- See:
-
management of burns
-
ossification of soft tissues:
-
hetertopic ossification:
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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;
- in the protocol outlined by Mcauliffe and Wolfson 1997, early operative excision (performed as soon as 3 months after injury) which
was followed by a total XRT dose of 1000 centigray, given in 200 centigray factions;
- the operative wound was not excluded from the field;
- the radial aspect of the elbow was spared inorder to preserve the lymphatic system;
- in the report by Viola etal. JHS 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;
- the authors elected to perform an anterior submuscular transposition of the 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;
- ref: Early simple release of posttraumatic elbow contracture associated with heterotopic ossification; Randall W. Viola, MD. J Hand Surg 1999;24A:370-380.
- Proximal Radial Resection:
- in the report by
Srinath Kamineni, the authors evaluated proximal radial resection as a
technique to manage hetertopic ossification about the 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;
- Radiation Therapy:
- in the report by R. Heyd 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 radiotherapy, with two fractions of 500 cGy applied on the first two postop days, and the remaining four were irradiated
with 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. R. Heyd. J Bone Joint Surg (Br) 2001;83-B:332-4.
Early Excision of Hetertopic Ossification about the Elbow followed by Radiation Therapy. J.A. Mcauliffe MD, A.H. Wolfson MD. JBJS Vol 79-A No 5. May 1997.
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
The Journal of Bone and Joint Surgery (American) 84:745-751 (2002)
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
