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Heterotopic Ossification of the Elbow

- 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.

Early Excision of Hetertopic Ossification about the Elbow followed by Radiation Therapy.

The surgical treatment of heterotopic ossification at the elbow following long-term coma.

Proximal Radial Resection for Posttraumatic Radioulnar Synostosis: a New Technique to Improve Forearm Rotation 

Heterotopic ossification of the elbow in patients with burns. Results after early excision.

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

A comparison of proximal radioulnar synostosis excision after trauma and distal biceps reattachment

Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study.

Surgical treatment of post-traumatic stiffness of the elbow.

Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies.

Heterotopic ossification after surgery for distal humeral fracture