatively, with the result rated as excellent in thirty-two patients, good in eight, and fair in two. Two patients had clinical recurrence of heterotopic ossification associated with a failure to obtain an increase in flexion. CONCLUSIONS This study demonstrates that posttraumatic heterotopic ossification, particularly in the posteromedial aspect of the capsule, is closely associated with loss of elbow flexion. Satisfactory restoration of elbow flexion can be obtained in the majority of patients by surgical release of the posterior band of the medial collateral ligament and excision of heterotopic bone.
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Affiliation(s)
- Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea.
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Hamid N, Ashraf N, Bosse MJ, Connor PM, Kellam JF, Sims SH, Stull DE, Jeray KJ, Hymes RA, Lowe TJ. Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study. J Bone Joint Surg Am 2010; 92:2032-8. [PMID: 20810853 DOI: 10.2106/jbjs.i.01435] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Nady Hamid
- Department of Orthopaedic Surgery, Carolinas Medical Center, 1616 Scott Avenue, Charlotte, NC 28203, USA.
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Robinson CG, Polster JM, Reddy CA, Lyons JA, Evans PJ, Lawton JN, Graham TJ, Suh JH. Postoperative Single-Fraction Radiation for Prevention of Heterotopic Ossification of the Elbow. Int J Radiat Oncol Biol Phys 2010; 77:1493-9. [DOI: 10.1016/j.ijrobp.2009.06.072] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 06/23/2009] [Accepted: 06/24/2009] [Indexed: 10/19/2022]
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Mackiewicz-Milewska M, Jung S, Lach-Inszczak S, Borland S, Szymku I, Cieski J, Cisowaka Adamiak M, Hagner W, Lasek W. Heterotopic ossification following cardiac arrest and hypoxic brain damage. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2010. [DOI: 10.12968/ijtr.2010.17.4.47307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aims Heterotopic bone can cause restriction of movement when deposited in the soft tissues around joints. Neurogenic heterotopic ossification may follow brain injury. This article describes research into the incidence of heterotopic ossification after brain injury, and its impact on rehabilitation. Methods Thirty-nine patients who were admitted to the rehabilitation unit of University Hospital Bydgoszcz, Poland, after hypoxic brain injury due to cardiac arrest, were examined. Findings Six patients were identified as having developed heterotopic bone around one or more joints causing limitation of movement and delay in the rehabilitation process. Conclusions Heterotopic ossification occurs in up to 15% of patients following hypoxic brain injury. The development of the condition may often be missed clinically, and can hinder rehabilitation.
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Affiliation(s)
| | | | | | | | - Iwona Szymku
- Department of Rehabilitation, CM UMK Bydgoszcz, Poland
| | - Jakub Cieski
- Department of Radiology, CM UMK Bydgoszcz, Poland,
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