This study reviewed the results of heterotopic ossification removal from the elbows in children following severe burns. Nine elbows in 7 children were evaluated at average of 56 months (range, 3-10 years) following surgical release. The average age of the children at the time of the burn injury was 12.5 years (range, 9-16 years). All patients had 3rd degree burns with a mean burned body surface area of 72% (range, 44 – 85%). All elbows were directly affected by the burn. The mean duration between the burn and surgical intervention was 17 months (range, 8-32 months). The average preoperative arc of motion of the involved elbow was 12 degrees (range, 0-30 degrees), and 4 elbows were ankylosed. The indications for surgical intervention included limitation of elbow motion of less than 50 degrees.
All elbows had some heterotopic ossification on the medial aspect usually posterior to the medial epicondyle and frequently extending into the medial olecranon fossa. Four elbows had ankylosis of the olecranon to the humerus posteriorly. Only 1 elbow had significant anterior heterotopic ossification. Generally a posteromedial incision was developed with an anterior ulnar nerve transposition. Two patients required transection of the triceps tendon in order to remove the significant heterotopic ossification. One patient required HO removal both medially and laterally and was approached through a posterior incision, which subsequently dehisced requiring several weeks for wound healing and ultimately resulted in restricted elbow motion. Two elbows required Z-plasty of the anterior skin and lengthening of the biceps tendon. There were no long-term ulnar nerve problems. Four patients required return to the operating room for manipulation of the elbow under general anesthesia 4 weeks following the operation. The postoperative therapy regimen varied during the study. The first 4 elbows were placed into CPM but was not well tolerated and ultimately resulted in poor motion. The subsequent 5 elbows were treated with active-assisted range of motion exercises beginning on the second postoperative day with supplemental use of alternating splints that maintained maximal flexion during the day and extension during the night. All 9 elbows had an improved arc of motion with an average increase of 57 degrees (range, 30-110 degrees). The group treated with alternating splinting averaged a 73 degree improvement in motion, whereas those treated early in the series with continuous passive motion improved an average of only 35 degrees. There was no recurrence in heterotopic ossification. The overall prevalence of severely limiting ossification at this institution was 0.25% among a total of 3,245 consecutively admitted burn patients.
This study confirms the utility of excision of heterotopic ossification in children following severe contracture and burns. Although all patients reported improvement in the ability to reach the face and perineum and became independent in the tasks associated with feeding and toileting, they still exhibited severe limitations of elbow motion with 30% having less than a 50 degree arc of total motion. Only 1 elbow achieved greater than a 100 degree arc of motion. Four of 9 elbows required re-manipulation. There was no recurrence of heterotopic ossification in this group of patients despite the lack of prophylaxis such as non-steroidal anti-inflammatory medication and/or radiation therapy. Postoperative therapy appeared better tolerated with assisted active motion and alternating flexion and extension splints.
J of Bone and Joint Surg 85A: 1538-1543, 2003.