{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T23:34:51Z","timestamp":1783812891831,"version":"3.55.0"},"reference-count":50,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2023,12,18]],"date-time":"2023-12-18T00:00:00Z","timestamp":1702857600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Life"],"abstract":"<jats:p>Heterotopic ossification (HO) is the process of ectopic bone formation in the periarticular soft tissues and is usually formed in the elbow, hip and knee joint as a complication of trauma, burns, brain injury or surgical procedures. The development of HO around the elbow joint can cause a severe limitation of range of motion (ROM) and may affect daily activities of the patient. Treatment of ectopic bone formation around the elbow is a challenge for many surgeons. Non-operative treatment usually fails to restore the ROM of the elbow joint; thus, surgery is necessary to restore the function of the joint. In the past, many surgeons suggested that a delayed excision of HO, until maturation of the ectopic bone, is the best option in order to avoid any possible recurrence. However, many authors now suggest that this delay may lead to complications such as muscular atrophy and formation of soft tissue contractures that can cause a greater impairment of elbow function; thus, early excision is a better option and can better restore the elbow ROM. We performed a literature research of articles that investigated which is the best time of HO excision and we also evaluated if the tethering effect of HO can lead to a greater impairment of the elbow function. We found numerous studies suggesting that a limitation in ROM of the elbow can appear from the tethering of the ectopic bone formation and not only from primary HO. Concerning the HO excision, there were no significant differences between patients who underwent delayed and early excision, concerning the recurrence rate of HO around the elbow. Patients who underwent early excision had better restoration of elbow ROM; thus, early excision, combined with a rehabilitation program, is reported to be the best option for these patients.<\/jats:p>","DOI":"10.3390\/life13122358","type":"journal-article","created":{"date-parts":[[2023,12,18]],"date-time":"2023-12-18T05:41:35Z","timestamp":1702878095000},"page":"2358","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Heterotopic Ossification around the Elbow Revisited"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8326-8376","authenticated-orcid":false,"given":"Aristeidis-Panagiotis","family":"Kontokostopoulos","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ioannis","family":"Gkiatas","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8476-6430","authenticated-orcid":false,"given":"George I.","family":"Vasileiadis","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, School of Medicine, University Hospital of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dimitrios","family":"Flevas","sequence":"additional","affiliation":[{"name":"Arthroscopy & Orthopaedic Surgery Department, Metropolitan Hospital, Neo Faliro, 185 47 Pireas, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Spyridon E.","family":"Tsirigkakis","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2979-0512","authenticated-orcid":false,"given":"Dimitrios","family":"Kosmas","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ioannis","family":"Kostas-Agnantis","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emilios","family":"Pakos","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1918-9478","authenticated-orcid":false,"given":"Ioannis","family":"Gelalis","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anastasios","family":"Korompilias","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,12,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1165","DOI":"10.1016\/j.jse.2015.05.044","article-title":"The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: Recommendation for early excision followed by early exercise","volume":"24","author":"Chen","year":"2015","journal-title":"J. Shoulder Elbow Surg."},{"key":"ref_2","first-page":"8661","article-title":"The stiff elbow: Current concepts","volume":"12","author":"Masci","year":"2020","journal-title":"Orthop. Rev."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1530\/EOR-23-0039","article-title":"Management of the stiff elbow: A literature review","volume":"8","author":"Siemensma","year":"2023","journal-title":"EFORT Open Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1016\/j.otsr.2014.10.021","article-title":"Clinically relevant heterotopic ossification after elbow fracture surgery: A risk factors study","volume":"101","author":"Hong","year":"2015","journal-title":"Orthop. Traumatol. Surg. Res."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1016\/j.aott.2017.11.008","article-title":"Appropriate excision time of heterotopic ossification in elbow caused by trauma","volume":"52","author":"He","year":"2018","journal-title":"Acta Orthop. Traumatol. Turc."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1289","DOI":"10.1016\/j.ijrobp.2006.03.053","article-title":"Heterotopic ossification: Pathophysiology, clinical features, and the role of radiotherapy for prophylaxis","volume":"65","author":"Balboni","year":"2006","journal-title":"Int. J. Radiat. Oncol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1197\/j.jht.2006.02.009","article-title":"Heterotopic Ossification about the Elbow: A Therapist\u2019s Guide to Evaluation and Management","volume":"19","author":"Casavant","year":"2006","journal-title":"J. Hand Ther."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1097\/00003086-198201000-00037","article-title":"A bovine low molecular weight bone morphogenetic protein (BMP) fraction","volume":"162","author":"Urist","year":"1982","journal-title":"Clin. Orthop."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"680","DOI":"10.1126\/science.6403986","article-title":"Bone Cell Differentiation and Growth Factors","volume":"220","author":"Urist","year":"1983","journal-title":"Science"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1097\/SLA.0000000000001841","article-title":"Predicting Heterotopic Ossification Early After Burn Injuries: A Risk Scoring System","volume":"266","author":"Schneider","year":"2017","journal-title":"Ann. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1186\/s43046-022-00149-w","article-title":"Fifteen years\u2019 experience of radiation therapy for resected advanced heterotopic ossification following motor vehicle accidents: Outcome and side effects","volume":"34","author":"Mohamed","year":"2022","journal-title":"J. Egypt Natl. Cancer Inst."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/j.ocl.2016.08.009","article-title":"Heterotopic Ossification in Trauma","volume":"48","author":"Barfield","year":"2017","journal-title":"Orthop. Clin. N. Am."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e815","DOI":"10.3928\/01477447-20120525-18","article-title":"Incidence and Risk Factors of Heterotopic Ossification Following Major Elbow Trauma","volume":"35","author":"Douglas","year":"2012","journal-title":"Orthopedics"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1101","DOI":"10.2106\/JBJS.N.01056","article-title":"Heterotopic Ossification: Basic-Science Principles and Clinical Correlates","volume":"97","author":"Ranganathan","year":"2015","journal-title":"J. Bone Jt. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e66","DOI":"10.2106\/JBJS.K.01533","article-title":"Heterotopic Ossification After Surgery for Fractures and Fracture-Dislocations Involving the Proximal Aspect of the Radius or Ulna","volume":"95","author":"Foruria","year":"2013","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1681","DOI":"10.1302\/0301-620X.96B12.34091","article-title":"Heterotopic ossification after surgery for distal humeral fractures","volume":"96","author":"Foruria","year":"2014","journal-title":"Bone Jt. J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1302\/2046-3758.23.2000152","article-title":"Heterotopic ossification after central nervous system trauma: A current review","volume":"2","author":"Sullivan","year":"2013","journal-title":"Bone Jt. Res."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1007\/s11914-020-00636-w","article-title":"When the Nervous System Turns Skeletal Muscles into Bones: How to Solve the Conundrum of Neurogenic Heterotopic Ossification","volume":"18","author":"Alexander","year":"2020","journal-title":"Curr. Osteoporos. Rep."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1097\/BCR.0b013e3182957768","article-title":"Characterization of Heterotopic Ossification in Burn Patients","volume":"35","author":"Medina","year":"2014","journal-title":"J. Burn Care Res."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Hu, X., Sun, Z., Li, F., Jiang, C., Yan, W., and Sun, Y. (2021). Burn-induced heterotopic ossification from incidence to therapy: Key signaling pathways underlying ectopic bone formation. Cell Mol. Biol. Lett., 26.","DOI":"10.1186\/s11658-021-00277-6"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"673","DOI":"10.1097\/01.ta.0000196000.96056.51","article-title":"Outcome of Open Release for Post-Traumatic Elbow Stiffness","volume":"61","author":"Tan","year":"2006","journal-title":"J. Trauma Inj. Infect. Crit. Care"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2319","DOI":"10.1097\/CORR.0000000000000726","article-title":"What Range of Motion and Functional Results Can Be Expected After Open Arthrolysis with Hinged External Fixation For Severe Posttraumatic Elbow Stiffness?","volume":"477","author":"Sun","year":"2019","journal-title":"Clin. Orthop."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1406","DOI":"10.1016\/j.jse.2018.10.029","article-title":"Loss of pronation-supination in patients with heterotopic ossification around the elbow","volume":"28","author":"Vasileiadis","year":"2019","journal-title":"J. Shoulder Elbow Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"793","DOI":"10.1016\/j.jseint.2021.04.004","article-title":"The efficacy of nonsteroidal anti-inflammatories in the prevention of heterotopic ossification following elbow trauma surgery","volume":"5","author":"Bochat","year":"2021","journal-title":"JSES Int."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"e588","DOI":"10.3928\/01477447-20210618-22","article-title":"Prophylaxis for Heterotopic Ossification Following Distal Biceps Tendon Repair","volume":"44","author":"Antonacci","year":"2021","journal-title":"Orthopedics"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1111\/j.1754-9485.2011.02275.x","article-title":"Safety and efficacy of radiation therapy as secondary prophylaxis for heterotopic ossification of non-hip joints: Prophylactic RT for heterotopic ossification of non-hip joints","volume":"55","author":"Mishra","year":"2011","journal-title":"J. Med. Imaging Radiat. Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e56","DOI":"10.1097\/BOT.0000000000002188","article-title":"Primary Versus Secondary Radiotherapy for Heterotopic Ossification Prevention About the Elbow","volume":"36","author":"Geller","year":"2022","journal-title":"J. Orthop. Trauma"},{"key":"ref_28","first-page":"400","article-title":"Radiation therapy for heterotopic ossification prophylaxis afer high-risk elbow surgery","volume":"40","author":"Strauss","year":"2011","journal-title":"Am. J. Orthop."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1055\/s-0040-1721880","article-title":"Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis","volume":"13","author":"Henstenburg","year":"2021","journal-title":"J. Hand Microsurg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1242","DOI":"10.1016\/j.jse.2023.02.119","article-title":"Indomethacin for heterotopic ossification prophylaxis following surgical treatment of elbow trauma: A randomized controlled trial","volume":"32","author":"Atwan","year":"2023","journal-title":"J. Shoulder Elbow Surg."},{"key":"ref_31","unstructured":"Lee, A., Maani, E.V., and Amin, N.P. (2023, March 01). Radiation Therapy for Heterotopic Ossification Prophylaxis, Available online: http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK493155\/."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e14403","DOI":"10.1097\/MD.0000000000014403","article-title":"Surgical treatment of postburn heterotopic ossification around the elbow: Three case reports","volume":"98","author":"Chen","year":"2019","journal-title":"Medicine"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1097\/PHM.0000000000002043","article-title":"The role of kinesiotherapy in the prevention of heterotopic ossification: A systematic review","volume":"102","author":"Vasileiadis","year":"2023","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1380","DOI":"10.1016\/j.jse.2020.02.026","article-title":"Treatment methods for post-traumatic elbow stiffness caused by heterotopic ossification","volume":"29","author":"Freibott","year":"2020","journal-title":"J. Shoulder Elbow Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1097\/00003086-199102000-00003","article-title":"A clinical perspective on common forms of acquired heterotopic ossification","volume":"263","author":"Garland","year":"1991","journal-title":"Clin. Orthop."},{"key":"ref_36","first-page":"94","article-title":"Heterotopic bone formation in thermal burns","volume":"263","author":"Evans","year":"1991","journal-title":"Clin. Orthop."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1016\/S1058-2746(97)90025-2","article-title":"Heterotopic ossification of the elbow","volume":"6","author":"Summerfield","year":"1997","journal-title":"J. Shoulder Elbow Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"749","DOI":"10.2106\/00004623-199705000-00015","article-title":"Early Excision of Heterotopic Ossification about the Elbow followed by Radiation Therapy","volume":"79","author":"McAuliffe","year":"1997","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"177","DOI":"10.3928\/01477447-20110124-08","article-title":"Heterotopic Ossification Revisited","volume":"34","author":"Mavrogenis","year":"2011","journal-title":"Orthopedics"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1302\/0301-620X.86B3.14480","article-title":"Heterotopic ossification of the elbow in patients with burns: Results after early excision","volume":"86","author":"Tsionos","year":"2004","journal-title":"J Bone Jt. Surg Br."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1097\/00005373-199611000-00010","article-title":"Range of Motion and Complications after Postburn Heterotopic Bone Excision about the Elbow","volume":"41","author":"Djurickovic","year":"1996","journal-title":"J. Trauma Inj. Infect. Crit. Care"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1067\/mse.2001.112055","article-title":"Early, wide excision of heterotopic ossification in the medial elbow","volume":"10","author":"Moritomo","year":"2001","journal-title":"J. Shoulder Elbow Surg."},{"key":"ref_43","first-page":"245","article-title":"Early surgical management for heterotopic ossification about the elbow presenting as limited range of motion associated with ulnar neuropathy","volume":"25","author":"Yang","year":"2002","journal-title":"Chang. Gung Med. J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1016\/j.rehab.2016.03.009","article-title":"Recurrence of heterotopic ossification after removal in patients with traumatic brain injury: A systematic review","volume":"59","author":"Almangour","year":"2016","journal-title":"Ann. Phys. Rehabil. Med."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1016\/j.anplas.2017.11.009","article-title":"Our 35 years\u2019 experience on postburn heterotopic ossification: A three-step treatment","volume":"63","author":"Malca","year":"2018","journal-title":"Ann. Chir. Plast. Esth\u00e9t."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1128","DOI":"10.1016\/j.jse.2013.04.019","article-title":"Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification","volume":"22","author":"Koh","year":"2013","journal-title":"J. Shoulder Elbow Surg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"206","DOI":"10.3944\/AOTT.2010.2441","article-title":"The results of surgical treatment for posttraumatic heterotopic ossification and ankylosis of the elbow","volume":"44","author":"Akman","year":"2010","journal-title":"Acta Orthop. Traumatol. Turc."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1080\/000164700317413076","article-title":"A systematic survey of 13 randomized trials of non-steroidal anti-inflammatory drugs for the prevention of heterotopic bone formation after major hip surgery","volume":"71","author":"Neal","year":"2000","journal-title":"Acta Orthop. Scand."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"888","DOI":"10.1016\/j.ijrobp.2003.11.015","article-title":"Radiotherapy vs. nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip procedures: A meta-analysis of randomized trials","volume":"60","author":"Pakos","year":"2004","journal-title":"Int. J. Radiat. Oncol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1097\/00003086-199102000-00009","article-title":"Prevention of heterotopic ossification in high-risk patients by radiation therapy","volume":"263","author":"Ayers","year":"1991","journal-title":"Clin. Orthop."}],"container-title":["Life"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-1729\/13\/12\/2358\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T21:40:38Z","timestamp":1760132438000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-1729\/13\/12\/2358"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,12,18]]},"references-count":50,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2023,12]]}},"alternative-id":["life13122358"],"URL":"https:\/\/doi.org\/10.3390\/life13122358","relation":{},"ISSN":["2075-1729"],"issn-type":[{"value":"2075-1729","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,12,18]]}}}