Heterotopic Ossification - Shoulder
 

In January, my son and I were in a very bad motorcycle accident. We were t-boned by a young girl in a Volkswagon.

The impact occurred on the right side, and of course I went sailing about 50 feet to the left. Evidently when I came down, I must have not performed a proper PLF and landed such that I ripped my left shoulder to shreds. The EMT's put it back into place at the scene, but it came back out when I rolled onto it in the ICU. A day or so later they scoped it and then performed an open "massive" rotator cuff repair.

I don't have all the particulars in front of me regarding exactly what was done, other than I know that I now have 4 screws and a bunch of nylon line holding everything back in place. The Dr. had me in a sling for 3 months. I started passive PT at 2 months, and full ROM PT at 3. His remarks were that the shoulder basically looked like a bomb went off inside, and that he rarely see's them this bad. Certainly only in high impact trauma.

It's been about a month now since I started heavy PT, and haven't seen a ton of improvement in my external rotation, abduction, or elevation. At my last visit, my Dr. explained that "heterotopic ossification" is visible, and that I'm going to have some stiffness to deal with. Of course at this point, he became a little more conservative in terms of making a prognosis, and I really didn't know what questions to ask either.

Just curious if anyone here know's how well this condition will respond to ongoing PT, and at what point do I begin inquiring about more surgery. If surgery is an option, can someone explain what's involved with it, and what can generally be expected afterwards? Is it an open procedure, or scope? What questions should I be asking my osteo?

Thanks for your time and assistance.

C

if it worth saying, it will be quoted.

H.O.
 

C,
I see H.O. mostly in trauma but at times it accumulates after routine hip surgery. (A type of controlled trauma) It is calcification within the muscle tissue itself. Some times when present the patient is asymptomatic, the patient doesn't even know it's there. Some times it can be very debilitating and limit motion. At this point in your recovery I would continue with your rehab and just see how things turn out. If your injury is as bad as you indicate I would expect you to improve for 6-9 months. If at the end of that period you are limited in a way that is unacceptable consider why. Is it because of the H.O. or is it just because you had a really bad injury and this is as good as it will get. If however there is a large amount of H.O. in and around your shoulder and your surgeon is certain it is your limiting factor consider your options. Will excision of the mass make you better? Will excision of the mass do more damage? If the mass is removed, will it reaccumulate? We have done a few H.O. removals with good results but we did one or two concurrent therapies, low dose radiation (current preference) and or indomethacin. How is your son?
Good luck to you both,
Boomer

Ascetic acid
 

In Physical therapy we had some sucess with ascedic acid in IONTOphoresis. Check with your Physical therapist.

The vinegar is run through the muscle fiber electricaly and desolves the calcified material.

If you want to see what vinegar does to calcium just put some in a class jar with a chicken leg bone and give it a few days. You will have what looks like a bone but can be tied in knots. Blitzzz

Hey Blitzz, I just got out of therapy and one of the PT's was mentioning that, as well as Dextramethadone (I believe that's what they said it was). Interesting stuff.

Info
 

The Dex is a steriod and is good for inflammation in the tendon and ligiments as well as muscle. The Acidic Acid (medical grade Vinegar) will desolve the assess calcium. Note that it needs be controlled as it also takes some of the normal bone with will grow back while the ossification generally does not. Go for it. Blitzzz

Thanks for the continued updates fellas. I'll do whatever it takes to get to the point where I can at least put on a glove an play catch with my daughter.

Boomer, my son is doing well all things considered. It looks like he won't have any long term issues such as mine. His injuries included a broken femur neck, broken tib & fib, broken ankle, and a broken radius. Until Thursday, he had an internal fixator on the hip, external fixator w/ pins on the tib/fib and a screw in the ankle. His radius had a cast for several weeks, but has been off for some time now. Scottish Rite here in Atlanta pulled all of it out, and they expect a full recovery. I'll be honest, it was a very emotional day at the hospital the other day. I was in a coma for 4 days while he was going through all of this after the accident, and I didn't see him for a month while we were both in separate hospitals. Seeing him go through this in person was tough.

Update
 

C,
Thanks for the update. You guys took a beating, I'm sorry. I am glad to hear you are both on the mend and that your son was at the Rite; you can't find a better place for pediatrics in the Atlanta area. Good luck to you both with your rehab.
Boomer

Thanks Boomer.

Resurgens had me in an MRI tube on Monday, looking the shoulder over for an hour. Dr. said this morning, that there's too much metal in my shoulder to effectively show the issues. They're scheduling me for a CT Arthrogram next week. My trauma surgeon said that I basically tore my arm off, without it actually coming off... if that makes any sense. I'm now seeing a shoulder specialist, that says that if the ossification is in the right location that he can deburr the area and maybe get the ROM I'm looking for. Total resection is a massive heroic effort though, and if that's the case I guess I'll have to live with what I've got.

Son got his cast off today, so it was straight to the pool with the family this evening. He's been dying to get out and play.

Arthrogram was fun ;) Took 2 radiologists 30 minutes to get the needle through the new bone that developed in the front of the humeral head. Then they spent another 20 trying to feed it into an abnormally narrow joint space. Very little contrast would feed in. Shoulder dude says "good news is, there's no "frank" tear." (no $hit doc... i had that fixed shortly after my wreck). Anyhow, looks like once I'm off crutches he'll want to debride the bone, (supraspinatus as well) and manipulate under anesthesia. Good times.

Had a visit with my shoulder surgeon a few weeks ago, and he became very conservative with respects to removing the ossification. Evidently the mass is involved with the arterty, and nerve and would be a very risky procedure. We opted to manipulate under anesthesia. With a nerve block in the shoulder, it was straight to 2 hours of therapy after the surgeon cranked it over my head. That was two weeks ago today, and I'm fairly pleased. Better elevation, but not much on the external rotation side of things. The manip. free'd the shoulder up to where it's no longer just jacked in there throbbing all the time.

Attached is the new tatt on my affected arm.

C

if it worth saying, it will be quoted.

I say again....
 

The Acidic Acid (medical grade Vinegar) will dissolve the excess calcium. This is dome wth Iontophoresis (moving it through the tissue with mild electric current. The acidic acid will remove the calcium. We used this frequenly in the last clinic I worked. Ask a Physical Therapist..

Thanks for all the help guys. I'm in the gym now training around the limitations I have. I'll deal with it, it's not the end of the world by any stretch. So I no longer have a golf swing... big damn deal. I can still hunt and fish. I thought about getting back into skydiving as my son became of age, but with my current range of rotation, I would be in a perpetual left turn. A little right rudder might correct it though. For now, my smashed calcaneous is what's occupying most of my time. When they said it would be the hardest part of this ordeal, they were right.

Blitzz, on your recommendation, I discussed the acedic acid/ionto idea with my surgeon and the therapist back over the summer. The surgeon said that the ossification was too deep for the acid/ionto to have any effect on it.

Red, I didn't have any steriods injected yet. I do need to schedule an appointment with the doc, so I'll ask if it's necessary.

progress report
 

C, Thanks for the progress report. I was in the OR this am pulling H.O. out of a young mans hip. It was very mature and fully integrated with the muscle tissue and bone in and around the joint. It was a double edged (no pun intended) surgery, take too much out and loose function secondary to muscle trauma, not enough and you don't regain any function. We did radiate him prior to taking him to the OR. Sounds like you're getting very reasonable results with the porgram you're on. The calcaneous is a booger to heal. Was the fracture intra articular? Meaning did it go through the joint of just crush the body of the bone? My wife had one several years ago and my partner screwed it back together, put her in a short leg cast and was not allowed to touch the foot to the ground for 3 months. Rehab afterward was a long row to hoe but thankfully it healed nicely. How's your son these days?
Boomer