Pansard et al.

(2013)

France

Case Series

N=16

Population: TBI=11, Spinal cord injury=2, stroke=1, Cerebral anoxia=2; Mean Age=30.1yr; Gender: Male=15, Female=1; Mean Time Post Injury=64mo.

Intervention: Participants were included in retrospective analysis after receiving surgery for shoulder HO.

Outcome Measure: Range of Motion (ROM).

1.        Mean ROM increased significantly for forward elevation (69°), abduction (60°), and external rotation (13°).

2.        Surgical approaches were superolateral (15.8%), deltopectoral (26.3%), posterior (26.3%), posterior-deltopectoral (10.5%), superolateral-deltopectoral (5.3%), axillary (5.3%), and martini (10.5%).

3.        No recurrence was reported for any of the participants.

Fuller et al.

(2013)

USA

Case Series

N=10

Population: TBI; Mean Age=30yr; Gender: Male=6, Female=4, Mean Time Post Injury=46.54mo.

Intervention: Retrospective review of individuals who had resection of HO for restrictive shoulder HO.

Outcome Measure: Range of Motion (ROM).

1.        ROM improved in all 3 planes of motion (p<0.001). Specifically 85°, 59.1° and 66.9° for the sagittal, coronal and axial plane respectively.

2.        Three of 11 shoulders had recurrence of HO. One patient developed osteoarthrosis and had avascular necrosis in the opposite shoulder, one had a greater predisposition due to multiple joint involvement, and the other patient had severe post-operative swelling.

Genet et al.

(2012)

France

Case Control

N=80

Population: TBI; Gender: Male=65, Female=15. Recurrence Group (n=16): Mean Age=30.8yr; Mean Time Post Injury=25.3mo. No Recurrence Group (n=64): Mean Age=30.3yr; Mean Time Post Injury=31.7mo.

Intervention: Patients who had surgery for HO (hip, knee or shoulder) were examined for recurrence.

Outcome Measure: recurrence of HO

Genet et al.

(2009)

France

Case Series

N=143

Population: TBI=118(hips), Spinal Cord Injury=65(hips); Mean Age=34.5yr; Gender: Male=114, Female=29

Intervention: Prospective review of surgical intervention for HO of the hip.

Outcome Measure: Range of Movement (ROM), surgical complications, pre-operative joint pathology, time from HO diagnosis to surgery

1.        Of the 183 hips, 70 had developed ankylosis prior to surgery and 113 had no ankylosis.

2.        The mean delay from HO diagnosis to surgery in the ankylosed hips was 34.9mo, compared to 40.8mo in the non-ankylosed hips.

3.        The mean ROM in ankylosed hips was 0° before surgery, 90° after surgery, and 63° at last follow-up.

4.        The mean ROM in non-ankylosed hips was 38° before surgery, 95° after surgery, and 85° at last follow-up.

5.        There were no surgical or post-operative complications in the non-ankylosed hips. In the ankylosed hips there were 25 intraoperative femoral neck fractures, leading to 12 total hip replacements, 4 symptomatic non-unions, and 3 deep infections.

Fuller et al.

(2005)

USA

Case Series

N=17

Population: TBI=15, Anoxia=1, SCI=1; Mean Age=33yr; Gender: Male=10, Female= 7; Mean Time Post Injury=25mo.

Intervention: A retrospective review of individuals who had surgical excision of HO of the knee. All patients then participated in an inpatient rehabilitation program (e.g., range of motion, passive stretching, weight bearing) and received 20 mg/kg of etidronate disodium for 2mo.

Outcome Measure: Passive range of motion, Five-level Ambulatory scale, sitting function scale.

1.        There was a significant improvement in arc of motion (mean 65°, p<0.0001).

2.        Extension and flexion significantly improved postoperatively (p<0.002 and p<0.0001, respectively).

3.        Significant improvements were found in ambulation and sitting ability postoperatively (both p<0.0001).

4.        There were no recurrences of HO by clinical or radiographic examinations at 2, 6, or 12 wk.

Melamed et al. (2002)

Israel

Pre-Post

N=9

Population: TBI; Mean Age=38yr; Gender: Male=8, Female=1; Mean Time Post Injury=29mo.

Intervention: Surgical resection of HO (8 hips, 3 knees, 1 elbow). All patients received postoperative physical therapy and participated in a rehabilitation program.

Outcome Measure: Functional Status, Range of Motion (ROM), radiographic evaluation, Brooker Classification.

1.        The mean preoperative flexion-extension arc of hips was 33°; postoperatively it was 93°.

2.        The mean preoperative and postoperative ROM in knees was 58° and 67° respectively.

3.        Improved ROM was seen in 7 of 8 hips; 4 patients had marked improvement in gait, 2 of whom no longer required prosthetics.

4.        For follow-up (n=8), 7 graded themselves as functionally improved and 7 reported improved ROM.

de Palma et al. (2002)

Italy

Case Series

N=10

Population: TBI; Gender: Male=6, Female=4.

Intervention: Surgical resection of HO of the elbow with Indomethacin (25 mg, 3x/day for 6 wk) administered postoperatively. Active mobilization of the elbow joint commenced 1 mo after surgery.

Outcome Measure: Garland’s Classification, Range of Motion (ROM).

1.        All patients had improved ROM in the early postoperative period, especially in those who had the most severe restriction in joint mobility.

2.        Improvement correlated with residual neurological damage. Class I and II (minimal physical/cognitive benefits) patients had the greatest improvements, achieving satisfactory ROM, while class III (more marked physical deficits) had only partial improvement in ROM.

Lazarus et al.

(1999)

USA

Pre-Post

N=24

Population: TBI; Mean Age=37.4yr; Gender: Male=20, Female=7; Mean Time Post Injury=35.4mo.

Intervention: Patients had HO resection in a total of 27 elbows. All patients received indomethacin (25-50 mg, 2x/day) after surgery. Some patients (n=17) received continuous passive motion.

Outcome Measure: Range of Motion (ROM).

1.        Maximum flexion increased from 80.1° preoperatively to 111.9° postoperatively (p=0.0003).

2.        Maximum extension increased from 58.9° preoperatively to 32.1° postoperatively (p=0.0005).

3.        Twenty-three elbows gained motion and 4 lost a mean of 15°.

4.        The patients with ankylosed elbows (n=17) preoperatively, made greater gains than the remaining patients (n=10), mean of 59.1° vs 23.2° (p=0.03).

5.        Patients with longer injury to resection times had worse outcomes compared to those with shorter times (p=0.02).

6.        Patients who had continuous passive motion after surgery had greater ROM gains than those who did not (57.9° vs 24.1°, p=0.04).

Ippolito et al. (1999a)

Italy

Case Series

N=12

Population: TBI; Mean Age=29yr; Gender: Male=9, Female=3.

Intervention: Surgical resection of hip HO (total of 13 hips). As an antibiotic prophylaxis, each patient received Cefazolin (800 mg, 3x/day for 2 wk). Indomethacin (50 mg, 2x/day for 6 wk) was also given after the operation.

Outcome Measure: Walking capacity, hip range of motion (ROM).

1.        All patients showed satisfactory ROM following the surgery.

2.        Radiographs revealed remnants of HO following surgery; these remnants did not interfere with ROM.

3.        At final follow up (mean 38 mo post-operative), 8 hips maintained initial gains in ROM, 2 had decreased ROM with no evidence of HO recurrence and 3 decreased ROM with partial or full recurrence of HO.

4.        All patients who had a painful hip prior to operation (n=5) were pain free after.

5.        Nine of 12 patients were non-ambulatory prior to surgery; post-operatively, 10/12 were able to ambulate (5 with braces or crutches).

Ippolito et al.

(1999b)

Italy

Case Series

N=14

Population: TBI; Mean Age=30.8yr; Gender: Male=10, Female=4.

Intervention: Surgical resection of HO in 16 elbows. Immediately after the surgery, a continuous passive motion machine was applied and was gradually increased until the joint regained the whole arc of motion (6wk). Patients assigned to one of two groups. Group 1: elbows ankylosed in position (ranged from 0-100°; n=11 elbows) or group 2: elbows in which 10–25° of flexion was available (n=5 elbows).

Outcome Measure: Arc of elbow range of motion (ROM).

1.        At the end of surgery, the arc of flexion attained ranged from 90-145° in group 1 and 115-140° in group 2.

2.        At follow up (mean 30.7 mo), the arc of flexion (both active and passive) attained ranged from 30-135° in group 1 and 80-145° in group 2.

3.        9 joints lost ROM, 3 joints gained ROM and 4 joints retained the same ROM at follow-up, relative to post operation.

4.        Partial recurrence was observed in 3 elbows.

5.        The average arc of flexion for those who had surgery <18 mo (n=11) or >18mo (n=5) after coma, was 105° and 92°, respectively.

Ippolito et al.

(1999cc)

Italy

Case Series

N=5

Population: TBI; Mean Age=26yr; Gender: Male=3, Female=2.

Intervention: Patients had surgical resection of HO in 7 knees. Post-surgery, a continuous passive motion machine was applied and used daily until the joint had regained the whole arc of motion that was seen at time of operation (approximately 6 wk).

Outcome Measure: Arc of knee motion, recurrence of HO.

1.        At baseline all knees were in a fixed flexed position (10-40°) with a painful arc of motion (20-70°).

2.        At follow up (mean 34 mo) the arc of motion had improved in all of the knees (0–130° in 3 knees, 0–120° in 3 knees, and 10–120° in 1 knee).

3.        At follow up, arc of flexion was 10-100° for 2 patients, 0-120° for another 2 patients, and 0-90°, 5-110°, and 0-130° for the remaining 3 patients.

4.        None of the patients could walk before the operation; however, at follow up, all patients could walk and all knees were pain free.

5.        Ossification did not recur in any of the knees.

Charnley et al. (1996)

France

Case Series

N=5

Population: TBI; Mean Age=28.4yr; Gender: Male=5, Female=0.

Intervention: Patients underwent surgical excision of HO around the knee (total of 7 knees). Postoperatively, all patients underwent early rehabilitation to maintain function and were given indomethacin to prevent recurrence of HO.

Outcome Measure: Range of Motion (ROM), recurrence of HO.

1.        At follow up (mean 18mo) there was no delayed wound healing or recurrence of HO around the knee.

2.        All patients had significant pain relief and improved ROM.

3.        Overall benefit meant patients could lie in bed, sit and transfer with greater ease and comfort.

Kolessar et al. (1996)

USA

Case Series

N=17

Population: TBI; Mean Age=35yr; Gender: Male=14, Female=3; Mean Time Post Injury=30mo.

Intervention: Retrospective review of surgical excision of HO (24 procedures: 11 hips, 10 elbows, 3 knees). Post operatively patients received Indomethacin (min. 75mg/d) and Etidronate (20mg/kg/d) for approximately 3mo. Physical therapy was also provided.

Outcome Measure: Range of Motion (ROM), recurrence of HO, ambulation.

1.        The mean improvement in motion for the hips, elbows and knees were 73.2° and 75.7°, and a 52.6° increase in ROM, respectively.

2.        Of 21 cases with radiographic follow-up, recurrence of HO was found in 23.8% based on the Brooker classification or 4.8% based on the Stover and colleague classification.

3.        91.3% participants were satisfied with the functional outcome.

4.        Functional goals were achieved by 83.3% of the sample and improvements in ambulation were found in 75% of patients.

Moore (1993)

USA

Case Series

N=17

Population: TBI; Mean Age=26yr; Gender: Male=17, Female=0; Mean Time Post Injury to Surgery=21mo.

Intervention: Retrospective study of patients who had surgical excision of HO (13 hips, 7 elbows). Patients received etidronate disodium (10 mg/kg per day for approximately 3mo) post-surgery.

Outcome Measure: Range of Motion (ROM).

1.        The average arc of motion obtained immediately after surgery was 85° in for the hips and 65° for the elbows.

2.        Eleven hip joints and 6 elbow joints maintained sufficient ROM to achieve pre-operative functional goals (e.g., enhanced wheelchair sitting, improvement in bed to wheelchair transfers or improvements in activities of daily living.

3.        Three of 20 joints had recurrence of HO.