Heterotopic bone formation following total shoulder arthroplasty

The incidence and location of heterotopic bone formation following total shoulder arthroplasty were evaluated in 58 Neer Mark-II total shoulder replacements. One year after surgery, 45% had developed some ectopic ossification. In six shoulders (10%) the ossifications roentgenographically bridged the glenohumeral and/or the glenoacromial space. There was no correlation between shoulder pain and the development of ossification. Shoulders with grade III heterotopic bone formation had a limited range of active elevation compared with shoulders without or with only a milder lesion. Men and patients with osteoarthritis of the shoulder joint were significantly disposed to the development of heterotopic bone. Heterotopic bone formation following total shoulder arthroplasty is frequent, but disabling heterotopic ossifications seem to be rare.     

Heterotopic bone formation following hip arthroplasty: A retrospective study of 65 bilateral cases

Heterotopic bone formation after two-stage bilateral cemented total hip arthroplasty was evaluated in 65 patients (23 women and 42 men) who had not received treatment with anti-inflammatory drugs in the immediate postoperative weeks. The mean age at the first operation was 65 years, and the median interval between the two arthroplasties was 3 months. Fifty-two patients developed heterotopic ossification after the initial hip arthroplasty. Of these patients, 40 also developed ossifications after contralateral hip arthroplasty. Out of 11 males developing Grade-III heterotopic ossification after the initial hip arthroplasty, 8 also developed Grade-III ossification after contralateral hip arthroplasty. Two females developed Grade-III ossification after the initial arthroplasty, but neither of them developed a Grade-III lesion after contralateral total hip arthroplasty. Males with Grade-III heterotopic ossification after the initial hip arthroplasty were shown to be at a high risk of developing the same severe lesion after contralateral total hip arthroplasty, making them candidates for postoperative prophylaxis.     

Heterotopic bone formation following hip arthroplasty. A retrospective study of 65 bilateral cases

Heterotopic bone formation after two-stage bilateral cemented total hip arthroplasty was evaluated in 65 patients (23 women and 42 men) who had not received treatment with antiinflammatory drugs in the immediate postoperative weeks. The mean age at the first operation was 65 years, and the median interval between the two arthroplasties was 3 months. Fifty-two patients developed heterotopic ossification after the initial hip arthroplasty. Of these patients, 40 also developed ossifications after contralateral hip arthroplasty. Out of 11 males developing Grade-III heterotopic ossification after the initial hip arthroplasty, 8 also developed Grade-III ossification after contralateral hip arthroplasty. Two females developed Grade-III ossification after the initial arthroplasty, but neither of them developed a Grade-III lesion after contralateral total hip arthroplasty. Males with Grade-III heterotopic ossification after the initial hip arthroplasty were shown to be at a high risk of developing the same severe lesion after contralateral total hip arthroplasty, making them candidates for postoperative prophylaxis.     

Periarticular heterotopic ossification after total hip arthroplasty. Risk factors and consequences

The formation of periarticular heterotopic bone after total hip arthroplasty is a frequent complication. The reported occurrences concerning this complication vary considerably in different reports, ranging from 15% to 90% with significant amounts in 1%-27% of the cases. Heterotopic ossification (HO) starts with the surgical operation, and the extent is well delineated on roentgenograms after six to 12 weeks. The amount of bone varies from small islands in the soft tissue to widespread bridging ossification. The cause of HO seems to be mainly related to systemic factors and is chiefly dependent on gender, diagnosis, and concurrent antiinflammatory medication. Patients at risk seem to be those with HO after a previous surgical operation, patients suffering from certain types of ankylosing spondylitis, otherwise healthy men with osteoarthrosis, patients with hypertrophic osteoarthrosis, and patients operated upon for fresh fractures or other posttraumatic conditions. The surgical technique and the local tissue trauma probably moderate both the occurrence and amount of HO. HO does not seem to cause pain or to decrease hip muscle strength but does limit hip mobility in cases with significant amount of ossification.     

Development of heterotopic ossification around the hip. A long-term follow-up of patients who underwent surgery with two different types of endoprostheses

Heterotopic ossification has been reported in many pathological situations, most important clinically as a sequel to hip arthroplasty and spinal trauma. The etiology of heterotopic ossification is yet not clear, but the disease is supposed to be connected with trauma. Heterotopic bone was found in 53% (1.2% with the severe form) of 623 patients operated on at the Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland; the operations included 849 arthroplasties. The rate of heterotopic ossification was higher after revision arthroplasty, following operation of the contralateral side, in men, and in primary coxarthrosis, and the incidence was higher with the Brunswik (metal-on-plastic) endoprosthesis than in the McKee-Farrar type (metal-on-metal). Heterotopic bone formation generally seemed to increase and to be more manifest during long-term observation.     

Development of heterotopic ossification around the hip

Summary Heterotopic ossification has been report ed in many pathological situations, most important clinically as a sequel to hip arthroplasty and spinal trauma. The etiology of heterotopic ossification is yet not clear, but the disease is supposed to be connected with trauma. Heterotopic bone was found in 53% (1.2% with the severe form) of 623 patients operated on at the Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland; the operations included 849 arthroplasties. The rate of heterotopic ossification was higher after revision arthroplasty, following operation of the contralateral side, in men, and in primary coxarthrosis, and the incidence was higher with the Brunswik (metal-on-plastic) endoprosthesis than in the McKee-Farrar type (metal-on-metal). Heterotopic bone formation generally seemed to increase and to be more manifest during long-term observation.     

Primary noncemented total hip arthroplasty in patients with ankylosing spondylitis: Clinical and radiographic results at an average follow-up period of 6 years

Twenty consecutive primary noncemented total hip arthroplasties performed on 12 men with ankylosing spondylitis were available to be studied clinically and radiographically at an average follow-up period of 75 months (range, 27–121 months). The average patient age at the time of surgery was 35 years (range, 23–53 years). Harris hip scores averaged 48.4 before surgery and 89.1 at the most recent follow-up examination. Significant improvements in pain, function, and range of motion were observed following total hip arthroplasty. No hip has required a surgical revision or reoperation. Heterotopic ossification was observed in 6 of 14 hips (43%) in the ankylosing spondylitis patients who had not had any perioperative prophylaxis for heterotopic bone formation. By contrast, 43 of 49 hips (88%) demonstrated heterotopic bone formation in a well-defined control group of 45 men with other diagnoses undergoing the same procedure by the same group of surgeons at the same institution. During the same period using the same implants. A thorough review of the literature and data from the institution does not support the notion that ankylosing spondylitis patients are necessarily predisposed to form heterotopic ossification. The use of routine perioperative prophylaxis for heterotopic ossification may not be warranted in all patients with ankylosing spondylitis undergoing routine primary noncemented total hip arthroplasty.     

Heterotopic bone formation after total hip arthroplasty in patients with primary or secondary coxarthrosis

Heterotopic bone formation was investigated in 392 Charnley low-friction total hip arthroplasties. A multivariate linear regression analysis was used to account for the influence of co-variables: sex, age at surgery, postoperative treatment with antiinflammatory drugs during at least the first 2 weeks, and previous ipsilateral hip surgery. A total of 232 hips had been treated for primary coxarthrosis, and 114 and 46 hips for secondary coxarthrosis due to congenital dislocation and fracture-dislocation of the hip, respectively. None of the hips with primary coxarthrosis previously had ipsilateral hip surgery, whereas 41 hips (36%) in patients with congenital dislocation of the hip and 28 hips (61%) in patients with fracture-dislocation of the hip had one or more ipsilateral surgical procedures prior to the arthroplasty. The sex ratio varied between the groups, with a male:female hip ratio of 1:1, 1:10, and 3:1 for the three groups, respectively. The risk of developing grades 2 or 3 heterotopic ossification after total hip arthroplasty were significantly higher in men, patients without postoperative treatment with antiinflammatory drugs, and patients above age 60. In contrast, the analysis documented that previous ipsilateral hip surgery and type of coxarthrosis did not influence lesion development, supporting the theory that a systemic, rather than local factor, is responsible for the development of heterotopic bone formation after total hip arthroplasty.     

Preliminary study of rofecoxib (25 mg) in prevention of heterotopic ossification after total hip replacement

Abstract Heterotopic ossification is a well-known complication of surgical approaches to the hip that involve dissection of the gluteal muscles. Heterotopic ossification has been reported as an incidental finding on radiographs of as many as 84% of patients who have had total hip arthroplasty. This study evaluated the possibility of using rofecoxib, a COX II selective inhibitor, to prevent heterotopic bone formation after total hip replacement. Sixty consecutive patients operated by the same surgeon, using the same surgical approach (lateral approach) for total hip replacement and who were considered to be at risk for postoperative heterotopic ossification, were enrolled into this prospective study. The patients were randomly assigned to one of two treatment groups: group 1 received rofecoxib (25 mg) daily from the day after total hip replacement for three weeks; group 2 received no pharmacological treatment.The two groups were clinically and radiographically controlled at 3-monthly intervals up to 1 year after surgery with a minimum follow-up of 6 months. Three patients in group 1 were lost to follow-up and consequently were not considered in the final evaluation.In group 1, 14 patients (51.9%) showed no ossification, 9 (33.3%) showed Brooker grade I ossification, 4 (14.8%) showed grade II ossification, and no patients with grades III and IV were detected. In group 2, 15 (50.0%) of the patients showed no ossification, 6 (20.0%) showed grade I ossification, 5 (16.7%) showed grade III ossification, and no patient with grade IV ossification was detected. The difference between the two treatment groups regarding extent of heterotopic ossification was statistically significant (p=0.028) and consequently gives a rational basis for a larger successive study.     

Total hip replacement for patients who have ankylosing spondylitis. The importance of the formation of heterotopic bone and of the durability of fixation of cemented components

Fifty-three total hip replacements were performed in thirty-one patients who had ankylosing spondylitis. After an average period of follow-up of 6.3 years, cemented conventional hip prostheses proved to be very durable in this young population (average age, forty-three years). Only one primary conventional hip prosthesis was revised for aseptic loosening, seventeen years after implantation. Clinically important heterotopic bone (Classes III and IV of Brooker et al.) developed in 11 per cent of the patients, all of whom had had a previous operation on the hip, postoperative infection, or complete ankylosis preoperatively. If a patient has clinically important heterotopic bone after one operation on the hip, and an arthroplasty of the contralateral hip or reoperation on the same hip is to be done, prophylactic treatment should be considered for prevention of formation of heterotopic bone.     

Heterotopic bone formation following total hip arthroplasty in ankylosing spondylitis

Heterotopic ossification is a well-recognized complication of total hip arthroplasty. In a retrospective survey of 98 total hip arthroplasties in ankylosing spondylitis performed between 1970 and 1977, 39.8% showed some evidences of heterotopic ossification. Restriction of hip movements was noted in only two. Heterotopic ossification occurred within one year and was higher (64.6%) in patients with bilateral hip replacements if there was evidence of heterotopic bone formation in one hip. The complications were relatively high in hips with previous operations (55%); trochanteric bursitis (50%); and trochanteric detachment (63.3%). No correlation was found between high erythrocyte sedimentation rate and the incidence or extent of heterotopic bone formation.     

Correlations of hip mobility with degree of back pain and lumbar spinal mobility in chronic low-back pain patients

Mobility of hips and lumbar spine were measured in 301 men and 175 women who were in employment but suffered from chronic or recurrent low-back pain. The degree of low-back pain (LBP) was assessed with a questionnaire. Hip flexion, extension, internal rotation, and hamstring flexibility in the men, and hip flexion and extension in the women had statistically significant negative correlations with LBP. Among the correlations between hip and lumbar spinal mobility, hip flexion and extension with lumbar rotation were strongest.     

Heterotopic ossification after treatment of femoral head osteonecrosis with free vascularized fibular graft

This study evaluated patients with heterotopic ossification after implantation of a free vascularized fibular graft for the treatment of femoral head osteonecrosis. We hypothesized that the osteogenic tendency of these patients might enhance the graft-host union and new bone formation in the femoral head, although the presence of heterotopic ossification might influence adversely the clinical result. Of patients with femoral head osteonecrosis, 32% developed heterotopic ossification after treatment with free vascularized fibular graft. Heterotopic bone formation did not influence the efficacy of the procedure to preserve the hip joint. The radiographic and clinical results and the rate of subsequent total hip arthroplasty were not affected by the heterotopic bone, but local trochanteric tenderness was associated with large heterotopic lesions.     

Heterotopic ossification in total hip arthroplasty: the significance for clinical outcome

This study evaluates 706 patients with 835 primary total hip replacements documented in a prospective fashion in a multicenter study with respect to correlation between heterotopic ossification (HO) and clinical outcome. Only patients without prophylaxis against HO entered the study. The mean clinical and radiological follow-up was 3.1 years (+/- 0.7). Heterotopic ossification was noted in 47% of all total hips replaced. It was graded as mild (Brooker I) in 29.1%, moderate (Brooker II) in 12.7%, and severe (Brooker III and IV) in 5.2%. All clinical parameters investigated were significantly affected with the increasing amount of heterotopic ossification. The strongest correlation was found in flexion range and spreading distance. Both factors were significantly decreased with higher degrees of ossification. The other clinical parameters investigated, walking capacity, limp, and use of analgesics, were altered to a lesser extent and only with higher degrees of heterotopic bone formation. Finally, patient satisfaction was significantly influenced by the degree of heterotopic ossification and dropped from almost 90% good or excellent patient satisfaction in the non-ossification group to less than 30% in the group with severe ossification.     

髋臼骨折内固定术后的全髋关节置换

目的探讨髋臼骨折经内固定术后出现并发症而导致疗效不佳,行全髋关节置换(TH R)的方法和疗效。方法总结经切开复位内固定治疗的髋臼骨折患者11例,因术后27～63个月(平均46.5个月)内继发创伤性关节炎或股骨头坏死,继而行全髋关节置换术。其中合并髋臼骨缺损6例,进行颗粒性植骨2例,结构性加颗粒性植骨4例;异位骨化4例,均发生于K-L入路。采用后外侧入路9例,髂股延伸切口2例,其中6例为原手术切口。结果11例患者全部得到随访,随访1年6个月～7年3个月,平均3年5个月。出现感染1例,脱位1例,无菌松动1例。术后再次异位骨化2例,其中1例引起坐骨神经症状,再次行神经松解术。所有随访病例髋关节功能均有改善,H arris评分由术前平均47分,提高到术后88分。结论选择正确的手术入路,适当处理异位骨化组织和内固定物,重建髋臼骨缺损,是髋臼骨折经切开复位内固定术后,再行全髋关节置换成功的关键。     

Functional outcome of excision of heterotopic ossification after total hip arthroplasty

Fifty-three cases of symptomatic heterotopic ossification were evaluated after total hip arthroplasty for the specific purpose of determining the value of surgical excision without revision or other concurrent procedures. The mean followup was 3.5 years for range of motion and 7.8 years for radiographic evaluation. A statistically significant increase in range of motion was obtained for the group at final followup. The mean increase in flexion arc was 34 degrees, abduction and adduction arc was 22 degrees, and rotation arc was 21 degrees. Of the patients who underwent surgical excision of heterotopic bone solely because of pain, none had complete alleviation of symptoms. It is concluded that surgical excision of heterotopic bone results in significant improvement in functional outcome, but it cannot be expected to predictably alleviate pain. Finally, the ultimate arc of motion was better than that suggested radiographically by the Brooker classification system.     

Heterotopic bone formation following hip arthroplasty in Paget's disease

Heterotopic bone formation in soft tissues occurs commonly in Paget's disease patients following a primary total hip arthroplasty (THA). The nature of this heterotopic bone has not been documented. In this report, we show that the heterotopic bone removed 14 years after primary THA in a case of Paget's disease was sclerotic, contained prominent mosaic cement lines and showed increased remodelling activity on the bone surface. In addition to these typically Pagetic histological features, it was noted ultrastructurally that the osteoclasts contained characteristic intranuclear viral-like inclusions. In contrast, the foreign body macrophages found in the joint pseudocapsule and pseudomembrane, which are a population of mononuclear precursor cells from which osteoclasts can be formed, did not contain viral-like inclusions. These findings are of interest regarding the pathogenesis of heterotopic bone formation following hip arthroplasty and the ontogeny of Pagetic osteoclasts.     

Acceptable outcome following resection of bilateral large popliteal space heterotopic ossification masses in a spinal cord injured patient: a case report

Spinal cord injury is a well-known predisposing factor for development of heterotopic ossification around the joints especially hip and elbow. Heterotopic ossification about the knee is usually located medially, laterally or anteriorly; besides, the knee is generally fixed in flexion. There are only a few reports of heterotopic bone formation at the posterior aspect of the knee (popliteal space) and fixation of both knees in extension; so, there is little experience in operative management of such a problem.     

Flurbiprofen inhibits heterotopic bone formation in total hip arthroplasty

Summary A double-blind prospective parallel group study comparing slow-release flurbiprofen with placebo in the control of ectopic bone formation was carried out in 68 patients undergoing total hip arthroplasty. Eight weeks after surgery there was evidence, significant at the 1% level, that the incidence and extent of periarticular calcification was lower in the flurbiprofen group. At an early phase, serum calcium level decreased and after 8 weeks serum alkaline phosphatase level increased more in the placebo group than in the flurbiprofen group, indicating an effect of flurbiprofen on bone mineral metabolism. Six patients were withdrawn in each treatment group, four due to side effects in the flurbiprofen group and three due to side effects in the placebo group. Overall, five patients in each group reported side effects, the nature and severity of the side effects being very similar in each group. We conclude that flurbiprofen is an efficient and safe drug in limiting ectopic bone formation following total hip arthroplasty. Heterotopic bone formation is a frequent complication after total hip replacement [1, 2, 4–6, 8–16]. Heterotopic bone reduces the extent of hip motion, reduction being more evident in cases with extensive ectopic bone formation around the hip joint [3, 10, 11]. Various treatment regimens have been proposed for discouraging heterotopic bone formation. Anti-inflammatory agents such as indomethacin and ibuprofen have turned out effective [11, 12, 14]. Local irradiation also prevents ectopic bone formation [4], but diphosphonates seem not be effective in this respect [15]. The aim of the present study was to assess the efficacy of flurbiprofen, a new anti-inflammatory agent, in limiting heterotopic bone formation, and to note the frequency and severity of any side effects of the treatment.     

Short-course indomethacin prevents heterotopic ossification in a high-risk population following total hip arthroplasty

The efficacy of a 10-day course of indomethacin in preventing heterotopic ossification after total hip arthroplasty was studied in a consecutive series of male patients who were at increased risk for bone formation. Between September 1991 and June 1994, all male patients (123 hips in 109 patients) who underwent total hip, revision, or surface arthroplasty were placed on a 10-day course of indomethacin. Of these, 106 patients (119 hips) successfully completed the 10-day course. There was no significant formation of heterotopic ossification (Brooker grade III or IV). From a group of 45 known heterotopic bone formers following previous total hip arthroplasty, only 2 developed new heterotopic ossification. Overall there were 9 (7.6%) new cases of heterotopic ossification: 7 Brooker grade 1 (5 primary and 2 revision cases) and 2 Brooker grade II (both primary cases). A 10-day course of indomethacin prevents the more significant grades of heterotopic ossification and is effective at reducing the incidence of heterotopic ossification following total hip arthroplasty. Further, this regimen appears safe and cost effective.