Corrective and reconstructive surgery in patients with postburn heterotopic ossification and bony ankylosis: an evidence-based approach

Abstract

Articular heterotopic ossification (HO) and subsequent bony ankylosis (BA) are infrequent yet devastating complications of severe burn injuries. These conditions are diagnosed clinically and confirmed by imaging. Patients then begin active physical therapy until cleared for surgery, which remains the standard of care. This study critically reviews the existing literature on the diagnosis, treatment, and surgical outcomes of HO/BA in severely burned patients and provides an evidence-based treatment algorithm. A comprehensive search for all the studies addressing HO and BA after burn injury was conducted using PubMed and Google Scholar from 1957 to 2013. Fifty-one studies on postburn HO/BA have been published, reporting incidences from 0.1 to 35.3%. Most patients suffered from third-degree, thermal burns, with a mean TBSA of 49 ± 14%. The mean time from burn until diagnosis was 7 ± 11 months. Seventy-nine percent of the affected joints were elbows and 84% had adjacent and/or overlying burns. Ninety-one percent of joints had solely extra-articular HO. Ninety percent of HO/BA cases were treated with anatomic excision, and all achieved appreciable increases in range of motion with infrequent recurrence. Perioperative radiotherapy was used infrequently. Surgical articular reconstruction is the standard of care for postburn HO/BA severe enough to limit joint movement and/or function. Early detection and initiation of physical therapy are paramount in preventing progression to complete BA. Increased awareness and more rapid means of detecting postburn articular changes may permit earlier discontinuation of passive range of motion exercises, thereby halting the initiation and progression of HO.