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