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Massive heterotopic ossification associated with late deficits in posterior wall of acetabulum after failed acetabular fracture operation
© Zhang et al.; licensee BioMed Central Ltd. 2013
Received: 27 February 2013
Accepted: 17 December 2013
Published: 26 December 2013
Heterotopic ossification is a common postoperative complication of acetabular fracture. However, functionally significant heterotopic ossification with associated late bone defects in the posterior wall of the acetabulum is rare and challenging to treat. When heterotopic ossification is a late complication of failed acetabular fracture operation, it is disabling and may only be treated by THA. THA is highly susceptible to premature failure in young and active patients and may require numerous revisions.
This article describes a 40-year-old man with massive heterotopic ossification associated with late bone defects in the posterior wall of the acetabulum after a failed acetabular fracture operation. The primary fracture type was a 62-A2.3 fracture according to the AO/OTA Classification.Surgical excision and anatomical reconstruction of the acetabular wall using heterotopic ossific bone were performed 10 months after the fracture repair. Postoperatively, indomethacin was administered for prophylaxis against recurrence of heterotopic ossification, and hip range of motion was progressively increased. At 5 years and 6 months follow-up, the patient’s pain was relieved and hip function had recovered. Though radiography and CT showed minimal subchondral cysts and mild joint-space narrowing, there was no evidence of graft resorption, progressive posttraumatic osteoarthritis or necrosis of the femoral head.
To the authors’ knowledge, this is the first case of such a challenging condition. Although it is an extremely rare case, it provides an attractive option for avoiding THA, as the long-term follow-up shows a satisfactory outcome.
Heterotopic ossification (HO), the development of bone outside its normal location in the skeleton, is a common postoperative complication of acetabular fractures . Irradiation and indomethacin have been shown to be effective in the prevention of severe heterotopic ossification . However, once formed, heterotopic bone can be managed only with surgical excision . In one study, functionally significant heterotopic ossification (Brooker et al. class III or IV) developed in 23% of those patients who did not receive regular prophylaxis . Although surgical excision of heterotopic ossification has been reported with satisfactory results [4, 5], the management of disabling HO with associated bone defects in the posterior wall of the acetabulum is a challenge for surgeons and has not been reported to the best of our knowledge.
We describe a rare case of massive HO surrounding the hip joint with associated bone defects in the posterior wall of the acetabulum following a failed operation of acetabular fractures. The management and outcome, five years and six months after the excision, as well as measures to prevent recurrence are discussed. Informed consent for participation in the study was obtained from the patient.
The drainage tube was removed 2 days after surgery. In the postoperative period, prophylaxis for recurrence of heterotopic ossification (indomethacin 25 mg three times daily) was administered for 6 weeks. Isometric contraction training of the lower limbs was encouraged starting one day after surgery. One week after surgery, the patient was asked to initiate and gradually increase the degree of extension and flexion of the hip while supine. Partial, toe-touch weight bearing with crutches or a walker was allowed four weeks postoperatively. Complete weight bearing on the affected limb was restricted until radiography demonstrated signs of union.
The authors clarify that the written informed consent for participation and publication of clinical images was obtained from the patient in our study.
The etiopathogenesis of HO, though incompletely understood, involves genetic abnormalities, neurologic injury, and musculoskeletal trauma . The high incidence of radiographic HO and potential morbidity after acetabular surgery has led to the standardization of prophylactic therapies [10–13]. Irradiation and indomethacin are thought to be effective in the prevention of heterotopic ossification. According to recent studies, both indomethacin and radiation therapy variably decrease the rates of severe HO after acetabular surgery by 4% to 15% [14, 15]. However, other studies have not verified this reduction. Sean M. et al.  found no reduction in HO rates after acetabular surgery with indomethacin compared with placebo.
The patient in our study did not accept any prophylaxis after the first surgery, which we conclude was the main cause of such massive heterotopic ossification. Therefore, indomethacin (25 mg three times daily) was administered for 6 weeks in the postoperative period as prophylaxis for recurrence of heterotopic ossification. Radiation therapy was not applied due to poor compliance, poor tolerance, and radiation-associated morbidities. In cases of mature hyperostotic macrodactyly, operative resection of the deposits or the osteophytes might be indicated when pain increases or the range of motion is limited.
A literature review revealed reports of satisfactory results from surgical resection of HO followed by indomethacin therapy after failed open reduction and internal fixation or total hip arthroplasty. Wick et al.  retrospectively analyzed the clinical effect of surgical excision of heterotopic bone after hip surgery in 21 patients. Of these patients, 19 (90.4%) had excellent relief of pain and improved hip range of motion. Only one patient (4.8%) suffered a recurrence of heterotopic bone formation. Cobb et al.  evaluated the outcomes of excision of heterotopic ossification after total hip arthroplasty. In all 53 cases, joint function was significantly improved. However, disabling HO with associated bone defects, mal-union in the posterior wall and incongruence of the hip joint following a failed operation of acetabular fractures have not been previously reported. Bone defect in the posterior wall of the acetabulum and joint incongruence can significantly affect the stability of the hip and lead to high incidence of posttraumatic arthritis . Thus, merely the resection of the HO can hardly contribute to a favorable outcome. The usual treatment method described in the literature includes two options: one therapeutic alternative is THA [18, 19]. However, posterior acetabular wall fractures occur predominantly in individuals younger than 40 years old. These exceptionally active patients are highly susceptible to premature failure of arthroplasty and may require numerous revisions throughout their lives. Another option is reconstruction of the posterior wall with the use of a graft. Among the various graft materials, the iliac crest autograft is the most common and reliable measure . Nevertheless, only a few reports described reconstruction of posterior wall deficits of the acetabulum using iliac crest autograft. Daum et al.  first described the method in two cases of acute comminuted posterior wall acetabular fractures in 1993. The long-term functional outcome was satisfactory in one case, whereas the other case needed total hip arthroplasty after two years. Sen et al.  reported a series of eight cases of similar fractures where the comminuted fragments were excised and the defect in the posterior acetabular wall was reconstructed with iliac crest strut graft. The medium-term clinical outcomes were satisfactory. To our knowledge, Zha et al.  uniquely performed the procedure for the treatment of late posterior acetabular wall deficits following unsuccessfully managed posterior wall fractures and recommended this procedure as a noteworthy technique, especially for pediatric patients or adults without posttraumatic osteoarthritis. Compared with their reports, our technique is unique because the autograft was structured by a reamer, which has exactly the same cambered surface as the posterior acetabular surface. Furthermore, the autograft was harvested from a large heterotopic ossific bone. In addition, a Ni-Ti shaped-memory alloy device named ATMFS was used for fixation instead of screws and plates. The fixation system, as a functional metal material, has been successfully used in acetabular fractures for many years .
At the final follow-up, though the radiography and CT showed minimal subchondral cysts and mild joint-space narrowing, there was no evidence of graft resorption, progressive posttraumatic osteoarthritis or necrosis of the femoral head. The patient’s hip function had recovered well. We believe that the reconstruction in the presence of a concentrically reduced hip contributed to the favorable outcome. It is possible that with extension of the follow-up period, posttraumatic osteoarthritis of the hip would develop and progress, ultimately requiring THA. However, the surgical reconstruction significantly delayed the eventual THA, and the sufficient bone stock for seating of the prosthetic socket can be provided by the grafting procedure.
We report the first case of massive heterotopic ossification with associated posterior acetabular wall deficits. We also describe an audacious and unique treatment for anatomical reconstruction using heterotopic ossific bone. Although it is an extremely rare case, the long-term follow-up shows a satisfactory outcome, and it provides an attractive option for avoiding THA.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
- Daum WJ, Scarborough MT, Gordon W, et al: Heterotopic ossification and other perioperative complications of acetabular fractures. J Orthop Traumatol. 1992, 6: 427-432.Google Scholar
- Burd TA, Lowry KJ, Anglen JO: Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures. J Bone Joint Surg Am. 2001, 83-A: 1783-1788.PubMedGoogle Scholar
- Cohn RM, Schwarzkopf R, Jaffe F: Heterotopic ossification after total hip arthroplasty (THA). Am J Orthop. 2011, 40: E232-E235.PubMedGoogle Scholar
- Wick M, Müller EJ, Hahn MP, et al: Surgical excision of heterotopic bone after hip surgery followed by oral indomethacin application: is there a clinical benefit for the patient?. Arch Orthop Trauma Surg. 1999, 119: 151-155. 10.1007/s004020050379.View ArticlePubMedGoogle Scholar
- Cobb TK, Berry DJ, Wallrichs SL, et al: Functional outcome of excision of heterotopic ossification after total hip arthroplasty. Clin Orthop Relat Res. 1999, 361: 131-139.View ArticlePubMedGoogle Scholar
- Liu XW, Xu SG, Zhang CC, Su JC: Application of a shape-memory alloy internal fixator for treatment of acetabular fractures with a follow-up of two to nine years in China. Int Orthop. 2009, 34: 1033-1041.View ArticlePubMedPubMed CentralGoogle Scholar
- Zhang CC, Xu SG, Wang JL, et al: Design and clinical applications of acetabular tridimensional memory alloy-fixation system. Chin J Orthop. 2002, 22: 709-713.Google Scholar
- Liu XW, Xu SG, Zhang CC, et al: Biomechanical study of posterior wall acetabular fracture fixation using acetabular tridimensional memory alloy-fixation system. Clini Biomech. 2010, 25: 312-317. 10.1016/j.clinbiomech.2010.01.008.View ArticleGoogle Scholar
- Sumner DR, Turner TM, Igloria R, et al: Functional adaptation and ingrowth of bone vary as a function of hip implant stiffness. J Biomech. 1998, 31: 909-917. 10.1016/S0021-9290(98)00096-7.View ArticlePubMedGoogle Scholar
- Nauth A: Heterotopic ossification in orthopaedic trauma. J Orthop Trauma. 2012, 26: 684-688. 10.1097/BOT.0b013e3182724624.View ArticlePubMedPubMed CentralGoogle Scholar
- MacFarlane RJ, Ng BH, Gamie Z, et al: Pharmacological treatment of heterotopic ossification following hip and acetabular surgery. Expert Opin Pharmacother. 2008, 9: 767-786. 10.1517/14656522.214.171.1247.View ArticlePubMedGoogle Scholar
- Zeckey C, Hildebrand F, Frink M, Krettek C: Heterotopic ossification following implant surgery - epidemiology, therapeutical approaches, and current concepts. Semin Immunopathol. 2011, 33: 273-286. 10.1007/s00281-011-0240-5.View ArticlePubMedGoogle Scholar
- Baird EO, Kang QK: Prophylaxis of heterotopic ossification - an updated review. J Orthop Surg Res. 2009, 4: 12-10.1186/1749-799X-4-12.View ArticlePubMedPubMed CentralGoogle Scholar
- Blokhuis TJ, Frölke JP: Is radiation superior to indomethacin to prevent heterotopic ossification in acetabular fractures? A systematic review. Clin Orthop Relat Res. 2009, 467: 526-530. 10.1007/s11999-008-0532-9.View ArticlePubMedGoogle Scholar
- Karunakar MA, Sen A, Bosse MJ, Sims SH, Goulet JA, Kellam JF: Indomethacin as prophylaxis for heterotopic ossification after the operative treatment of fractures of the acetabulum. J Bone Joint Surg Br. 2006, 88: 1613-1617.View ArticlePubMedGoogle Scholar
- Sean MG, Stephen HS, Madhav AK, et al: Heterotopic Ossification Rates After Acetabular Fracture Surgery Are Unchanged Without Indomethacin Prophylaxis. Clin Orthop Relat Res. 2013, 471: 2776-2782. 10.1007/s11999-013-2871-4.View ArticleGoogle Scholar
- Bellabarba C, Berger RA, Bentley CD, et al: Cementless acetabular reconstruction after acetabular fracture. J Bone Joint Surg Am. 2001, 83A: 868-876.Google Scholar
- Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H: Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br. 2005, 87: 2-9.PubMedGoogle Scholar
- Mears DC, Velyvis JH: Primary total hip arthroplasty after acetabular fracture. Instr Course Lect. 2001, 50: 335-354.PubMedGoogle Scholar
- Sen RK, Tripathy SK, Aggarwal S, Tamuk T: Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall fracture. Int Orthop. 2011, 35: 1223-1228. 10.1007/s00264-010-1177-3.View ArticlePubMedGoogle Scholar
- Daum WJ: Traumatic posterior acetabular defects reconstructed with iliac crest autograft. A report of two cases. Clin Orthop Relat Res. 1993, 291: 188-192.PubMedGoogle Scholar
- Zha GC, Sun JY, Chen L, et al: Late reconstruction of posterior acetabular wall fractures using iliac crest. J Trauma. 2012, 72: 1386-1392.Google Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/368/prepub
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