Session III - Reconstruction
Early Excision of Heterotopic Ossification in Trauma-Related Amputations
Purpose: In spite of substantial literature regarding heterotopic ossification (HO) due to other inciting events, relatively little is known about the prevalence and treatment of HO in the residual limbs of traumatic and combat-related amputees; however, HO formation in residual limbs may contribute to skin breakdown and pain, complicating or preventing optimal prosthetic fitting and utilization. The purpose of this study is to review the prevalence and results of early excision of HO in trauma-related amputations.
Methods: We retrospectively reviewed the medical records and radiographs of all traumatic or combat-related amputations treated at our institutions since September 11, 2001. The prevalence, severity, and risk factors for HO within the residual limb(s) were analyzed for all patients with at least 2 months of radiographic follow-up from injury. Additional focus was placed on reviewing the clinical data and outcomes of 25 limbs in 24 amputees who required surgical excision of symptomatic HO in their residual limbs following traumatic, generally combat-related, injuries. Outcomes were determined based on perioperative complications, clinical or radiographic evidence of HO recurrence, and ability to fit with and utilize a functional prosthesis with minimal/no pain postoperatively.
Results: The overall prevalence of HO was in trauma-related residual limbs (n = 213) was 62%, with 33% having moderate or severe HO. Significant risk factors (P <0.05) for HO development were a blast mechanism of injury and final amputation level within, rather than above, the initial zone of injury. All patients requiring surgical excision of symptomatic HO were male (average age = 26.2 years; range, 19-46) with an average follow-up of 9 months. Of these patients, 20 sustained blast injuries while the remaining four were injured in motor vehicle (2 patients), electrical burn (1), or boating accidents (1). All amputation levels were within the zone of initial injury. The average duration between date of injury and date of excision was 8.2 months (range, 3-24; median, 6). In each case the surgical indications included breakdown of residual limb, difficulties with prosthetic fitting, and painful problems with normal prosthetic wear. Radiographically, the HO was graded as mild in seven, moderate in 10, and severe in eight limbs. 13 patients (13 limbs) were treated with a 6-week course of nonsteroidal anti-inflammatory drugs (NSAIDs), and 20 limbs underwent local radiation therapy within 24 hours postoperatively. At follow-up, 22 patients (23 limbs) demonstrated no radiographic evidence of recurrence, and two patients/limbs demonstrated mild radiographic juxtacortical, clinically asymptomatic, recurrence of HO. All 25 limbs have been successfully fit for prostheses and all patients have resumed prosthetic wear. Six patients experienced wound complications, all of which necessitated at least one return to the operating room. Two patients required minor late revisions for reasons other than HO recurrence.
Conclusions/Significance: HO is more common than previously appreciated following trauma-related amputation. With short-term follow-up, early surgical excision of HO resulted in low rates of recurrence and an excellent rate of clinical success based on the ability to utilize a functional prosthesis with minimal or no pain.