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Traumatic Heterotopic Ossification Treatment & Management

  • Author: John B Wood, MBBS, FRCS(Edin); Chief Editor: Harris Gellman, MD  more...
 
Updated: Sep 29, 2015
 

Surgical Therapy

Heterotopic ossification is seldom excised, because pain relief is often inadequate and improvement in range of motion may not last. In established cases of heterotopic ossification following total hip arthroplasty, excision may be performed. The results of this procedure are varied. Patients may find that their range of movement improves, but pain relief is likely to be limited.

After trauma to the elbow, surgical excision may be indicated on the basis of pain, nerve entrapment, and stiffness. In such cases, the surgical procedure may be beneficial in that associated contractures are released, and this release can be as important as removal of the heterotopic ossification. The timing of surgery is controversial. Heterotopic ossification is often thought to take approximately 12 months to mature; however, surgical treatment of posttraumatic heterotopic ossification at the elbow has been performed effectively at 3 and 6 months post trauma.[7]

The pearls for surgical treatment of heterotopic ossification are as follows:

  • Handle tissue carefully
  • Avoid excess bleeding
  • Achieve good hemostasis
  • Beware of lesions that span internervous tissue planes

Because removal of heterotopic ossification may involve substantial blood loss and excision may be incomplete, and because the risks of recurrence are high, surgeons attempting surgical removal of heterotopic ossification need to be familiar with the relevant surgical approaches to the affected region and to know how to enlarge and extend the wounds safely.

A definitive list of surgical contraindications to surgical excision of heterotopic ossification has not been established. However, excision should not be performed before the heterotopic ossification has matured, because incomplete and inadequate excision may result. Surgery on a joint that has wound sepsis or deep sepsis is contraindicated because the outcome is likely to be suboptimal. Because the outcome of surgery is unpredictable, the indications must be considered carefully. Pain relief cannot be predicted reliably after excision of heterotopic ossification as a complication of total hip arthroplasty, whereas better results for improved range-of-movement arcs are more likely.

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Activity

Depending on where the range of movement in the joints is impaired following arthroplasty as a result of heterotopic ossification, outpatient rehabilitation physiotherapy and hydrotherapy may be useful. The nature of the physiotherapy used for treatment is controversial. Forceful manipulation can be detrimental because the trauma involved can increase the heterotopic ossification development. Physiotherapy that involves passive and active elements to maintain and increase the range of movement in the affected joints can be beneficial.

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Prevention

Traumatic heterotopic ossification can be treated in a number of ways. In the case of iatrogenic surgical trauma, prevention of the formation of heterotopic ossification should be considered the index treatment. A number of risk factors can be considered important in the pathogenesis of types of acquired heterotopic ossification:

  • Trauma
  • Burns
  • Neurologic injury
  • Previous heterotopic ossification
  • Previous resection of heterotopic ossification
  • Hip and pelvic surgery
  • Previous hip surgery sepsis
  • Revision surgery
  • Reoperation upon an existing arthroplasty
  • Reimplantation following an excision arthroplasty
  • Male sex
  • Advanced age (>60 years)
  • Genetic predisposition (possible)

Furthermore, patients who have conditions such as diffuse idiopathic skeletal hyperostosis, Paget disease, a preexisting hip fusion, posttraumatic arthrosis, hypertrophic osteoarthritis, or ankylosing spondylitis may be more likely to develop heterotopic ossification as a complication of total hip arthroplasty. Children with cerebral palsy who undergo hip soft-tissue releases or spinal surgery are thought to have an increased risk of developing heterotopic ossification.

Risk factors that are related to surgical technique and therefore are potentially modifiable are as follows:

  • Prolonged surgery
  • Presence of pressure sores near the surgical field
  • Amount of bone resected
  • Amount of soft tissue dissected
  • Muscle ischemia
  • Tissue trauma
  • Bone trauma
  • Persistence of bone debris (reamings, marrow, or dust within the surgical field)
  • Prolonged soft-tissue retraction
  • Presence of devitalized tissue
  • Presence of hematoma
  • Postoperative wound infection
  • Prolonged postoperative wound drainage

Some case series have shown that factors such as the lateral approach to the hip, the use of cementless components, and the use of a trochanteric osteotomy may increase the risk of heterotopic ossification in total hip arthroplasty, but these factors for increased risk are by no means certain. A meta-analysis by Zhu et al identified the following as risk factors for heterotopic ossification after total hip arthroplasty[8] :

  • Male gender
  • Cemented implant
  • Bilateral operations
  • Ankylosing spondylitis
  • Ankylosed hip

A patient with heterotopic ossification following total hip arthroplasty is thought to have a 90-100% chance of developing it on the contralateral hip if this hip also undergoes total arthroplasty. Consequently, certain patients with preexisting risk factors could conceivably be regarded as high-risk and be treated with a more intensive prophylaxis regimen than the standard one, though this may not be practical. Nevertheless, it would be prudent to minimize the risk of heterotopic ossification developing after arthroplasty by performing surgery whereby the following are ensured:

  • Exposure is meticulous
  • Retraction is performed carefully and soft tissue is handled carefully
  • Irrigation is adequate
  • Devitalized tissue is excised
  • Hemostasis is adequate
  • Postoperative drains (when used) are not retained for longer than necessary
  • Perioperative antibiotic prophylaxis is used
  • Postoperative anticoagulation (when used for deep vein thrombosis prophylaxis) is carefully controlled

After procedures that may be complicated by heterotopic ossification, recommendations indicate that prophylaxis should be given in the form of nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, or aspirinlike drugs that act as nonspecific cyclooxygenase inhibitors.[9, 10] The duration of treatment is controversial. Some studies have shown that treatment should continue for 6 weeks after the procedure; others have suggested that it need only be continued for 20, 14, or 7 days after the procedure. Bisphosphonates are ineffective in the prophylaxis of heterotopic ossification.

An alternative or possible adjunct to cyclooxygenase inhibition is the use of localized irradiation.[11] However, clinical evidence suggests that localized irradiation is not better than indomethacin alone for heterotopic ossification prophylaxis following surgery of acetabular fractures. Some clinicians would advocate the use of adjuvant radiation therapy in the prophylaxis of heterotopic ossification in individuals considered to be at high risk (defined as a ≥50% chance) for this condition.

The irradiation protocol is controversial. Radiation therapy may be effective if given up to 24 hours preoperatively or within 72 hours postoperatively. However, it is unclear whether an optimal time to apply the treatment dose exists within these differing schedules. Randomized trials have shown that single fractions are as effective as multifraction schedules. Debate exists regarding the irradiation dosage. Some studies indicate that 7 Gy may be more effective than 5.5 Gy as a single dose; others recommend 8 Gy or 12 Gy doses as single fractions or multifraction regimens. The role of radiation therapy in heterotopic ossification prophylaxis is not fully defined, and because its logistic availability is limited, its use will continue to be selective rather than widespread.

Pakos et al evaluated the efficacy of combined radiotherapy and indomethacin against that of indomethacin alone for prevention of heterotopic ossification after hip arthroplasty in 96 patients, who received either a single dose of postoperative radiotherapy of 7.0 Gy and indomethacin for the first 15 postoperative days or indomethacin alone for the same period.[12] A historical group of 50 patients who received indomethacin alone served as the control group.

In this study, four patients in the combined-therapy group developed heterotopic ossification, compared with 13 patients in the indomethacin group and 13 patients in the control group.[12] One patient in the combined-therapy group and one in the control group developed Brooker III heterotopic ossification. Duration of surgery and congenital hip disease were associated with heterotopic ossification development in the indomethacin groups; in the combined-therapy group, age and congenital hip disease were associated with heterotopic ossification.

Prophylaxis using NSAIDs may be complicated by the adverse effects of these drugs. Radiation therapy complications may also occur if this approach is used for prophylaxis. However, the exact incidence of these complications is not known. Long-term follow-up studies to detect late complications are lacking. A case-control analysis by Sheybani did not demonstrate any increase in the risk of radiation-induced malignancy in patients who received radiation therapy as prophylaxis for heterotopic ossification.[13]

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Contributor Information and Disclosures
Author

John B Wood, MBBS, FRCS(Edin) FRCS(Tr & Orth), FEBOT, Dip Sports Med (UNSW) Consultant Surgeon, Department of Trauma and Orthopedic Surgery, University Hospital Lewisham, London,UK

John B Wood, MBBS, FRCS(Edin) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, British Medical Association, Royal Society of Medicine, British Orthopaedic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Richard Hargrove, MBBS, FRCS(Ire), FRCS Consulting Staff, Hip and Hip Revision Arthroplasty, Frimley Park Hospital

Richard Hargrove, MBBS, FRCS(Ire), FRCS is a member of the following medical societies: Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ian D Dickey, MD, FRCSC Adjunct Professor, Department of Chemical and Biological Engineering, University of Maine; Consulting Staff, Adult Reconstruction, Orthopedic Oncology, Department of Orthopedics, Eastern Maine Medical Center

Ian D Dickey, MD, FRCSC is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Royal College of Physicians and Surgeons of Canada, British Columbia Medical Association, Canadian Medical Association

Disclosure: Received consulting fee from Stryker Orthopaedics for consulting; Received honoraria from Cadence for speaking and teaching; Received grant/research funds from Wright Medical for research; Received honoraria from Angiotech for speaking and teaching; Received honoraria from Ferring for speaking and teaching.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Miguel A Schmitz, MD 

Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, North American Spine Society

Disclosure: Nothing to disclose.

Chris McLean, MRCS, MBBS, AFRCS(Ire) Specialist Registrar, Departments of Orthopedic and Trauma Surgery, Frimley Park Hospital, UK

Chris McLean, MRCS, MBBS, AFRCS(Ire) is a member of the following medical societies: British Medical Association

Disclosure: Nothing to disclose.

References
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Brooker I heterotopic ossification associated with an uncemented total hip arthroplasty.
Brooker I heterotopic ossification associated with a cemented total hip replacement that has undergone acetabular component augmentation and fixation of the greater trochanter.
Brooker II heterotopic ossification associated with a right cemented total hip replacement. On the left side, an uncemented total hip arthroplasty is present with no heterotopic ossification.
Brooker III heterotopic ossification associated with a left uncemented total hip arthroplasty.
Brooker I heterotopic ossification associated with a revision hip arthroplasty.
Brooker II heterotopic ossification associated with a right revision hip arthroplasty.
Brooker I heterotopic ossification associated with bilateral revision hip arthroplasties.
 
 
 
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