Zemenfes Semaie

Radiation Oncology II
Research Paper
11/22/2014

Radiation Therapy
Research Paper
Heterotopic Bone Formation

Zemenfes Semaie
Radiation Oncology II
Research Paper
11/22/2014
Heterotopic Bone Formation
According to MedicineNet, Heterotopic bone formation is defined as bone
formation in nonosseous tissues. In other words, heterotopic bone formation occurs
when a bone is being formed or a bone starts growing in an area that the bone is not
supposed to grow. Heterotopic can be the result of several things. For example, one of the
main things that can lead to heterotopic bone formation is when a person experiences
different types of trauma such as, bone fractures and surgical procedures with mostly
being from car or motorcycle accidents. In addition, heterotopic can also been seen in
such cases as neurologic disorders. For instance, some examples of neurologic disorders
are spinal cord and brain injury as well.
There are many areas or types of heterotopic bone formation, the most common is
in the hip area called, total hip arthroplasty or THA. Heterotopic bone formation occurs
in about 53% of all patients who receive total hip arthroplasty. In addition, not only will
this procedure cause heterotopic bone formation, it can also lead to postoperative
disability such as, pain and having a limited range of motion around the hip and through
out the whole entire leg area.
It is very difficult to pint point which types of people get heterotopic bone
formation because some people can live with this condition without ever knowing they
have it. However, according to Physiopedia, heterotopic bone formation prevalence
reports are as follows:
Condition or Surgery
Lower extremity amputee
Traumatic brain injuries
Spinal cord injuries
Total hip arthroplasty (THA)
Total knee arthroplasty (TKA)

Percentage of Incidence %
7%
11%
20%
53%
15%

Although the exact cause of heterotopic bone formation is currently unknown, just
like with any cases, there are always many risk factors that may lead to the development
of heterotopic bone formation. Some of the risk factors that may lead to the development
of heterotopic bone formation are, having a pervious history of heterotopic bone
formation after hip surgery, pervious trauma or procedure, Pagets disease, post traumatic
arthritis and hypertrophic osteoarthritis. In addition, it known that heterotopic bone
formation can be caused by pluripotential mesenchymal cells differentiate into

Zemenfes Semaie
Radiation Oncology II
Research Paper
11/22/2014
osteoblasts, which in turn causes heterotopic bone formation. Moreover, genetic can be
a risk factor, according to Physiopedia, in the year 2005, there were about 400 patients in
U.S. with heterotopic bone formation as a result of there genetic make up.
As to any type of condition, there are always some types of sings and symptoms
that we can use to identify the condition or disease. Therefore, some of the signs and
symptoms or clinical presentations for heterotopic bone formation are swelling or a warm
feeling in the joins, pain in the joins, firm palpable mass and the decrease range of
motion, meaning that the patient will have some difficulty moving the effected join or
area. Although these sign and symptoms can be present in some patient, they might not
be present in other patients. In addition, when these sings and symptoms do appear, that
time is about 3 to 12 weeks.
The diagnostic work-up for heterotopic bone formation is a process that involves
the use of different imaging modalities. After the patient notice that something might be
wrong because of the sings and symptoms they noticed with their body, they usually go
to the doctor. As usually, the doctor examines the patient and sends them to get some
images done to see whats going on inside the patient. Some of the images that are done
for heterotopic bone formation are MRI, CT, Ultrasound. MRI is better in determining
heterotopic bone formation at its early phases/stages. Although it is great to use all the
imaging modalities, because they are very expensive plain films radiographs are use very
commonly in most cases.
According to Healio Orthopedics and Physiopedia, heterotopic bone formation is staged
by the Brookers Grading scale
Heterotopic ossification of the hip is graded according to Brookers Grading scale
Grade 1. Islands of bone within the soft tissues about the hip.
Grade 2. Bone spurs in the pelvis or the proximal end of the femur with at least 1
cm between the opposing bone surfaces.
Grade 3. Bone spurs from the pelvis or proximal end of the femur with <1 cm
between opposing bone structures
Grade 4. Radiographic ankylosis.
In Grade 1, the location of the heterotopic bone formation is within the soft tissues
about the hip. However, when it is Grade 2 the bone braches out into the pelvis or the
proximal end of the femur with at least 1cm between the opposing bone surfaces.
Although Grade 3 is similar to Grade 2 it has some differences. Grade 3, the bone braches
out from the pelvis or the proximal end of the femur with less than 1cm between the

Zemenfes Semaie
Radiation Oncology II
Research Paper
11/22/2014
opposing bone structures. The last or worse Grade is Grade 4, which is when the patient
has Radiographic ankylosis, which is pain and stiffness of the join that is caused from the
effected bone being very rigid.
Surgery is one of the most effective treatments for heterotopic bone formation
because when done with accuracy, it can correct the condition or the new bone from
growing. There are two main reasons for heterotopic bone formation surgery treatment to
be done. The first reason for surgery is to alter or fix the position of the effected join so
that it is not going causing discomfort to the patient. The second reason that surgery is
done is if the patient is having a limited range of motion, meaning that they cant move as
freely as possible. Therefore, surgery is done and it will correct the patient range of
motion so that they can move freely.
Radiation therapy is another very effective and very important treatment for
heterotopic bone formation after surgery. The reason that radiation therapy is used for
heterotopic bone formation is to radiate the pluripotential mesenchymal cells, since they
are responsible for the development of heterotopic bone formation. Therefore, if those
cells are radiated, they will not be able to grow and increase the rate of heterotopic bone
formation. More importantly, radiation therapy treatment should follow surgery with 72
hours for the treatment to wok. It is best within 72 hours after surgery so that the
pluripotential mesenchymal cells dont start growing again.
The radiation dose for heterotopic bone formation is 700-800cGy within one
fraction. It is done in one fraction because it is very difficult it to have a patient go
through the treatment more than once and it also has to be done right after surgery. The
treatment borders are different depending of the area that is being treated. Therefore, that
also goes for the critical structures are well because it depends where the area being
treated is located and the different structure are surrounding it. However, when
heterotopic bone formation is treaded in the hip area, the testicles are protected and
shielded out of he field. In the use of radiation therapy, the patient usually doesnt use a
lot of Immobilization devices. The patient is usually treated with a blue mat, only if the
patient is in a lot of pain. In addition, to support the head, a pillow or two are used and a
blue ring is also used to keep the patient from moving and to keep them in position.
In conclusion, heterotopic bone formation is a condition that is the formation or
growth of a new bone as a result of many things, one being trauma. However, just like
with any condition there are several modalities of treatment put in place for this
condition, such as surgery and radiation therapy. As a result of either treatment, patient
have a better quality of life with little or no side effects at all.

Zemenfes Semaie
Radiation Oncology II
Research Paper
11/22/2014
References
Buring K. On the origin of cells in heterotopic bone formation. Clin Orthop Relat Res.
1975; 110:293-302.
Chao, Samuel, John Suh, and Michael Joyce. "Treatment of Heterotopic
Ossification."Treatment of Heterotopic Ossification 30.6 (2007). Print.
Heterotopic Ossification Treatment & Management - Heterotopic Ossification
Treatment & Management http://emedicine.medscape.com/article/327648treatment
Heterotopic Ossification (- Physiopedia, universal access to physiotherapy
knowledge.) http://www.physio-pedia.com/Heterotopic_Ossification
Lo TC. Radiation therapy for heterotopic ossification. Semin Radiat Oncol.
1999; 9:163- 170.
Principle and Practice of Radiation Therapy, Washington and Leaver