Radiotherapy for the prophylaxis of heterotopic ossification after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trails

Hu, Zheng-Hao; Chen, Wang; Sun, Jie; Zhang, Ye; Chen, Xiangyang; Feng, Shuo

doi:10.1016/j.meddos.2020.07.010

Cited by 12 publications

(10 citation statements)

References 37 publications

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“…To aid the development of a HO reduction protocol, further research should also investigate other prophylactic techniques, such as radiation therapy. Research suggests this technique is effective in reducing the risk of HO following open total hip arthroplasty; however its use in HA has not been investigated [ 88 , 89 ].…”

Section: Discussionmentioning

confidence: 99%

Incidence of heterotopic ossification following hip arthroscopy is low: considerations for routine prophylaxis

Arshad

Maughan

Garner

et al. 2022

International Orthopaedics (SICOT)

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Purpose This scoping review aims to map and summarise the available literature on heterotopic ossification (HO) following hip arthroscopy, with particular focus on incidence, distribution as per Brooker classification, efficacy of prophylactic measures and factors that may influence the likelihood of production of HO. Methods A computer-based search was performed on PubMed, Embase, Emcare, Cinahl, ISI web of science and Scopus using the terms ‘heterotopic ossification’ and ‘hip arthroscopy’. Articles reporting heterotopic ossification following hip arthroscopy for any condition were included after two-stage title/abstract and full-text screening. Results Of the 663 articles retrieved, 45 studies were included. The proportion of patients with HO ranged from 0 to 44%. The majority of the cases were either Brooker grade I or II. Of the six studies investigating the effect of NSAID prophylaxis, five reported a significantly lower incidence of heterotopic ossification associated with its use. Weak evidence suggests that an outside-in arthroscopic approach, no capsular closure, male sex and mixed cam and pincer resection may be associated with an increased risk of HO. Conclusion Although there is a large variation in rates of HO following hip arthroscopy in the current literature, the majority of studies report a low incidence. Evidence exists advocating the administration of post-operative NSAIDs to reduce the incidence of HO following hip arthroscopy. This, combined with the low risk of complications, means there is a favourable risk–benefit ratio for prophylactic NSAID used in HA. Future research should work to identify patient clinical and demographic factors which may increase the risk of development of HO, allowing clinicians to risk stratify and select only specific patients who would benefit from receiving NSAID prophylaxis.

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Section: Discussionmentioning

confidence: 99%

Incidence of heterotopic ossification following hip arthroscopy is low: considerations for routine prophylaxis

Arshad

Maughan

Garner

et al. 2022

International Orthopaedics (SICOT)

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“…Comparing pre-versus post-operative prophylactic RT, three studies did not show significant differences between the efficacy of the two strategies (28, 49, 50). This equivalence was confirmed by three meta-analyses (64,65,67).…”

Section: Discussionmentioning

confidence: 65%

“…In addition, one study showed the greater efficacy of 4×3 Gy compared to 1×5 Gy (51). Finally, two meta-analyses did not record a significant impact of RT dose on postoperative HO incidence (64,65), while another showed an advantage of multi-fractionated RT over single-fraction RT (67).…”

Section: Discussionmentioning

confidence: 94%

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Prophylactic Radiotherapy of Hip Heterotopic Ossification: A Narrative Mini Review

Galietta

Gaiani

Giannini

et al. 2022

In Vivo

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Evidence on prophylactic radiotherapy (RT) in hip heterotopic ossification (HO) is sparse and conflicting.The aim of this literature review was to collect and summarize the available data on RT efficacy in preventing hip HO. The results of this review show that RT is effective in the prevention of hip HO, albeit with large variability across series. Effective prophylactic RT requires optimal treatment fields and time intervals with surgery. On the contrary, there is no clear evidence on the optimal timing (post-operative versus pre-operative RT). Comparisons between prophylactic RT and use of non-steroidal antiinflammatory drugs showed conflicting results, although most were in favor of RT. In conclusion, RT is an established prophylactic treatment for hip HO. However, optimal dose, technique and timing remain unclear, as does the usefulness of combining RT with drugs.Heterotopic ossification (HO) is defined as the formation of new bone in soft tissue outside the skeletal system (1). HO can be differentiated into three main groups: traumatic HO (mainly following fractures), non-traumatic HO (usually occurring after burns), and neurological HO (2).Several prophylactic treatments for HO have been proposed, such as non-steroidal anti-inflammatory drugs (NSAIDs), Noggin (an extracellular peptide that binds and antagonizes bone morphogenetic proteins), pulsed electromagnetic fields, and free radical scavengers (3)(4)(5)(6)(7)(8)(9)(10)(11).HO is a particularly frequent complication after total hip arthroplasty, with reported rates ranging from 15% to 90%. In patients with a significant amount of ossification, hip mobility can be impaired (12). Main risk factors for HO after total hip arthroplasty are male gender, hip ankylosis, and previous history of HO (13,14). The only effective treatment of symptomatic, established HO is surgical resection (15).From the early 1980s ( 16), radiotherapy (RT) has been extensively studied and used in this setting. Most evidence on RT efficacy in preventing hip HO comes from nonrandomized studies (17-45), although some randomized trials (46-61) and systematic-reviews and meta-analyses (62-68) have been performed.However, evidence on prophylactic RT is sparse and conflicting, no international guidelines are available, and several questions remain unanswered. Therefore, the aim of this literature review was to collect and summarize the main available evidence on RT efficacy in preventing hip HO.

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“…Radiotherapy with a medium biologically effective dose from 20 to 24 Gy has proven to be an effective prophylaxis for HO after total hip arthroplasty. Preoperative and postoperative radiotherapy have similar prophylactic efficacy while multiple fractions might be more effective than single-fraction radiotherapy [79]. An in vitro experiment showed that radiotherapy can suppress the BMP2 signaling pathway in MSCs, thus interfering with BMP2-mediated osteoblastic differentiation [80].…”

Section: Radiotherapymentioning

confidence: 99%

Burn-induced heterotopic ossification from incidence to therapy: key signaling pathways underlying ectopic bone formation

Sun

et al. 2021

Cell Mol Biol Lett

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Burn injury is one of the potential causes of heterotopic ossification (HO), which is a rare but debilitating condition. The incidence ranges from 3.5 to 5.6 depending on body area. Burns that cover a larger percentage of the total body surface area (TBSA), require skin graft surgeries, or necessitate pulmonary intensive care are well-researched risk factors for HO. Since burns initiate such complex pathophysiological processes with a variety of molecular signal changes, it is essential to focus on HO in the specific context of burn injury to define best practices for its treatment. There are numerous key players in the pathways of burn-induced HO, including neutrophils, monocytes, transforming growth factor-β1-expressing macrophages and the adaptive immune system. The increased inflammation associated with burn injuries is also associated with pathway activation. Neurological and calcium-related contributions are also known. Endothelial-to-mesenchymal transition (EMT) and vascularization are known to play key roles in burn-induced HO, with hypoxia-inducible factor-1 (HIF-1) and vascular endothelial growth factor (VEGF) as potential initiators. Currently, non-steroidal anti-inflammatory drugs (NSAIDs) and radiotherapy are effective prophylaxes for HO. Limited joint motion, ankylosis and intolerable pain caused by burn-induced HO can be effectively tackled via surgery. Effective biomarkers for monitoring burn-induced HO occurrence and bio-prophylactic and bio-therapeutic strategies should be actively developed in the future.

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Radiotherapy for the prophylaxis of heterotopic ossification after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trails

Cited by 12 publications

References 37 publications

Incidence of heterotopic ossification following hip arthroscopy is low: considerations for routine prophylaxis

Incidence of heterotopic ossification following hip arthroscopy is low: considerations for routine prophylaxis

Prophylactic Radiotherapy of Hip Heterotopic Ossification: A Narrative Mini Review

Burn-induced heterotopic ossification from incidence to therapy: key signaling pathways underlying ectopic bone formation

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