Heterotopic Ossification of the Elbow : Wheeless' Textbook of Orthopaedics

- See:
- management of burns
- ossification of soft tissues
- hetertopic ossification
- management of elbow flexion contracture

- Excision of Hetertopic Bone About the Elbow:
- hetertopic bone is most often located along the posteromedial aspect;
- medial approach to the elbow is performed along with an anterior transposition of the ulnar nerve;
- careful proximal and distal exposure of the nerve is required before any attempt is made to dissect the nerve out of the hetertopic bone;
- further exposure is obtained w/ osteotomy of the medial epicondyle, which can then be fixed w/ a single cannulated screw at the end of the case;
- postoperatively the elbow is splinted in extension, when not undergoing supervised ROM;
- McAuliffe and Wolfson (1997): early operative excision (within 3 months after injury) which was followed by a total XRT dose of 1000 centigray, given in 200 centigray factions;
- operative wound was not excluded from the field, and radial aspect of the elbow was spared inorder to preserve the lymphatic system;
- in the report by Viola and Hanel (1999), the authors performed performed early excision of HO about the elbow;
- 14 patients (15 elbows) were managed w/ early excision of posttraumatic, HO, immediate postop mobilization, and a 5-day course of indomethacin;
- average time from injury to release was 23 weeks - mean preoperative arc of flexion/extension was 43°; that of pronation/supination was 79°;
- after 2 years, the corresponding values were 120° and 152°;
- cubital tunnel syndrome, present in 5 patients, resolved after surgery - authors elected to perform an anterior submuscular transposition of ulnar nerve;
          - submuscular, rather than subcutaneous, transposition was performed because nearly all the necessary steps, including flexor-pronator
   mass elevation, were already completed during HO and capsule resection;
- there were no recurrent contractures or loss of motion;
- references:
                   Early "simple" release of posttraumatic elbow contracture associated with heterotopic ossification.
                   Early excision of heterotopic ossification about the elbow followed by radiation therapy.

- Proximal Radial Resection:
- Kamineni S, et al evaluated proximal radial resection as a technique to manage HO about elbow and for proximal radioulnar synostosis;
- 7 patients were managed with a partial proximal radial resection distal to the synostosis and were followed for an average of eighty months;
- forearm rotation improved from an average fixed pronation of 5° to an average arc of 98 deg;
- the authors noted that the application of bone wax at the resection site improved outcomes;
- Proximal radial resection for posttraumatic radioulnar synostosis: a new technique to improve forearm rotation.

- Radiation Therapy:
- in the report by Heyd R, et al, the authors present 9 patients (5 men and 4 women) who underwent surgical excision of clinically significant HO at the elbow;
- they also received perioperative radiation therapy using total doses between 600 and 1000 cGy;
- 5 received fractionated XRT, w/ 2 fractions of 500 cGy on 1st 2 postop days, and remaining 4 were irradiated w/ single doses of 600 and 700 cGy;
- after a mean period of observation of 7.7 months (6 to 13) none had radiological recurrence of HO and eight showed clinical improvement;
- assessment of the functional outcome showed a mean improvement in the Morrey score from 33.3 to 84.5 points indicating a high therapeutic efficacy of prophylactic irradiation;
- references:
- Radiation therapy for the prevention of heterotopic ossification at the elbow.
- Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study.