eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions

Heterotopic Ossification: Differential Diagnoses & Workup

Author: 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
Coauthor(s): John Speed, MBBS, Interim Chairman, Associate Professor, Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine
Contributor Information and Disclosures

Updated: May 22, 2008

Differential Diagnoses

Cellulitis
Osteomyelitis
Thrombophlebitis

Other Problems to Be Considered

Joint sepsis
Fracture
Hematoma
Early pressure sore (before skin breakdown is evident)
Local trauma

Workup

Laboratory Studies

  • Creatine kinase
    • This test is not specific for HO but is of value in determining the severity of muscle involvement and may be helpful in planning treatment of HO. Rossier and colleagues showed in 1973 that patients with an acute form of HO after SCI have elevated CK levels that correlate with histologic involvement of muscle.4 Two subsequent studies found CK to be useful in the diagnosis and management of HO. Singh and coauthors reported significantly higher CK levels in patients with HO.11 Data published by Sherman and colleagues indicated that a higher level of CK ultimately correlates with a more severe form of HO, suggesting more widespread involvement of surrounding muscle.12
    • These results are promising, because they indicate that CK may reliably predict a higher risk of HO development, can help to predict the severity of a patient's HO, and can be used to follow treatment success.
  • C-reactive protein
    • The initial stage of HO is manifested by a prominent inflammatory response. This acute reaction is accompanied by changes in levels of cytokines that stimulate the production of acute-phase proteins, one of these being C-reactive protein (CRP).
    • A study by Estrores and colleagues indicated that the serum concentration of CRP correlates better than does the erythrocyte sedimentation rate with the inflammatory activity of HO after SCI.13 In their study, the normalization of CRP in serum was accompanied by a resolution of the inflammation of soft tissue. It seems that administering nonsteroidal anti-inflammatory drugs (NSAIDs) in the early phase of HO, as well as monitoring the serum CRP level, may provide added benefit in reducing the inflammatory reaction that is proposed to be an important factor in HO's genesis.
  • Alkaline phosphatase
    • The AlkP level, once a commonly used test, is not often employed today.
    • In many patients, serum AlkP levels are not elevated in acute HO.
    • The elevation can be nonspecific because of associated skeletal injuries or the surgical treatment of fractures.
    • The serum AlkP level is of little value in determining the maturity of HO prior to surgical removal.

Imaging Studies

  • Bone scintigraphy14
    • Ideally, the use of diagnostic imaging should focus on the detection of nonmineralized HO, because the presently available medication, etidronate, can inhibit early mineralization.14 In this respect, bone scintigraphy and ultrasonography are recommended imaging studies for the early diagnosis of HO.
    • Bone scintigraphy is highly sensitive in the early diagnosis of HO. This is the most commonly used diagnostic study for HO.
    • Freed and colleagues evaluated the 3-phase bone scan in the detection of HO and found that a marked vascular blush and increased blood pool about the hips preceded the development of clinical HO by 2-4 weeks.15
    • The 3-phase bone scan using technetium-99m (99m Tc) diphosphonate is used in diagnosing and monitoring HO.
  • Ultrasonography - This is also used in the early diagnosis of HO about the hips. However, no data are available on the diagnostic value of ultrasonography in the diagnosis of HO in other joints (eg, knee, shoulder, elbow).
  • Radiography
    • While plain radiography is highly specific in the diagnosis of HO, this method lacks sensitivity in early diagnosis. Because soft-tissue calcification must occur for radiographic evidence of HO to be present, radiographs are not helpful in the early stages. Radiologic examinations do not show evidence of HO until a flocculent, patchy appearance develops, as calcium is deposited about 7-10 days after the onset of clinical symptoms.
    • This patchy appearance coalesces and enlarges on subsequent examinations, and by 2-3 months, the boundaries of the HO demarcate with the appearance of mature bone. Radiography, however, is not reliable at assessing the maturity of HO, because more mature areas may hide immature areas.
  • Computed tomography (CT) scanning and magnetic resonance imaging (MRI)
    • CT scanning and MRI may be useful in delineating local anatomy prior to resection.
    • The role of CT scanning and MRI in the evaluation of other aspects of HO has not been well established.

Other Tests

  • Biopsy
    • Biopsy has no role in the diagnosis of HO, but it has been considered as a means of helping to determine maturity.
    • There is a possible risk of inadequate sampling, because mature and immature HO may be intermixed.

More on Heterotopic Ossification

Overview: Heterotopic Ossification
Differential Diagnoses & Workup: Heterotopic Ossification
Treatment & Medication: Heterotopic Ossification
Follow-up: Heterotopic Ossification
References
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References

  1. Kaplan FS, Xu M, Glaser DL, et al. Early diagnosis of fibrodysplasia ossificans progressiva. Pediatrics. May 2008;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. May 2008;34(3):355-60. [Medline].

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

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

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

  6. 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. Aug 1995;33(8):464-8. [Medline].

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

  8. 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. Apr 10 2008;[Medline].

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

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

  11. 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. Nov 2003;84(11):1584-8. [Medline].

  12. 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].

  13. 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].

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

  15. 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. Aug 1982;20(4):208-16. [Medline].

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

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

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

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

  20. 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. Jan 28 2008;[Epub ahead of print]. [Medline].

  21. 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.

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

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Further Reading

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Keywords

paraosteoarthropathy, periarticular bone formation, neurogenic ossifying fibromyopathy, osteosis neurotica (ie, para-articularis), myositis ossificans circumscripta neurotica, myositis ossificans progressiva, fibrodysplasia ossificans progressiva, traumatic myositis ossificans, neurogenic heterotopic ossification

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

John Speed, MBBS, Interim Chairman, Associate Professor, Division of Physical Medicine and Rehabilitation, 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, and Utah Medical Association
Disclosure: Nothing to disclose.

Medical Editor

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, and American College of Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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