Yeungnam Univ J Med.  2018 Jun;35(1):130-134. 10.12701/yujm.2018.35.1.130.

Preoperative arterial embolization of heterotopic ossification around the hip joint

• Kim JH
• Park C
• Son SM
• Shin WC
• Jang JY
• Jeong HS
• Lee IS
• Moon TY

• KMID: 2415747
• DOI: http://doi.org/10.12701/yujm.2018.35.1.130

Abstract

Heterotopic ossification (HO) around the hip joint is not uncommon following neurological injury. Often, surgical treatment is performed in patients with restricted motion and/or refractory pain due to grade III or IV HO according to Brooker classification. The major complication that occurs as a result of surgical HO removal is perioperative bleeding due to hyper-vascularization of the lesion. Here, we report a case of preoperative embolization in a 51-year-old male patient presenting with restricted bilateral hip range of motion (ROM) due to HO following a spinal cord injury. In the right hip without preoperative arterial embolization, massive bleeding occurred during surgical removal of HO. Thus, the patient received a transfusion postoperatively due to decreased serum hemoglobin levels. For surgery of the left hip, preoperative embolization of the arteries supplying HO was performed. Surgical treatment was completed without bleeding complications, and the patient recovered without a postoperative transfusion. This case highlights that, while completing surgical removal for ROM improvements, orthopedic surgeons should consider preoperative arterial embolization in patients with hip HO.

Keyword

Hip; Heterotopic ossification; Arterial embolization; Gelatin sponge

MeSH Terms

Arteries
Classification
Hemorrhage
Hip Joint*
Hip*
Humans
Male
Middle Aged
Orthopedics
Ossification, Heterotopic*
Pain, Intractable
Range of Motion, Articular
Spinal Cord Injuries
Surgeons

Figure

• 

  Fig. 1. (A) Pelvis anteroposterior radiograph shows diffuse heterotopic ossification around both hip joints. (B) Sagittal reconstruction computed tomography (CT) image shows nearly complete bone ankylosis of the left hip joint, causing total stiffness of the hip joint. (C) Technetium 99m-methyl diphosphonate bone scan shows intense uptake in bilateral hip joints. (D) Preoperative axial CT with contrast enhancement shows hypertrophied arteries (arrowheads) supplying the heterotopic bone formation around the bilateral hip joints.

• 

  Fig. 2. (A) Common iliac arteriogram reveals hypertrophied bilateral superior gluteal arteries (black arrows), left lateral circumflex femoral artery (arrowhead), and the stump of right lateral circumflex femoral artery (white arrow), which was ligated during the previous surgery. (B) External iliac angiography demonstrates hypertrophied left lateral circumflex femoral artery (arrow) and diffuse hypervascular area involving the left hip joint (dashed circle). Note that the left lateral circumflex femoral artery arises from common femoral artery, as a normal anatomical variant. (C) Angiography obtained after embolization with gelatin sponge slurry shows decreased vascular flow in the left superior gluteal artery (arrow) and lateral circumflex femoral artery (arrowhead).

• 

  Fig. 3. (A) Gross specimen showing multiple bone fragments with hemorrhage. (B) Passive flexion of the left hip joint was available after surgical removal of heterotopic ossification. (C) Immediate postoperative pelvis anteroposterior radiograph shows a decreased extent of heterotopic ossification compared with that in the preoperative pelvic radiograph.

Reference

1. Clements NC Jr, Camilli AE. Heterotopic ossification complicating critical illness. Chest. 1993; 104:1526–8.

2. Hannallah D, Peng H, Young B, Usas A, Gearhart B, Huard J. Retroviral delivery of Noggin inhibits the formation of heterotopic ossification induced by BMP-4, demineralized bone matrix, and trauma in an animal model. J Bone Joint Surg Am. 2004; 86:80–91.

3. Almangour W, Schnitzler A, Salga M, Debaud C, Denormandie P, Genêt F. Recurrence of heterotopic ossification after removal in patients with traumatic brain injury: a systematic review. Ann Phys Rehabil Med. 2016; 59:263–9.

4. Bedi A, Zbeda RM, Bueno VF, Downie B, Dolan M, Kelly BT. The incidence of heterotopic ossification after hip arthroscopy. Am J Sports Med. 2012; 40:854–63.

5. Board TN, Karva A, Board RE, Gambhir AK, Porter ML. The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty. J Bone Joint Surg Br. 2007; 89:434–40.

6. Dilling CF, Wada AM, Lazard ZW, Salisbury EA, Gannon FH, Vadakkan TJ, et al. Vessel formation is induced prior to the appearance of cartilage in BMP-2-mediated heterotopic ossification. J Bone Miner Res. 2010; 25:1147–56.

7. Reichel LM, Salisbury E, Moustoukas MJ, Davis AR, Olmsted-Davis E. Molecular mechanisms of heterotopic ossification. J Hand Surg Am. 2014; 39:563–6.

8. Warren SB, Brooker AF Jr. Intramedullary nailing of tibial nonunions. Clin Orthop Relat Res. 1992; 285:236–43.

9. Baird EO, Kang QK. Prophylaxis of heterotopic ossification - an updated review. J Orthop Surg Res. 2009; 4:12.

10. Salisbury E, Rodenberg E, Sonnet C, Hipp J, Gannon FH, Vadakkan TJ, et al. Sensory nerve induced inflammation contributes to heterotopic ossification. J Cell Biochem. 2011; 112:2748–58.

11. Rilling WS, Chen GW. Preoperative embolization. Semin Intervent Radiol. 2004; 21:3–9.

12. Vogl TJ, Wolff JD, Balzer J, Skripitz R. Preoperative arterial embolization in heterotopic ossification: a case report. Eur Radiol. 2001; 11:962–4.

13. Medsinge A, Zajko A, Orons P, Amesur N, Santos E. A casebased approach to common embolization agents used in vascular interventional radiology. AJR Am J Roentgenol. 2014; 203:699–708.