J Shoulder Elbow Surg (2015) 24, 333-338
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Heterotopic ossification formation after fracture-dislocations of the elbow Dave R. Shukla, MD*, Gita Pillai, MD, Steven McAnany, MD, Michael Hausman, MD, Bradford O. Parsons, MD Leni and Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA Background: Heterotopic ossification (HO) is a serious complication of traumatic elbow injuries, particularly fracture-dislocations. Limited data exist in the literature regarding the risk factors associated with HO formation in these injuries. The purpose of this study was to review the incidence of HO after fracture-dislocation of the elbow and to identify potential risk factors associated with its formation. Methods: Twenty-seven patients (28 elbows) were surgically treated for elbow fracture-dislocations during 8 years, with an average follow-up of 14 months. Records were reviewed with attention paid to several factors: demographic data, comorbidities, time interval from injury to surgical intervention, number of closed reductions attempted before surgery, surgical approach, management of the radial head, treatment of the anterior capsular injury, and coronoid fixation. Results: Of the 28 elbows, 12 (43%) developed HO postoperatively; 9 of 28 elbows underwent multiple attempted closed reductions before definitive surgical stabilization, with HO formation in 7 of the 9 (77%). Time to surgery, age, gender, radial head fixation or replacement, coronoid open reduction and internal fixation, capsular repair, and medical comorbidities were not found to influence HO formation, although the performance of multiple reductions was identified as a risk factor. Discussion: HO developed in 77% of patients with multiple attempted closed reductions. We found a 43% incidence of HO in patients surgically treated for elbow fracture-dislocations. Neither time to surgery after the injury nor demographic or other factors relating to the manner in which associated osseous or soft tissue injuries were managed influenced the formation of HO. Level of evidence: Level IV, Case Series, Prognosis Study. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Elbow; heterotopic ossification; fracture-dislocation; terrible triad; coronoid; radial head
The formation of heterotopic ossification (HO) is a known complication of elbow injuries, but few studies have reported on its incidence specifically after elbow fracturedislocations (Figs. 1-3). Several reports have examined the This study was approved by the Institutional Review Board: No. 171319. *Reprint requests: Dave R. Shukla, MD, Leni and Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA. E-mail address: [email protected] (D.R. Shukla).
incidence of HO after elbow trauma, although much of the currently available data were reported from larger groups of patients with heterogeneous injuries of the elbow. One of the earliest studies by Thompson and Garcia15 noted a 17.6% rate of HO in heterogeneously treated patients with fracture-dislocations. Gaston et al8 described a 20% incidence of HO in their series of patients with fracturedislocations. More recently, Ring et al14 reviewed 11 patients with ‘‘terrible triad’’ injuries and noted a 9% incidence of HO. Pugh et al,12 who described a standard
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.11.037
334
D.R. Shukla et al.
Figure 3 Postoperative lateral view of the elbow after radial head open reduction and internal fixation and ligamentous reconstruction, with subsequent formation of heterotopic ossification.
Figure 1 Anteroposterior view of patient with a fracturedislocation of the elbow.
formation of HO in patients sustaining fracture-dislocations of the elbow. Previously, delay in treatment time between the injury and operative intervention has been noted to be related to formation of HO after these injuries.5-7,13 Because many patients who develop HO require secondary surgical release or excision to regain motion and function, the development of HO can have a dramatic impact on outcome as well as the added burden of additional procedures. The ability to identify patients at risk for HO formation after elbow fracture-dislocations may be helpful in guiding treatment protocols. The purpose of this study was to define the incidence of HO after operative treatment of elbow fracture-dislocations and to identify risk factors associated with its formation after an elbow fracture-dislocation injury.
Materials and methods
Figure 2 Lateral view of patient with a fracture-dislocation of the elbow.
surgical protocol to treat terrible triad injuries, described a 14% incidence of HO. Neither study attempted to identify risk factors for the formation of HO. Although there are certain established risk factors for the development of HO, such as injury to the central nervous system and severe burn injuries, there have been few studies that have attempted to identify risk factors for the
After receiving approval from our Institutional Review Board, we conducted a retrospective review of the hospital records of 27 patients who sustained fracture-dislocation injuries of the elbow. Each was managed by 1 of 2 surgeons (B.P. and M.H.) at our institution or our affiliate institution, Elmhurst Hospital (Queens, NY, USA). Our patient population consisted of 16 women (59%) and 11 men (31%), ranging in age from 15 to 78 years (mean, 46 years). The patients were observed for an average of 14 months (range, 8-32 months). Of the 27 patients, 23 (85%) sustained a terrible triad injury, defined as a coronoid fracture, a radial head fracture, and an ulnohumeral dislocation, with 1 patient sustaining bilateral terrible triad injuries. Of the remaining 4 patients, 2 (8%) sustained capitellar fracture-dislocations, whereas the other 2 sustained coronoid fracture-dislocations. After operative treatment of their injury, no patients were given oral prophylaxis (indomethacin) to prevent HO. All patients began physical therapy in a standardized fashion. Patients who suffered concomitant head injuries or burns or had sustained prior injury to the affected elbow were excluded from analysis.
Heterotopic ossification after elbow surgery Table I
335
Data for the 7 of 12 patients who developed HO and underwent a subsequent surgical procedure
Patient number
Side
No. of closed reductions
Brooker stage at final follow-up
HO locations at final follow-up
Surgical treatments
1
Left
2
2
A
2
Right
2
3
A, P
3
Right
3
2
A, L
4
Left
2
3
A, P, M, L
5
Right
2
3
A, P, M, L
6
Right
3
2
M, L
7
Left
2
1
M, L
RH arthroplasty LUCL graft reconstruction ORIF of RH ORIF of capitellum LUCL repair ORIF of RH LUCL reconstruction Placement of external fixator RH arthroplasty MCL repair LUCL repair ORIF of RH Interosseous membrane release Annular ligament reconstruction Radial and ulnar neuroplasties ORIF of RH LUCL repair Anterior and posterior capsulectomy Complete capsular resection RH arthroplasty Excision of radioulnar synostosis LUCL reconstruction Radial and ulnar neuroplasties
HO, heterotopic ossification; A, anterior; P, posterior; M, medial; L, lateral; RH, radial head; LUCL, lateral ulnar collateral ligament; ORIF, open reduction and internal fixation; MCL, medial collateral ligament.
Patient and treatment variables were analyzed for possible association with HO formation, including the patient’s age and gender, number of attempted closed reduction maneuvers before surgical intervention, time interval from injury to surgical intervention, type of surgical approach, radial head repair vs. replacement, anterior capsular repair or lack thereof, and coronoid repair. In 11 of 12 patients who developed heterotopic bone, sufficient radiographic data were available at review to determine the locations (i.e., anterior, posterior, medial, lateral) and Brooker stage4 of heterotopic bone. Although the Brooker classification was originally described for HO around the hip, it is commonly used to describe heterotopic bone formation about the elbow: stage I describes islands of bone in the surrounding soft tissue; stage II describes spurs of bone proximal or distal to the elbow, with at least 1 cm between opposing surfaces; stage III describes bone spurs from proximal or distal to the elbow, with less than 1 cm between the opposing surfaces; and stage IV describes apparent bridging bone across the joint, with ankylosis of the elbow. Categorical data were assessed by c2 testing. Continuous variables were treated with the Student t test. The level of significance was set at P < .05. Post hoc analyses, including estimation of an odds ratio with 95% confidence intervals, were performed where appropriate.
Results Our review identified 27 patients with 28 elbow fracturedislocation injuries who underwent operative treatment of
their injury. No patients in this cohort had prior elbow trauma or disease or concomitant head trauma or burn injury. HO was identified in 12 of 28 elbows (43% incidence) postoperatively. Of 12 elbows that developed HO, 7 (58%) underwent subsequent surgery to excise the HO and to improve final function of the elbow (Table I). The Brooker classification was determined in 11 of 12 elbows. Of 11 elbows, 2 (18%) developed stage I, 5 (46%) developed stage II, and 4 (36%) developed stage III. Heterotopic bone formed in at least 2 locations around the elbow joint in all 11 patients (e.g., medial/lateral, or medial/lateral/posterior). Of 11 elbows, 8 (73%) formed HO anteriorly, 8 laterally, 7 (64%) medially, and 3 (27%) posteriorly.
Risk factor analysis We identified 9 of 27 elbows that underwent multiple closed reduction maneuvers (2 or more) before definitive surgical repair. Of these 9 elbows, 7 (78%) developed HO (P ¼ .01). The performance of multiple reduction (>1) attempts was found to be a risk factor for development of HO (odds ratio, 9.8; 95% confidence interval, 1.6-60.8). The average time to surgery was not significantly different for patients who developed HO postoperatively (7 days; range, 3-12) and those who did not (13 days; range, 3-62; P ¼ .16). The longest delay (62 days) was from a patient who first presented to an outside hospital where that
336 individual was treated nonoperatively. After surgical repair, this patient did not develop HO. Similarly, the patient’s gender and age, type of surgical approach, type of radial head fracture management, coronoid open reduction and internal fixation, and capsular repair were not found to have a significant impact on the formation of HO. Of 27 elbows, 26 were treated with either an isolated lateral column approach or a combined mediallateral approach. One patient was treated by an extensile posterior approach, and this patient did not develop HO postoperatively.
Discussion HO is a known complication or consequence of elbow trauma and, if severe enough, may require surgical excision for functional range of motion of the elbow to be restored. Many series have discussed the incidence of and factors associated with HO formation after elbow trauma, but most have contained a heterogeneous series of elbow injuries and patients and have examined factors specific to timing or patient demographics. We sought to examine a homogeneous series of patients with elbow fracture-dislocations, evaluating a variety of factors, including injury patterns, recurrent instability of the joint, timing of surgery, type of surgical repair, and patient demographics, in hopes of obtaining a better sense of which patients are at greater risk for HO formation postoperatively. In our series, we found a 43% incidence of HO after the surgical treatment of elbow fracture-dislocations, a higher incidence than in many previous studies examining the incidence of HO after elbow trauma.1-3,5,12,15 In our review, the factor with the greatest impact on the formation of postoperative HO was the unstable elbow that underwent multiple closed reduction maneuvers before definitive surgical management. HO developed in 7 of 9 of elbows (78%) that had multiple closed reduction maneuvers preoperatively (2 or more), as opposed to 5 of 16 elbows (31%) that underwent only 1 reduction maneuver in our series. Other factors, including the patient’s gender and age and the procedure performed (i.e., radial head repair vs. radial head replacement, coronoid internal fixation, and capsular repair), did not have a significant impact on HO formation, similar to other series.2,5,9 We did not find that time to operative intervention had a significant impact on the formation of HO postoperatively in our patients. The formation of HO in the elbow after trauma has been well documented in the literature.1,2,5,8-10,15 Predisposing factors, such as head injury and burns, have been well delineated.6,7,13 The largest series that looked at the incidence of post-traumatic elbow HO is a study by Thompson and Garcia,15 which reported a 3% incidence of post-traumatic HO about the elbow in 1314 patients. This study reviewed a heterogeneous group of elbow
D.R. Shukla et al. injuries, including distal humeral fractures, Monteggia fractures, olecranon fractures, isolated radial head fractures, simple dislocations of the elbow, and fracturedislocations. The authors reported a 17.6% incidence of HO in 136 patients who had fracture-dislocations of the elbow. Of note, 8 of 24 patients (33%) with radial head fracture-dislocations and subsequent HO formation underwent multiple attempts at closed reduction, which the authors suggested was likely to be a risk factor for its development. Some recent series have looked at the outcomes of management of terrible triad injuries of the elbow and reported the rate of heterotopic bone formation that occurred postoperatively. Pugh et al12 reported that 5 of 36 elbows (13.9%) formed heterotopic bone after operative management. Broberg and Morrey,3 in their study of ulnohumeral dislocations with radial head fractures, noted 1 case of HO in their review of 24 patients (4%). Ring et al,14 in their review of 11 patients with terrible triad injuries, reported 1 patient who developed HO. None of these series attempted to analyze risk factors for the formation of HO in their patients. Prophylaxis against HO formation after surgical repair of elbow fracture-dislocations is not well defined in the literature, and its role would seem to require further evaluation. Currently, one of the senior authors routinely administers indomethacin to patients after surgical treatment of elbow fracture-dislocations. In our study, we found no significant difference in time to operative treatment between the patients who developed HO and the patients who did not. McLaughlin11 examined patients with elbow dislocations and radial head fractures and noted a decrease in the incidence of HO when treating the patients operatively within 24 hours. Gaston et al8 similarly found that in 10 patients with radial head fractures and elbow dislocations, 50% of the patients who were treated operatively after 48 hours developed HO. Similarly, a study by Ilahi et al9 examined the effect of surgical timing on HO formation in 41 patients treated for elbow fractures, including 6 patients with fracture-dislocations, specifically examining 24-, 48-, and 72-hour delays. Patients operated on after 48 hours had a significantly increased incidence of HO. Although our study did not find a correlation between operative time and heterotopic bone formation, a limitation is that none of our patients underwent operative treatment within 48 hours of the injury because of the tertiary referral pattern of our center. Thus, direct comparison of this factor between our data and prior studies may not be accurate. Our increased incidence of HO in elbows requiring multiple reduction attempts would seem to make inherent sense. These elbows often had greater osseous or soft tissue injury, which may predispose the elbow to increased heterotopic bone formation. In these patients, earlier intervention (given previous literature findings) as well as the
Heterotopic ossification after elbow surgery potential use of oral prophylaxis may be warranted in an effort to decrease the likelihood of heterotopic bone formation. We observed that 7 of 12 patients (58%) who developed HO underwent subsequent surgery. The currently available literature has demonstrated varying rates of reoperation for excision of HO. Whereas Bauer et al2 noted a reoperation rate of 71%, most other studies report lower rates. For example, a reoperation rate for excision of HO of 26% was reported by Douglas et al,5 20% by Thompson and Garcia,15 and only 9% by Abrams et al.1 It is possible that our rate of reoperation for excision of HO was higher than that currently reported as ours is a tertiary referral center for elbow disorders. There are several limitations to this study, including the retrospective nature of the data collection and the small number of patients, which limit the power of our data analysis. One specific flaw inherent to retrospective review is that in one patient who developed HO, we did not have sufficient final radiographs to fully classify the heterotopic bone. In addition, although we identified patients who developed HO, including patients who underwent additional surgery to excise symptomatic heterotopic bone, we did not attempt to correlate the location of HO, its severity of formation, or its subsequent treatment in any manner. However, given that our purpose was to analyze the incidence of HO and factors associated with its formation, as opposed to the management of postoperative HO, we do not think that this adversely affected the findings of the study. In specific comparison to the prior available literature, we did not find an effect of timing of surgery on formation of HO; but again, given that none of our patients were operatively treated within 48 hours of injury owing to the referral pattern of our center, we cannot conclude that delay does or does not have a consequence on HO formation after injury to the elbow. Despite these limitations, the strength of the study is its analysis of a specific injury to the elbow, the fracturedislocation, and the factors that may have an impact on the formation of HO in these patients. The finding that the recurrently unstable elbow, which requires multiple attempts at closed reduction before surgical management, significantly increases the risk of HO formation would seem to be relevant to the surgeon and patient and has not been the focus of any prior investigation to our knowledge. Importantly, in contradistinction to other risk factors for HO formation after elbow trauma, this is one risk factor within this spectrum of injury that is preventable and should be eliminated. Our data suggest that multiple attempts at reduction increase the risk of HO formation and should therefore be minimized if at all possible. In addition, the initial management of this injury pattern might best be performed by a surgeon who has sufficient experience and can proceed to early open reduction in the event that an acceptable, stable reduction
337 cannot be achieved through minimal attempts at closed manipulation. In the patient with the recurrently unstable elbow fracture-dislocation, administering prophylaxis against HO formation perioperatively may be warranted, and we now counsel these patients that they are at higher risk for heterotopic bone formation. However, the exact role of prophylaxis and its proper administration in patients with elbow injuries, including fracture-dislocations, require further work and investigation.
Conclusion In patients who have undergone operative procedures after elbow fracture-dislocations, the performance of multiple reduction attempts increases the risk of subsequent HO formation. Patient demographic factors and surgical factors (i.e., approach, fracture and soft tissue management) did not independently influence the risk of HO formation in our series. Patients and surgeons should be aware of the increased risk after highly unstable injuries as it has the potential to influence outcomes.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Abrams GD, Bellino MJ, Cheung EV. Risk factors for development of heterotopic ossification of the elbow after fracture fixation. J Shoulder Elbow Surg 2012;21:1550-4. http://dx.doi.org/10.1016/j. jse.2012.05.040 2. Bauer AS, Lawson BK, Bliss RL, Dyer GS. Risk factors for posttraumatic heterotopic ossification of the elbow: case-control study. J Hand Surg Am 2012;37:1422-9.e1-6. http://dx.doi.org/10.1016/j.jhsa. 2012.03.013 3. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res 1987:109-19. 4. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973;55: 1629-32. 5. Douglas K, Cannada LK, Archer KR, Dean DB, Lee S, Obremskey W. Incidence and risk factors of heterotopic ossification following major elbow trauma. Orthopedics 2012;35:e815-22. http://dx.doi.org/10. 3928/01477447-20120525-18 6. Garland DE. A clinical perspective on common forms of acquired heterotopic ossification. Clin Orthop Relat Res 1991:13-29.
338 7. Garland DE, O’Hollaren RM. Fractures and dislocations about the elbow in the head-injured adult. Clin Orthop Relat Res 1982: 38-41. 8. Gaston SR, Smith FM, Baab OD. Adult injuries of the radial head and neck; importance of time element in treatment. Am J Surg 1949;78: 631-5. Disc, 47-51. 9. Ilahi OA, Strausser DW, Gabel GT. Post-traumatic heterotopic ossification about the elbow. Orthopedics 1998;21:265-8. 10. Lee EK, Namdari S, Hosalkar HS, Keenan MA, Baldwin KD. Clinical results of the excision of heterotopic bone around the elbow: a systematic review. J Shoulder Elbow Surg 2013;22:716-22. http://dx.doi. org/10.1016/j.jse.2012.11.020
D.R. Shukla et al. 11. McLaughlin HL. Some fractures with a time limit. Surg Clin North Am 1955; New York No.:553-61. 12. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am 2004;86:1122-30. 13. Puzas JE, Miller MD, Rosier RN. Pathologic bone formation. Clin Orthop Relat Res 1989:269-81. 14. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-51. 15. Thompson HC 3rd, Garcia A. Myositis ossificans: aftermath of elbow injuries. Clin Orthop Relat Res 1967;50:129-34.
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Heterotopic ossification formation after fracture-dislocations of the elbow Dave R. Shukla, MD*, Gita Pillai, MD, Steven McAnany, MD, Michael Hausman, MD, Bradford O. Parsons, MD Leni and Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA Background: Heterotopic ossification (HO) is a serious complication of traumatic elbow injuries, particularly fracture-dislocations. Limited data exist in the literature regarding the risk factors associated with HO formation in these injuries. The purpose of this study was to review the incidence of HO after fracture-dislocation of the elbow and to identify potential risk factors associated with its formation. Methods: Twenty-seven patients (28 elbows) were surgically treated for elbow fracture-dislocations during 8 years, with an average follow-up of 14 months. Records were reviewed with attention paid to several factors: demographic data, comorbidities, time interval from injury to surgical intervention, number of closed reductions attempted before surgery, surgical approach, management of the radial head, treatment of the anterior capsular injury, and coronoid fixation. Results: Of the 28 elbows, 12 (43%) developed HO postoperatively; 9 of 28 elbows underwent multiple attempted closed reductions before definitive surgical stabilization, with HO formation in 7 of the 9 (77%). Time to surgery, age, gender, radial head fixation or replacement, coronoid open reduction and internal fixation, capsular repair, and medical comorbidities were not found to influence HO formation, although the performance of multiple reductions was identified as a risk factor. Discussion: HO developed in 77% of patients with multiple attempted closed reductions. We found a 43% incidence of HO in patients surgically treated for elbow fracture-dislocations. Neither time to surgery after the injury nor demographic or other factors relating to the manner in which associated osseous or soft tissue injuries were managed influenced the formation of HO. Level of evidence: Level IV, Case Series, Prognosis Study. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Elbow; heterotopic ossification; fracture-dislocation; terrible triad; coronoid; radial head
The formation of heterotopic ossification (HO) is a known complication of elbow injuries, but few studies have reported on its incidence specifically after elbow fracturedislocations (Figs. 1-3). Several reports have examined the This study was approved by the Institutional Review Board: No. 171319. *Reprint requests: Dave R. Shukla, MD, Leni and Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA. E-mail address: [email protected] (D.R. Shukla).
incidence of HO after elbow trauma, although much of the currently available data were reported from larger groups of patients with heterogeneous injuries of the elbow. One of the earliest studies by Thompson and Garcia15 noted a 17.6% rate of HO in heterogeneously treated patients with fracture-dislocations. Gaston et al8 described a 20% incidence of HO in their series of patients with fracturedislocations. More recently, Ring et al14 reviewed 11 patients with ‘‘terrible triad’’ injuries and noted a 9% incidence of HO. Pugh et al,12 who described a standard
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.11.037
334
D.R. Shukla et al.
Figure 3 Postoperative lateral view of the elbow after radial head open reduction and internal fixation and ligamentous reconstruction, with subsequent formation of heterotopic ossification.
Figure 1 Anteroposterior view of patient with a fracturedislocation of the elbow.
formation of HO in patients sustaining fracture-dislocations of the elbow. Previously, delay in treatment time between the injury and operative intervention has been noted to be related to formation of HO after these injuries.5-7,13 Because many patients who develop HO require secondary surgical release or excision to regain motion and function, the development of HO can have a dramatic impact on outcome as well as the added burden of additional procedures. The ability to identify patients at risk for HO formation after elbow fracture-dislocations may be helpful in guiding treatment protocols. The purpose of this study was to define the incidence of HO after operative treatment of elbow fracture-dislocations and to identify risk factors associated with its formation after an elbow fracture-dislocation injury.
Materials and methods
Figure 2 Lateral view of patient with a fracture-dislocation of the elbow.
surgical protocol to treat terrible triad injuries, described a 14% incidence of HO. Neither study attempted to identify risk factors for the formation of HO. Although there are certain established risk factors for the development of HO, such as injury to the central nervous system and severe burn injuries, there have been few studies that have attempted to identify risk factors for the
After receiving approval from our Institutional Review Board, we conducted a retrospective review of the hospital records of 27 patients who sustained fracture-dislocation injuries of the elbow. Each was managed by 1 of 2 surgeons (B.P. and M.H.) at our institution or our affiliate institution, Elmhurst Hospital (Queens, NY, USA). Our patient population consisted of 16 women (59%) and 11 men (31%), ranging in age from 15 to 78 years (mean, 46 years). The patients were observed for an average of 14 months (range, 8-32 months). Of the 27 patients, 23 (85%) sustained a terrible triad injury, defined as a coronoid fracture, a radial head fracture, and an ulnohumeral dislocation, with 1 patient sustaining bilateral terrible triad injuries. Of the remaining 4 patients, 2 (8%) sustained capitellar fracture-dislocations, whereas the other 2 sustained coronoid fracture-dislocations. After operative treatment of their injury, no patients were given oral prophylaxis (indomethacin) to prevent HO. All patients began physical therapy in a standardized fashion. Patients who suffered concomitant head injuries or burns or had sustained prior injury to the affected elbow were excluded from analysis.
Heterotopic ossification after elbow surgery Table I
335
Data for the 7 of 12 patients who developed HO and underwent a subsequent surgical procedure
Patient number
Side
No. of closed reductions
Brooker stage at final follow-up
HO locations at final follow-up
Surgical treatments
1
Left
2
2
A
2
Right
2
3
A, P
3
Right
3
2
A, L
4
Left
2
3
A, P, M, L
5
Right
2
3
A, P, M, L
6
Right
3
2
M, L
7
Left
2
1
M, L
RH arthroplasty LUCL graft reconstruction ORIF of RH ORIF of capitellum LUCL repair ORIF of RH LUCL reconstruction Placement of external fixator RH arthroplasty MCL repair LUCL repair ORIF of RH Interosseous membrane release Annular ligament reconstruction Radial and ulnar neuroplasties ORIF of RH LUCL repair Anterior and posterior capsulectomy Complete capsular resection RH arthroplasty Excision of radioulnar synostosis LUCL reconstruction Radial and ulnar neuroplasties
HO, heterotopic ossification; A, anterior; P, posterior; M, medial; L, lateral; RH, radial head; LUCL, lateral ulnar collateral ligament; ORIF, open reduction and internal fixation; MCL, medial collateral ligament.
Patient and treatment variables were analyzed for possible association with HO formation, including the patient’s age and gender, number of attempted closed reduction maneuvers before surgical intervention, time interval from injury to surgical intervention, type of surgical approach, radial head repair vs. replacement, anterior capsular repair or lack thereof, and coronoid repair. In 11 of 12 patients who developed heterotopic bone, sufficient radiographic data were available at review to determine the locations (i.e., anterior, posterior, medial, lateral) and Brooker stage4 of heterotopic bone. Although the Brooker classification was originally described for HO around the hip, it is commonly used to describe heterotopic bone formation about the elbow: stage I describes islands of bone in the surrounding soft tissue; stage II describes spurs of bone proximal or distal to the elbow, with at least 1 cm between opposing surfaces; stage III describes bone spurs from proximal or distal to the elbow, with less than 1 cm between the opposing surfaces; and stage IV describes apparent bridging bone across the joint, with ankylosis of the elbow. Categorical data were assessed by c2 testing. Continuous variables were treated with the Student t test. The level of significance was set at P < .05. Post hoc analyses, including estimation of an odds ratio with 95% confidence intervals, were performed where appropriate.
Results Our review identified 27 patients with 28 elbow fracturedislocation injuries who underwent operative treatment of
their injury. No patients in this cohort had prior elbow trauma or disease or concomitant head trauma or burn injury. HO was identified in 12 of 28 elbows (43% incidence) postoperatively. Of 12 elbows that developed HO, 7 (58%) underwent subsequent surgery to excise the HO and to improve final function of the elbow (Table I). The Brooker classification was determined in 11 of 12 elbows. Of 11 elbows, 2 (18%) developed stage I, 5 (46%) developed stage II, and 4 (36%) developed stage III. Heterotopic bone formed in at least 2 locations around the elbow joint in all 11 patients (e.g., medial/lateral, or medial/lateral/posterior). Of 11 elbows, 8 (73%) formed HO anteriorly, 8 laterally, 7 (64%) medially, and 3 (27%) posteriorly.
Risk factor analysis We identified 9 of 27 elbows that underwent multiple closed reduction maneuvers (2 or more) before definitive surgical repair. Of these 9 elbows, 7 (78%) developed HO (P ¼ .01). The performance of multiple reduction (>1) attempts was found to be a risk factor for development of HO (odds ratio, 9.8; 95% confidence interval, 1.6-60.8). The average time to surgery was not significantly different for patients who developed HO postoperatively (7 days; range, 3-12) and those who did not (13 days; range, 3-62; P ¼ .16). The longest delay (62 days) was from a patient who first presented to an outside hospital where that
336 individual was treated nonoperatively. After surgical repair, this patient did not develop HO. Similarly, the patient’s gender and age, type of surgical approach, type of radial head fracture management, coronoid open reduction and internal fixation, and capsular repair were not found to have a significant impact on the formation of HO. Of 27 elbows, 26 were treated with either an isolated lateral column approach or a combined mediallateral approach. One patient was treated by an extensile posterior approach, and this patient did not develop HO postoperatively.
Discussion HO is a known complication or consequence of elbow trauma and, if severe enough, may require surgical excision for functional range of motion of the elbow to be restored. Many series have discussed the incidence of and factors associated with HO formation after elbow trauma, but most have contained a heterogeneous series of elbow injuries and patients and have examined factors specific to timing or patient demographics. We sought to examine a homogeneous series of patients with elbow fracture-dislocations, evaluating a variety of factors, including injury patterns, recurrent instability of the joint, timing of surgery, type of surgical repair, and patient demographics, in hopes of obtaining a better sense of which patients are at greater risk for HO formation postoperatively. In our series, we found a 43% incidence of HO after the surgical treatment of elbow fracture-dislocations, a higher incidence than in many previous studies examining the incidence of HO after elbow trauma.1-3,5,12,15 In our review, the factor with the greatest impact on the formation of postoperative HO was the unstable elbow that underwent multiple closed reduction maneuvers before definitive surgical management. HO developed in 7 of 9 of elbows (78%) that had multiple closed reduction maneuvers preoperatively (2 or more), as opposed to 5 of 16 elbows (31%) that underwent only 1 reduction maneuver in our series. Other factors, including the patient’s gender and age and the procedure performed (i.e., radial head repair vs. radial head replacement, coronoid internal fixation, and capsular repair), did not have a significant impact on HO formation, similar to other series.2,5,9 We did not find that time to operative intervention had a significant impact on the formation of HO postoperatively in our patients. The formation of HO in the elbow after trauma has been well documented in the literature.1,2,5,8-10,15 Predisposing factors, such as head injury and burns, have been well delineated.6,7,13 The largest series that looked at the incidence of post-traumatic elbow HO is a study by Thompson and Garcia,15 which reported a 3% incidence of post-traumatic HO about the elbow in 1314 patients. This study reviewed a heterogeneous group of elbow
D.R. Shukla et al. injuries, including distal humeral fractures, Monteggia fractures, olecranon fractures, isolated radial head fractures, simple dislocations of the elbow, and fracturedislocations. The authors reported a 17.6% incidence of HO in 136 patients who had fracture-dislocations of the elbow. Of note, 8 of 24 patients (33%) with radial head fracture-dislocations and subsequent HO formation underwent multiple attempts at closed reduction, which the authors suggested was likely to be a risk factor for its development. Some recent series have looked at the outcomes of management of terrible triad injuries of the elbow and reported the rate of heterotopic bone formation that occurred postoperatively. Pugh et al12 reported that 5 of 36 elbows (13.9%) formed heterotopic bone after operative management. Broberg and Morrey,3 in their study of ulnohumeral dislocations with radial head fractures, noted 1 case of HO in their review of 24 patients (4%). Ring et al,14 in their review of 11 patients with terrible triad injuries, reported 1 patient who developed HO. None of these series attempted to analyze risk factors for the formation of HO in their patients. Prophylaxis against HO formation after surgical repair of elbow fracture-dislocations is not well defined in the literature, and its role would seem to require further evaluation. Currently, one of the senior authors routinely administers indomethacin to patients after surgical treatment of elbow fracture-dislocations. In our study, we found no significant difference in time to operative treatment between the patients who developed HO and the patients who did not. McLaughlin11 examined patients with elbow dislocations and radial head fractures and noted a decrease in the incidence of HO when treating the patients operatively within 24 hours. Gaston et al8 similarly found that in 10 patients with radial head fractures and elbow dislocations, 50% of the patients who were treated operatively after 48 hours developed HO. Similarly, a study by Ilahi et al9 examined the effect of surgical timing on HO formation in 41 patients treated for elbow fractures, including 6 patients with fracture-dislocations, specifically examining 24-, 48-, and 72-hour delays. Patients operated on after 48 hours had a significantly increased incidence of HO. Although our study did not find a correlation between operative time and heterotopic bone formation, a limitation is that none of our patients underwent operative treatment within 48 hours of the injury because of the tertiary referral pattern of our center. Thus, direct comparison of this factor between our data and prior studies may not be accurate. Our increased incidence of HO in elbows requiring multiple reduction attempts would seem to make inherent sense. These elbows often had greater osseous or soft tissue injury, which may predispose the elbow to increased heterotopic bone formation. In these patients, earlier intervention (given previous literature findings) as well as the
Heterotopic ossification after elbow surgery potential use of oral prophylaxis may be warranted in an effort to decrease the likelihood of heterotopic bone formation. We observed that 7 of 12 patients (58%) who developed HO underwent subsequent surgery. The currently available literature has demonstrated varying rates of reoperation for excision of HO. Whereas Bauer et al2 noted a reoperation rate of 71%, most other studies report lower rates. For example, a reoperation rate for excision of HO of 26% was reported by Douglas et al,5 20% by Thompson and Garcia,15 and only 9% by Abrams et al.1 It is possible that our rate of reoperation for excision of HO was higher than that currently reported as ours is a tertiary referral center for elbow disorders. There are several limitations to this study, including the retrospective nature of the data collection and the small number of patients, which limit the power of our data analysis. One specific flaw inherent to retrospective review is that in one patient who developed HO, we did not have sufficient final radiographs to fully classify the heterotopic bone. In addition, although we identified patients who developed HO, including patients who underwent additional surgery to excise symptomatic heterotopic bone, we did not attempt to correlate the location of HO, its severity of formation, or its subsequent treatment in any manner. However, given that our purpose was to analyze the incidence of HO and factors associated with its formation, as opposed to the management of postoperative HO, we do not think that this adversely affected the findings of the study. In specific comparison to the prior available literature, we did not find an effect of timing of surgery on formation of HO; but again, given that none of our patients were operatively treated within 48 hours of injury owing to the referral pattern of our center, we cannot conclude that delay does or does not have a consequence on HO formation after injury to the elbow. Despite these limitations, the strength of the study is its analysis of a specific injury to the elbow, the fracturedislocation, and the factors that may have an impact on the formation of HO in these patients. The finding that the recurrently unstable elbow, which requires multiple attempts at closed reduction before surgical management, significantly increases the risk of HO formation would seem to be relevant to the surgeon and patient and has not been the focus of any prior investigation to our knowledge. Importantly, in contradistinction to other risk factors for HO formation after elbow trauma, this is one risk factor within this spectrum of injury that is preventable and should be eliminated. Our data suggest that multiple attempts at reduction increase the risk of HO formation and should therefore be minimized if at all possible. In addition, the initial management of this injury pattern might best be performed by a surgeon who has sufficient experience and can proceed to early open reduction in the event that an acceptable, stable reduction
337 cannot be achieved through minimal attempts at closed manipulation. In the patient with the recurrently unstable elbow fracture-dislocation, administering prophylaxis against HO formation perioperatively may be warranted, and we now counsel these patients that they are at higher risk for heterotopic bone formation. However, the exact role of prophylaxis and its proper administration in patients with elbow injuries, including fracture-dislocations, require further work and investigation.
Conclusion In patients who have undergone operative procedures after elbow fracture-dislocations, the performance of multiple reduction attempts increases the risk of subsequent HO formation. Patient demographic factors and surgical factors (i.e., approach, fracture and soft tissue management) did not independently influence the risk of HO formation in our series. Patients and surgeons should be aware of the increased risk after highly unstable injuries as it has the potential to influence outcomes.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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