Safety of Arthroscopic Versus Open or Combined Heterotopic Ossification Removal Around the Elbow

Purpose: To analyze the complications of arthroscopic heterotopic ossification (HO) excision and compare them with those of open removal of HO or a combined open-arthroscopic approach. Methods: We performed a retrospective review of elbow HO removal cases performed by a single surgeon from 1997 to 2014. In all cases studied, the intention was to restore range of motion owing to the presence of HO causing functional impairment. The arthroscopic, open, and combined treatment groups were compared. Results: The study cohort consisted of 223 surgical procedures performed on 213 elbows in 211 patients. Fifty major complications occurred in 46 cases (21%): 17 hematomas (8%) treated by irrigation and debridement, 8 cases of HO requiring reoperation (4%), 7 deep infections (3%), 4 contractures (2%), 3 cases of delayed-onset ulnar neuritis (1%), 2 cases of distal humeral avascular necrosis (1%), 2 tendon ruptures (1%), 2 cases of instability requiring reconstruction (1%), 2 postoperative fractures (1%), 1 intraoperative fracture (<0.5%), 1 case of worsening of pre-existing neuropathic pain (<0.5%), and 1 permanent partial posterior interosseous nerve injury (<0.5%). Of these 46 cases, the major complications occurred in 6 of the 41 (15%) performed arthroscopically, in 36 of the 158 (23%) performed open and in 4 of the 21 (17%) with combined (i.e. open + arthroscopic) HO removal. Preventive strategies, introduced to prevent hematomas and delayed-onset ulnar neuritis, reduced the rate of major complications from 35% during the period from 1997 to 2005 to 10% during the period from 2006 to 2014 (P < .0001). Moreover, the rate of reoperations was reduced from 34% to 10% in the same periods (P < .0001). Minor complications occurred in 36 cases (16%), including 17 cases of transient nerve palsy, 9 cases of superficial infection or delayed wound healing, 6 cases of mild instability, and 4 cases of hematoma resolved by aspiration. Conclusions: The use of arthroscopy-or a combination of arthroscopic and open techniques-to remove HO around the elbow by a surgeon skilled in both arthroscopic and open elbow surgery does not increase the risk of major complications or need for reoperation compared with traditional open surgery. Preventive strategies, such as avoiding raising skin flaps by using multiple separate incisions for open and prophylactic ulnar nerve decompression in arthroscopic cases, were developed during the study period. These strategies were monitored prospectively and found to be effective in preventing two-thirds of the major complications needing reoperation with both open and arthroscopic HO removal.