Scientific Article   |    
Heterotopic Ossification Around the Elbow Following Burns in Children: Results After Excision
Alok Gaur, MD; Marc Sinclair, MD; Enzo Caruso, MD; Giuseppe Peretti, MD; David Zaleske, MD
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Investigation performed at the Boston Shriners Hospital and Massachusetts General Hospital, Boston, Massachusetts

Alok Gaur, MD
Department of Orthopedic Surgery, Hahnemann University Hospital, Philadelphia, PA 19102
Marc Sinclair, MD

Orthopedic Surgery, Altona Children's Hospital, Bleickenallee 38, D-22763 Hamburg, Germany
Enzo Caruso, MD
Orthopaedic Department, Luigi Sacco University Hospital, Milan, Italy

Giuseppe Peretti, MD
Orthopaedic Department, San Raffaele Hospital, Milan, Italy

David Zaleske, MD
Pediatric Orthopaedics Department, Children's National Medical Center, 111 Michigan Avenue, Washington, DC 20010-2970.

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive 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, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 Aug 01;85(8):1538-1543
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Background: Major burn injuries close to joints alter the function of the musculoskeletal system through tissue loss and limitation of joint motion. In children with involvement of the hand, wrist, and forearm, restriction of elbow motion secondary to heterotopic ossification following a burn injury severely limits the function of the upper extremity. The purpose of this study was to review elbow function following excision of heterotopic ossification around the elbow in children.

Methods: Eight children (ten elbows) from a population of 3245 consecutive patients who were admitted to our pediatric burn center were found to have severe heterotopic ossification of the elbow, leading to an inability to reach the mouth for feeding and the head and the perineum for self-care. Excision of the heterotopic ossification was undertaken if the patient had this limitation of function and if movement was restricted to a total arc of motion of <50°. Pain was not an indication for the operation. The procedure was performed at an average of 17.3 months following the injury.

Results: Seven children (nine elbows) were available for follow-up at an average of fifty-six months after surgery. All nine elbows had an improved arc of motion (an average increase of 57°). Following excision, heterotopic ossification did not recur. All children were able to reach the face and the perineum following the operation.

Conclusions: Excision of heterotopic ossification around the elbow following a burn injury in children can improve the arc of motion and improve the function of the extremity. A relatively simple operative and postoperative regimen can achieve satisfactory results.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    Shawn W. O'Driscoll
    Posted on October 30, 2003
    Results of Surgery for Heterotopic Ossification Around the Elbow
    Mayo Clinic

    In their paper, "Heterotopic Ossification Around The Elbow Following Burns in Children: Results After Excision" by Gaur, et al., the authors have reported the results of contracture release and heterotopic bone excision in nine pediatric patients whose elbows were fused or nearly fused. I am not completely in agreement with the conclusion that "A relatively simple operative and postoperative regimen can achieve satisfactory results."

    Of their nine patients, only one achieved a "functional arc of motion" which I would define as 30 to 130° of flexion, the range of motion that affords most patients the possibility of achieving essentially normal activities of daily living (1). Achieving this functional range of motion is also what is considered a criterion for a satisfactory outcome following contracture release around the elbow.(2)

    If we were to be more lenient and accept an arc of 40 degrees to 120 degrees of flexion as a satisfactory range of motion, still, only one patient in this study achieved that range. Even when we look at extension and flexion separately, only five of nine patients achieved at least minus 40° of extension and only two patients achieved flexion to at least 120°. Furthermore, four of the patients required manipulation under anesthesia, presumably for unsatisfactory maintenance of their post- operative motion.

    These numbers are clearly and dramatically less satisfactory than those reported in several published series of patients treated for contracture release about the elbow, although few of these reports included children and few related to complete bony ankylosis after burns.( 2-17) The reasons could be many, and I certainly do not take issue with those reasons. My main concern is that the expected outcome of a functional arc of motion following contracture release, was not achieved in the large majority of these patients and that we should strive to achieve further improvements in the operative and postoperative care of these patients.

    At our institution, we have had fewer satisfactory outcomes following contracture release in pediatric patients when compared to adult patients for reasons that we do not yet fully understand.


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