Therapeutic strategies for elbow ankylosis due to heterotopic ossification in patients with severe burns

Abstract

Background: Heterotopic ossification (HO) occurs frequently in the elbow in burn patients, and extends beyond the anatomical structure. HO of the elbow can cause joint contracture and adversely affect activities of daily living.Currently, there is no effective prophylaxis for HO as the precise underlying mechanism remains unknown. Therefore, there is no choice but to treat HO after it has developed. To date, however, no effective standard treatment has been reported, and therefore treatment methods vary between different facilities. Surgical resection is widely accepted as the only therapeutic option once HO limits functional mobility of the elbow.

Purposes: Based on past reports, we examined our cases and recommend effective therapeutic strategies. We posed the following three questions: (1) Is the surgical intervention effective or detrimental for elbow ankylosis due to HO? (2) What is the best timing for the intervention? (3) What is the most effective postoperative rehabilitation plan?

Methods: We treated three patients with complete ankylosis of the elbow due to HO after severe burn injury using different protocols.

Results: Surgery was performed in two cases and rehabilitation therapy was commenced immediately from the first postoperative day. Both patients showed improvement in the active range of motion in their elbow joints. The other patient did not undergo surgery, and his elbows became fixed in the completely extension position.

Conclusion: Surgical resection is beneficial for elbow ankylosis due to HO after burn injury. Although the exact surgical timing is still controversial, we recommend that surgery should be performed as soon as possible after improving the skin condition around the elbow and confirming the maturation of HO on radiographs. Early rehabilitation and pain control are also important after surgery.

Keywords: Burn; Ectopic bone; Elbow; Heterotopic ossification; Rehabilitation; Surgical resection.

© 2018 The Authors.

Figures

Figure 1

(a). Nine weeks after the injury. Elbows were ankylosed in extension position. (b), (c): Six months postoperatively. She could touch the anterior chest and the back of her head.

Figure 2

The progress of the HO on X-ray or Three dimensional computed tomography (3DCT) images of the left elbow. (a). (9 weeks after the injury) The border of HO (yellow arrow) was irregular. (b). (14 weeks after the injury, immediately after the operation) The HO was all resected. (c). (17 weeks after the injury, 3 weeks postoperatively) The HO recurred (yellow arrow). (d). (21 weeks after the injury, 7 weeks postoperatively) The recurrent HO was resolving spontaneously. (e). (30 weeks after the injury, 16 weeks postoperatively) Recurrent HO was absent. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

Figure 3

The progress of the HO on X-ray or 3DCT images of the right elbow. (a). (9 weeks after the injury) The border of HO (the yellow arrow) was irregular. (b). (17 weeks after the injury) A continuous osseous bridge between humerus and ulna (the yellow arrow), and bone resorption of ulnar (the yellow triangle) were seen. (c). (21 weeks after the injury) The well-defined margin of the HO was identified (the yellow arrow). (d). (30 weeks after the injury, 7 weeks postoperatively) No recurrence was seen. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

Figure 4

The right elbow treated surgically at 23 weeks after the injury. After an initial capsulotomy, abnormal macroscopic findings were not found in joint cartilage.