Current therapeutic strategies of heterotopic ossification – a survey amongst orthopaedic and trauma departments in Germany

Abstract

BackgroundHeterotopic ossification (HO) is a complication after tissue trauma, fracture and surgery (i.e. total hip arthroplasty). Prophylaxis is the most effective therapy. If HO formations become symptomatic and limit patients’ quality of life, revision surgery is indicated and is usually combined with a perioperative oral prophylaxis (NSAIDs) and/or irradiation. However, a long-term use of NSAIDs can induce gastro-intestinal or cardiac side-effects and possible bony non-unions during fracture healing. Subject of this study was to assess the current status of HO prophylaxis after injuries or fractures and to evaluate current indications and strategies for excision of symptomatic HO.MethodsBetween 2013 and 2014, a questionnaire was sent to 119 orthopaedic and trauma surgery departments in Germany. Participation was voluntary and all acquired data was given anonymously.ResultsThe cumulative feedback rate was 71 %. Trauma and orthopaedic surgery departments in Germany recommend oral HO prophylaxis after acetabulum and femoral neck fractures, elbow dislocation, and fracture or dislocation of the radial head. Pain upon movement and an increasing loss of range of motion in the affected joint are considered to be clear indications for HO surgery. A partial removal of ROM-limiting HO formations was also considered important. The vast majority of all departments include perioperative oral HO prophylaxis and/or irradiation if surgical HO removal is planned. The choice and duration of NSAIDs is highly variable.ConclusionHO is of clinical significance in current traumatology and orthopaedics. Certain fractures and injuries are prone to HO, and prophylactic measures should be taken. The respondents in this survey assessed current therapeutic strategies for HO formations similarly. These concepts are in line with the literature. However, the duration of perioperative oral HO prophylaxis varied greatly among the specialist centres. This is significant as a long-term use of NSAIDs fosters a potential risk for the patients’ safety and could influence the clinical outcome. National and international guidelines need to be developed to further reduce HO rates and improve patients’ safety in trauma and orthopaedic surgery.

Challenges of heterotopic ossification—Molecular background and current treatment strategies

“…NSAIDs target the first step of HO formation, which is the inflammation of muscles and soft tissue due to various factors. Prophylactic intervention with NSAIDs has been widely used, inter alia, after THA, hip arthroscopy, hip resurfacing, open reduction internal fixation, acetabular fracture, elbow dislocation, radial head dislocation, radial head fracture, femoral neck fracture, femoral shaft fracture, clavicular fracture, acromioclavicular joint injury, traumatic brain injury, and spinal cord injury …”

“…Radiotherapy inhibits the differentiation of mesenchymal stem cells into osteogenic pathways; thus, it prevents bone repair and abnormal bone growth. According to Winkler et al, radiotherapy in the prevention of HO is applied before surgery 83% of the time. In 17% of cases, it is applied after the procedure.…”

“…However, increasing the time after surgery before radiotherapy is applied significantly reduces its effectiveness, and radiotherapy should be applied as soon as possible . Researchers recommend combining radiotherapy with NSAIDs . Some researchers claim that radiotherapy is even more effective than administration of NSAIDs .…”

A case of the management of Heterotopic ossification as the result of acetabular fracture in a patient with traumatic brain injury

“…The literature on the surgical excision of heterotopic ossification in the hip, knee, and elbow with secondary prophylaxis demonstrates significant improvements in pain and ROM with low rates of recurrence (0-19%) and acceptable rates of peri-operative complications (0-25%) [12,13].…”

“…Treatments such as indomethacin (25 mg 3 times a day), radiation therapy (700cGy) and shock waves, decrease the incidence of this complication by 10% [9][10][11][12].…”