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Case report: Management of heterotopic ossification associated with
myocutaneous flap reconstruction of a sacral pressure ulcer
Colin W. McInnes1, Richard A.K. Reynolds2, Jugpal S. Arneja3
1Faculty of Medicine, University of British Columbia, Vancouver, BC2Department of Orthopedics, Children’s Hospital of Michigan, Detroit, MI3Division of Plastic Surgery, British Columbia Children’s Hospital, Vancouver, BC
Heterotopic ossification (HO) is a process whereby lamellar bone forms in the soft tissues
HO has traditionally been a challenging diagnosis to successfully treat. Surgical excision has
surrounding a joint, often following injury, such as trauma, burns, or arthroplasty.1,2,3 Clinically,
been described as the treatment of choice for symptomatic HO although it comes with the
patients can present with a decreased range of motion, pressure ulcers, nerve compression,
associated risks of surgery.2,4 Due to high recurrence rates if surgical resection is performed
swelling, pain, or asymptomatically. Symptomatic patients are most commonly treated with
on an immature lesion, treatment is often delayed for months before operative intervention is
surgical debridement of the affected heterotopic deposits.
performed for mature lesions.3 Another option is radiation treatment, which can be used for both therapeutic and prophylactic purposes in HO, but it also has common side effects.5-7
Spinal dysraphism (SD) is a term describing a wide range of congenital malformations of the neural tube. Many patients with SD have neuropathy below the affected neurologic level,
Daily bisphosphonate therapy is believed to act through a combination of factors such as
making them particularly susceptible to pressure ulcers. If these ulcers are severe and do not
delaying apatite crystal aggregation, inhibiting calcium phosphate precipitation, and reducing
respond to conservative therapy, they often require surgical debridement and flap
the conversion of calcium phosphate into hydroxyapatite.8 It is likely that the aggressive PT,
reconstruction, a clinical scenario that rarely results in HO. Herein we report a case history of a
which has been used in patients with HO to improve range of motion and decrease
patient with pelvic HO following myocutaneous flap reconstruction of a pressure ulcer who was
recurrence8, had a synergistic effect with the bisphosphonate therapy.
successfully managed with oral bisphosphonate and aggressive physiotherapy (PT).
The outcome of this case suggests that non-surgical options for the treatment of established
A 16-year-old Caucasian male with a diagnosis of spinal dysraphism at the L5 level presented
HO are possible. Given the inherent risks of either surgery or radiation therapy, and considering
with a 2 month history of a recurrent right ischial pressure ulcer. Computed tomography
the low-risk nature of PT and bisphosphonate, the later may be suitable as an initial therapeutic
confirmed right ischial osteomyelitis. The patient was treated with wide surgical debridement of
option for symptomatic HO. We also hypothesize that combined PT and bisphosphonate
soft tissue, ostectomy of the right ischial tuberosity, and right gluteus maximus myocutaneous
therapy could also have a prophylactic role in patients at high risk for HO, such as those
flap reconstruction. Three months post-operatively, the patient complained of limited hip
mobility; a plain pelvis radiograph confirmed bilateral heterotopic ossification of the iliac crest to the femur (Figure 1). The patient was subsequently managed with a six-month course of
aggressive physical therapy and oral bisphosphonate treatment (etidronate 20 mg/kg/day tid dosing), with significant clinical and radiographic improvement of bilateral hip range of motion
1. Venier LH, Ditunno JF,Jr. Heterotopic ossification in the paraplegic patient. Arch Phys Med Rehabil
(Figure 2). Follow-up at 3 years post-therapy revealed no signs of recurrence.
1971;52:475-479. 2. Appelt EA, Kenkel JM, Ballard JR, Lopez JA, Anthony T, Castillo T. Preoperative embolization of
heterotopic ossification for the treatment of a recalcitrant pressure sore. Plast Reconstr Surg
2005;116:50e-53e. 3. Gear AJ, Buckley C, Kaplan F, Vanbeek A. Multifactorial refractory heterotopic ossification. Ann Plast Surg
2004;52:319-324. 4. Chen HC, Yang JY, Chuang SS, Huang CY, Yang SY. Heterotopic ossification in burns: Our experience and literature reviews. Burns
2009;35:857-862. 5. Jang SH, Shin SW, Ahn SH, Cho IH, Kim SH. Radiation therapy for heterotopic ossification in a patient with traumatic brain injury. Yonsei Med J
2000;41:536-539. 6. Schaeffer MA, Sosner J. Heterotopic ossification: Treatment of established bone with radiation therapy. Arch Phys Med Rehabil
1995;76:284-286. 7. Vavken P, Castellani L, Sculco TP. Prophylaxis of heterotopic ossification of the hip: Systematic review and meta-analysis. Clin Orthop Relat Res
2009. [In press].
8. Ellerin BE, Helfet D, Parikh S, et al. Current therapy in the management of heterotopic ossification of the elbow: A review with case studies. Am J Phys Med Rehabil
Figure 1. Pelvis radiograph showing large heterotopic ossification from the iliac crest to the femoral head (arrows) before commencing PT and bisphosphonate therapy.
Figure 2. Pelvis radiograph showing significant reduction of heterotopic ossification and correction of femur position in relation to the pelvis (arrows) 6 months after commencing aggressive PT and bisphosphonate therapy.
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