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

Heterotopic Ossification: Follow-up

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

Follow-up

Further Inpatient Care

  • Patients with advanced HO who undergo surgical intervention generally require hospitalization and further inpatient care. For a discussion of care following anterior hip resection surgery, see Surgical Intervention.

Further Outpatient Care

  • Monitoring of HO maturation
    • Monitoring of HO maturation should be performed regularly.
    • In patients with functional limitations for whom surgery is a consideration, radiography should be performed every 4-6 months.
    • CT scanning and MRI may offer more precise delineation of ectopic bone, which may be helpful in preoperative planning.

Deterrence

  • As previously stated, the prophylactic use of medications to prevent HO has been studied in individuals with SCI, with promising outcomes.18,19 NSAIDs do have a role in the prevention of HO and in the prevention of postoperative recurrence after the excision of HO. Radiation therapy also may be used to prevent recurrence postoperatively in some patients.3

Complications

  • Potential complications associated with surgical intervention in patients with HO include hemorrhage and postsurgical infections (see Surgical Intervention).
  • HO in patients with SCI may lead to other complications, such as pressure sores and DVT.16,17

Prognosis

  • Approximately 20-30% of patients with SCI develop clinically evident HO, and 3-8% of them develop severe functional limitations.

Patient Education

  • Patient and family education is an important part of the treatment process in individuals with HO. Physical therapists may instruct patients and family members, if needed, to complete ROM exercises as instructed by the physician. Patients should also be taught to watch for signs of other potential complications when dealing with heterotopic ossification (in order, for example, to prevent pressure sores in patients with SCI).

Miscellaneous

Medicolegal Pitfalls

  • Careful consideration of the differential diagnosis of the swollen limb and appropriate imaging studies clarify the diagnosis.
  • No general standard of care has been agreed on for prophylaxis of HO except in the postoperative setting.
 


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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