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Heterotopic ossification of the elbow: a current concepts review

Heterotope Ossifikationen des Ellenbogens: eine aktuelle Übersicht

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Abstract

Background

Heterotopic ossification (HO) is defined as the formation of mature lamellar bone in non-skeletal tissues. Heterotopic ossification of the elbow is recognized as an uncommon but challenging complication following specific mechanisms of injury. However, the underlying pathophysiology as well as the optimal management and prophylaxis strategies continue to be debated.

Methods

We reviewed the available literature searching Medline via the PubMed interface. The main objective was to highlight current concepts of the pathophysiology, risk factors, diagnostic modalities, treatment practices, and prophylaxis recommendations of elbow HO.

Results

Heterotopic ossification of the elbow is commonly observed after trauma or surgery (3%–89%), CNS injuries (20%), and burns (0.1%–3%). The pathologic recruitment, activation, and expansion of chondro-osseous progenitors is affected by the local microenvironment resulting in formation of ectopic bone. Risk factors include specific mechanisms of injury, patient morbidity, and treatment modalities. Standard radiographs are usually sufficient for clinical assessment; however, ultrasound may be used as an early diagnostic modality and computed tomography (CT) scans can facilitate preoperative planning. Nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) are the most common prophylactic options for HO. In advanced stages, surgical resection has been found to improve patient outcomes regardless of the initial cause of injury.

Conclusion

Elbow HO is a diverse pathologic process with specific risk factors related to the individual etiology. The prophylactic use of NSAIDs and RT needs to be further investigated in the context of elbow HO. Patients with persistent functional impairment due to the disorder may be treated effectively by open or arthroscopic excision.

Zusammenfassung

Hintergrund

Heterotope Ossifikationen (HO) werden als abnorme Bildung von reifem Lamellenknochen in nichtskelettalen Geweben definiert. HO des Ellenbogens gelten als seltene, aber schwerwiegende Komplikation nach bestimmten Verletzungsmechanismen. Die zugrunde liegende Pathophysiologie sowie die optimalen Behandlungs- und Prophylaxestrategien werden jedoch weiterhin diskutiert.

Methoden

Die verfügbare Literatur in der Datenbank Medline wurde über die PubMed-Schnittstelle durchsucht. Ziel war es, aktuelle Konzepte zur Pathophysiologie, zu Risikofaktoren, Diagnosemodalitäten, Behandlungsmethoden und Prophylaxeempfehlungen für HO des Ellenbogens zu identifizieren.

Ergebnisse

HO des Ellenbogens werden insbesondere nach Traumata bzw. Operationen (3–89 %), Verletzungen des zentralen Nervensystems (ZNS, 20 %) sowie Verbrennungen (0,1–3 %) beobachtet. Hierbei wird die pathologische Rekrutierung, Aktivierung und Expansion von chondroossären Vorläuferzellen durch die lokale Mikroumgebung beeinflusst, was zur Bildung von ektopem Knochen führt. Zu den Risikofaktoren gehören spezifische Verletzungsmechanismen, die jeweilige Patientenmorbidität und die Behandlungsmodalitäten. Für die klinische Beurteilung sind Standard-Röntgenaufnahmen in der Regel ausreichend; allerdings können Ultraschalluntersuchungen zur frühzeitigen Diagnostik eingesetzt werden und computertomographische Aufnahmen die präoperative Planung erleichtern. Nichtsteroidale Antirheumatika (NSAID) und Strahlentherapie (RT) sind die gängigsten prophylaktischen Optionen für HO. In fortgeschrittenen Stadien hat sich gezeigt, dass eine chirurgische Resektion die Ergebnisse der Patienten unabhängig von der ursprünglichen Verletzungsursache verbessert.

Schlussfolgerung

Eine HO des Ellenbogens ist ein pathologischer Prozess mit vielfältigen Aspekten und spezifischen Risikofaktoren, die mit der jeweiligen Ätiologie assoziiert sind. Sowohl der prophylaktische Einsatz von NSAID als auch die RT müssen im Kontext von HO des Ellenbogens weiter untersucht werden. Patienten mit anhaltenden Funktionseinschränkungen aufgrund der Erkrankung können jedoch durch eine offene oder arthroskopische Exzision wirksam behandelt werden.

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Authors and Affiliations

  1. Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany

    Christoph-Johannes Pucher, Fabian Lanzerath, Michael Hackl MD, Lars Peter Müller MD PhD & Tim Leschinger MD

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  1. Christoph-Johannes Pucher
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  2. Fabian Lanzerath
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Correspondence to Fabian Lanzerath.

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C.-J. Pucher, F. Lanzerath, M. Hackl, L.P. Müller and T. Leschinger declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.

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Pucher, CJ., Lanzerath, F., Hackl, M. et al. Heterotopic ossification of the elbow: a current concepts review. Obere Extremität 18, 142–148 (2023). https://doi.org/10.1007/s11678-023-00747-7

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