HETEROTOPIC OSSIFICATION

5-MINUTE ORTHOPAEDIC CONSULT

Presented by:Anggiat Humusor Ulina

C11107226

Advisor :dr. Hendrian Chaniago

Supervisor:dr. Karya Triko, Sp. OT. (K) Spine

Orthopedic dan TraumatologyFaculty of Medicine Hasanuddin University

Makassar 2011

DESCRIPTION Pathologic bone formation as a consequence of direct trauma or central nervous system injuries

Bone formed in heterotopic locations such as muscle, subcutaneous tissues, or nerves

Most commonly occurs at the hip, elbow, and shoulder joints

EPIDEMIOLOGY Less common in children than in adults, and more common in males than in females.

Incidence: Occurs in 10%-20% of patients with central nervous system or traumatic injuries, with an average onset of 2 months after injury.

THREE COMMON LOCATIONS OF HETEROTOPIC OSSIFICATION AROUND THE HIP JOINTA: Anterolateral/anteromedial location; B: Inferior and medial location; and C: Location around the femoral neck and posterior.

RISK FACTORS Central nervous system injury

Osteoarthrosis Osteophyte formation Surgical approach Previous surgical procedures Trochanteric osteotomy

ETIOLOGYTraumatic brain injury

Spinal cord injury

Trauma

Associated Conditions

Fibrodysplasia ossificans progressiva

Primary osteoma cutis

DIAGNOSIS Signs and Symptoms

Unexplained increase in pain, spasticity, or muscle guarding

Decreased ROMStiffnessRadiographic evidence of ectopic bone

Physical ExamLimited ROM is the most common and

earliest sign.Erythema, swelling, and signs of

inflammation also may be noted.

TESTS Lab

Serum alkaline phosphatase levels are elevated.

Value begins to rise 2-3 weeks after injury.

ImagingOn plain radiographs, new bone formation may

be 1st visible at 3-6 weeks; but radiographs generally are not confirmatory until 3 months.

Bone scans allow for earlier detection and show intense uptake.

CT may be used for preoperative planning and to show the zonal pattern: Mineralized in the periphery and lucent in the center.

EXTENSIVE HETEROTOPIC OSSIFICATION AT THE MEDIAL ASPECT OF THE LEFT KNEE

TESTS Pathological Findings

Initially, an intense inflammatory response occurs with myofibroblasts and osteoblasts.

Such a high degree of cellular activity occurs that the inflammatory response can be mistaken for a neoplasm.

DIFFERENTIAL DIAGNOSIS Septic joint Thrombophlebitis Neoplasm in the soft tissues

TREATMENT General Measures

Joint motion is maintained to allow normal functioning.

Most patients are treated successfully with nonoperative measures, including physical therapy, analgesics, and NSAIDs.

Few patients require surgical excision. Special Therapy

Radiotherapy Radiation therapy is ineffective once heterotopic ossification has

been documented. When used for prophylaxis, it must be delivered within 72

hours. Physical Therapy

Use ROM exercises and treatment modalities that are designed to increase joint mobility.

MEDICATION First LineAnti-inflammatories are used to prevent or to lessen the amount of heterotopic ossification formation after the initial insult and to prevent recurrence after surgical excision.Indomethacin, naproxen, or other NSAIDs for 6 weeks

SURGERY Surgery is indicated to restore joint motion or to

correct contractures in disabled patients, it should not be resected earlier than 6 months after injury.

Excision after 2 years increases the likelihood of permanent contractures.

After resection, patients are treated with low doses of irradiation (must be delivered within 72 hours).

Some patients elect to take NSAIDs (e.g., indomethacin) for 6 weeks after resection. For effective prophylaxis, the medications must be taken. Gastric intolerance prevents 10–20% of patients from

taking these medications.

FOLLOW-UP Prognosis

Prognosis varies, depending on the location of heterotopic ossification and its cause.

Most patients with nonneurogenic heterotopic ossification maintain reasonable function and do not require surgical intervention.

FOLLOW-UP Complications

Loss of mobilityAnkylosis

Patient MonitoringSerial radiographs are obtained at 1-3 month intervals for 6 months.

THANK YOU