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Revista de Osteoporosis y Metabolismo Mineral

versión On-line ISSN 2173-2345versión impresa ISSN 1889-836X

Rev Osteoporos Metab Miner vol.15 no.3 Madrid jul./sep. 2023  Epub 08-Mar-2024 


Heterotopic ossification after hip arthroplasty: role of bone SPECT/CT scintigraphy

Ana Moreno-Ballesteros1  , María de Bonilla-Candau2  , Blanca Cabaleiro-Burguillos3  , Ángel Custodio Rebollo-Aguirre1  , Elena Sánchez-de Mora1  , Amelia Jiménez-Heffernan1 

1Department of Nuclear Medicine. Hospital Universitario Juan Ramón Jiménez. Huelva, Spain

2Department of Nuclear Medicine. Hospital Universitari Vall d’Hebron. Barcelona, Spain

3Department of Rehabilitation. Hospital Universitario Juan Ramón Jiménez. Huelva, Spain


Heterotopic ossification is a limiting condition that predominantly affects the hip. Because of its association with post-traumatic/postoperative pathology, bone SPECT/CT scintigraphy has proven to be especially useful regarding differential diagnosis involving prosthetic mobilization, even in the absence of radiological abnormalities. Additionally, it is an effective tool for surgical planning, considering the degree of bone maturation and the possibility of creating biomodels using 3D printing.

Keywords: Heterotopic ossification; Bone scintigraphy; SPECT/CT; Biomodel; 3D


This is the case of a 55-year-old man treated with right total hip arthroplasty (THA) two and a half years ago with persistent pain and limited mobility, but without any significant abnormalities according to the X-rayimages (Fig. 1). A three-phase bone scintigraphy using 99mTc-diphosphonates was requested to assess prosthetic mobilization. The early-phase images did not show any significant changes (Figs. 2 A and B). However, in the late bone phase, increased tracer uptake was seen in the right femur proximal third (Fig. 2C, arrow) that in the SPECT/CT images (Fig. 3) was consistent with an enhanced osteogenic activity in bone islands (up to 1.8 cm) inside the soft tissues adjacent to the greater trochanter. These findings are consistent with heterotopic ossifications (HO), and rule out the presence of right THA mobilization.

Figure 1. Plain hip X-ray after 2 years and 4 months following right THA implantation showing no signs of mobilization. 

Figure 2. Anterior (left column) and posterior sections (right column) of bone scintigraphy, revealing no significant abnormalities to the early flow (A) and vascular pool phases (B). In the late bone phase (C), a focal and irregular increase in osteoblastic activity can be identified in the right femur proximal third (arrows). 

Figure 3. Axial slice of fused SPECT/CT image (A), 3D reconstruction (B), and segmentation using 3Dslicer software (9) (C) of heightened osteoblastic activity (arrows) in periarticular heterotopic ossification that rules out the presence of significant right THA mobilization. The semiautomatic segmentation of the osteoblastic activity area could be a useful tool for surgical planning. 


HO is a limiting condition that causes pain and reduced joint range of motion due to abnormal mature lamellar bone formation inside the soft tissues adjacent to periarticular bone (1,2). Of variable prevalence (ranging from 10 % to 53 %) (3), the hip joint is the most widely affected one. Despite its uncertain etiology, HO is associated with a previous congenital/post-traumatic/postoperative pathology that activates osteoblast and chondroblast progenitor cells, leading to calcium salt deposits inside the connective tissue (4). Also, former studies show the presence of elevated serum levels of inflammatory cytokines (TNF, IL-1, IL-6, and monocyte chemotactic protein), and alkaline phosphatase during the early phases of this bone formation that are also present in post-traumatic repair processes (5). Scintigraphy allows the diagnosis of HO early even before radiographic changes become apparent, and even before the findings become evident on the CT/MRI (6). Additionally, SPECT/CT acquisition is particularly useful to differentiate HO from prosthetic mobilization and myositis ossificans, and enable surgical planning through 3D printing of biomodels (7,8). Although the early management of HO is conservative, scintigraphy can provide insights on the degree of bone maturation, thus determining the optimal timing for surgery if indicated (9).


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Moreno-Ballesteros A, de Bonilla-Candau M, Cabaleiro-Burguillos B, Custodio Rebollo-Aguirre Á, Sánchez-de Mora E, Jiménez-Heffernan A. Heterotopic ossification after hip arthroplasty: role of bone SPECT/CT scintigraphy. Rev Osteoporos Metab Miner 2023;15(3):125-128

Received: May 04, 2023; Accepted: July 10, 2023

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