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Use of Acellular Dermal Matrix to Prevent Recurrent Radioulnar Heterotopic Ossification
Paymon Rahgozar, MD1; Joshua Campbell, MD2; David Kulber, MD2
1University of Southern California, Los Angeles, CA; 2Cedars Sinai Medical Center, Los Angeles, CA

Hypothesis: We projected that the recurrence of distal radioulnar heterotopic ossification can easily be prevented with interposition of an acellular dermal matrix at the time of excision of the heterotopic ossification while maintaining good post-operative pronation/supination range of motion.
Methods: Patient 1 is a 54 year-old otherwise healthy female who had undergone a radiocarpal fusion and a Darrach resection for severe wrist pain and decreased range of motion. The patient presented ten months later complaining of inability to supinate or pronate with X-ray confirmation of distal radioulnar heterotopic ossification. Using a saw osteotomy and an osteotome, the ossification was resected through a dorsal incision. Return of 60 degrees of pronation and supination was verified. Acellular dermal matrix (HD Flex) was sutured to itself in a cigar fashion and interposed between the radius and ulna with Tycron and Mersilene sutures. Patient 2 is an 83 year-old female with no medical problems that had a comminuted distal radius and ulna fracture treated with ORIF of the radius and Darrach resection. She presented with heterotopic ossification 3 months post-op and was treated in a similar fashion to Patient 1. Both patients were seen in follow up and were examined and had post-operative radiographs.
Results: At 1.5 years post-op Patient 1 remained without pain and has a return of her baseline pronation/supination. Radiographs show no evidence of recurrence of heterotopic ossification. Patient 2 at 1.5 years post-op is found to have complete range of motion of pronation/supination with no radiographic evidence of recurrence of radioulnar synostosis.
Summary: Radioulnar heterotopic ossification is a rare occurrence found in approximately 2% of all forearm injuries. It is even more rare to occur in the distal radioulnar joint. The main complication following resection of heterotopic ossification is recurrence. To prevent recurrence multiple methods including radiation, NSAIDs, and creation of a barrier have been proposed with mixed results. Barriers studied include a block of silicone, dermal/silicone sheet implant, interposition of muscle, free fat transfer, or even free vascularized flap transfer. We show that use of a readily available, commonly used product such as acellular dermal matrix can easily be interposed between the radius and ulna preventing recurrence of heterotopic ossification. Additional advantages include lack of donor site morbidity involved with harvesting local or distant flaps as barriers, and the facile nature of the operation making it easy to learn and implement.

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