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Heterotopic Ossification Clinical Presentation

  • Author: John Speed, MBBS; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Apr 02, 2015
 

History

See the list below:

  • The onset of HO usually is 1-4 months after injury in SCI patients, although it may occur as early as 19 days or as late as 1 year following injury.
  • The condition may occur later with other precipitating circumstances (eg, fracture, surgery, severe systemic illness).[12, 13, 14]
  • Not uncommonly, incidental HO that was not noted clinically may be detected much later on radiographs.
  • HO always occurs below the level of injury in SCI patients, and most authors agree that there is no relation to presence or absence of spasticity in SCI patients.
  • HO tends to occur more frequently with complete injuries.
  • In SCI patients with HO, the hips are most commonly involved.
    • At the hip, the flexors and abductors tend to be involved more frequently than are the extensors or adductors.
    • At the knee, the medial aspect is most commonly affected by HO.
    • Shoulders and elbows are the most commonly affected upper extremity joints.
    • One report in the literature notes involvement of the metacarpophalangeal joints of the hand.
    • The lumbar paravertebral region also has been mentioned as an infrequent site.
  • In patients who have sustained head injury or stroke, the story is a bit different. HO almost always occurs on the affected side, and most authors have noted that HO is more frequent in patients with spasticity than in those without it.
    • Garland and colleagues studied 496 patients with severe head injuries.[15] Clinically significant HO, causing pain and decreased ROM, was noted in 100 joints in 57 patients. Of the 100 involved joints, 89 were in spastic extremities. The frequency of involvement of different joints was slightly different than it was in patients with SCI; the hips were most commonly involved (44), followed by the shoulders (27) and elbows (26). HO was detected in only 3 knee joints.
    • Spielman also looked at the occurrence of HO in patients with head injuries. In that study, the inclusion criteria were (1) initial Glasgow Coma Scale score of 8 or less and (2) coma lasting more than 2 weeks. All patients had passive range of motion (PROM) of unknown frequency. Once again, HO was more common in the limbs of patients with severe spasticity. Prolonged coma also appeared to increase the likelihood of HO development.
  • In patients with neurologic deficits, increased limb spasticity, decreased joint ROM, and inflammatory signs near a joint strongly suggest the possibility of HO.
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Physical

See the list below:

  • A diagnosis of HO can be made clinically if localized inflammatory reaction, palpable mass, or limited ROM is observed.
  • Clinically, the onset of larger masses of HO is often characteristic of any inflammatory reaction.
  • Fairly suddenly, a warm and swollen extremity becomes obvious, and fever is present.
  • If sensation is intact, the area of swelling is painful.
    • The swelling usually is localized more than it is in thrombophlebitis, and within several days, a more circumscribed, firmer mass is palpable within the edematous area.
    • If the mass is adjacent to a joint, gradual loss of PROM may follow.
  • With the development of early HO at the hip or knee, effusion may be noted at the knee.
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Causes

See Pathophysiology.

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Contributor Information and Disclosures
Author

John Speed, MBBS Professor (Clinical), Division of Physical Medicine & Rehabilitation, Adjunct Associate Professor, Department of Physical Therapy, Adjunct Professor, NursingDirector, Traumatic Brain Injury Rehabilitation, Medical Director, Inpatient Rehabilitation Unit, University of Utah School of Medicine

John Speed, MBBS is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Pain Society, Association of Academic Physiatrists, International Association for the Study of Pain, International Society of Physical and Rehabilitation Medicine, Utah Medical Association

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.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear ($1,500).

Acknowledgements

Kresimir Banovac, MD, PhD Professor, Departments of Rehabilitation Medicine and Medicine, Associate Vice Chairman, Department of Rehabilitation Science, University of Miami Miller School of Medicine; Medical Director, Spinal Cord Injury Rehabilitation Unit, Jackson Memorial Medical Center

Kresimir Banovac, MD, PhD is a member of the following medical societies: American Spinal Injury Association

Disclosure: Nothing to disclose.

References
  1. Kaplan FS, Xu M, Glaser DL, et al. Early diagnosis of fibrodysplasia ossificans progressiva. Pediatrics. 2008 May. 121(5):e1295-300. [Medline].

  2. Shafer DM, Bay C, Caruso DM, et al. The use of eidronate disodium in the prevention of heterotopic ossification in burn patients. Burns. 2008 May. 34(3):355-60. [Medline].

  3. Peterson JR, De La Rosa S, Sun H, Eboda O, Cilwa KE, Donneys A, et al. Burn Injury Enhances Bone Formation in Heterotopic Ossification Model. Ann Surg. 2013 May 12. [Medline].

  4. Subbarao JV, Garrison SJ. Heterotopic ossification: diagnosis and management, current concepts and controversies. J Spinal Cord Med. 1999 Winter. 22(4):273-83. [Medline].

  5. Pathophysiology of heterotopic ossification. Orthop Nurs. 2013 May-Jun. 32(3):178-9. [Medline].

  6. Zychowicz ME. Pathophysiology of heterotopic ossification. Orthop Nurs. 2013 May-Jun. 32(3):173-7. [Medline].

  7. Rossier AB, Bussat P, Infante F, et al. Current facts of para-osteo-arthropathy (POA). Paraplegia. 1973 May. 11(1):38-78. [Medline].

  8. Wilson KW, Dickens JF, Heckert R, Tintle SM, Keeling JJ, Andersen RC, et al. Heterotopic ossification resection after open periarticular combat-related elbow fractures. J Surg Orthop Adv. 2013 Spring. 22(1):30-5. [Medline].

  9. Bodley R, Jamous A, Short D. Ultrasound in the early diagnosis of heterotopic ossification in patients with spinal injuries. Paraplegia. 1993 Aug. 31(8):500-6. [Medline].

  10. Snoecx M, De Muynck M, Van Laere M. Association between muscle trauma and heterotopic ossification in spinal cord injured patients: reflections on their causal relationship and the diagnostic value of ultrasonography. Paraplegia. 1995 Aug. 33(8):464-8. [Medline].

  11. Hassard GH. Heterotopic bone formation about the hip and unilateral decubitus ulcers in spinal cord injury. Arch Phys Med Rehabil. 1975 Aug. 56(8):355-8. [Medline].

  12. Downing MR, Knox D, Gibson P, et al. Impact of trochanteric heterotopic ossification on measurement of femoral bone density following cemented total hip replacement. J Orthop Res. 2008 Apr 10. [Medline].

  13. Macfarlane RJ, Ng BH, Gamie Z, et al. Pharmacological treatment of heterotopic ossification following hip and acetabular surgery. Expert Opin Pharmacother. 2008 Apr. 9(5):767-86. [Medline].

  14. Foruria AM, Augustin S, Morrey BF, Sánchez-Sotelo J. Heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna. J Bone Joint Surg Am. 2013 May 15. 95(10):e661-7. [Medline].

  15. Garland DE, Blum CE, Waters RL. Periarticular heterotopic ossification in head-injured adults. Incidence and location. J Bone Joint Surg Am. 1980 Oct. 62(7):1143-6. [Medline].

  16. Singh RS, Craig MC, Katholi CR, et al. The predictive value of creatine phosphokinase and alkaline phosphatase in identification of heterotopic ossification in patients after spinal cord injury. Arch Phys Med Rehabil. 2003 Nov. 84(11):1584-8. [Medline].

  17. Sherman AL, Williams J, Patrick L, et al. The value of serum creatine kinase in early diagnosis of heterotopic ossification. J Spinal Cord Med. 2003. 26(3):227-30. [Medline].

  18. Estrores IM, Harrington A, Banovac K. C-reactive protein and erythrocyte sedimentation rate in patients with heterotopic ossification after spinal cord injury. J Spinal Cord Med. 2004. 27(5):434-7. [Medline].

  19. Banovac K. The effect of etidronate on late development of heterotopic ossification after spinal cord injury. J Spinal Cord Med. 2000 Spring. 23(1):40-4. [Medline].

  20. Freed JH, Hahn H, Menter R, et al. The use of the three-phase bone scan in the early diagnosis of heterotopic ossification (HO) and in the evaluation of Didronel therapy. Paraplegia. 1982 Aug. 20(4):208-16. [Medline].

  21. Bachman DR, Kamaci S, Thaveepunsan S, et al. Preoperative nerve imaging using computed tomography in patients with heterotopic ossification of the elbow. J Shoulder Elbow Surg. 2015 Mar 11. [Medline].

  22. Lindeque BG, Fleming ME, Waterman SS, Lewandowski LR, Chi BB. Use of 3-dimensional stereolithographic polymer models for heterotopic ossification surgical excision. Orthopedics. 2013 Apr 1. 36(4):282-6. [Medline].

  23. Bradleigh LH, Perkash A, Linder SH, et al. Deep venous thrombosis associated with heterotopic ossification. Arch Phys Med Rehabil. 1992 Mar. 73(3):293-4. [Medline].

  24. Varghese G, Williams K, Desmet A, et al. Nonarticular complication of heterotopic ossification: a clinical review. Arch Phys Med Rehabil. 1991 Nov. 72(12):1009-13. [Medline].

  25. Banovac K, Williams JM, Patrick LD, et al. Prevention of heterotopic ossification after spinal cord injury with indomethacin. Spinal Cord. 2001 Jul. 39(7):370-4. [Medline].

  26. Banovac K, Williams JM, Patrick LD, et al. Prevention of heterotopic ossification after spinal cord injury with COX-2 selective inhibitor (rofecoxib). Spinal Cord. 2004 Dec. 42(12):707-10. [Medline].

  27. Choi WJ, Lee JW. Heterotopic ossification after total ankle arthroplasty. J Bone Joint Surg Br. 2011 Nov. 93(11):1508-12. [Medline].

  28. Klaassen MA, Pietrzak WS. Platelet-rich plasma application and heterotopic bone formation following total hip arthroplasty. J Invest Surg. 2011. 24(6):257-61. [Medline].

  29. Genet F, Ruet A, Almangour W, et al. Beliefs relating to recurrence of heterotopic ossification following excision in patients with spinal cord injury: a review. Spinal Cord. 2015 Feb 17. [Medline].

  30. Strauss JB, Chen SS, Shah AP, et al. Cost of radiotherapy versus NSAID administration for prevention of heterotopic ossification after total hip arthroplasty. Int J Radiat Oncol Biol Phys. 2008 Jan 28. [Epub ahead of print]. [Medline].

  31. Strauss JB, Wysocki RW, Shah A, Chen SS, Shah AP, Abrams RA, et al. Radiation therapy for heterotopic ossification prophylaxis afer high-risk elbow surgery. Am J Orthop (Belle Mead NJ). 2011 Aug. 40(8):400-5. [Medline].

  32. Hoff P, Rakow A, Gaber T, Hahne M, Sentürk U, Strehl C, et al. Preoperative irradiation for the prevention of heterotopic ossification induces local inflammation in humans. Bone. 2013 Apr 6. [Medline].

  33. Sautter-Bihl ML, Liebermeister E, Nanassy A. Radiotherapy as a local treatment option for heterotopic ossifications in patients with spinal cord injury. Spinal Cord. Jan 2000. 38(1):33-6.

  34. Banovac K, Gonzalez F, Renfree KJ. Treatment of heterotopic ossification after spinal cord injury. J Spinal Cord Med. 1997 Jan. 20(1):60-5. [Medline].

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