Current Therapy in the Management of Heterotopic Ossification of the Elbow

Ellerin, Bruce E.; Helfet, David L.; Parikh, Suhrid; Hotchkiss, Robert N.; Levin, Nancy; Nisce, Lourdes Z.; Nori, Dattatreyudu; Moni, Janaki

doi:10.1097/00002060-199905000-00016

Cited by 71 publications

(45 citation statements)

References 23 publications

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“…Initial reports found indomethacin to be effective in preventing clinically important HO, which has been defined as Brooker Classes III and IV HO [4], although more recent prospective studies have found increased risk of posterior wall nonunion and no change in rates of clinically important HO [22]. Radiotherapy prevents abnormal formation of bone by inhibiting the differentiation of mesenchymal stem cells to osteogenic pathways [8,19]. Although radiotherapy has been shown to be effective in numerous studies, the potential risk of malignant transformation and wound complications must be considered [1,4,9,17].…”

Section: Introductionmentioning

confidence: 99%

Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture?

Davis¹,

Roper²,

Munz³

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Controversy regarding heterotopic ossification (HO) prophylaxis exists after Kocher-Langenbeck for treatment of acetabular fracture. Prophylaxis options include antiinflammatory oral medications, single-dose radiation therapy, and débridement of gluteus minimus muscle. Prior literature has suggested single-dose radiation therapy as the best prophylaxis to prevent HO fo'rmation. However, recent reports have emerged of radiation-induced sarcoma after radiotherapy for HO prophylaxis, which has led many surgeons to reconsider the risks and benefits of single-dose radiation therapy. We set out to determine if radiotherapy, in addition to standard débridement of gluteus minimus muscle, affected postoperative HO formation after a Kocher-Langenbeck approach for acetabular fracture. Questions/purposes (1) After the Kocher-Langenbeck approach and gluteus minimus débridement, is single-dose radiotherapy associated with a decreased risk of HO? (2) Does addition of single-dose radiotherapy prolong length of stay after a Kocher-Langenbeck approach and gluteus minimus débridement as compared with patients without radiotherapy? Methods After institutional review board approval, all adult patients treated for acetabular fracture by a single surgeon with a Kocher-Langenbeck approach between August 2011 and October 2014 were identified (n = 60). Débridement of gluteus minimus muscle caudal to the superior gluteal bundle was standard in all patients. Radiotherapy was given with a single dose of 700 cGy within 72 hours of surgery from August 2011 until April 2013. Patients treated subsequently did not receive radiotherapy. Patients treated with indomethacin (n = 1) and with fewer than 10 weeks followup were excluded (n = 12) because several studies suggest that most HO that develops is visible by that point in time. Our study group totaled 46 patients with 24 in the radiotherapy and débridement group and 22 in the débridement group. Charts were reviewed to determine length of stay. Attending orthopaedic trauma surgeons who were blinded to the patient's treatment group graded all followup radiographs according to the Brooker system, and Classes III and IV HO were considered clinically important Fisher's exact test was used to analyze clinically significant differences HO between the two groups. Length of stay was compared using a t-test. Results Single-dose radiotherapy is associated with a decreased risk of clinically important (Brooker III-IV) HO Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research 1 neither advocates nor endorses the use of any trea...

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Section: Introductionmentioning

confidence: 99%

Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture?

Davis¹,

Roper²,

Munz³

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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“…At the same time, measures should be taken to prevent recurrence. In addition, pre-and postoperative medication and radiation are helpful in reducing the recurrence of the heterotopic bone [15].…”

Section: Discussionmentioning

confidence: 99%

Treatment and Rehabilitation of Knee Joints Straight Stiffness After Burns

Tang

et al. 2014

Indian J Surg

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The knee release surgery and postoperative rehabilitation of patients after burns and knee straight stiffness were investigated. Eleven patients were treated for 16 side burns and knee stiffness who consisted of nine males and two females, aged 19 to 54 years (mean=33.2). The duration of the patients' knee stiffness ranged from 8 to 26 months, with an average of 12.6 months. Their preoperative flexion ranged from 5°to 50°, with an average of 26.2°. Their preoperative Hospital for Special Surgery (HSS) knee scores ranged from 46 to 72 points, with an average of 55.8 points. All stiff knees were treated with release surgery, along with total release of intra-articular adhesion and excision of vastus intermedius. After the arthrolysis of the stiff knee joint, the tight skin was completely loose in the adhesions. The soft tissue contracture was not grafted, but the shade fascia was freed to increase skin ductility. All knee joints were released to more than 90°of flexion in the operation, and reversed fascia flaps were used to suture the loss of the deep fascia at the position of flexion of 90°. After the operation, the knee joint was fixed in flexion for 72 h while being actively cared for by early rehabilitation. Subsequently, the patient's skin coverage, joint motion, and joint function recovery were observed. Based on the followup of the patients for the following 16 to 36 months (mean= 25.7), the knee flexion of the patients ranged from 110°to 135°, with an average of 122.2°and 96°increase (P<0.01). Furthermore, the patients had better skin ductility to meet the increase in joint flexion. HSS knee function scores at the end of follow-up ranged from 93 to 100 points, with an average of 97.5 points and an increase of 41.7 points (P<0.01). The joint function improved significantly. The arthrolysis of straight stiff knee joints after burns can ease muscle contracture and free the shade fascia, thus avoiding the need to undergo skin grafting. Short-term fixation of the joints after surgery and active flexion rehabilitation may also be the key to improve skin ductility and joint function of the patients.

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“…They are purported to act through a combination of factors such as delaying apatite crystal aggregation, inhibiting calcium phosphate precipitation and reducing the conversion of calcium phosphate into hydroxyapatite (9). Previous studies (10,11) have shown that bisphosphonate therapy can slow the progression of HO and ultimately result in smaller lesions, although long-term outcomes were not documented.…”

Section: Discussionmentioning

confidence: 99%

Management of pelvic heterotopic ossification post-myocutaneous flap reconstruction of a sacral pressure ulcer

2011

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A 16-year-old Caucasian boy with a diagnosis of spinal dysraphism at the L5 level presented with a two-month history of a recurrent right ischial pressure ulcer. His surgical history included debridement and flap reconstruction of previous sacral and right ischial ulcers. On physical examination, a stage IV pressure ulcer was present overlying the right ischium in the setting of local postsurgical scarring. Computed tomography confirmed right ischial osteomyelitis. The patient was treated with wide surgical debridement of the involved soft tissues, ostectomy of the right ischial tuberosity and right gluteus maximus myocutaneous flap reconstruction, with postoperative care in the prone and lateral positions. Three months postoperatively, the patient complained of limited hip mobility; a plain pelvis radiograph confirmed bilateral heterotopic ossification (HO) of the iliac crests to the femurs (Figure 1). The patient was subsequently treated with a six-month course of aggressive physical therapy (twice a day treatment sessions) and oral bisphosphonate (etidronate 20 mg/kg three times a day), which resulted in significant clinical and radiographic improvement of bilateral hip range of motion (Figure 2). DisCUssionHO has traditionally been a challenging diagnosis to successfully treat. Surgical excision has been described as the treatment of choice for symptomatic HO (1,2). As with all invasive surgical procedures, there is a risk of infection and blood loss (1), a considerable rehabilitation process and accumulation of scar tissue. Furthermore, due to the high recurrence rates, if surgical resection is performed on an immature lesion, treatment is often delayed for months before operative intervention is performed on mature lesions (3).Another option is radiation treatment, which can be used for both therapeutic and prophylactic purposes in HO (4-6). The therapeutic use of radiation therapy in established HO was first described by Schaeffer and Sosner (5) in 1995, who found that giving a 2 gray dose of radiation for several consecutive days resulted in improved range of motion. For prophylactic therapy, a single dose of 700 centigray administered within 48 h postoperatively is effective at reducing the recurrence rate of HO (7). Side effects of radiation therapy are common and present an obvious limitation to this treatment modality. An alternative postoperative prophylactic option is a course of a nonsteroidal anti-inflammatory Heterotopic ossification (HO) is a process whereby lamellar bone forms in the soft tissues surrounding a joint. The most common type of HO is traumatic myositis ossificans, which develops following traumatic injuries, burns or arthroplasty. A variety of other forms of HO also exist, such as those associated with central nervous system injury and systemic forms that can manifest at other joints simultaneously. Clinically, patients can present with decreased range of motion, pressure ulcers, nerve compression, swelling, pain or asymptomatically. Symptomatic patients are most commonly treated ...

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Current Therapy in the Management of Heterotopic Ossification of the Elbow

Cited by 71 publications

References 23 publications

Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture?

Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture?

Treatment and Rehabilitation of Knee Joints Straight Stiffness After Burns

Management of pelvic heterotopic ossification post-myocutaneous flap reconstruction of a sacral pressure ulcer

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