HETEROTOPIC OSSIFICATION AFTER SHOULDER ARTHROSCOPY:

HETEROTOPIC
OSSIFICATION AFTER
SHOULDER
ARTHROSCOPY:
HOW TO SOLVE IT
Larry D. Field, M.D.
Mississippi Sports Medicine and
Orthopaedic Center
Jackson, Mississippi
DISCLOSURES
The following relationships exist:
1. Royalties and stock options
 None
2. Consulting income
 Smith & Nephew
3. Research and educational support
 Arthrex
 Mitek
 Smith & Nephew
4. Other support
 None
HETEROTOPIC
OSSIFICATION (HO)
• Trabecular bone forms
outside of skeletal
structure
• Occupies space within
soft tissues
HETEROTOPIC
OSSIFICATION
• Potential complication
– Elective surgery
– Trauma
– Neurological injury
– Severe burns
HETEROTOPIC
OSSIFICATION
• Most common sites
– Acetabulum after
ORIF
– THA (5%-90%)
• 3-7% clinically
significant
– Elbow
HETEROTOPIC
OSSIFICATION
• Pathophysiology poorly understood
and probably multifactorial
• HO formation more likely:
– prostaglandin activity (PGE-2)
– Hypercalcemia
– Tissue hypoxia
– Prolonged immobilization
HETEROTOPIC OSSIFICATION AFTER
SHOULDER ARTHROSCOPY
• Arthroscopic surgery
– Constant irrigation
– Dilutes osteoinductive
marrow elements
• HO analogous to bone at IM
rod tips (“Callus Cap”)
– Spilled osteogenic
reamings and marrow
elements
HETEROTOPIC
OSSIFICATION
• Open rotator cuff surgery
– Very little literature
• 4 case reports
• 2 retrospective studies
• Arthroscopic surgery
– 1 study – open and arthroscopic
JSES, 1995
• Retrospective review
– 40 patients (3.2% incidence)
– Open and arthroscopic
acromioplasty and distal
clavicle
excision
– chronic pulmonary diseases
– 20 of 40 patients underwent open surgery to
remove HO
HO FOLLOWING ARTHROSCOPIC
SHOULDER SURGERY
•
•
•
•
Literature almost nonexistent
Does occur
Can affect outcomes
May require revision
surgery
• Prompted to review our
experience
– Incidence
– Arthroscopic HO excision
PURPOSE OF STUDY
• Evaluate consecutive series
of patients
– Outcome compromised
by HO post-op
• Stiffness
• Pain
• Failure to respond to postop management
• Report surgical technique
and outcomes
MATERIALS AND METHODS
• Retrospective review of 17 patients
– Developed moderate to severe HO
– Revision arthroscopic surgery
• January 2003 to January 2011 (8 years)
– 8509 arthroscopic shoulder procedures
• Two surgeons (LDF, ERH)
• 0.2% of patient population
• Average follow up 34 months
– (Range: 12-84 months)
MATERIALS AND METHODS
• Index arthroscopic procedure
– Acromioplasty + distal
clavicle (17)
– Rotator cuff repair (15/17)
• HO recognized from 2 weeks
to 3 months after surgery
– Persistent pain
– Stiffness
• 7 males, 10 females
• Average age 56 years
(41-67 years)
HO PRIMARILY IN 2 SITES
• Resected AC joint
• Subacromial space
PATIENT MANAGEMENT
• After HO diagnosis, treatment
consisted of:
– NSAIDs
– Physical therapy
– Corticosteroild injections
• Great majority of patients recovered
without additional surgery
SURGICAL MANAGEMENT
•
All 17 underwent arthroscopic excision of HO and contracture release
– All HO removed
• Arthroscopic visualization
• Fluoroscopic confirmation
SURGICAL MANAGEMENT
•
Contracture releases involving:
– Glenohumeral joint
– Subacromial space
– Supplemental arthroscopic application of bone wax (10/17)
MANAGEMENT FOLLOWING
EXCISION OF HO
•
•
•
•
Radiographic confirmation
NSAIDs x 1 month (Indomethacin)
Aggressive physical therapy (ROM)
Perioperative radiotherapy
– Recommended to all patients
– Carried out in 6/17
• 750 cGy pre-op
RESULTS
• Average time frame between index
procedure and HO removal
– 7.1 months (range 3 – 28 months)
• UCLA
– Pre-op 23
Post-op 33
• (p<0.05)
• No significant return of HO at a minimum of
1 year
RESULTS
Pre-op
FF 70° (40° - 100°)
ER 18° (-10° - 45°)
Post-op
FF 148°* (110° – 170°)
ER 68°* (40° – 90°)
*p<0.05
STUDY FINDINGS
• All 17 patients improved significantly post-op
– UCLA score & ROM
• No significant complications
• No additional surgical intervention
• Aggressive arthroscopic HO excision with
prophylaxis (NSAIDs +/- radiation +/- bone
wax) was effective
SUMMARY
• HO uncommon after shoulder arthroscopy
• Characterized post-op:
– Persistent pain
– Significant motion loss
• Post-op x-rays important
• Symptomatic treatment usually adequate
• Moderate to severe HO development
– Arthroscopic release and HO excision effective
THANK YOU