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Background: Heterotopic ossification (HO) is a known finding after total hip arthroplasty (THA) that potentially affects clinical outcomes. The incidence of HO is related to various factors, including soft-tissue trauma, postoperative medication, surgical approach, and the surgeon's experience. Because use of the direct anterior approach (DAA) is gaining popularity, we aimed (1) to determine the incidence of HO after DAA-THA and (2) to evaluate the impact of HO on patient-reported outcomes (PROs)., Methods: We retrospectively reviewed 401 THAs (67 ± 10 years old, 210 men). The incidence and grade of HO were evaluated using the Brooker classification with anteroposterior and lateral radiographs. PROs were collected with use of the Oxford Hip Score (OHS) and the Core Outcome Measures Index (COMI)-Hip and were correlated with HO grades using generalized multiple regression models., Results: The incidence of HO was 29.9% on the anteroposterior radiographic views (Brooker grade 1, 14.5%; grade 2, 11.1%; grade 3, 2.7%; and grade 4, 0.57%); the lateral radiographic views detected 9% additional HO when compared with the anteroposterior radiographs alone (Brooker grade 1, 8%, and grade 2, 1%). HO was more frequent in men. The American Society of Anesthesiologists (ASA) grade, age in women, and higher body mass index (BMI) in men were associated with higher HO grades. A transverse "bikini" incision was associated with a lower rate (4%) of Brooker grades 3 and 4 HO when compared with a longitudinal incision (12%). A Brooker grade of 0 to 3 HO did not impact outcomes. Only Brooker grade-4 HO was associated with significantly worse PROs; however, pain was not affected., Conclusions: Low-grade HO after DAA-THA is not uncommon, and its rate is underestimated when anteroposterior radiographic views are evaluated without lateral views. The risk factors for developing HO in our cohort were an ASA grade of >3, male sex (especially with a high BMI), older age in women, and use of longitudinal incisions. With use of the bikini incision, patients had lower rates of severe HO, but mostly senior surgeons with more experience performed their surgery. Age, ASA grade, experience level of the surgeon, and Brooker grade-4 HO all had a significant influence on PROs. Clinically important HO (Brooker grade 4) remains rare after DAA-THR., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Heterotopic ossification is the ectopic formation of mature lamellar bone in nonosseous tissue. The prevalence of heterotopic ossification following combat injuries is much higher than civilian data would suggest. In certain cases, the aberrant bone formation can envelop major neurovascular structures in the lower extremity, leading to symptomatic neurovascular entrapment., Methods: We describe five consecutive cases of heterotopic ossification leading to symptomatic neurovascular entrapment in the lower extremity as a result of blast trauma and present our method of patient assessment, preoperative planning, and surgical excision., Results: Heterotopic bone was successfully excised without neurovascular injury in all patients. At a mean of twenty months (range, eight to forty-five months) postoperatively, all patients demonstrated continued improvement of their pre-excision function. All patients who had neuropathic pain had a decrease in the pain. Those with decreased joint motion regained motion once their wounds were stable. Sensory deficits resolved before motor deficits did. There was no recurrence of clinically relevant heterotopic ossification in this series., Conclusions: Excision of heterotopic bone, particularly with concurrent neurovascular entrapment, can be associated with major short-term and long-term complications. With use of our treatment algorithm, involving careful preoperative planning and meticulous operative excision, heterotopic bone entrapping major neurovascular structures following severe extremity trauma can be safely excised with subsequent clinical improvement.

Background: The objectives of this study were to (1) determine the prevalence of heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna, (2) identify risk factors associated with the development of heterotopic ossification in these injuries, and (3) characterize the severity and location of the heterotopic ossification and the associated range of elbow motion., Methods: From 2004 to 2008, 142 elbow fractures and fracture-dislocations involving the proximal aspect of the radius or ulna were treated surgically at our institution. Records and radiographs of 130 elbows with adequate follow-up were retrospectively reviewed to identify cases of heterotopic ossification, characterize the ectopic bone, and analyze associated risk factors. The most frequent injuries included olecranon fractures, Monteggia fracture-dislocations, and various combinations of fractures of the radial head and coronoid with or without dislocation or subluxation., Results: Heterotopic bone was identified on the radiographs of forty-eight elbows (37%). Heterotopic ossification interfered with motion in twenty-six elbows (20%), and thirteen elbows (10%) underwent additional surgery to remove heterotopic bone with the goal of improving motion. Risk factors associated with the development of heterotopic ossification included elbow subluxation or dislocation at the time of presentation, an open fracture, a severe chest injury, and a delay in definitive surgical treatment. Ectopic bone was preferentially located at the origin of torn soft-tissue structures or around fracture sites, and it was particularly common around the posterior aspect of the ulna and the neck of the radius. Heterotopic ossification was classified on radiographs as hazy immature in twenty-two elbows, limited mature in eighteen, extensive mature in five, and a complete bone bridge in three. Heterotopic ossification was more common in patients with an associated distal humeral fracture, radial head and coronoid fractures with an associated elbow dislocation (terrible triad injury), and a transolecranon fracture-dislocation., Conclusions: Thirty-seven percent of elbows treated surgically for fractures involving the proximal aspect of the radius and/or ulna developed heterotopic ossification. In twenty percent of elbows, heterotopic ossification was associated with clinically relevant motion deficits. More severe heterotopic ossification was encountered in patients presenting with an associated distal humeral fracture, terrible triad injury, transolecranon fracture-dislocation, or Monteggia fracture-dislocation. Patients with an open injury, instability, severe chest trauma, or delay in definitive surgical treatment had a higher prevalence of heterotopic ossification.

Background: Heterotopic ossification following lower-limb joint arthroplasty is a challenging clinical problem. No comprehensive study has been conducted on heterotopic ossification after total ankle arthroplasty, to our knowledge. The purpose of this study was to evaluate the prevalence and location of heterotopic ossification after primary total ankle arthroplasty, predisposing factors, and effects on clinical outcomes, and to develop a method of classification., Methods: Eighty ankles in eighty patients with a primary total ankle arthroplasty were followed for a mean (and standard deviation) of 31.9 ± 11.3 months (range, twenty-four to sixty-five months). The prevalence and location of heterotopic ossification, predisposing factors, and outcomes were analyzed, and a method of classification was developed., Results: Twenty (25%) of the eighty ankles demonstrated postoperative heterotopic ossification, with the majority of the cases in the posterior aspect of the ankle. The heterotopic ossification was Class I in four cases (20%); Class II, in five (25%); Class III, in four (20%); and Class IV, in seven (35%). Symptomatic heterotopic ossification was reported in eight patients (10%), and two required surgical resection because of intractable pain. Ankles that developed heterotopic ossification had significantly longer operative times, less postoperative motion, and lower American Orthopaedic Foot & Ankle Society ankle-hindfoot scores at the six, twelve, and twenty-four-month follow-up examinations (p < 0.05 for all)., Conclusions: This study demonstrates that the prevalence of heterotopic ossification following primary total ankle arthroplasty is considerable, and that heterotopic ossification is associated with reduced ankle motion and a poor clinical outcome at a mean of two years postoperatively. Care is needed to attempt to reduce the occurrence of heterotopic ossification.

Background: Several surgical approaches have been suggested for the treatment of posttraumatic elbow stiffness; however, the optimal approach to elbows with considerable loss of flexion has not been well described. We investigated the pathologic lesions causing posttraumatic loss of elbow flexion and analyzed the results of surgical release., Methods: Forty-two patients with <100° of elbow flexion due to an extrinsic contracture following trauma underwent surgical release at a median of ten months after injury. To achieve maximum flexion, release of the posterior band of the medial collateral ligament was mandatory in all patients, and only four patients required additional anterior procedures. The ulnar nerve was transposed anteriorly in forty patients, including three who had had a previous transposition. To evaluate the results, we compared preoperative and postoperative elbow motion, Mayo Elbow Performance Index (MEPI) scores, and radiographs., Results: Intraoperatively, heterotopic ossification was observed in forty patients. It was located predominantly in the posteromedial aspect of the capsule. Heterotopic bone was more commonly found during surgery than it was identified preoperatively on radiographs. Mean flexion increased significantly from 89° preoperatively to 124° (range, 90° to 140°) at a mean of thirty-nine months postoperatively. The mean size of the flexion contracture decreased from 34° preoperatively to 9° (range, 0° to 30°) postoperatively. Overall, ≥120° of final flexion and a total arc of ≥100° were regained by 88% of the patients. The mean MEPI score improved significantly from 73 points preoperatively to 94 points (range, 72 to 100 points) postoperatively, with the result rated as excellent in thirty-two patients, good in eight, and fair in two. Two patients had clinical recurrence of heterotopic ossification associated with a failure to obtain an increase in flexion., Conclusions: This study demonstrates that posttraumatic heterotopic ossification, particularly in the posteromedial aspect of the capsule, is closely associated with loss of elbow flexion. Satisfactory restoration of elbow flexion can be obtained in the majority of patients by surgical release of the posterior band of the medial collateral ligament and excision of heterotopic bone.

Background: Despite reports of good clinical outcomes in patients treated with lumbar and cervical disc replacements, varying degrees of heterotopic bone have been observed around these devices. The purposes of the present study were to determine the prevalence of heterotopic ossification following lumbar disc replacement and to investigate whether heterotopic ossification results in loss of motion or negatively affects clinical outcome., Methods: All preoperative and postoperative radiographs from a completed prospective, randomized, United States Food and Drug Administration-regulated trial comparing replacement with the CHARITE Artificial Disc with anterior interbody arthrodesis were analyzed. In each of 276 patients treated with disc replacement, heterotopic ossification was categorized with use of a validated 5-point radiographic classification system both preoperatively and at all protocol-specified follow-up intervals to two years. The range of motion on flexion and extension radiographs made preoperatively was compared with that on radiographs made two years postoperatively, and the motion was correlated with the presence or absence of heterotopic ossification. Similarly, validated clinical outcome measures were correlated with the presence or absence of heterotopic ossification at two years., Results: The prevalence of heterotopic ossification in the 276 consecutive patients treated with lumbar disc replacement with the CHARITE Artificial Disc was 4.3%. There were four cases of Class-I heterotopic ossification and eight cases of Class-II heterotopic ossification. In five of the twelve patients, heterotopic bone was visible as early as six weeks postoperatively, and eleven of the twelve patients had evidence of heterotopic ossification by three months postoperatively. The postoperative range of motion exceeded the preoperative range in all of the patients with heterotopic ossification. With the numbers available, no difference in either the range of motion or the clinical outcome at twenty-four months postoperatively was found between the patients who had and those who did not have heterotopic ossification., Conclusions: Heterotopic ossification is infrequent in patients treated with the CHARITE Artificial Disc, and it does not impact the range of motion or clinical outcome.

Background: It has been our experience that ossification occurs adjacent to anterior cervical plates. Our hypothesis was that the closer the plate is to the adjacent disc space, the greater the ossification., Methods: We retrospectively reviewed the lateral radiographs of the cervical spine of 118 patients who had a solid fusion following an anterior cervical arthrodesis with a plate for the treatment of a degenerative cervical condition; none of the patients had had cervical spine surgery prior to the index arthrodesis. The plate-to-disc distance was measured on the postoperative lateral radiograph and was used to divide the patients into two groups for each of the two adjacent disc spaces. In group A the plate-to-disc distance was <5 mm, and in group B it was >/=5 mm. The mean duration of follow-up was 25.7 months. The severity of the ossification at the two adjacent disc spaces was classified on a scale ranging from grade 0 (no ossification) to grade 3 (complete bridging). Eighteen patients were excluded from the measurement of the severity of the caudal ossification because overlapping by the bone of the shoulder precluded adequate visualization of the caudal level., Results: Ossification developed in seventy (59%) of the 118 cephalad adjacent disc spaces and twenty-nine (29%) of the 100 caudal adjacent disc spaces (p < 0.001). The mean cephalad plate-to-disc distance was shorter than the mean caudal plate-to-disc distance (p < 0.001). The rate of ossification was higher in group A than in group B, both at the cephalad adjacent disc spaces (67% compared with 24%) and at the caudal adjacent disc spaces (45% compared with 5%) (both p < 0.001). In addition, 93% (twenty-six) of the twenty-eight cases of moderate-to-severe ossification developed in group A., Conclusions: We found a positive association between adjacent-level ossification following anterior cervical plate procedures and the plate-to-disc distance. We now strive to place anterior cervical plates at least 5 mm away from the adjacent disc spaces in order to decrease the likelihood of moderate-to-severe adjacent-level ossification.

Background: Major burn injuries close to joints alter the function of the musculoskeletal system through tissue loss and limitation of joint motion. In children with involvement of the hand, wrist, and forearm, restriction of elbow motion secondary to heterotopic ossification following a burn injury severely limits the function of the upper extremity. The purpose of this study was to review elbow function following excision of heterotopic ossification around the elbow in children., Methods: Eight children (ten elbows) from a population of 3245 consecutive patients who were admitted to our pediatric burn center were found to have severe heterotopic ossification of the elbow, leading to an inability to reach the mouth for feeding and the head and the perineum for self-care. Excision of the heterotopic ossification was undertaken if the patient had this limitation of function and if movement was restricted to a total arc of motion of <50 degrees. Pain was not an indication for the operation. The procedure was performed at an average of 17.3 months following the injury., Results: Seven children (nine elbows) were available for follow-up at an average of fifty-six months after surgery. All nine elbows had an improved arc of motion (an average increase of 57 degrees ). Following excision, heterotopic ossification did not recur. All children were able to reach the face and the perineum following the operation., Conclusions: Excision of heterotopic ossification around the elbow following a burn injury in children can improve the arc of motion and improve the function of the extremity. A relatively simple operative and postoperative regimen can achieve satisfactory results.

We reviewed the results, in eight patients, of excision of heterotopic ossification about the elbow performed three to ten months (average, seven months) after the initial injury and followed by radiation therapy to prevent recurrence. The etiology of the heterotopic ossification included a neurological (head or spinal cord) injury in five patients and a local injury (fracture or fracture-dislocation) of the elbow in three patients. The average preoperative arc of motion of the three joints that were capable of motion was 12 degrees (5, 10, and 20 degrees); the remaining five joints were fixed in an average of 56 degrees (range, 10 to 90 degrees) of flexion. All of the patients received a total dose of radiation of 1000 centigray, divided into five fractions. The radiation therapy was instituted on the first postoperative day, and at least three of the remaining four treatments were administered on consecutive days. Radiation therapy was not performed on the weekend, so the five fractions were administered over the course of seven days. At an average of forty-six months (range, twenty-five to seventy-two months), the arc of motion averaged 103 degrees, which compared favorably with the 121-degree arc of motion that had been attained intraoperatively. Two patients who had residual motor deficits in the involved extremity had an arc of motion of 50 and 70 degrees at the latest follow-up evaluation; those who had normal motor function fared considerably better, averaging 118 degrees of motion. There was no substantial recurrence of ossification either radiographically or that limited motion, and no complications attributable to the radiation therapy were noted. On the basis of this experience, it seems that the generally recommended twelve to eighteen-month delay between injury and excision, to allow for maturation of heterotopic bone and thus to lessen the likelihood of recurrence, may be eliminated. Additional studies are needed to define the relative risk of recurrence in the various clinical settings in which heterotopic ossification is seen and to determine whether radiation therapy is necessary to prevent recurrence after early excision in each of these instances.

One hundred patients who had painful dysplasia of the hip were treated with a Chiari osteotomy of the pelvis, and the postoperative radiographs were reviewed for the development of heterotopic ossification. Sixty patients did not receive indomethacin postoperatively, and eighteen (30 per cent) had heterotopic ossification of at least class 1; forty patients received indomethacin for two weeks postoperatively, and only three (8 per cent) of them had heterotopic ossification. This difference was significant (p < 0.025). No class-3 or 4 heterotopic ossification was seen in the patients who were given indomethacin. The prevalence of side-effects was relatively low, and no delayed union of the osteotomy was observed in any patient. We concluded that indomethacin, in the dosage schedule and regimen that we used, provides effective prophylaxis for heterotopic ossification after a Chiari pelvic osteotomy.

As part of a multi-center study, 238 titanium stems that were proximally coated with hydroxyapatite were implanted in 220 patients between January 1988 and December 1989. Ninety-two of these stems in eighty-three patients had a minimum of two years of follow-up, including analysis of the clinical and radiographic data. Clinically, the patients were essentially pain-free before six months and had a low (4 per cent) prevalence of pain in the thigh and a very high composite Harris hip-score (mean, 95 points) at two years. Radiographically, subsidence was detected in 8 per cent of the implants; no implant had more than three millimeters of subsidence. Radiolucencies were characteristically seen around the uncoated distal part of the stem, in 70 per cent of the implants. Contrastingly, radiolucencies were rare in the hydroxyapatite-coated proximal zones and were most often found anteriorly, in only 5 per cent of the implants. Areas of increased formation of cancellous bone were seen beneath femoral cortical bone at the interface between the hydroxyapatite-coated and uncoated parts of the stem, in 67 per cent of the implants. Calcar resorption was found in 49 per cent of the implants. Cortical thickening was present in 17 per cent of the implants at the uncoated distal part of the stem. Two of the 238 femoral implants were revised: one because of infection and one because of aseptic loosening associated with non-union of a subtrochanteric osteotomy.

Sixty-two hips in fifty-five patients who were considered to be at risk for postoperative heterotopic ossification were randomly divided into two groups: one received a single 800-centigray dose of limited-field radiation and the other, 1000 centigray of limited-field radiation in divided doses. The risk for heterotopic-bone formation was identified on the basis of previously described criteria, which included previous heterotopic ossification after an operation about the hip, hypertrophic osteoarthritis or post-traumatic osteoarthrosis characterized by formation of extensive osteophytes, radiographic evidence of diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, and male sex. The treatment portals excluded prosthetic surfaces that were intended for biological fixation by ingrowth of bone. At a minimum six-month follow-up, progression of heterotopic ossification had occurred in seven (21 per cent) of thirty-four hips in the first group and in six (21 per cent) of twenty-eight hips in the second group. The ossification had advanced more than one grade in only one hip. Extra-field ossification occurred in fifteen (43 per cent) of thirty-five hips that had not had previous heterotopic ossification. Since the time of the study, the treatment portal has been modified to include the lateral aspect of the greater trochanter, so that the risk of bursitis associated with ossification in this area is minimized. Single-dose limited-field radiation is effective for the prevention of heterotopic ossification, without compromise of early fixation of an uncemented implant.

Twelve patients who had had a total hip arthroplasty had extensive excision of heterotopic bone, followed by prompt, low-dose irradiation, between 1983 and 1990. Volumes of as much as 900 milliliters of heterotopic bone tissue were resected. Of these patients, eleven had excellent relief of pain, and all twelve gained an average of 45 degrees of flexion and 25 degrees of abduction. Two patients had a recurrence of heterotopic bone (Brooker et al. class II); however, only one of these patients was symptomatic and had a result that was considered a failure.

Twenty-four patients were evaluated and diagnosed, between August 1975 and July 1989, as having probable osteoid-osteoma. Fifteen patients had operative treatment (twelve immediate and three delayed); all fifteen had complete relief of pain. The remaining nine patients were treated with non-steroidal anti-inflammatory medications; all nine had complete relief of pain, and six had resolution of the symptoms without using non-steroidal anti-inflammatory drugs, after an average of thirty-three months (range, thirty to forty months) of treatment. Thus, long-term administration of non-steroidal anti-inflammatory drugs can often be as effective as excision for the treatment of osteoid-osteoma, without the morbidity that is associated with the operation, especially in patients in whom operative treatment would be complex or might lead to disability.

One hundred and thirty-one patients who had 144 cemented or uncemented hip prostheses were followed prospectively for two to four years. A cemented or a hybrid prosthesis (consisting of a cemented femoral component and an uncemented acetabular component) was used in men older than seventy years, in women older than sixty years, and in younger patients in whom adequate initial fixation could not be obtained without cement. Uncemented, porous-surfaced implants were used in all other patients. The over-all clinical results were similar for the three groups. For the fifty-two hips that had a cemented prosthesis, the mean total Harris hip rating was 91 points and the score for pain, 42 points; for the twenty-seven hips that had a hybrid prosthesis, 90 and 43 points; and for the sixty-five hips that had an implant allowing ingrowth of bone in both the acetabulum and the femur, 95 and 43 points. Two prosthetic stems that were designed to allow ingrowth of bone had aseptic loosening; one was revised. Pain in the thigh, usually slight and not disabling, occurred at one year in 24 per cent of the patients in whom a femoral component allowing ingrowth had been used; the prevalence of pain then declined. The incidences of migration of the components and of radiolucent lines were greater in the acetabula that had a cemented component than in those that had a cup allowing ingrowth of bone.

Seventy-three fractures of the femoral shaft (seventy patients) were randomized to treatment with interlocked nailing with either the Brooker-Wills femoral nail (thirty-nine fractures) or the Russell-Taylor femoral nail (thirty-four fractures). Sixty-one patients (sixty-four fractures) were prospectively followed from admission until healing of the fracture. Specific attention was paid to recording operative details, including technical difficulties associated with insertion of the nails. Technical difficulties were encountered in insertion of the proximal screw, distal screw, and nail, and in deployment of the fins. Insertion of the Russell-Taylor nail was associated with less technical difficulty, operative time, and estimated loss of blood. The two nails differ in their biomechanical properties, methods of fixation, and instrumentation. These differences did not affect the clinical outcome; the fractures in both groups of patients healed with excellent functional results.

A prospective study of 100 consecutive unilateral fractures of the shaft of the femur was performed to delineate the incidence of, and the factors predisposing to, heterotopic ossification about the hip after intramedullary nailing. Bone debris from reaming of the endosteal canal is deposited in the soft tissues surrounding the site of insertion of the nail, and we postulated that this debris may stimulate the formation of heterotopic bone and that decreasing the amount of debris left in the tissues after nailing may decrease the amount of heterotopic ossification. To test this theory, the patients were treated with routine intramedullary nailing and were randomly divided into two groups. In Group I, the operative incision was irrigated with 250 milliliters of normal saline solution with use of a bulb syringe before the wound was closed, and in Group II, the incision was irrigated with 3000 milliliters of normal saline solution with use of pulsatile lavage. The two groups were similar in all other respects. Eighty patients (eighty fractures; forty in Group I and forty in Group II) were available for follow-up and were evaluated in a blind fashion after the fracture had united. A grading system that was based on the length of the heterotopic ossification, as measured on antero-posterior radiographs of the hip, was used. In thirty-two of the patients (40 per cent), no heterotopic ossification developed, whereas minimum or mild ossification developed in twenty-seven patients (34 per cent). Moderate ossification developed in twelve patients (15 per cent) and severe ossification, in nine patients (11 per cent).(ABSTRACT TRUNCATED AT 250 WORDS)

This study concerns the fate of the first 100 Charnley total hip replacements done in ninety ninety patients at The Hospital for Special Surgery. At the time of this study, the follow-up of the surviving sixty-seven patients ranged from nine and one-half to eleven and one-half year (average, ten years). When studied at an average of ten years after the initial operation, twenty-six of the original 100 hips that had been operated on had been lost to follow-up due to death, and seven could not be traced. Of the remaining sixty-seven hips that were available for clinical evaluation, thirty-seven were rated as excellent; twenty-two, as good; four, as fair; and four, as poor, according to The Hospital for Special Surgery scoring system. The radiographs of fifty-four of the sixty-seven hips were available for this evaluation. Twenty-three of these hips showed radiographic signs of problems that appeared to have no significant bearing on the quality of their clinical results. There was loosening of the femoral component in five hips which occurred within the first three years after operation and then apparently stabilized. One required reoperation eight years after the original surgery. There was one fracture of the femoral stem eight years after the original operation, requiring reoperation. Six hips demonstrated so-called calcar resorption, the greatest measuring fourteen and thirty millimeters. Ten acetabular components showed wear of more than one millimeter, the maximum being five millimeters in both components of a patient with bilateral hip replacement. Two acetabular components migrated, one requiring reoperation due to progressive bone loss nine and one-half years after the original procedure. All three reoperations have been successful to date.

In the total examination of the knee, degenerative changes and ossification in the quadriceps tendon easily recognized on the lateral roentgenogram may cause confusion in diagnosis when seen on the axial view. Vertical ridging of the osteophytes at the patellar insertion of the quadriceps tendon can resemble dentate structure ("tooth" sign). Two hundred and fifty examinations of the knee in different age groups were reviewed and several anatomical sections of the quadriceps-patella insertion were studied. The "tooth" sign represents the relief of severe osteophyte formation in the bundle of the quadriceps tendon at its insertion into the patella.

Eleven patients with hypoplasia and partial or complete aplasia of the ulna (examples of a complex spectrum of postaxial forearm and hand abnormalities) were reviewed. Three types of ulnar deformity were observed: (1) hypoplasia, (2) partial aplasia (ossification of the proximal part of the ulna present at birth); and (3) total aplasia (ossification not development). The roentgenographically "absent" segment of the ulna may be a large fibrocartilaginous anlage attached distally to the distal radial epiphysis or the ulnar side of the carpus, or both. The tethering effect of this band may cause ulnar deviation of the wrist (and hand) and dislocation of th badial head in utero as well as progression of these deformities after birth. Resection of the distal end of the fibrocartilaginous anlage during the first to second year of life is recommended, since the results of this procedure suggest that it reduces the angular growth deformities. It is also suggested that if the one-bone-forearm operation is indicated, it should be deferred until a later age, since complications may be less likely to occur then than at the time that the anlage is resected.

Twenty patients with spinal cord injury complicated by ossification around the hip were followed for eighteen months or more. The bone scan, roentgenogram, level of alkaline phosphatase, and range of hip motion of each patient were analyzed. The average follow-up was forty months. The heterotopic ossification usually did not mature until after one and one-half years. The roentgenograms were of no value in judging its maturity. The bone scan correlated well with the results of the alkaline phosphatase testing in judging maturity of the ossification. We concluded that before operative resection, a patient should have a normal level of alkaline phosphatase, decreasing activity on the bone scans, and a restriction of motion to less than 50 degrees of hip flexion.

Nine cases of heterotopic ossification at the elbow in seven patients who had a cerebral injury and prolonged coma were treated by excision of the extra-articular bone bridge from the humerus to the ulna. The bridge was either anterior or posterior, and did not involve the radius. The articular cartilage in all elbows showed no significant evidence of degeneration in spite of the prolonged immobility of the joints during the period of coma. Two of the patients also had resection of heterotopic bone about the hip joint which resulted in rapid reformation of bone. In all patients there was restoration of satisfactory function in the elbow operated on without reformation of bone. Follow-up was from ten months to 8.7 years.

A prospective study was done to evaluate the efficacy of treatment with 1,000 rads of radiation in the prevention of heterotopic ossification after total hip arthroplasty in patients who are at high risk. In a previous prospective study, patients who were at high risk for heterotopic ossification after total hip arthroplasty were identified and an effective regimen for its prevention was established. It was demonstrated that treatment with 2,000 rads of radiation that was initiated within four days after the total hip arthroplasty was highly effective in the prevention of heterotopic ossification and in the prevention of recurrence after resection of existing ossification. In the present study, 1,000 rads of radiation was administered in increments of 200 rads over a period of five to seven days and was as effective as treatment with 2,000 rads. The protocol of 1,000 rads is preferable because it reduces the risk of malignancy and the duration of hospitalization.

Cheilectomy, the excision of an irregular osseous rim that interferes with motion of a joint, was performed on the distal part of the first metatarsal of twenty-five patients who had hallux rigidus. Relief of pain was achieved in all but three patients, whose cases were considered as failures. Joint motion improved by an average of 20 degrees, and it was in an acceptable range in twenty-three patients. There were no complications other than persistence of swelling in six patients. No patient required additional operative intervention during an average follow-up of fifty-six months. We concluded that cheilectomy is a better method of treatment for hallux rigidus than arthrodesis, resection arthroplasty, or arthroplasty with the use of a flexible implant.

Patients who had total hip arthroplasty were categorized according to the risk of development of ectopic bone. Radiation therapy was administered after operation to those considered to be at high risk of formation of ectopic bone. The dosage used was 2,000 rads given in ten fractions (875 rets). Forty-eight hips in forty-two patients were treated from 1970 to 1977. Massive formation of ectopic bone did not occur in any hip when the radiation was given relatively early after operation. Thus, we believe that radiation aids in the prevention of formation of ectopic bone. Radiation was found to be of doubtful value, however, hence the ectopic bone was visible on radiography.