Disuse osteoporosis in heterotopic ossification resection complicated with femoral neck fracture: A case report
M Rajaei A.M.Z., Sahran Yahaya, Faisham W.I.,
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( M Rajaei A.M.Z. )
Universiti Sains Malaysia School of Medical Sciences Department of Orthopedic
( Sahran Yahaya )
Universiti Sains Malaysia School of Medical Sciences Department of Orthopedic
( Faisham W.I. )
Universiti Sains Malaysia School of Medical Sciences Department of Orthopedic
Abstract
Introduction: Heterotopic ossification (HO) is an abnormal formation of bone in areas of the body other than skeletal tissue. It is commonly occurs in association with traumatic brain injury. Surgical excision is indicated in severe HO limiting mobility. Osteoporotic bone should be considered to prevent intraoperative complication.
Materials & methods: We report a case of 26-year-old lady, who had history of traumatic brain injury (left temporoparietal subdural haemorrhage with cerebral oedema). There was no injury to the hip. Subsequently, she developed severe HO of left hip. Two years post trauma, she presented with severe restriction of left hip motion, causing inability to sit on wheelchair normally. CT images showed HO over left hip Brooker stage 4. Severe ossification noted within the muscles in left superior pubic ramus, extended to medial aspect of proximal left femur. Hip joints reported to be preserved, and quality of the femoral neck bone was not commented in the CT scan report.
Results: She underwent HO resection about 3 years post trauma. Planned osteotomy site over the HO was checked intraoperative with image intensifier. During the osteotomy, her left femoral neck was fractured by the indirect impact. Hence, complete resection of the HO was done together with the proximal femur part. Initial plan of simple HO resection was changed to left bipolar hemiarthroplasty intraoperatively. The hip capsule was reinforced using Uni-Graft (Woven Impregnated Vascular Prosthesis) originally used for reconstructive procedure in cardiac and vascular surgery. This is our normal approach to stabilize hip arthroplasty when adequate soft tissue stability could not be achieved.
Discussions: There is controversy whether to resect HO early or late. Delayed surgery will allows maturation of bone and reduced recurrence. Possible benefit of early excision is prevention of soft-tissue contracture and muscle atrophy, and prevention of intra-articular ankylosis. This case illustrates one of rare complications which can occur in delayed excision. Disuse osteopenia of femoral neck and head leads to high risk of fracture even with minimal manipulation during and after surgery.
Conclusion: Careful evaluation of femoral head and neck bone quality is very important prior to delayed resection of severe hip heterotopic ossification. Bipolar hemiarthroplasty is an option post resection in severe osteoporosis of femoral head and neck at risk of iatrogenic fracture. This method is not well described in literature and warrant further study.
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