Excision and radiotherapy for heterotopic ossification of the elbow

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Introduction  Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods  We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results  Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion  There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence  Level III.

Radiotherapy for prevention of heterotopic ossification of the elbow: a systematic review of the literature

BACKGROUND

Heterotopic ossification is a pathological process characterized by abnormal formation of bone in nonskeletal tissue. Radiotherapy for heterotopic ossification of the elbow is questionable because of possible adverse effects.

METHODS

A systematic review of the literature was conducted in MEDLINE, Scopus, ISI Web of Science, National Institute for Health and Clinical Excellence, National Guideline Clearinghouse, System for Information on Grey Literature in Europe, ClinicalTrials.gov, Cochrane Central Register of Clinical Trials, and Cochrane Database of Systematic Reviews up to April 2012. All published articles assessing interventions including radiotherapy for prevention of heterotopic ossification in the elbow of adult patients were considered. Information was recorded by the first two authors, and disagreements in interpretation were resolved by consensus.

RESULTS

In total, 27 studies using radiotherapy for elbow heterotopic ossification were identified (1 randomized clinical trial, 1 case-control study, and 25 case reports and case series) in the literature. Most of them used a single dose of 7.0 Gy. The randomized clinical trial was stopped early because of severe adverse effects (pseudarthrosis) caused by radiation. The case-control study showed that radiotherapy did not effectively prevent recurrence of heterotopic ossification. The case reports and case series mentioned only sparse adverse events.

CONCLUSION

The use of radiation therapy for prevention of heterotopic ossification of the elbow is supported by weak evidence.

Open release and a hinged external fixator for the treatment of elbow stiffness in young patients

Elbow stiffness is a well-recognized complication following elbow trauma, but little information is available regarding the surgical treatment of elbow stiffness in children and adolescents. This article presents the results of open arthrolysis with twin incisions and a hinged external fixator to treat severe elbow contracture in children and adolescents. Twenty-one patients (mean age, 14.9 years; range, 7-19 years) were evaluated. All patients underwent surgery using a hinged external fixator and a combined mediolateral approach to address the elbow contracture. Mayo elbow score and range of motion (ROM) were measured preoperatively and at 3, 12, and 24 months postoperatively. All but 1 patient achieved a functional ROM of 100°. Preoperatively, mean flexion was 70.2° (range, 30°-100°), extension was 42.6° (range, 0°-80°), and total ROM was 28.5° (range, 0° to 80°); postoperatively, mean flexion improved to 122.8° (range, 90°-140°), extension to 10° (range, 0°-30°), and total ROM to 114.5° (range, 60°-140°). The Mayo elbow score improved from a mean of 48 points (range, 35-65 points) to 90 points (range, 75-100 points), and 9 patients had excellent results, 7 had good results, 4 had fair results, and 1 had a poor result. No significant differences existed between postoperative measurements at 3, 12, and 24 months. No pin-tract infections or deep infections occurred, and no vascular or neurological complications were noted. Surgical treatment of elbow stiffness using a hinged external fixator and open arthrolysis is an effective procedure in children and adolescents.

Extensive heterotopic ossification after suspensory cortical fixation of acute distal biceps tendon ruptures

Suspensory cortical fixation is commonly used for distal biceps tendon repair and reconstruction with one of several commercially available devices. The single-incision approach typically used with these devices is believed to have a lower incidence of heterotopic ossification than the dual-incision technique, but the true incidence of heterotopic ossification is unknown. The role of chemotherapeutic or radiation prophylaxis is undefined. We have identified 4 cases of extensive heterotopic ossification after biceps fixation with a suspensory button and single-incision approach. Surgeons should be aware of this potential complication when using suspensory cortical buttons for distal biceps fixation.

Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion

We compared 16 patients with post-traumatic heterotopic ossification (HO) restricting elbow motion (but not complete bony ankylosis) after elbow trauma with 21 patients with capsular contracture alone to test the hypothesis that HO is associated with diminished motion after release. Patients with burns or head injury were excluded. The preoperative flexion arc averaged 59 degrees in the HO cohort and 52 degrees in the capsular contracture cohort. The mean flexion arc after the index surgery improved by 54 degrees to a mean arc of 113 degrees in the HO cohort and by 35 degrees to a mean of 87 degrees in the capsular contracture cohort (P = .02). After all subsequent procedures (including procedures to address residual stiffness in 1 patient in the HO cohort and 4 patients in the capsular contracture cohort), the flexion arc averaged 116 degrees in the HO cohort and 98 degrees in the capsular contracture cohort (P = .19). Open release of post-traumatic elbow stiffness is more effective when HO hindering motion is removed than when there is capsular contracture alone.

Spontaneous defect remodeling in a distal humerus fracture with extensive osseous loss: a case report of a complex elbow fracture

Sideswipe injuries to the elbow cause complex fracture patterns and remain difficult management problems. The authors report a case of spontaneous bone remodeling of an extensive metaphyseal defect zone.

[Treatment of neurogenic heterotopic ossifications (NHO) in brain injured patients: review of literature]

This article is a review of the literature about treatment of neurogenic heterotopic ossifications (NHO) in brain injured patients, from analysis of the main data bases (Medline, Embase, Reedoc). In spite of the hope they arouse in the seventies, biphosphonates, including etidronate, have not demonstrated their efficiency to inhibit NHO in clinical practice. In fact a very early diagnosis, with the scintigraphic overactivity of the joint area and the increase of serum alkaline phosphatases, must lead to begin passive motion and postures, and may contribute to save functional range of motion. Yet, when joint stiffness or even ankylosis have led to severe functional disorders, surgery with NHO resection is the only way; it looks more reliable to manage it when NHO is mature, after a delay of more than 12 months after the first signs, but earlier operations have been reported without an enhanced risk of recurrence; this surgery must be associated with continuous passive motion for several weeks; radiation therapy and/or non-steroid anti-inflammatory drugs have been proposed in the immediate after-surgery period, but their role is still discussed.

Posttraumatic elbow stiffness: evaluation and management

Posttraumatic elbow stiffness is a common problem that is often difficult to manage. The goal of treatment is to restore a functional range of elbow motion (> or =30 degrees to 130 degrees ). Nonsurgical treatment includes physical therapy and splinting. If nonsurgical treatment has failed, the type of surgical treatment required depends on the extent of degenerative changes. When degenerative changes are absent or mild, soft-tissue release offers reliable increases in elbow motion. When moderate degenerative changes exist within the joint, debridement arthroplasty of osteophytes and soft tissue has shown some success with increase in joint motion. With advanced degenerative changes, the therapeutic options are more limited. Results from biologic resurfacing arthroplasty are unpredictable, and total elbow arthroplasty should be reserved for the lower-demand elbow in a physiologically older individual.