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Heterotopic Ossification Following Traumatic and Combat-Related AmputationsPrevalence, Risk Factors, and Preliminary Results of Excision
Benjamin K. Potter, MD1; Travis C. Burns, MD2; Anton P. Lacap, MD1; Robert R. Granville, MD2; Donald A. Gajewski, MD1
1 Orthopaedic Surgery (B.K.P., A.P.L., and D.A.G.) and Amputee (D.A.G.) Services, Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue N.W., Building 2, Clinic 5A, Washington, DC 20307. E-mail address for B.K. Potter: Benjamin.Potter@na.amedd.army.mil
2 Orthopaedic Surgery (T.C.B. and R.R.G.) and Amputee (R.R.G.) Services, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234-6200
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the United States Government. All authors are employees of the United States government. This work was prepared as part of their official duties and as such, there is no copyright to be transferred.
Investigation performed at the Walter Reed Army Medical Center, Washington, DC, and Brooke Army Medical Center, Fort Sam Houston, Texas

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Mar 01;89(3):476-486. doi: 10.2106/JBJS.F.00412
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Background: Although infrequently reported in amputees previously, heterotopic ossification has proven to be a common and problematic clinical entity in our recent experience in the treatment of traumatic and combat-related amputations related to Operation Enduring Freedom and Operation Iraqi Freedom. The purpose of the present study was to report the prevalence of and risk factors for heterotopic ossification following trauma-related amputation as well as the preliminary results of operative excision.

Methods: We identified 330 patients with a total of 373 traumatic and combat-related amputations who had been managed at our centers between September 11, 2001 and November 30, 2005. We reviewed the medical records and radiographs of 187 patients with 213 amputations who had adequate radiographic follow-up. Additional analysis was performed for twenty-four patients with twenty-five limbs that required excision of symptomatic lesions. The mechanism and zone of injury, amputation level, timing of excision, use of prophylaxis against recurrence, and other confounding variables were examined. Outcomes were assessed by determining clinical and radiographic recurrence rates, perioperative complications, preoperative and follow-up pain medication requirements, and the ability to be fit with a functional prosthesis.

Results: Heterotopic ossification was present in 134 (63%) of 213 residual limbs, with twenty-five lesions requiring excision. A final amputation level within the zone of injury was a risk factor for both the development and the grade of heterotopic ossification (p < 0.05). A blast mechanism was predictive of occurrence (p < 0.05) but did not correlate with grade. All patients who had been managed with excision were tolerating the prosthetic limb at an average of twelve months of follow-up. Twenty-three limbs demonstrated no evidence of recurrence, and two limbs had development of clinically asymptomatic, radiographically minimal recurrences. Six patients experienced wound-related complications that required reoperation, and two patients required subsequent minor revision surgery. There was a significant decrease in the use of pain medication following surgery (p < 0.05).

Conclusions: Heterotopic ossification following trauma-related amputation is more common than the literature would suggest, particularly following amputations that are performed within the initial zone of injury and those that are due to blast injuries. Many patients are asymptomatic or can be successfully managed with modification of the prosthesis. For patients with refractory symptoms, surgical excision is associated with low recurrence rates and decreased medication requirements, with acceptable complication rates.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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