Ectopic ossification after total hip arthroplasty. Predisposing factors, frequency, and effect on results.

In a statistical analysis of 398 consecutive patients with 507 total hip arthroplasties which was designed to identify factors predisposing to ectopic ossification and to determine the frequency of ossification and its effect on the results, it was found that male patients with considerable bilateral osteophytic osteoarthritis were statistically most likely to have ectopic ossification, especially if ossification had existed before arthroplasty consequent to previous surgery. Ectopic ossification which was first noted six weeks after total hip arthroplasty in 96 per cent of the cases did not change in amount thereafter, though the bone did mature. Both the range of motion of the hip and the function of the patient were affected by the ectopic bone during the first postoperative year, but after that only the range of hip motion was influenced.     

Surgical excision of heterotopic ossification associated with anti-N-methyl-d-aspartate receptor encephalitis: A case report

Introduction and importanceHeterotopic ossification (HO) associated with Anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis is rare and the treatment strategy is unclear.Case presentationWe report the case of a 31-year-old female diagnosed with anti-NMDA receptor encephalitis from Osaka General Medical Center, Osaka, JAPAN that developed heterotopic ossification of the knees during prolonged coma. She was unable to walk because of pain and limited range of motion in both knees. Thirty months after the onset of the coma, surgical excision of the heterotopic bone in both knees was performed. The range of motion of both the knees improved markedly and she had no recurrence of heterotopic ossification on a three-year follow-up. Thus, this case can be used as a guide for surgeons with such patients.ConclusionsWe reported a case of heterotopic bone formation in the periarticular region of both bilateral knees in a patient who suffered a 2-month coma following anti-NMDA receptor encephalitis. Surgical excision of the heterotopic bones significantly improved the passive range of motion in both knees. Three years after the operation, the patient had no complaints about her knees, and there was no recurrence of HO.     

Heterotopic ossification around the hip in spinal cord-injured patients. A long-term follow-up study.

Twenty patients with spinal cord injury complicated by ossification around the hip were followed for eighteen months or more. The bone scan, roentgenogram, level of alkaline phosphatase, and range of hip motion of each patient were analyzed. The average follow-up was forty months. The heterotopic ossification usually did not mature until after one and one-half years. The roentgenograms were of no value in judging its maturity. The bone scan correlated well with the results of the alkaline phosphatase testing in judging maturity of the ossification. We concluded that before operative resection, a patient should have a normal level of alkaline phosphatase, decreasing activity on the bone scans, and a restriction of motion to less than 50 degrees of hip flexion.     

Postburn heterotopic ossification: insights for management decision making

An analysis of 1,478 consecutive admissions to the University of Kansas Burnett Burn Center revealed 18 patients who developed heterotopic ossification (1.2% incidence). Seventeen patients developed this disease in the elbows; one patient had shoulder involvement. Two patients eventually developed bilateral elbow disease. All patients initially presented with pain and limitation of joint motion. The diagnosis was then confirmed radiographically. All patients suspected of heterotopic ossification received physical therapy consisting of active range of motion only. Ten patients responded to conservative treatment and regained functional range of motion, and eight patients developed refractory ankylosis requiring surgical management. All surgically managed patients achieved a functional range of motion with an average followup of 35.0 months.     

Multiple osteochondroses of bilateral knee joints

We experienced a patient with a combination of multiple osteochondroses: Blount's disease, bipartite patella, and Sinding-Larsen-Johansson disease in the left knee, and a combination of bipartite patella and Osgood-Schlatter disease in the right knee. The patient was a healthy, active 12-year-old boy with bilateral knee pain. He had been diagnosed with Blount's disease of the left tibia at 2 years of age, and had been treated with open wedge osteotomy. He was diagnosed with bilateral bipartite patellae at the age of 9 years, and was diagnosed with Osgood-Schlatter disease in the right knee and Sinding-Larsen-Johansson disease in the left knee at 10 years of age. The second growth spurt was observed during this period. At 11 years of age, he was diagnosed with an osteochondral fracture of the left lateral femoral condyle and was observed without surgery. This patient showed the sequential appearance of an ossification disorder, probably due to the abnormal response of enchondral ossification to mechanical stress. Overuse in this growth period may have played a role in the development of these osteochondroses. The osteochondral fracture was probably caused by a disruption at one of the weakest parts of the developing skeleton, between the ossification center and the overlying cartilage in the background of an ossification disorder. Received: August 10, 2000 / Accepted: January 31, 2001     

Heterotopic ossification after total shoulder arthroplasty

Fifty-eight primary ingrowth total shoulder arthroplasties, performed between 1989 and 1992, with a minimum of 2 years' radiographic and clinical follow-up (mean, 4.7 years), were reviewed to determine the frequency and clinical significance of heterotopic ossification after total shoulder arthroplasty. Fourteen of the 58 shoulders had radiographic evidence of heterotopic ossification: grade I (12 shoulders) and grade II (2 shoulders). Heterotopic ossification was present on the early postoperative radiographs (1-2 months) in 12 of the 14 shoulders. Among these 12 shoulders, there was no increase in the grade of ossification comparing the early postoperative radiographs with those obtained at a minimum of 2 years. There were no identifiable preoperative patient characteristics associated with the development of heterotopic ossification (P > .05). Range of motion, pain, and result rating were not statistically different comparing patients with and without heterotopic ossification (P > .05). The data from this study suggest that when heterotopic ossification develops after elective total shoulder arthroplasty, it is usually low grade, is present in the early postoperative period, is nonprogressive, and does not adversely affect the clinical results.     

Indomethacin-induced postoperative psychosis.

Indomethacin is used commonly for the prevention of postoperatively heterotopic ossification. There have been 3 reports in the pharmacologic literature of indomethacin-induced psychosis. We describe a case of indomethacin-induced psychosis in a patient in whom indomethacin was used for the prevention of postoperative heterotopic ossification after bilateral uncemented total hip replacements.     

Indomethacin inhibits the recurrence of excised ectopic ossification after hip arthroplasty: A 3–4 year follow-up of 8 cases

Eight patients were treated with indomethacin and excision of paraarticular ossification after hip arthroplasty. In 1986 we reported that after 3 months substantial ossification had recurred in only 2 patients. We now report that ossification had not progressed further at follow-up 3–4 years later. All 8 patients were painfree and the majority had good hip motion. We conclude that indomethacin permanently prevents recurrence after excision of paraarticular ossification.     

Indomethacin for prevention of ectopic ossification after hip arthroplasty

Twelve patients at risk of developing postoperative para-articular ossifications were treated with indomethacin. Ossification after previous total hip arthroplasty was excised in eight patients. Four patients had ossification in the opposite hip after previous arthroplasty. Five patients in whom ectopic ossification was excised developed recurrences of lesser degree than the primary ossifications. One patient with the condition in the opposite hip developed ossification. No patients complained of stiffness in the hip and all had markedly increased hip motion. Indomethacin seems to be valuable as prophylaxis in patients at risk of developing ectopic ossification and as a supplement to secondary excision.     

Indomethacin for prevention of ectopic ossification after hip arthroplasty

Twelve patients at risk of developing postoperative para-articular ossifications were treated with indomethacin. Ossification after previous total hip arthroplasty was excised in eight patients. Four patients had ossification in the opposite hip after previous arthroplasty. Five patients in whom ectopic ossification was excised developed recurrences of lesser degree than the primary ossifications. One patient with the condition in the opposite hip developed ossification. No patients complained of stiffness in the hip and all had markedly increased hip motion. Indomethacin seems to be valuable as prophylaxis in patients at risk of developing ectopic ossification and as a supplement to secondary excision.     

Heterotopic bone formation following anterior cruciate ligament reconstruction with BPTB autograft

In this study, we present a 36-year-old male patient who developed heterotopic ossification after anterior cruciate ligament (ACL) reconstruction performed using bone-patellar tendon-bone autograft harvested from the 1/3 middle part of the patellar tendon. This ossified part, which restricted range of motion of the affected knee, was excised surgically 1 year after diagnosis. Physical examination, conducted 36 months later, revealed the achievement of full range of motion without any complaints or recurrences. Heterotopic ossification following ACL reconstruction is a very rare complication, which should be removed with open surgery.     

Heterotopic Ossification in Total Ankle Arthroplasty: Case Series and Systematic Review

Heterotopic ossification after total ankle arthroplasty (TAA) is a known sequela and has been reported to contribute to reduced range of motion and poor functional outcomes. However, conflicting results have been reported in the literature. The present study documents the incidence of heterotopic ossification for a novel fourth-generation fixed-bearing 2-component prosthesis and reports a systematic review of the literature. We reviewed the incidence and functional outcome of consecutively enrolled patients who underwent primary Infinity TAA between 2013 and 2015 in a prospective observational study. Preoperative and postoperative radiographic and functional outcome data were collected. A systematic review was also conducted investigating all published studies between 1998 and 2018 reporting the incidence of heterotopic ossification after TAA. The incidence of heterotopic ossification was 70.5% in the 61 patients who underwent primary TAA in the case series. There was no association between heterotopic ossification and American Orthopaedic Foot and Ankle Society (AOFAS) score, foot function index (FFI), visual analogue scale (VAS), and ankle osteoarthritis scale (AOS). Sixteen studies on 1339 TAA implants were included. The overall incidence of heterotopic ossification after TAA was 66.0% at average 3.6 years (range 22.2% to 100%). Four studies (299 ankles) did not address functional outcomes. Eleven studies (960 ankles) reported no association between heterotopic ossification and functional outcomes. One study (80 ankles) reported a statistically significant difference in range of motion (7°) and AOFAS score (7 points). In conclusion, although the incidence of heterotopic ossification after TAA is considerable, there is insufficient literature to suggest that heterotopic ossification after TAA impacts range of motion or functional outcome.     

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.     

Heterotopic ossification of the shoulder following head injury. A case report

Heterotopic ossification of the shoulder following head injury is a rare occurrence. In a 26-year-old woman with a head injury and extraarticular ossification of the glenohumeral joint, the heterotopic bone was resected surgically when the mass had matured. A vigorous physical therapy program was instituted early after operation to maintain shoulder mobility. Despite the formation of adhesions, the partial reformation of heterotopic bone, and an axillary neuropraxia, the patient achieved an excellent range of active shoulder motion ten months after operation.     

Effusion of the hips in a patient with tetraplegia

BACKGROUND: Patients with spinal cord injury are at risk for knee effusion, most likely as a result of repetitive microtrauma. Patients with paralysis are susceptible to effusions of the hip similar to those seen in documented cases regarding the knee. The etiology is likely similar and is related to repetitive microtrauma, such as that experienced when aggressive range of motion exercises are applied. DESIGN: Case report. SETTING: Acute rehabilitation department of a spinal cord injury center. FINDINGS: A 19-year-old man with a complete cervical spinal cord injury presented to acute rehabilitation on postinjury day 25 with a C6 American Spinal Injury Association classification A injury, complete. He was found to have bilateral hip effusions. Joint aspiration yielded a right sterile hydroarthrosis and a left sterile hemarthrosis. During his rehabilitation stay, the patient developed one mildly elevated alkaline phosphatase level, but he showed no radiographic evidence of heterotopic ossification and maintained full passive range of motion of the hips. CONCLUSION: This case indicates that hip effusion may be a similar, less-common occurrence than knee effusion in patients with spinal cord injury. In this case, bilateral aseptic hip effusion was not associated with heterotopic ossification. More research is needed to determine the etiology and sequelae of this condition.     

Heterotopic ossification as a complication of total hip replacement]

Heterotopic ossification is the most common complication after THR. The authors present the distribution of frequency of ectopic ossification after cementless THR using Mittelmeier and Parhofer-M?nch prosthesis and it's influence on THR outcome. 151 hip joints were evaluated with a follow-up period of more than 2 years. All procedures were performed by a lateral approach. The ectopic ossification was verified according to the Brooker classification. Clinical evaluation was performed according to the d'Aubigne-Postel method in Charnley's modification. The 3rd degree ectopic ossification was found in 14 hip joint and 4th degree ectopic ossification in 2 hip joints (together 10.6%). The positive correlation between the degree of ossification (3rd and 4th) and the decrease of range of motion of the hip joint along with an increase in pain after THR was found.     

Heterotopic ossification of the adductor longus muscle presenting as dyspareunia

Dyspareunia after heterotopic ossification of the adductor longus is a rare complication. We describe a patient with symptomatic heterotopic ossification of the adductor muscle that developed years after sustaining a fracture of the inferior pubic ramus in association with an injury to the adductor longus muscle. The patient's pain was reduced and his dyspareunia resolved after excision of the adductor longus heterotopic ossification and subsequent physical therapy.     

Heterotopic Ossification in a Throwing Athlete After Elbow Arthroscopy

A case of heterotopic ossification occurring after elbow arthroscopy in a young, healthy, throwing athlete is reported. The heterotopic bone caused a loss of motion post-arthroscopy in the patient and was confirmed with plain radiographs and bone scan. Twenty-two months after elbow arthroscopy, the patient underwent an open excision of the heterotopic bone. He returned to competitive throwing the next season. While this complication is rare after such minimally invasive procedures, this entity should be considered in the differential diagnosis in the throwing athlete who is unable to recover full range of motion after elbow arthroscopy.     

Heterotopic ossification around the elbow following burns in children: results after excision

BACKGROUND: Major burn injuries close to joints alter the function of the musculoskeletal system through tissue loss and limitation of joint motion. In children with involvement of the hand, wrist, and forearm, restriction of elbow motion secondary to heterotopic ossification following a burn injury severely limits the function of the upper extremity. The purpose of this study was to review elbow function following excision of heterotopic ossification around the elbow in children. METHODS: Eight children (ten elbows) from a population of 3245 consecutive patients who were admitted to our pediatric burn center were found to have severe heterotopic ossification of the elbow, leading to an inability to reach the mouth for feeding and the head and the perineum for self-care. Excision of the heterotopic ossification was undertaken if the patient had this limitation of function and if movement was restricted to a total arc of motion of <50 degrees. Pain was not an indication for the operation. The procedure was performed at an average of 17.3 months following the injury. RESULTS: Seven children (nine elbows) were available for follow-up at an average of fifty-six months after surgery. All nine elbows had an improved arc of motion (an average increase of 57 degrees ). Following excision, heterotopic ossification did not recur. All children were able to reach the face and the perineum following the operation. CONCLUSIONS: Excision of heterotopic ossification around the elbow following a burn injury in children can improve the arc of motion and improve the function of the extremity. A relatively simple operative and postoperative regimen can achieve satisfactory results.