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The Influence Of Nerve Surgical Techniques At Time Of Amputation On The Prevalence Of Heterotopic Ossification In Transtibial Amputees
Floris V. Raasveld, MD, Carla H. Lehle, MD, Charles D. Hwang, MD, Rachel E. Cross, BSc, Jad S. Husseini, MD, Frank J. Simeone, MD, Erik T. Newman, MD, Krystle R. Tuaño, MD, Santiago A. Lozano-Calderon, MD, PhD, Ian L. Valerio, MD, MS, MBA, FACS, Kyle R. Eberlin, MD.
Massachusetts General Hospital, Boston, MA, USA.

PURPOSE: Heterotopic ossification (HO) can develop after amputation, leading to pain and functional impairment. We aimed to describe the prevalence of HO in civilian transtibial amputees, and hypothesized that lower symptomatic neuroma formation after active nerve surgeries (Targeted Muscle Reinnervation or Regenerative Peripheral Nerve Interface) may lead to a reduced prevalence of HO compared to passive nerve surgeries (e.g., traction neurectomy) performed at amputation.
METHODS: Adult patients undergoing transtibial amputation at a tertiary care center (2000-2023) were included. Patient data were obtained through chart review. The most recent post-amputation X-ray of the residual limb was evaluated for HO, using Walter Reed classification. A random 10% of X-rays were independently reviewed by five clinicians and two radiologists, with inter-rater reliability (IRR) assessed using Cohen’s kappa (κ). Multivariable logistic regression was used to identify factors associated with HO presence.
RESULTS: In total, 665 limbs of 632 patients were included. The median time between amputation and X-ray was 1.7 years (IQR: 0.3-6.2). HO was identified in 326 X-rays (49.0%) (IRR κ=0.92). Passive nerve surgery during amputation (OR=2.0, p=0.014)), and the presence of a symptomatic neuroma (OR=2.3, p<0.001), were independently associated with a higher prevalence of HO.
CONCLUSION: HO is a common finding in transtibial amputees. The use of peripheral nerve surgery that actively treat amputated nerve endings to reduce symptomatic neuroma formation may decrease the prevalence of HO.

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