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Heterotopic Ossification

  • Michael J. TauntonEmail author
Chapter
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Abstract

Heterotopic ossification (HO) after total hip arthroplasty can have a devastating impact on clinical function, and is often unpredictable. It is important, however, to inventory the risk factors for HO and to better understand the epidemiology of HO as reviewed above to better prevent its occurrence. The complete pathogenesis of HO is unknown, but surgical trauma to soft tissue or bone appears to induce the process. Current prophylactic measures generally adhere to one or more of the following three principles: disrupting the relevant inductive signaling pathways, altering the relevant osteoprogenitor cells in the target tissue, or modifying the environment conducive to heterotopic osteogenesis. The diagnosis of HO is made at postoperative visits both by physical exam and radiographic evaluation. Range of motion may be significantly reduced or eliminated altogether. Patients often complain of achy pain that has been progressive with concurrent decrease in motion. Gentle stretching and strengthening may prevent further stiffness, and encourage improved gait, and optimal positioning and function of the limb. Generally, after 1 year the bone is considered to be matured, and at that time if the decreased range of motion and pain are bad enough, excision may be contemplated.

Keywords

Total hip arthroplasty (THA) Complications of total hip arthroplasty (THA) Heterotopic ossification (HO) Brooker classification Range of motion (ROM) Pain Spondylitis, ankylosing/complications 

References

  1. 1.
    Brooker AF, et al. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am. 1973;55(8):1629–32.CrossRefPubMedGoogle Scholar
  2. 2.
    Vastel L, et al. Heterotopic ossification after total hip arthroplasty: risk factors and prevention. Rev Rhum Engl Ed. 1998;65(4):238–44.PubMedGoogle Scholar
  3. 3.
    Toom A, Haviko T, Rips L. Heterotopic ossification after total hip arthroplasty. Int Orthop. 2001;24(6):323–6.CrossRefPubMedGoogle Scholar
  4. 4.
    Spinarelli A, et al. Heterotopic ossification after total hip arthroplasty: our experience. Musculoskelet Surg. 2011;95(1):1–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Sneath RJS, et al. The effect of pulsed irrigation on the incidence of heterotopic ossification after total hip arthroplasty. J Arthroplasty. 2001;16(5):547–51.CrossRefPubMedGoogle Scholar
  6. 6.
    Pai VS. Heterotopic ossification in total hip arthroplasty. The influence of the approach. J Arthroplasty. 1994;9(2):199–202.CrossRefPubMedGoogle Scholar
  7. 7.
    Higo T, et al. The incidence of heterotopic ossification after cementless total hip arthroplasty. J Arthroplasty. 2006;21(6):852–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Goel A, Sharp DJ. Heterotopic bone formation after hip replacement. The influence of the type of osteoarthritis. J Bone Joint Surg Br. 1991;73(2):255–7.PubMedGoogle Scholar
  9. 9.
    Bal BS, et al. Heterotopic ossification after 2-incision total hip arthroplasty. J Arthroplasty. 2010;25(4):538–40.CrossRefPubMedGoogle Scholar
  10. 10.
    Newman EA, et al. Incidence of heterotopic ossification in direct anterior vs posterior approach to total hip arthroplasty: a retrospective radiographic review. Int Orthop. 2016;40:1967–73.CrossRefPubMedGoogle Scholar
  11. 11.
    Edwards DS, et al. Posterior mini-incision total hip arthroplasty controls the extent of post-operative formation of heterotopic ossification. Eur J Orthop Surg Traumatol. 2015;25(6):1051–5.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Corrigan CM, et al. Heterotopic ossification after hemiarthroplasty of the hip—a comparison of three common approaches. J Clin Orthop Trauma. 2015;6(1):1–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Biz C, et al. Heterotopic ossification following hip arthroplasty: a comparative radiographic study about its development with the use of three different kinds of implants. J Orthop Surg Res. 2015;10(1):176.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Shehab D, Elgazzar AH, Collier BD. Heterotopic ossification. J Nucl Med. 2002;43(3):346–53.PubMedGoogle Scholar
  15. 15.
    Vasileiadis GI, et al. Effect of heterotopic ossification on hip range of motion and clinical outcome. J Arthroplast. 2015;30(3):461–4.CrossRefGoogle Scholar
  16. 16.
    Rama KRBS, et al. Heterotopic ossification after surface replacement arthroplasty and total hip arthroplasty. A randomized study. J Arthroplasty. 2009;24(2):256–62.CrossRefPubMedGoogle Scholar
  17. 17.
    Thomas BJ. Heterotopic bone formation after total hip arthroplasty. Orthop Clin N Am. 1992;23(2):347–58.Google Scholar
  18. 18.
    Zhu Y, et al. Incidence and risk factors for heterotopic ossification after total hip arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2015;135(9):1307–14.CrossRefPubMedGoogle Scholar
  19. 19.
    Iorio R, Healy WL. Heterotopic ossification after hip and knee arthroplasty: risk factors, prevention, and treatment. J Am Acad Orthop Surg. 2002;10(6):409–16.CrossRefPubMedGoogle Scholar
  20. 20.
    Maloney WJ, et al. Prophylaxis for heterotopic bone formation after total hip arthroplasty using low-dose radiation in high-risk patients. Clin Orthop Relat Res. 1992;280:230–4.Google Scholar
  21. 21.
    Thilak J, et al. Risk factors of heterotopic ossification following total hip arthroplasty in patients with ankylosing spondylitis. J Arthroplasty. 2015;30(12):2304–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Kaliyaperumal K, Sathappan SS, Peng LY. Total hip arthroplasty for ankylosed hip secondary to heterotopic ossification. J Arthroplasty. 2008;23(3):470–5.CrossRefPubMedGoogle Scholar
  23. 23.
    Eggli S, Woo A. Risk factors for heterotopic ossification in total hip arthroplasty. Arch Orthop Trauma Surg. 2001;121(9):531–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Regis D, Sandri A, Sambugaro E. Incidence of heterotopic ossification after surface and conventional total hip arthroplasty: a comparative study using anterolateral approach and indomethacin prophylaxis. Biomed Res Int. 2013;2013:293528.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Aljurayyan A, Tanzer D, Tanzer M. Acute revision hip arthroplasty: a previously unrecognized risk factor for heterotopic ossification. Eur J Orthop Surg Traumatol. 2016;26(2):183–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Fransen M, et al. Determinants of heterotopic ossification after total hip replacement surgery. Hip Int. 2009;19(1):41–6.PubMedGoogle Scholar
  27. 27.
    Pakos EE, et al. Heterotopic ossification after total hip arthroplasty (THA) in congenital hip disease: comparison of two different prophylactic protocols. Clin Transl Oncol. 2009;11(2):103–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Pakos EE, et al. Prevention of heterotopic ossification in high-risk patients with total hip arthroplasty: the experience of a combined therapeutic protocol. Int Orthop. 2006;30(2):79–83.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Zimmermann SM, et al. Prevention of heterotopic ossification: an experimental study using a plasma expander in a murine model. BMC Surg. 2016;16(1):29.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Anthonissen J, et al. The role of muscular trauma in the development of heterotopic ossification after hip surgery: an animal-model study in rats. Injury. 2016;47(3):613–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Ahrengart L, Sahlin K, Lindgren U. Myositis ossificans after total hip replacement and perioperative muscle ischemia. J Arthroplasty. 1987;2(1):65–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Barthel T, et al. Prophylaxis of heterotopic ossification after total hip arthroplasty: a prospective randomized study comparing indomethacin and meloxicam. Acta Orthop Scand. 2002;73(6):611–4.PubMedGoogle Scholar
  33. 33.
    Beckmann JT, et al. The effect of NSAID prophylaxis and operative variables on heterotopic ossification after hip arthroscopy. Am J Sports Med. 2014;42(6):1359–64.CrossRefPubMedGoogle Scholar
  34. 34.
    Bek D, et al. Aspirin decreases the prevalence and severity of heterotopic ossification after 1-stage bilateral total hip arthroplasty for osteoarthrosis. J Arthroplasty. 2009;24(2):226–32.CrossRefPubMedGoogle Scholar
  35. 35.
    D'Lima DD, et al. Indomethacin versus radiation therapy for heterotopic ossification after hip arthroplasty. Orthopedics. 2001;24(12):1139–43.PubMedGoogle Scholar
  36. 36.
    Grohs JG, Schmidt M, Wanivenhaus A. Selective COX-2 inhibitor versus indomethacin for the prevention of heterotopic ossification after hip replacement: a double-blind randomized trial of 100 patients with 1-year follow-up. Acta Orthop. 2007;78(1):95–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Kan SL, et al. Nonsteroidal anti-inflammatory drugs as prophylaxis for heterotopic ossification after total hip arthroplasty: a systematic review and meta-analysis. Medicine (Baltimore). 2015;94(18):e828.CrossRefGoogle Scholar
  38. 38.
    Lavernia CJ, et al. Celecoxib and heterotopic bone formation after total hip arthroplasty. J Arthroplasty. 2014;29(2):390–2.CrossRefPubMedGoogle Scholar
  39. 39.
    Nunley RM, et al. Aspirin decreases heterotopic ossification after hip resurfacing. Clin Orthop Relat Res. 2011;469(6):1614–20.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Macfarlane RJ, et al. Pharmacological treatment of heterotopic ossification following hip and acetabular surgery. Expert Opin Pharmacother. 2008;9(5):767–86.CrossRefPubMedGoogle Scholar
  41. 41.
    Beckmann JT, et al. Effect of naproxen prophylaxis on heterotopic ossification following hip arthroscopy: a double-blind randomized placebo-controlled trial. J Bone Joint Surg Am. 2015;97(24):2032–7.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Saudan M, et al. Celecoxib versus ibuprofen in the prevention of heterotopic ossification following total hip replacement: a prospective randomised trial. J Bone Joint Surg Br. 2007;89(2):155–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Vasileiadis GI, et al. COX-2 inhibitors for the prevention of heterotopic ossification after THA. Orthopedics. 2011;34(6):467.CrossRefPubMedGoogle Scholar
  44. 44.
    Raisz LG. Potential impact of selective cyclooxygenase-2 inhibitors on bone metabolism in health and disease. Am J Med. 2001;110(Suppl 3A):43S–5S.CrossRefPubMedGoogle Scholar
  45. 45.
    Cohn RM, Valle AGD, Cornell CN. Heterotopic ossification is less after THA in patients who receive aspirin compared to coumadin. Bull NYU Hosp Jt Dis. 2010;68(4):266–72.PubMedGoogle Scholar
  46. 46.
    Han CD, Choi CH, Suh CO. Prevention of heterotopic bone formation after total hip arthroplasty using 600 rad in single dose in high risk patient. Yonsei Med J. 1997;38(2):96–100.CrossRefPubMedGoogle Scholar
  47. 47.
    Kienapfel H, et al. Prevention of heterotopic bone formation after total hip arthroplasty: a prospective randomised study comparing postoperative radiation therapy with indomethacin medication. Arch Orthop Trauma Surg. 1999;119(5–6):296–302.CrossRefPubMedGoogle Scholar
  48. 48.
    Padgett DE, et al. The efficacy of 500 centigray radiation in the prevention of heterotopic ossification after total hip arthroplasty: a prospective, randomized, pilot study. J Arthroplasty. 2003;18(6):677–86.CrossRefPubMedGoogle Scholar
  49. 49.
    Strauss JB, et al. Cost of radiotherapy versus NSAID administration for prevention of heterotopic ossification after total hip arthroplasty. Int J Radiat Oncol Biol Phys. 2008;71(5):1460–4.CrossRefPubMedGoogle Scholar
  50. 50.
    Pohl F, et al. Radiation-induced suppression of the Bmp2 signal transduction pathway in the pluripotent mesenchymal cell line C2C12: an in vitro model for prevention of heterotopic ossification by radiotherapy. Radiat Res. 2003;159(3):345–50.CrossRefPubMedGoogle Scholar
  51. 51.
    Kjaersgaard-Andersen P, et al. Heterotopic bone formation after total hip arthroplasty in patients with primary or secondary coxarthrosis. Orthopedics. 1990;13(11):1211–7.PubMedGoogle Scholar
  52. 52.
    Sheybani A, et al. Risk of radiation-induced malignancy with heterotopic ossification prophylaxis: a case-control analysis. Int J Radiat Oncol Biol Phys. 2014;89(3):584–9.CrossRefPubMedGoogle Scholar
  53. 53.
    Ahrengart L, Lindgren U. Functional significance of heterotopic bone formation after total hip arthroplasty. J Arthroplasty. 1989;4(2):125–31.CrossRefPubMedGoogle Scholar
  54. 54.
    Cobb TK, et al. Functional outcome of excision of heterotopic ossification after total hip arthroplasty. Clin Orthop Relat Res. 1999;361:131–9.CrossRefGoogle Scholar
  55. 55.
    De Smet K, Pattyn C, Verdonk R. Early resection of heterotopic ossification after total hip arthroplasty: a review of the literature. Hip Int. 2002;12(4):383–7.PubMedGoogle Scholar
  56. 56.
    Warren SB, Brooker Jr AF. Excision of heterotopic bone followed by irradiation after total hip arthroplasty. J Bone Joint Surg Am. 1992;74(2):201–10.CrossRefPubMedGoogle Scholar
  57. 57.
    Childs III HA, et al. A prospective evaluation of the timing of postoperative radiotherapy for preventing heterotopic ossification following traumatic acetabular fractures. Int J Radiat Oncol Biol Phys. 2000;47(5):1347–52.CrossRefPubMedGoogle Scholar
  58. 58.
    Seegenschmiedt MH, Makoski HB, Micke O. Radiation prophylaxis for heterotopic ossification about the hip joint—a multicenter study. Int J Radiat Oncol Biol Phys. 2001;51(3):756–65.CrossRefPubMedGoogle Scholar
  59. 59.
    Chao ST, et al. External beam radiation helps prevent heterotopic bone formation in patients with a history of heterotopic ossification. J Arthroplasty. 2006;21(5):731–6.CrossRefPubMedGoogle Scholar
  60. 60.
    Lonardi F, et al. Preoperative, single-fraction irradiation for prophylaxis of heterotopic ossification after total hip arthroplasty. Int Orthop. 2001;25(6):371–4.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryMayo ClinicRochesterUSA

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