Heterotopic ossification of the supraspinatus tendon after rotator cuff repair: case report

Heterotopic Ossification After Arthroscopic Procedures: A Scoping Review of the Literature

Background:

Heterotopic ossification (HO) is the formation of bone in soft tissue resultant from inflammatory processes. Lesion formation after arthroscopic procedures is an uncommon but challenging complication. Optimal prophylaxis and management strategies have not been clearly defined.

Purpose:

To present a scoping review of the pathophysiology, risk factors, diagnostic modalities, prophylaxis recommendations, and current treatment practices concerning HO after arthroscopic management of orthopaedic injuries.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

A scoping review via a PubMed search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The search strategy was based on the terms “heterotopic ossification” AND “arthroscopy.” The clinical outcomes review included studies on the arthroscopic management of orthopaedic injuries in which the primary subject matter or a secondary outcome was the development of HO. An analysis of the pathophysiology, diagnostic modalities, and management options was reported.

Results:

A total of 43 studies (33,065 patients) reported on HO after hip arthroscopy, while 21 (83 patients) collectively reported on HO after arthroscopic procedures to the shoulder, elbow, knee, or ankle; however, management techniques were not standardized. Identified risk factors for HO included male sex and mixed impingement pathology, while intraoperative capsular management was not suggested as a contributing factor. Diagnosis of ossification foci was performed using radiography and computed tomography. The rate of HO after hip arthroscopy procedures approached 46% without prophylaxis, and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) decreased occurrence rates to 4% but carries associated risks. External beam radiation has not been exclusively studied for use after arthroscopic procedures.

Conclusion:

HO is a known complication after arthroscopic management of orthopaedic injuries. NSAID prophylaxis has been demonstrated to be effective after hip arthroscopy procedures. Patients with persistent symptoms and mature lesions may be indicated for surgical excision, although variability is present in patient-reported outcome scores postoperatively.

Local rhBMP-12 on an Absorbable Collagen Sponge as an Adjuvant Therapy for Rotator Cuff Repair - A Phase 1, Randomized, Standard of Care Control, Multicenter Study: Safety and Feasibility

BACKGROUND

Recombinant human bone morphogenetic protein-12 (rhBMP-12) has been shown to induce tendon and ligament formation in rats and to improve tendon healing; however, the safety and feasibility of implanting rhBMP-12/absorbable collagen sponge (ACS) in humans are not known.

PURPOSE

To investigate the safety and feasibility of rhBMP-12 on an ACS as an adjuvant therapy in open rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

This study consisted of 20 patients with full-thickness rotator cuff tears. Patients were randomized either to standard of care (SOC) treatment (open rotator cuff repair) or to receive 0.015 mg/mL rhBMP-12/ACS and SOC treatment during their open rotator cuff repair (rhBMP-12/ACS group) at a rate of 1/4 SOC/rhBMP-12/ACS. The feasibility of implanting the product and the safety of the product were evaluated during the 1-year follow-up period. The evaluation involved up to 10 postoperative visits, which included physical examinations, radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans with an emphasis on heterotopic ossification (HO), pharmacokinetics, immunogenicity, laboratory evaluations, and local and systemic adverse events at specified time points.

RESULTS

Small amounts of HO were seen on follow-up CT scans in 10 of 16 patients in the rhBMP-12/ACS group and in 2 of 3 patients in the SOC group. HO did not increase at 26 weeks and was not associated with any adverse events or unsatisfactory clinical outcomes. Pharmacokinetics demonstrated that circulating levels of rhBMP-12 were not detectable after administration. Five of 16 patients showed a postoperative immunogenic response but did not show any correlating adverse events. Complete healing of the rotator cuff was observed in 14 of 16 patients; 2 of 16 imaging results could not be analyzed because of artifacts in the rhBMP-12 group on MRI scans. In the SOC group, 1 of 4 patients showed a retear at 12 weeks after surgery.

CONCLUSION

The use of rhBMP-12/ACS has been shown to be feasible and safe in a concentration of 0.015 mg/mL when used in open rotator cuff repair. Higher dose concentrations of rhBMP-12 should be evaluated in the future to evaluate their safety and potential to increase rotator cuff healing after open surgical repair.

Ossifying tendinitis of the rotator cuff after arthroscopic excision of calcium deposits: report of two cases and literature review

Ossifying tendinitis (OT) is a type of heterotopic ossification, characterized by deposition of hydroxyapatite crystals in a histologic pattern of mature lamellar bone. It is usually associated with surgical intervention or trauma and is more commonly seen in Achilles or distal biceps tendons, and also in the gluteus maximus tendon. To our knowledge, there is no description of OT as a complication of calcifying tendinitis of the rotator cuff. In this report, we describe two cases in which the patients developed an OT of the supraspinatus after arthroscopic removal of calcium deposits. The related literature is reviewed.

The Effect of NSAID Prophylaxis and Operative Variables on Heterotopic Ossification After Hip Arthroscopy

BACKGROUND

Heterotopic ossification (HO) is a known complication of hip arthroscopy. Little is known about the factors that lead to HO after hip arthroscopy.

PURPOSE

The aim of this study was to evaluate the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) and other operative variables on the development of HO.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 357 consecutive cases of hip arthroscopy were retrospectively reviewed over a 3-year period. Routine NSAID prophylaxis was not performed for the first 117 cases. Prophylaxis with naproxen for 3 weeks was then routinely prescribed for the remaining 240 cases. Complete follow-up was available for 288 of the original 357 cases. The presence of HO and its characteristics were recorded for each patient, along with baseline demographic and surgical variables. Odds ratios and logistic regression were used to identify causal factors for HO.

RESULTS

The incidence of HO in cases in which the patient did not receive NSAID prophylaxis was 25.0% (23/92) versus 5.6% (11/196) of cases in which the patient received NSAIDs. Patients who received no NSAID prophylaxis were 13.6 times more likely to develop HO postoperatively (95% confidence interval, 2.44-75.5; P = .003). Comparing just mixed-type femoroacetabular impingement resections, patients who received no NSAID prophylaxis were 16.6 times more likely to develop HO postoperatively (95% confidence interval, 2.2-126.0; P = .006). Multivariate logistic regression identified the performance of a mixed-type femoroacetabular impingement resection (P = .011) and the absence of NSAID prophylaxis (P = .003) as predictors of HO development. The majority of HO cases (29/34) occurred in patients with mixed-type femoroacetabular impingement who had both osteochondroplasty and acetabuloplasty. Complications of NSAID therapy in this study population included acute renal failure, hematochezia from acute colitis, and gastritis.

CONCLUSION

Routine NSAID prophylaxis reduces but does not eliminate the incidence of HO in patients undergoing hip arthroscopy. Heterotopic ossification was more likely to develop in patients undergoing acetabuloplasty along with osteochondroplasty and in those who did not receive prophylactic postoperative NSAIDs. Side effects from the investigated NSAID regimen can be serious and should be weighed against the potential benefits in preventing the formation of HO.

The incidence of heterotopic ossification after hip arthroscopy

BACKGROUND

Minimally invasive techniques to treat femoroacetabular impingement (FAI), snapping hip syndrome, and peritrochanteric space disorder (PSD) were developed to reduce complications and recovery time. Although a multitude of studies have reported on the incidence of heterotopic ossification (HO) after open procedures of the hip, there is little known about the rate of HO after hip arthroscopy.

HYPOTHESES

The incidence of HO after hip arthroscopy is comparable with that after open surgical dislocation of the hip and can be reduced with the addition of indomethacin to an existing nonsteroidal anti-inflammatory medication prophylaxis protocol.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between July 2008 and July 2010, 616 primary hip arthroscopies were performed to treat FAI and PSD. In July 2009, indomethacin was added in the acute postoperative period to an existing HO prophylactic protocol of naproxen administered for 30 days postoperatively. Postoperative radiographs were reviewed to detect the presence and classify the size and location of HO. Odds ratios and logistic regression explored predictor variables and their relationships with HO, with P < .05 defined as significant.

RESULTS

Twenty-nine (21 male, 8 female) of 616 (4.7%) hip procedures developed HO postoperatively. Brooker classification of HO was 18 grade I, 4 grade II, 6 grade III, and 1 grade IV. Mean follow-up was 13.2 months (range, 2.9-26.5 months). Rate of HO for cases with and without indomethacin for prophylaxis was 1.8% (6/339) and 8.3% (23/277), respectively. This difference was statistically significant (P < .05), and patients who underwent protocol 1 were 4.36 times more likely to develop HO postoperatively than those who had protocol 2. The majority of cases of HO (72.4%) occurred in male patients, and all cases occurred in the setting of osteoplasty performed for symptomatic FAI. We were not able to demonstrate statistically significant clinical risk factors that were predictive for the development of postoperative HO. However, the data clearly demonstrate that the performance of arthroscopic osteoplasty with a capsular cut in male patients represented the majority of cases, who are likely the group at highest risk. Seven cases (~1%) required revision procedures to excise HO. There were no cases of recurrence of HO after excision, whether it was performed open or arthroscopically.

CONCLUSION

The addition of indomethacin is effective in reducing the incidence of HO after hip arthroscopy and should be especially considered in male patients who undergo osteoplasty for correction of symptomatic FAI.

Heterotopic ossification after minimally invasive rotator cuff repair

Heterotopic ossification is a common phenomenon after spinal cord injury, head injury, neurologic disorders, burns and other trauma, and joint arthroplasty. Periarticular ossifications after shoulder surgery have been known to occur since the 19th century, at an incidence of up to 27%. After arthroscopic and minimally invasive shoulder surgical procedures were introduced and came into broad use, reports about heterotopic ossification became very rare. We describe here a case of heterotopic bone formation in the subdeltoid fascia after arthroscopic subacromial decompression, acromioclavicular joint resection, and mini-open rotator cuff reconstruction were performed with 2 absorbable suture anchors 3 months postoperatively. Computed tomography (CT) confirmed a massive heterotopic ossification of the deltoid muscle. During revision surgery, a 4 x 6.5-cm bone shell that consisted primarily of immature trabecular bone and lamellar bone in smaller proportions was removed. The case presented here is unique in the scientific literature. Although risk factors have been identified, the underlying pathomorphogenetic mechanism of such heterotopic bone formation remains unclear. Prophylactic administration of nonsteroidal anti-inflammatory drugs (NSAIDs) or radiation for arthroscopic or minimally invasive shoulder surgery is not justified, given the low incidence of heterotopic ossification and the known adverse effects. Apparently, information on basic science and on evidence-based therapy is lacking.