Posttraumatic Heterotopic Ossification

Posttraumatic Heterotopic Ossification

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In 1918, Dejerine and Ceillier first described heterotopic ossification (HO) in paraplegic patients injured in World War I, referring to the process as paraosteoarthropathy. HO has been defined as the formation of mature lamellar bone in soft tissues. The process involves true osteoblastic activity and bone formation. HO has been reported in cases of brain injury, spinal cord injury, stroke, poliomyelitis, myelodysplasia, tabes dorsalis, carbon monoxide poisoning, spinal cord tumors, syringomyelia, tetanus, and multiple sclerosis. This condition also has been reported after burns and total hip replacement/joint arthroplasty. [1]

Several terms have been used to describe the condition, including heterotopic ossification, ectopic ossification, and myositis ossificans. HO usually involves the large joints of the body (eg, hips, elbows, shoulders, knees). Excessive bone formation may result in significant disability by severely limiting the range of motion (ROM) of these joints (see image below).

In a study of patients who suffered a traumatic spinal cord injury, Ohlmeier et al, examining the frequency of heterotopic ossification (HO) in muscle groups around the hip, found HO to be most prevalent in the gluteal muscle group (55.8%). The second-highest prevalence (31.1%) was reported to be in the deep muscle group. [2]

The following 3 categories of HO have been described:

Myositis ossificans progressiva – This is a rare metabolic bone disease in children with progressive metamorphosis of skeletal muscle to bone; it is characterized by an autosomal dominant pattern of genetic transmission.

Myositis ossificans circumscripta without trauma – Also referred to as neurogenic HO, this is a localized soft-tissue ossification occurring after neurologic injury or burns.

Traumatic myositis ossificans – This condition occurs from direct injury to the muscles. Fibrous, cartilaginous, and osseous tissues near bone are affected; the muscle may not be involved.

Related Medscape Reference topics:

Heterotopic Ossification [Physical Medicine and Rehabilitation]

Heterotopic Ossification Imaging [Radiology]

Heterotopic Ossification in Spinal Cord Injury

Pediatric Fibrodysplasia Ossificans Progressiva (Myositis Ossificans)

Traumatic Heterotopic Ossification

Related Medscape resource:

Resource Center Joint Disorders

The specific cause and pathophysiology of heterotopic ossification (HO) remain uncertain, but the condition appears to involve the inappropriate differentiation of mesenchymal cells into osteoblastic stem cells in response to still-unidentified inducing agents.

HO may be due to an interaction between local factors (eg, the pool of available calcium in adjacent skeleton, soft-tissue edema, vascular stasis tissue hypoxia, mesenchymal cells with osteoblastic activity) and an unknown systemic factor or factors. The basic defect in HO is the inappropriate differentiation of fibroblasts into bone-forming cells. Early edema of connective tissue proceeds to tissue with foci of calcification and then to maturation of calcification and ossification.

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The reported incidence of heterotopic ossification (HO) varies. In cases of severe trauma or insult to the central nervous system (CNS), 10-20% of patients develop HO, and the condition has been observed in 20% of patients with severe brain injury. The incidence is higher in patients who undergo open reduction and internal fixation of a fracture. With an elbow fracture, dislocation, or fracture-dislocation, the incidence of traumatic HO at the elbow approaches 90%. Traumatic HO of the elbow occurs in 20% of forearm fractures. Fifty-five percent of patients with hip fractures develop HO. The incidence increases to 83% if open reduction and internal fixation are performed. The incidence is similar in the upper and lower extremities.

An association has been cited between spasticity and HO. The incidence is higher in a spastic extremity; 84% of patients with HO had spasticity, and 54% of patients with HO had no spasticity. HO is seen in the elbow in 4% of patients with traumatic brain injury (TBI); however, if fracture or dislocation is associated with brain injury, the incidence of HO rises to 89%.

Related Medscape Reference topics:

Classification and Complications of Traumatic Brain Injury

Traumatic Brain Injury in Children

Traumatic Brain Injury: Definition, Epidemiology, Pathophysiology


Studies from Europe and Japan have shown the incidence of HO to range between 11% and 76%, depending on the population studied and on the method of detection.

Only 10-20% of all heterotopic ossification (HO) patients have functionally significant deficits.

No race predilection exists for heterotopic ossification.

The development of heterotopic ossification is independent of the patient’s sex.

An increased incidence of heterotopic ossification (HO) has been found in persons over age 30 years. The incidence of HO in children appears to be lower than that in adults (8-22.5%).

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Auri Bruno-Petrina, MD, PhD Physiatrist

Auri Bruno-Petrina, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Canadian Association of Physical Medicine and Rehabilitation, International Society of Physical and Rehabilitation Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc, Mediwound.

Posttraumatic Heterotopic Ossification

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