Heterotopic Ossification Treatment & Management
- Author: John Speed, MBBS; Chief Editor: Consuelo T Lorenzo, MD more...
The use of physical therapy (PT) in HO has long been controversial. Rossier and co-investigators noted occasional transverse microfractures on sections of HO that they thought might be caused by spasticity or by overly aggressive PROM. Since then, the debate between resting the joint and aggressive PROM has continued. In the literature, however, the developing consensus appears to be that aggressive PROM and continued mobilization, once acute inflammatory signs have subsided, are indicated, because they help to maintain ROM and (in more extensive HO) they may lead to the formation of a pseudarthrosis. Resting the joint appears more likely to lead to decreased ROM or to ankylosis.
During the acute inflammatory stage, the patient should rest the involved joint in a functional position, and the physical therapist should initiate gentle PROM as soon as possible. The role of continuous PROM machines has not been studied in this situation. For patients with incomplete SCI or head injuries, maintaining ROM may be difficult because of pain from ROM exercises. The use of joint manipulation has been reported in patients with HO who, because of limited joint ROM, have functional limitations. However, such manipulation is controversial owing to the risk of the formation of new hematoma and because of the chance that long-bone fracture will occur in patients with secondary osteoporosis.
Nonarticular complications of HO are rare, but they have been reported. These complications include ulnar nerve compression with HO at the elbow, vascular (predominantly venous) compression with or without associated deep venous thrombosis (DVT), and lymphatic obstruction leading to lymphedema.[23, 24]
Although no effective protocol had previously been developed for preventing HO after SCI, the authors' studies, based on the well-documented beneficial effect of NSAIDs in the prevention of HO after total hip arthroplasty, showed that the following drugs can also be helpful in reducing the incidence and severity of HO after SCI:[13, 25, 26, 27, 28]
- The nonselective NSAID indomethacin SR prescribed for 3 weeks in a dose of 75 mg/d, after SCI, reduced the incidence of HO by 2-3 times.
- A 25 mg/d prescription of the selective COX-2 inhibitor rofecoxib decreased the risk of HO formation by 2.5 times.
These positive results with NSAIDs in the prevention of HO may be an important step forward in the clinical management of this condition.
Once HO has developed to the point that it interferes significantly with the functional capacity of the patient, the only treatment option remaining is surgery, which most commonly is required at the hip. Ensure that the HO has reached maturity before resection, because resection of immature HO leads to recurrence rates of nearly 100% (although a study by Gen ê t et al disagrees with this assertion, suggesting instead that early excision [< 6 mo] of the ossification does not affect recurrence ). Hemorrhage may be a significant problem at the time of surgery, with an average blood loss of 2100 mL reported. Postsurgical infection may lead to amputation; therefore, great care must be taken at the time of surgery. Initiate a presurgery program to eliminate any possible nidus of bacteremia or infections (eg, decubitus ulcers, urinary tract infections).
The usual surgical technique used on HO occurring anteriorly at the hip is anterior wedge resection. Postoperatively, position the joint properly with foam wedges so that the surgical correction can be maintained and any strain on the incision or pressure sores can be prevented. Start gentle PROM about 72 hours postoperation, and increase therapy intensity gradually to incorporate retraining in functional activities. Patient selection and careful identification of functional goals are critical for successful surgical intervention.
Consultation with an orthopedist is necessary for any consideration of surgical management of HO.
See the list below:
- Radiation therapy[4, 30, 31]
- Radiation therapy has been studied mostly in connection with the prevention of HO in patients at high risk for recurrence following hip arthroplasty.
- The most common use in the rehabilitation setting is for the prevention of postoperative recurrence, but the optimal dosage, frequency, and timing have not been established.
- Mesenchymal stem cells that may be in muscle and that transform into bone-forming cells are highly radiosensitive. Little is known of radiation therapy's effect on HO after SCI when it is used as a primary treatment. One reason that radiation therapy has not been established as a treatment for HO is a risk of local induction of malignancy. However, radiation has been used in Europe by Sautter-Bihl and colleagues as a primary treatment for early HO after SCI; no adverse effects were noted.
Kaplan FS, Xu M, Glaser DL, et al. Early diagnosis of fibrodysplasia ossificans progressiva. Pediatrics. 2008 May. 121(5):e1295-300. [Medline].
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].
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].
Subbarao JV, Garrison SJ. Heterotopic ossification: diagnosis and management, current concepts and controversies. J Spinal Cord Med. 1999 Winter. 22(4):273-83. [Medline].
Pathophysiology of heterotopic ossification. Orthop Nurs. 2013 May-Jun. 32(3):178-9. [Medline].
Zychowicz ME. Pathophysiology of heterotopic ossification. Orthop Nurs. 2013 May-Jun. 32(3):173-7. [Medline].
Rossier AB, Bussat P, Infante F, et al. Current facts of para-osteo-arthropathy (POA). Paraplegia. 1973 May. 11(1):38-78. [Medline].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Choi WJ, Lee JW. Heterotopic ossification after total ankle arthroplasty. J Bone Joint Surg Br. 2011 Nov. 93(11):1508-12. [Medline].
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].
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].
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].
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].
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].
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.
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].