Does Excision of Heterotopic Ossification of the Elbow Result in Satisfactory Patient-Rated Outcomes?

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1 Mlysin Orthopedi Journl 2017 Vol 11 No 1 Doi: Sndeep KN, et l Does Exision of Heterotopi Ossifition of the Elow Result in Stisftory Ptient-Rted Outomes? Sndeep KN, MS, Suresh G, B DNB, Gopisnkr B, MS, Ahishek N, MBBS, Sujiv A, MD Deprtment of Orthopedis, Jwhrll Institute of Postgrdute Medil Edution nd Reserh, Pondiherry, Indi This is n open-ess rtile distriuted under the terms of the Cretive Commons Attriution Liense, whih permits unrestrited use, distriution, nd reprodution in ny medium, provided the originl work is properly ited Dte of sumission: 22nd Novemer 2016 Dte of eptne: 13th Ferury 2017 ABSTRACT Introdution: Tretment of heterotopi ossifition (HO) of the elow is hllenging nd frught with omplitions. Ptients who sustin diret trum to the elow joint, the entrl nervous system, nd therml urns re t inresed risk for development of HO. There is puity of studies nd reports on ptient s self-evlution fter the exision of the heterotopi ossifition. Mterils nd Methods: This retrospetive study ssessed outomes fter exision of heterotopi ossifition round the elow in ohort of ten ptients operted from 2012 to The outome ssessment ws done y the Myo Elow Performne index (MEPI) nd the Amerin Shoulder nd Elow Surgeons-Elow sore (ASES-E sores). Results: The men follow-up ws months fter the opertion. The Myo Elow Performne Sore ws exellent in two elows, good in six nd fir in two. The men gin in flexion-extension r fter exision of HO ws 80 degrees. All of the ptients hd residul flexion deformity postopertively. Eight of the nine ptients were le to do tivities requiring flexion t finl follow-up. Conlusion: Exision of HO round the elow is ssoited with stisftory ptient-rted outomes in spite of filure to regin full rnge of motion. Key Words: heterotopi ossifition, elow joint, nkylosis, ulnr nerve, prontion, supintion INTRODUCTION Heterotopi ossifition (HO) of the elow joint results from the formtion of mture lmellr one in extr-osseous tissues. The resulting limittion of elow movements n rnge from mild to omplete nkylosis. Ptients who sustin diret trum to the elow joint, the entrl nervous system, nd therml urns re t n inresed risk for development of HO 1. The inidene of HO following elow trum rnges from 0% to 49% following distl humerus frture nd 4% to 18% following ulnr-humerl dislotions 2. The pulished linil studies re entered on the mesurement of elow rnge of motion fter the opertion. There is puity of studies nd reports on the ptient s self-evlution fter the exision of the HO. Hene, we did study on ptient-rted outomes nd elow rnge of motion following exision of HO of the elow joint. MATERIALS AND METHODS The hospitl reords were serhed for ptients who underwent exision of the HO round the elow joint from Jnury 2012 to My We identified nine ptients (ten elows) operted for HO during the study period. Ptients identified were requested to ome to the outptient deprtment for ssessment of their outomes. All ptients reported for ssessment; no ptient lost to follow-up. The HO ws lssified s per the sheme proposed y Hstings et l 3. Preopertive ssessment inluded n nteroposterior nd lterl rdiogrphs of the ffeted elow joint (Fig. 1 nd 2) nd omputed tomogrphy sn (CT) with three dimensionl (3D) reonstrution (Fig. 1 nd 2). Surgery for the exision of the HO ws performed under generl nesthesi. Cses were operted under the tourniquet ontrol for ler operting field. The surgil pproh ws individulized for every ptient depending on the ntomi lotion nd extent of the HO. Either the medil pproh or the lterl pproh or omintion of two ws used depending on the lotion of the HO in ll exept one ptient. One ptient required the midline nterior pproh with the protetion of the neurovsulr undle. The ulnr nerve ws routinely trnsposed nteriorly. Rdil nerve ws found ensed in one of the ses t the distl humerus nd deompressed during surgery. An initil psulotomy ws Corresponding Author: Sndeep Kumr Nem, Deprtment of Orthopedis, Jwhrll Institute of Postgrdute Medil Edution nd Reserh, Pondiherry, Indi Emil: drsndeepnem@gmil.om 35

2 Mlysin Orthopedi Journl 2017 Vol 11 No 1 Sndeep KN, et l Tle I: Demogrphi dt, use of HO nd durtion of follow-up Ptient Elow Age Sex Side Time to Cuse of HO Follow-up numer Hstings (yers) opertion (months) lss fter HO (months) 1 IIIA 50 M Right 2 d Long reumeny 16 (on life support fter snke ite) IIA Left 2 IIIA 24 M Left 26 Non-speifi elow trum 12 3 IIA 30 M Right 4 Elow dislotion 12 4 IIA 15 M Left 5 Interondylr frture of distl humerus 18 5 IIIA 23 F Right 12 Elow trum 20 6 IIC 29 M Right 16 Elow trum 22 7 IIIA 5 F Left 24 Suprondylr frture distl humerus 13 8 IIA 43 M Left 14 Elow dislotion 24 9 IIIC 43 M Right 24 Elow dislotion 26 Men ge of ptients ws 38.7 yers. 7 Mles nd 2 Femles. Ptient 1 hd oth elows with HO. d Ptient 1 ws on ventiltor support for 56 dys fter snke ite. Tle II: Elow rnge of motion nd ptient rted stisftion Ptient Elow Ptient MEPI Flexion/ d Flexion/ e Prontion f Supintion numer Hstings rted Extension Extension lss stisftion in degrees in degrees Min Mx 1 IIIA IIA IIIA IIA IIA IIIA IIC IIIA IIA IIIC The men gin in flexion/extension r 80 degrees Ptient stisftion fter opertion on sle of 1 to 10 with 1 not t ll stisfied nd 10 very stisfied. Myo elow performne index. Position of fixed flexion deformity in degrees. d End point of flexion on flexion extension r. e Prontion in degrees of the prontion/supintion r. f Supintion in degrees of the prontion supintion r. done in ll the ses to exise the etopi one (Fig. 3). The ollterl ligments were identified nd proteted during the opertive proedure. Medil ollterl ligment required repir in one of the se. The elow ws stilized with trns-olernon pin until the heling of the medil ollterl ligment. Rdil hed required exision in tht se. At the onlusion of the proedure, hemostsis ws hieved y dithermy. Bleeding nellous one surfe ws treted with the one wx. The elow joint ws irrigted, nd losure ws done in lyers over sution drin to prelude hemtom olletion in the post-opertive period. After the opertion, Orl Indomethin 25 mg three times dily ws strted for six weeks for prophylxis ginst HO reurrene. The dose ws djusted for ptients less thn 18 yers. The sution drin ws disontinued fter 48 hours of opertion. Pin ontrol ws otined y opites with dose djusted s per weight. Ptients were put on ontinuous pssive motion mhine fter 24 hours of opertion for eight hours per dy nd ontinued for one week. Ative ssisted, nd pssive movements of the elow were strted. Ative physiotherpy ws strted one week fter opertion nd ptients were followed up t regulr intervls. Rdiogrphs of the ptients were tken t regulr intervls (Fig. 4). One 36

3 Exision of heterotopi ossifition ptient needed devition from protool euse of injury to the medil ollterl ligment. The Elow ws stilized y trns-olernon pin in the se ove, nd moiliztion of the elow ws strted fter three weeks. Follow-up rnge of motion of the se ove is shown in Fig. 5. The outome ssessment ws done y the Myo elow performne index (MEPI) nd the Amerin Shoulder nd Elow Surgeons-Elow sore (ASES-E sores) 4. RESULTS Nine ptients with ten elows reported for ssessment. One ptient hd oth elows with HO. The men follow-up ws 18 months (12-26 months). The demogrphi dt is summrized in Tle I. The funtionl nd ojetive outome dt re summrized in Tle II. The Myo elow performne sore (Tle II) ws exellent in two, good in six nd fir in two elows. The men MEPI ws 81. The gin of flexion/extension r ws t men of 80 degrees. The gin of prontion nd supintion from mid-prone position ws t men of 51.5 nd 73 degrees respetively degrees. The men vlue for ptient s stisftion fter surgery ws 6.7 on sle of ten (Tle II). The medin Grip strength mesured y dynmometer ws deresed in five ptients y men of 30 perent. Grip strength ws equl in three ptients. The grip strength ouldn t e ompred in one ptient euse of elow HO on oth the sides. All elows hd residul flexion deformity in the post-opertive period. There ws residul flexion deformity of 10 degrees in two, 20 degrees in two, 30 degrees in five nd 40 degrees in one elow fter the opertion. The men vlues for intensity of pin on lifting hevy weight (5KG) nd pin on doing repeted elow movements were 4.62 nd 3.75 of 10 respetively. One ptient filed to gin ny movement fter opertion due to reurrene of HO. One ptient sustined rdil nerve plsy whih reovered. He lso sustined deep infetion whih heled on deridement nd ntiioti therpy. Eight of the nine ptients ould do tivities requiring flexion (om hir nd do up utton of shirt). All ptients ould reh the perineum. Nine of nine ptients ould mnge to tie the shoe. No ptient hd elow instility t follow-up. DISCUSSION Terms heterotopi ossifition nd myositis ossifins hve een used inonsistently nd interhngely for ellmedited lmellr etopi one formtion in musle nd soft tissues. Formtion of mture lmellr one onfined to musle is lled myositis ossifins, nd extr osseous soft tissues is lled heterotopi ossifition 5. Hstings et l lssified HO y the severity of restrition of elow movements 3. Clss I inludes ptients with positive rdiogrphs for heterotopi ossifition, ut no funtionl limittions. Clss II rdiogrphs demonstrte heterotopi ossifition, nd there is funtionl limittion either in the flexion/extension xis (Clss IIA), or the prontion/supintion xis (Clss IIB), or oth the xes (Clss IIC). Clss III ptients hve the etopi one with nkylosis either in flexion/extension (Clss IIIA), prontion/supintion (Clss IIIB), or oth (Clss IIIC). We hd four elows of lss IIIA, one IIIC, four IIA nd one IIC in our study. Ring et l reported results of opertive exision of omplete ony nkylosis in 20 elows with HO 8. The etiology of HO ws urns in 11 nd trum in nine elows. They reported omprle results of HO exision in urns nd trum. We did not hve ny urn ptient in our ohort. All exept one ptient hd HO fter elow trum in our ohort. One ptient sustined snke ite nd hd to e shifted to life support on ventiltor for 56 dys. He developed HO of oth elows. The outomes of the ptient ove were not different from others 6-8. The men MEPI sore of our ptients ws 81. The MEPI sore is influened y elow stility, pin nd tivities of dily living esides rnge of motion of the elow joint. Reovery of funtionl rnge of motion lone is not suffiient for exellent MEPI. Our results for reovery of elow rnge of motion re omprle to other studies 6-8. We ssessed pin in ASES-E sores in our ohort of ptients. Three of the ten elows were pinless. Seven elows were hving pin either on lifting hevy ojets (>5KG) or doing repeted elow movements. ASES-E sores mesure pin while doing different tivities. Therefore, ptients in our study hd pin either on lifting hevy ojets or doing repeted elow movements. This finding hs not een reported in other studies. In spite of pin, ll ptients were le to mnge their tivities of dily living exept one who hd reurrene of HO. We hd 20% (2 of 10 elows) postopertive omplitions in our study. We hd poor results on one of the elows with lss IIIA HO. The ptient did not gin ny movement in the elow joint fter the opertion euse of the reurrene. Another ptient with HO lss IIIC sustined rdil nerve plsy, deep infetion nd instility of his elow joint fter the opertion. His rdil nerve plsy reovered ut deep infetion required repeted surgil proedures. Slzr et l in retrospetive study of 46 elows whih underwent surgil exision of HO reported dverse outomes in preopertive to the finl r of motion of the elow joint in ptients with hypertension, oesity, nd sene of peropertive nterior trnsposition of the ulnr nerve 9. They reported n verge of 17 %( 8 of 46 ses) postopertive omplitions ssoited with HO exision. Their omplitions inluded three nerve plsies, one deep infetion, three HO reurrenes nd one instility. We operted ptients in our study t the time of presenttion. We did not depend on the rdiologil evidene of mturtion of HO in our study. Four ptients were operted in six months; two ptients were operted in one yer, nd 37

4 7-208_OA1 3/27/17 9:17 PM Pge 38 Mlysin Orthopedi Journl 2017 Vol 11 No 1 () Sndeep KN, et l () () () Fig. 1: () Antero-posterior nd Lterl rdiogrphs showing HO Hstings IIIA ridging the humero-ulnr joint nteromedilly (rrows), () 3D CT of se shown in Figure 1. Fig. 2: () Antero-posterior nd lterl rdiogrphs showing HO Hstings IIIC ridging the humero-ulnr (rrows) nd rdio-ulnr joints (rrows), () 3D CT of se shown in Figure 2. Fig. 3: Photogrph of exised one of HO t the time of opertion. Fig. 4: Post-opertive ntero-posterior nd lterl rdiogrph of the se ove in Figure 1 fter 12 months of opertion. 38

5 Exision of heterotopi ossifition () () post-trumti elow stiffness in dults 13. They found short ourse of eleoxi to e helpful in the prevention of HO reurrene fter open rthrolysis for elow stiffness in dults nd ould e n effetive nd sfe option. () (d) Fig. 5: Elow rnge of motion of the se shown in Figure 2 fter 12 months of opertion () Extension, () Flexion, () Prontion nd (d) Supintion. three ptients were operted in two yers fter the onset of HO. Conventionl surgil dely of one yer or more for mturtion of HO hs no sis. This hs een demonstrted in vrious studies from time to time 10, 11. Chlidis et l do not support the onept tht erly exision triggers the lter reurrene 10. Chen et l in retrospetive study of 164 ptients over four yers studied the time point in surgil exision of heterotopi ossifition of the stiff post-trumti elow 11. They reommended erly exision with erly exerise useful for the tretment of HO iming t low reurrene rte nd stisftory funtion. We routinely used Indomethin (dose djusted s per weight) for durtion of six weeks fter the opertion. Though our smple size ws smll, we hd the reurrene of HO in one of our ptients. Vrious studies hve demonstrted the effiy of NSAID s for HO prophylxis fter mjor hip nd elow surgery 12, 13. Sun et l in retrospetive study of 154 ptients ssessed the effiy of eleoxi in preventing heterotopi ossifition reurrene fter open rthrolysis for The role of rdiotherpy for the prophylxis of HO is ontroversil. Milkovi et l reviewed the 12 rndomized ontrolled trils in systemti review on the effiy of rdiotherpy for the prophylxis of heterotopi ossifition 14. They did not find differene etween postopertive or preopertive rdiotherpy in preventing HO progression. Ploumis et l in systemti review of studies on rdiotherpy for prevention of heterotopi ossifition of the elow reported wek evidene in support of its use 15. However, we did not use single or multiple doses of rdiotherpy in our ptients in post-opertive period for prophylxis ginst reurrent HO. The hoie of surgil pproh in our study ws sed upon the ntomil lotion of HO. Vrious studies hve reommended the hoie of surgil pproh, nd the tehnique for exision of HO 8, 9, 16, 17. We routinely trnsposed ulnr nerve in ll of our ses. Some loss of rnge of motion is ssoited with signifint injuries of the elow joint, ut the full rnge of motion is unneessry for tivities of dily living. Funtionl rnge of motion of the elow joint is onsidered to e from 30 degrees to 130 degrees of flexion, n r of 100 degrees. Flexion ontrtures exeeding 45 degrees re uneptle nd severely restrit ptient s ility to perform tivities of dily living. We hd residul flexion ontrtures in ll elows fter the opertion, ut most of our ptients ould perform tivities of dily living. The limittions of our study re its smll smple size, retrospetive nture nd filure to reord preopertive sujetive nd ojetive sores. To onlude, surgil exision of HO of elow results in exellent to good funtionl outomes. 39

6 Mlysin Orthopedi Journl 2017 Vol 11 No 1 Sndeep KN, et l REFERENCES 1. Arms GD, Bellino MJ, Cheung EV. Risk ftors for development of heterotopi ossifition of the elow fter frture fixtion. J Shoulder Elow Surg. 2012; 21: Dougls K, Cnnd LK, Arher KR, Den DB, Lee S, Oremskey W. Inidene nd risk ftors of heterotopi ossifition following mjor elow trum. Orthopedis. 2012; 35: Hstings H, TJ Grhm. The lssifition nd tretment of heterotopi ossifition out the elow nd forerm. Hnd Clin. 1994; 10: Longo UG, Frneshi F, Loppini M, Mffulli N, Denro V. Rting systems for evlution of the elow. Br Med Bull. 2008; 87: Summerfield SL, DiGiovnni C, Weiss AP. Heterotopi ossifition of the elow. J Shoulder Elow Surg. 1997; 6: Lee EK, Nmdri S, Hoslkr HS, Keenn MA, Bldwin KD. Clinil results of the exision of heterotopi one round the elow: systemti review. J Shoulder Elow Surg. 2013; 22: Bldwin K, Hoslkr HS, Donegn DJ, Rendon N, Rmsey M, Keenn MA. Surgil resetion of heterotopi one out the elow: n institutionl experiene with trumti nd neurologi etiologies. J Hnd Surg Am. 2011; 36: Ring D, Jupiter JB. Opertive relese of omplete nkylosis of the elow due to heterotopi one in ptients without severe injury of the entrl nervous system. J Bone Joint Surg Am. 2003; 85: Slzr D, Golz A, Isrel H, Mrr G. Heterotopi ossifition of the elow treted with surgil resetion: risk ftors, ony nkylosis, nd omplitions. Clin Orthop Relt Res. 2014; 472: Chlidis B, Stengel D, Ginnoudis PV. Erly exision nd lte exision of heterotopi ossifition fter trumti rin injury re equivlent: systemti review of the literture. J Neurotrum. 2007; 24: Chen S, Yu SY, Yn H, Ci JY, Ouyng Y, Run HJ, et l. The time point in surgil exision of heterotopi ossifition of posttrumti stiff elow: reommendtion for erly exision followed y erly exerise. J Shoulder Elow Surg. 2015; 24: Frnsen M, Nel B. Non-steroidl nti-inflmmtory drugs for preventing heterotopi one formtion fter hip rthroplsty. Cohrne Dtse of Syst Rev. 2004;3. Art. No.: CD doi: / CD pu Sun Y, Ci J, Li F, Liu S, Run H, Fn C. The effiy of eleoxi in preventing heterotopi ossifition reurrene fter open rthrolysis for post-trumti elow stiffness in dults. J Shoulder Elow Surg. 2015; 24: Milkovi M, Popovi M, Rmn S, Tso M, Lm H, Chow E. Rdiotherpy for the prophylxis of heterotopi ossifition: A systemti review nd met-nlysis of rndomized ontrolled trils. Rdiother Onol. 2015; 116: Ploumis A, Belsis L, Ntzni E, Tsekeris P, Xenkis T. Rdiotherpy for prevention of heterotopi ossifition of the elow: systemti review of the literture. J Shoulder Elow Surg. 2013; 22: Grlnd DE. Surgil pprohes for resetion of heterotopi ossifition in trumti rin-injured dults. Clin Orthop Relt Res. 1991; 263: Viol RW, Hstings H. Tretment of etopi ossifition out the elow. Clin Orthop Relt Res. 2000; 370: