Heterotopic Ossification of the Elbow: A Literature Review

Main Article Content

Sohail Qazi
John Reynolds
Hesham Abdelfattah
Joseph Thoder


Background: Aberrant ectopic bone formation of the elbow is a common clinical presentation after neurologic, burn, and traumatic injuries to the joint. This represents a significant source of patient burden, delayed recovery times and increased medical costs. Although there is an abundance of literature on heterotopic ossification (HO) of the hip, there is little literature on HO of the elbow in comparison.

Aims: This literature review seeks to summarize consensus regarding the appropriate system of classification, pathophysiology, clinical presentation, risk factors, and prophylactic treatment options associated with HO formation of the elbow. Clinicians may utilize this information to identify high risk patient populations for potential prophylactic therapy to prevent the occurrence/complications of HO at the elbow.

Methods: A PubMed literature review was conducted using combinations of the key words “heterotopic ossification,” “elbow,” and “fracture/dislocation.” All study types were considered and relevant articles were utilized for this review.

Results: Higher levels of injury, severe neurologic and burn injuries, delay to surgery, delay in fixation/stabilization of the elbow, multiple surgical treatments, and genetics were correlated with ectopic bone formation. Single dose pre/postoperative radiotherapy with 700cGy or preoperative NSAID regiments were found to be the main prophylactic treatments.

 Conclusion: Clinicians must consider the HO risk profile of their patients as well as the risk factors of treatment before deciding on prophylactic options. Surgical resection is reserved for the most severe cases.

Heterotopic, ossification, elbow; fracture, dislocation, injury.

Article Details

How to Cite
Qazi, S., Reynolds, J., Abdelfattah, H., & Thoder, J. (2019). Heterotopic Ossification of the Elbow: A Literature Review. Journal of Advances in Medicine and Medical Research, 30(6), 1-10. https://doi.org/10.9734/jammr/2019/v30i630207
Review Article


Mittal R. Posttraumatic stiff elbow. Indian Journal of Orthopaedics. 2017;51(1):4- 13.
DOI: 10.4103/0019-5413.197514

Foruria AM, Augustin S, Morrey BF, Sánchez-Sotelo J. Heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna. The Journal of Bone and Joint Surgery (American). 2013; 95(10):e66 1.
DOI: 10.2106/jbjs.k.01533.

Hastings H, Graham TJ. The classification and treatment of heterotopic ossification about the elbow and forearm. Hand Clinics. 1994;10(3):417-437.

Summerfield SL, DiGiovanni C, Weiss AP. Heterotopic ossification of the elbow. Journal of Shoulder and Elbow Surgery. 1997;6(3):321-332.
DOI: 10.1016/s1058-2746(97)90025

Ploumis A, Belbasis L, Ntzani E, Tsekeris P, Xenakis T. Radiotherapy for prevention of heterotopic ossification of the elbow: A systematic review of the literature. Journal of Shoulder and Elbow Surgery. 2013; 22(11):1580-1588.

Mitchell EJ, Canter J, Norris P, Jenkins J, Morris J. The genetics of heterotopic ossification: Insight in to the bone remodeling pathway. Journal of Orthopaedic Trauma. 2010;24(9):530.
DOI: 10.1097/bot.0b013e3181ed147b

Agarwal S, Loder S, Levi B. Heterotopic ossification following upper extremity injury. Hand clinics. 2017;33(2):363-373.
DOI: 10.1016/j.hcl.2016.12.013

de Vries TJ, Schoenmaker T, Micha D, Hogervorst J, Bouskla S, Forouzanfar, et al. Periodontal ligament fibroblastsas a cell model to study osteogenesis and osteoclastogenesis in fibro dysplasia ossificans progressiva. Bone. 2017;109: 168-177.
DOI: 10.1016/j.bone.2017.07.007

Barfield WR, Holmes RE, Hartsock LA. Heterotopic ossification in trauma. Orthopedic Clinics of North America. 2017; 48(1):35-46.

Ploumis A, Donovan JM, Olurinde MO, Clark DM, Wu JC, Sohn DJ, et al. Association between alendronate, serum alkaline phosphatase level, and hetero-topic ossification in individuals with spinal cord injury. The Journal of Spinal Cord Medicine. 2014;38(2):193-198.
DOI: 10.1179/2045772314y.0000000213

Bossche LV, Vanderstraeten G. Hetero-topic ossification: A review. Journal of Rehabilitation Medicine. 2005;37:129– 136.

Hong CC, Nashi N, Hey HW, Chee YH, Murphy D. Clinically relevant heterotopic ossification after elbow fracture surgery: A risk factors study. Orthopaedics & Traumatology: Surgery & Research. 2015; 101(2):209-213.
DOI: 10.1016/j.otsr.2014.10.021

Jennings JD, Hahn A, Rehman S, Haydel C. Management of adult elbow fracture dislocations. Orthopedic Clinics of North America. 2016;47(1):97-113.
DOI: 10.1016/j.ocl.2015.08.001

Salazar D, Golz A, Israel H, Marra G. Heterotopic ossification of the elbow treated with surgical resection: Risk factors, bony ankylosis, and complications. Clinical Orthopaedics and Related Research. 2014;472(7):2269-2275.
DOI: 10.1007/s11999-014-3591-0

Manske MC, Hanel DP. Postburn contractures of the elbow and heterotopic ossification. Hand Clinics. 2017;33(2):375-388.
DOI: 10.1016/j.hcl.2016.12.014

Lin SH, Chou CL, Chiou HJ. Ultrasonography in early diagnosis of heterotopic ossification. Journal of Medical Ultrasound. 2014;22(4):222-227.
DOI: 10.1016/j.jmu.2014.10.004

Mavrogenis AF, Soucacos PN, Papa-gelopoulos PJ. Heterotopic ossification revisited. Orthopedics. 2011;34(3):177.
DOI: 10.3928/01477447-20110124-08

Dey D, Wheatley BM, Cholok D, Agarwal S, Yu PB, Levi B, et al. The traumatic bone: Trauma-induced heterotopic ossify-cation. Translational Research. 2017;186: 95-111.
DOI: 10.1016/j.trsl.2017.06.004

Zagarella A, Impellizzeri E, Maiolino R, Attolini R, Castoldi MC. Pelvic heterotopic ossification: When CT comes to the aid of MR imaging. Insights into Imaging. 2013; 4(5):595-603.
DOI: 10.1007/s13244-013-0265-5

Abrams GD, Bellino MJ, Cheung EV. Risk factors for development of heterotopic ossification of the elbow after fracture fixation. Journal of Shoulder and Elbow Surgery. 2012;21(11):1550-1554.
DOI: 10.1016/j.jse.2012.05.040

Sandeep KN, Suresh G, Gopisankar B, Abhishek N, Sujiv A. Does excision of heterotopic ossification of the elbow result in satisfactory patient-rated outcomes? Malaysian Orthopaedic Journal. 2017; 11(1):35-40.
DOI: 10.5704/moj.1703.017

Douglas K, Cannada LK, Archer KR, Dean DB, Lee S, Obremskey W. Incidence and risk factors of heterotopic ossification following major elbow trauma. Orthopedics. 2012;35(6):e815-e822.
DOI: 10.3928/01477447-20120525-18

Wiggers JK, Helmerhost GT, Brouwer KM, Niekel MC, Nunez F, Ring D. Injury complexity factors predict heterotopic ossification restricting motion after elbow trauma. Clinical Orthopaedics and Related Research. 2014;472(7):2162-2167.
DOI: 10.1007/s11999-013-3304-0

Ilahi OA, Strausser DW, Gabel GT. Post-traumatic heterotopic ossification about the elbow. Orthopedics. 1998;21(3):265- 268.

Veltman ES, Lindenhovius AL, Kloen P. Improvements in elbow motion after resection of heterotopic bone: A systematic review. Strategies in Trauma and Limb Reconstruction. 2014;9(2):65-71.
DOI: 10.1007/s11751-014-0192-0

Bidner SM, Rubins IM, Desjardins JV, Zukor DJ, Goltzman D. Evidence for a humoral mechanism for enhanced osteo-genesis after head injury. The Journal of Bone and Joint Surgery American Volume. 1990;72(8):1144-1149.
DOI: 10.2106/00004623-199072080-000 04

Bargellesi S, Cavasin L, Scarponi F, De Tanti A, Bonaiuti D, Bartolo M, et al. Occurrence and predictive factors of heterotopic ossification in severe acquired brain injured patients during rehabilitation stay: Cross-sectional survey. Clinical rehabilitation. 2018;32(2):255-262.
DOI: 10.1177/0269215517723161

Levi B, Jayakumar P, Giladi A, Jupiter JB, Ring DC, Kowalske K, et al. Risk factors for the development of heterotopic ossification in seriously burned adults: A National Institute on Disability, Independent Living and Rehabilitation Research burn model system database analysis. Journal of Trauma and Acute Care Surgery. 2015;79(5):870.
DOI: 10.1097/ta.0000000000000838

Pontell ME, Sparber LS, Chamberlain RS. Corrective and reconstructive surgery in patients with post burn heterotopic ossification and bony ankylosis: An evidence-based approach. Journal of Burn Care & Research. 2015;36(1):57.
DOI: 10.1097/bcr.0000000000000116

Adegbite N, Xu M, Kaplan F, Shore E, Pignolo R. Diagnostic and mutational spectrum of progressive osseous hetero-plasia (POH) and other forms of GNAS‐based heterotopic ossification. American Journal of Medical Genetics Part A. 2008;146A(14):1788-1796.
DOI: 10.1002/ajmg.a.32346

Kaplan FS. Pagets disease of bone: Orthopedic complications. Seminars in Arthritis and Rheumatism. 1994;23(4):250-252.
DOI: 10.1016/0049-0172(94)90049-3

Zychowicz ME. Pathophysiology of heterotopic ossification. Orthopaedic Nursing. 2013;32(3):173-177.
DOI: 10.1097/nor.0b013e3182920d85

Hanna SA, Dawson-Bowling S, Millington S, Bhumbra R, Achan P. Total hip arthroplasty in patients with Paget’s disease of bone: A systematic review. World Journal of Orthopedics. 2017;8(4): 357-358.
DOI: 10.5312/wjo.v8.i4.357

Ferguson D, Itonaga I, Maki M, Mcnally E, Gundle R, Athanasou N. Heterotopic bone formation following hip arthroplasty in Pagets disease. Bone. 2004;34(6):1078-1083.
DOI: 10.1016/j.bone.2004.01.027

Mader R, Sarzi-Puttini P, Atzeni F, et al. Extraspinal manifestations of diffuse idiopathic skeletal hyperostosis. Rheu-matology. 2009;48(12):1478-1481.
DOI: 10.1093/rheumatology/kep308

Cao YJ, Wei Z, Zhang H, Zhang ZL. Expanding the clinical spectrum of osteogenesis imperfecta type V: 13 additional patients and review. Frontiers in Endocrinology. 2019;10(1):374-375.
DOI: 10.3389/fendo.2019.00375

Zhytnik L, Maasalu K, Duy BH, et al. IFITM5 pathogenic variant causes osteogenesis imperfecta V with various phenotype severity in Ukrainian and Vietnamese patients. Human Genomics. 2019;13(1):25.
DOI: 10.1186/s40246-019-0209-3

Guan S, Bai X, Wang Y, et al. Genetic mutation and clinical features of osteogenesis imperfecta type V. Chinese Journal of Medical Genetics. 2017;34(6): 797-801.
DOI: 10.3760/cma.j.issn.1003-9406.2017. 06.003

Brizola E, Mattos EP, Ferrari J, et al. Clinical and molecular characterization of osteogenesis imperfecta type V. Molecular Syndromology. 2015;6(4):164-172.
DOI: 10.1159/000439506

Robinson CG, Polster JM, Reddy CA, Lyons JA, Evans PJ, Lawton JN, et al. Postoperative single-fraction radiation for prevention of heterotopic ossification of the elbow. International Journal of Radiation Oncology Biology Physics. 2010;77(5): 1493-1499.
DOI: 10.1016/j.ijrobp.2009.06.072

Maender C, Sahajpal D, Wright TW. Treatment of heterotopic ossification of the elbow following burn injury: Recommenda-tions for surgical excision and perioperative prophylaxis using radiation therapy. Journal of Shoulder and Elbow Surgery. 2010;19(8):1269-1275.
DOI: 10.1016/j.jse.2010.05.029

Mishra MV, Austin L, Parvizi J, Ramsey M, Showalter TN. Safety and efficacy of radiation therapy as secondary prophylaxis for heterotopic ossification of non‐hip joints. Journal of Medical Imaging and Radiation Oncology. 2011;55(3):333-336.
DOI: 10.1111/j.1754-9485.2011.02275

Heyd R, Buhleier T, Zamboglou N. Radiation therapy for prevention of heterotopic ossification about the elbow. Strahlentherapie Und Onkologie. 2009; 185(8):506-511.
DOI: 10.1007/s00066-009-1968-x

Hamid N, Ashraf N, Bosse MJ, Connor PM, Kellam JF, Sims SH, et al. Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: A prospective randomized study. The Journal of bone and joint surgery American volume. 2010;92(11):2032-2038.
DOI: 10.2106/jbjs.i.01435

McGettigan P, Henry D. Cardiovascular risk with non-steroidal anti-inflammatory drugs: Systematic review of population-based controlled observational studies. PLoS Medicine. 2011;8(9):e1001098.
DOI: 10.1371/journal.pmed.1001098.

Sun Y, Cai J, Li F, Liu S, Ruan H, Fan C. The efficacy of celecoxib in preventing heterotopic ossification recurrence after open arthrolysis for post-traumatic elbow stiffness in adults. Journal of Shoulder and Elbow Surgery. 2015;24(11): 1735-1740.
DOI: 10.1016/j.jse.2015.07.006