Mature peritrochanteric heterotopic ossification as a mechanical block to intertrochanteric fracture reduction

Abstract

While heterotopic ossification (HO) around the hip is frequently cited as a late complication leading to stiffness or technical difficulty during reconstructive surgery, its role as a primary mechanical impediment to the reduction of acute intertrochanteric fractures is rarely documented. We present the case of a 45-year-old male with a significant history of polytrauma, traumatic brain injury, and conservatively managed bilateral acetabular fractures. The patient presented with mature peritrochanteric and periacetabular HO and an acute, comminuted right intertrochanteric femur fracture following a low-speed motor vehicle collision. Preoperative imaging confirmed extensive ossification bridging the greater trochanter and lateral acetabulum. Intraoperatively, standard closed reduction on a traction table proved impossible, as the proximal femoral fragment was anchored by a rigid, extra-articular bony block. To achieve reduction, a limited osteotome-assisted release of the obstructing HO bridge was performed without requiring radical excision. This maneuver restored proximal femoral mobility, facilitating successful reduction and internal fixation. The postoperative course was unremarkable; follow-up imaging confirmed fracture union and stable hardware. This case emphasizes that mature periarticular HO can act as a definitive mechanical block to closed reduction. Surgeons should utilize CT-based preoperative planning to identify such obstacles early, allowing for a targeted surgical release when standard reduction maneuvers fail.