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

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 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. All of the authors are employees of the US Government and this work was prepared as part of their official duties. As such, there is no copyright to transfer. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, nor the US Government. Nothing in the presentation implies any Federal/Department of Defense/Department of the Navy endorsement. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. This work was performed at Walter Reed National Military Medical Center, Bethesda, MD, USA. Conclusions HO is common after combat-related amputations, and patients undergoing surgical excisio...

Treatments and Preventative Measures for Trauma‐Induced Heterotopic Ossification: A Review

“…Excision of ectopic bone is required in approximately 20–41% of combat‐related amputees who have developed HO 22. This can be done as early as 6–8 months post‐injury without risk of recurrence in some cases 12.…”

“…This can be done as early as 6–8 months post‐injury without risk of recurrence in some cases 12. Excision of ectopic bone is not without complications, however, and may include severe blood loss, infection, postoperative pain management, rehabilitation obstacles, and recurrence 22. Unfortunately, the risk of infection increases after resection as ectopic bone excised from a patient with HO has been found to be highly vascularized despite its nontraditional placement and origin 43…”

“…In a recent retrospective study examining the symptomatic or radiographic recurrence rate of both partially and fully excised HO before or after 180 days post‐injury, a higher risk of recurrence was reported if HO was removed prior to 180 days. Likewise, partial excision was correlated with a higher likelihood of radiographic recurrence and higher potential for re‐excision as compared with full excision patients 22. Additionally, several studies have also documented the rate of recurrence after HO excision at the joints following traumatic brain injury (TBI) but the results have been inconsistent in magnitude and timing 54, 55, 56, 57, 58, 59, 60, 61, 62.…”

“…However, priority in theater is placed on life‐saving practices 15. Several NSAIDs are commonly used, including ketorolac, ibuprofen, celecoxib, and indomethacin; however, these are not without complications, including hemorrhage, gastritis, and patient noncompliance 22, 27. Although the use of systemic NSAIDs has been shown to reduce inflammation and the risk for HO manifestation and proliferation, they have garnered notoriety for their propensity to impede fracture healing, especially with the use of indomethacin 64, 65, 66, 67.…”

“…It does so by interfering with and suppressing mesenchymal‐cell progression to osteogenic cells 15, 22, 68. Preoperatively, RT delivery has shown varied reports of effectiveness 2.…”