The Incidence of Heterotopic Ossification in Hip Arthroscopy

Published:January 25, 2013DOI:


      The purpose of this study was to assess the incidence of heterotopic ossification (HO) after hip arthroscopy.


      Between July 2010 and July 2011, 83 patients underwent hip arthroscopy for various etiologies. We prospectively reviewed 50 consecutive hip arthroscopy procedures (31 male and 19 female patients; mean age, 36.7 years) with a mean follow-up of 29.56 weeks (range, 9 to 62 weeks) to assess the incidence of HO and its effect on function and clinical outcome. Preoperative and postoperative evaluation included general assessment by visual analog scoring, modified Harris Hip Score, Hip Outcome Score, and preoperative and postoperative radiographs. Heterotopic bone formation was assessed on radiographs at a minimum of 9 weeks from surgery with the Brooker classification.


      Of the patients, 22 (44%) had radiographic evidence of postoperative HO (15 male patients): 13 (26%) had Brooker stage 1, 5 (10%) had Brooker stage 2, and 4 (8%) had Brooker stage 3. HO appeared as early as 9 weeks after surgery. No significant difference was found in demographic data, surgery-related data, or clinical and functional scores between patients with HO and patients without HO. No factor was found to significantly affect the incidence of HO after logistic regression. No distinct clinical manifestation was associated with the presence of HO.


      This study shows that the incidence of HO after hip arthroscopy may be underestimated. We could not find a contributing factor to the formation of HO. Although in most cases the presence of HO will have minimal or no clinical and functional significance, it should be sought at a minimum of 9 weeks postoperatively.

      Level of Evidence

      Level IV, therapeutic case series.
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        • Kaplan F.S.
        • Hahn G.V.
        • Zasloff M.A.
        Heterotopic ossification: Two rare forms and what they can teach us.
        J Am Acad Orthop Surg. 1994; 2: 288-296
        • Shafritz A.B.
        • Shore E.M.
        • Gannon F.H.
        • et al.
        Overexpression of an osteogenic morphogen in fibrodysplasia ossificans progressiva.
        N Engl J Med. 1996; 335: 555-561
        • McCarthy E.F.
        • Sundaram M.
        Heterotopic ossification: A review.
        Skeletal Radiol. 2005; 34: 609-619
        • Garland D.E.
        Clinical observations on fractures and heterotopic ossification in the spinal cord and traumatic brain injured populations.
        Clin Orthop Relat Res. 1988; : 86-101
        • Wittenberg R.H.
        • Peschke U.
        • Botel U.
        Heterotopic ossification after spinal cord injury. Epidemiology and risk factors.
        J Bone Joint Surg Br. 1992; 74: 215-218
        • Neal B.
        • Gray H.
        • MacMahon S.
        • Dunn L.
        Incidence of heterotopic bone formation after major hip surgery.
        ANZ J Surg. 2002; 72: 808-821
        • Charnley J.
        The long-term results of low-friction arthroplasty of the hip performed as a primary intervention.
        J Bone Joint Surg Br. 1972; 54: 61-76
        • Rosendahl S.
        • Christoffersen J.K.
        • Norgaard M.
        Para-articular ossification following hip replacement. 70 Arthroplasties ad modum Moore using McFarland's approach.
        Acta Orthop Scand. 1977; 48: 400-404
        • Ritter M.A.
        • Vaughan R.B.
        Ectopic ossification after total hip arthroplasty. Predisposing factors, frequency, and effect on results.
        J Bone Joint Surg Am. 1977; 59: 345-351
        • Sundaram N.A.
        • Murphy J.C.
        Heterotopic bone formation following total hip arthroplasty in ankylosing spondylitis.
        Clin Orthop Relat Res. 1986; : 223-226
        • Ahrengart L.
        • Lindgren U.
        Heterotopic bone after hip arthroplasty. Defining the patient at risk.
        Clin Orthop Relat Res. 1993; : 153-159
        • Larson C.M.
        • Giveans M.R.
        Arthroscopic management of femoroacetabular impingement: Early outcomes measures.
        Arthroscopy. 2008; 24: 540-546
        • Clohisy J.C.
        • Zebala L.P.
        • Nepple J.J.
        • Pashos G.
        Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular impingement.
        J Bone Joint Surg Am. 2010; 92: 1697-1706
        • Randelli F.
        • Pierannunzii L.
        • Banci L.
        • Ragone V.
        • Aliprandi A.
        • Buly R.
        Heterotopic ossifications after arthroscopic management of femoroacetabular impingement: The role of NSAID prophylaxis.
        J Orthop Traumatol. 2010; 11: 245-250
        • Byrd J.W.
        • Jones K.S.
        Arthroscopic management of femoroacetabular impingement in athletes.
        Am J Sports Med. 2011; 39: 7S-13S
        • Bedi A.
        • Zbeda R.M.
        • Bueno V.F.
        • Downie B.
        • Dolan M.
        • Kelly B.T.
        The incidence of heterotopic ossification after hip arthroscopy.
        Am J Sports Med. 2012; 40: 854-863
        • Weiland D.E.
        • Philippon M.J.
        Arthroscopic technique of femoroacetabular impingement.
        Oper Tech Orthop. 2005; 15: 256-260
        • Bedi A.
        • Galano G.
        • Walsh C.
        • Kelly B.T.
        Capsular management during hip arthroscopy: From femoroacetabular impingement to instability.
        Arthroscopy. 2011; 27: 1720-1731
        • Brooker A.F.
        • Bowerman J.W.
        • Robinson R.A.
        • Riley Jr., L.H.
        Ectopic ossification following total hip replacement. Incidence and a method of classification.
        J Bone Joint Surg Am. 1973; 55: 1629-1632
        • Ekelund A.
        • Brosjo O.
        • Nilsson O.S.
        Experimental induction of heterotopic bone.
        Clin Orthop Relat Res. 1991; : 102-112
        • Aho A.J.
        • Isberg U.K.
        • Katevuo V.K.
        Acetabular posterior wall fracture. 38 cases followed for 5 years.
        Acta Orthop Scand. 1986; 57: 101-105
        • Michelsson J.E.
        • Rauschning W.
        Pathogenesis of experimental heterotopic bone formation following temporary forcible exercising of immobilized limbs.
        Clin Orthop Relat Res. 1983; : 265-272
        • Zaccalini P.S.
        • Urist M.R.
        Traumatic periosteal proliferations in rabbits. The enigma of experimental myositis ossificans traumatica.
        J Trauma. 1964; 4: 344-357
        • Rath E.M.
        • Russell Jr., G.V.
        • Washington W.J.
        • Routt Jr., M.L.
        Gluteus minimus necrotic muscle debridement diminishes heterotopic ossification after acetabular fracture fixation.
        Injury. 2002; 33: 751-756
        • McLaren A.C.
        Prophylaxis with indomethacin for heterotopic bone. After open reduction of fractures of the acetabulum.
        J Bone Joint Surg Am. 1990; 72: 245-247
        • Schmidt S.A.
        • Kjaersgaard-Andersen P.
        • Pedersen N.W.
        • Kristensen S.S.
        • Pedersen P.
        • Nielsen J.B.
        The use of indomethacin to prevent the formation of heterotopic bone after total hip replacement. A randomized, double-blind clinical trial.
        J Bone Joint Surg Am. 1988; 70: 834-838
        • Ayers D.C.
        • Evarts C.M.
        • Parkinson J.R.
        The prevention of heterotopic ossification in high-risk patients by low-dose radiation therapy after total hip arthroplasty.
        J Bone Joint Surg Am. 1986; 68: 1423-1430
        • Board T.N.
        • Karva A.
        • Board R.E.
        • Gambhir A.K.
        • Porter M.L.
        The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty.
        J Bone Joint Surg Br. 2007; 89: 434-440
        • Berndt C.
        • Ganko A.
        • Whitehouse S.L.
        • Crawford R.W.
        Heterotopic ossification within an arthroscopic portal after uneventful partial meniscectomy.
        Knee. 2008; 15: 416-418
        • Sanders B.S.
        • Wilcox III, R.B.
        • Higgins L.D.
        Heterotopic ossification of the deltoid muscle after arthroscopic rotator cuff repair.
        Am J Orthop (Belle Mead NJ). 2010; 39: E67-E71
        • Gofton W.T.
        • King G.J.
        Heterotopic ossification following elbow arthroscopy.
        Arthroscopy. 2001; 17 (E2)
        • Sodha S.
        • Nagda S.H.
        • Sennett B.J.
        Heterotopic ossification in a throwing athlete after elbow arthroscopy.
        Arthroscopy. 2006; 22: 802.e1-802.e3
        • Hughes S.C.
        • Hildebrand K.A.
        Heterotopic ossification—A complication of elbow arthroscopy: A case report.
        J Shoulder Elbow Surg. 2010; 19: e1-e5
        • Lu Y.
        • Wang M.
        • Jiang C.
        • Feng H.
        Short-term results of reconstruction of elbow under arthroscopy in patients with elbow osteoarthritis.
        Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2011; 25 (in Chinese): 1-4