Heterotrophic ossification

1. HETEROTOPIC
OSSIFICATION
DR ANIL KUMAR P
JUNIOR RESIDENT
DEPT OF ORTHOPAEDICS
SDUMC

2. HETEROTOPIC OSSIFICATION
• Heterotopic ossification seen most commonly in association
with trauma, burns, and head injuries.
• a complex interaction of factors results in the conversion of
progenitor cells to osteogenic cells with subsequent bone
formation.
• Furthermore, the character and location of heterotopic
ossification tend to vary with the associated pathology.
• if ectopic bone around the elbow is causing or contributing to a
loss of functional elbow motion, then an operative procedure is
warranted to remove the offending bone and release the joint
capsule.

4. • This principle applies whether the motion limitation is partial or
complete (ankylosis).
• Early surgical management of complex elbow trauma in an
attempt to limit ectopic bone formation.
• Criteria suggested for early excision (3 to 6 months after injury)
include union of all fractures, healing of all initial wounds, and
resolution of inflammation.
• Excision of heterotopic ossification around the elbow is typically
done through a limited or extended Kocher approach.

5. • A multiple incision technique also has been described for
heterotopic ossification excision after burn injuries, in which
soft-tissue preservation is paramount to avoid skin breakdown
and infection.
• Preoperative CT scanning is recommended to identify the
precise location of the ectopic bone and the position of the
median and ulnar nerves.

6. MORREY AND HARTER TECHNIQUE
• Usually a posterior skin incision is made,
• Subcutaneous dissection is carried laterally or medially
depending on the location of the heterotopic
ossification.
• Care must be taken to identify and protect the ulnar
nerve.

7. POSTEROLATERAL EXCISION
• For posterolateral resection, retract the triceps
mechanism medially without disturbing its insertion.
• Expose the ectopic bone subperiosteally.
• Resect the central portion of the bony bridge.
• Flex the elbow and remove the attachments of the
ectopic bone to the humerus and olecranon.
• Anterior capsular release is not necessary.
• Excise any ectopic bone in the olecranon fossa to
reduce olecranon impingement.

8. MEDIAL EXCISION
• When the posterior ectopic bone extends to the
medial aspect of the elbow, ulnar nerve transposition
is necessary.
• Identify the ulnar nerve, which may be completely
surrounded by bone.
• Expose the triceps expansion and incise it distal to
its insertion.
• Expose the ectopic bone subperiosteally and resect it.
• If the ectopic bone interferes with ulnar nerve
function, decompress the nerve or transfer it anteriorly
if necessary.

9. ANTERIOR EXCISION
• If anterior excision is necessary, elevate the origins of
the brachioradialis and brachialis muscles from the
lateral supracondylar ridge to expose the ectopic bone.
• Identify the radial nerve and retract it laterally. ■ Resect
the bone subperiosteally.

10. CLOSURE
• Deflate the tourniquet and obtain hemostasis before
routine layered closure over a suction drain.
• Do not close the capsule.
• Apply a soft dressing that will allow immediate
postoperative range of motion.

11. Skin incision for extensile
Kocher approach
Deep fascia is incised along
lateral margin of triceps
proximally and along interval
between anconeus and
extensor carpi ulnaris distally

12. To preserve periosteal continuity,
triceps tendon is reflected
subperiosteally from tip of
olecranon
Extensor mechanism of elbow is
reflected medially, tip of olecranon is
removed (inset), and common origin of
extensors of forearm is released from
lateral epicondyle and adjacent
structures. Extensor muscles are
elevated to expose anterior part of
capsule of elbow in interval between
brachialis and capsule

13. Lateral collateral ligament is identified and released as distally based flap that
can be reattached later to anatomic site of its proximal attachment on
humerus. With lateral collateral ligament carefully retracted, anterior part of
capsule now can be exposed and resected way across to medial site

14. POSTOPERATIVE CARE
• Indomethacin is prescribed for 6 weeks after surgery.
• Although low-dose radiation has been used for
prophylaxis against recurrence.
• Intensive physical therapy and adjunctive progressive
splinting are initiated to preserve the gains in range
of motion.
• If motion goals are not met, manipulation under
anesthesia can be done at about 6 weeks after
surgery.

15. OUTCOMES
• following ectopic bone excision are generallyimproved.
• Recent studies have reported an average gain in flexion arc of
approximately 50 to 70 degrees, and clinical results do not vary
by etiology (traumatic brain injury, burns, or direct elbow
trauma).
• Patients with preoperative ankylosis can expect more
improvement than those with partial motion restriction;
• However, recurrence is more common in patients with central
nervous system injuries.