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 Traumatology
Faculty 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 JOINT
A: 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

ETIOLOGY
Traumatic brain injury

DIAGNOSIS

Signs and Symptoms

Unexplained

increase in pain, spasticity, or

muscle guarding
Decreased ROM
Stiffness
Radiographic evidence of ectopic bone

Physical Exam
Limited

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.

Imaging
On 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 Line
Anti-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 1020% 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 mobility
Ankylosis

Patient Monitoring
Serial

radiographs are obtained

at 1-3 month intervals for 6
months.

THANK YOU