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Combined Radiotherapy and Indomethacin for the Prevention of Heterotopic Ossification after Total Hip Arthroplasty

Kombination von Radiotherapie und Indometacin zur Prävention heterotoper Ossifikationen nach Implantation einer Hüfttotalendoprothese

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Background and Purpose:

Heterotopic ossification (HO) is a frequent complication following total hip arthroplasty. The aim of this study was to evaluate the efficacy of combined radiotherapy and indomethacin as compared to indomethacin alone for the prevention of HO after hip arthroplasty.

Patients and Methods:

96 patients were prospectively enrolled to receive either a single dose of postoperative radiotherapy of 7.0 Gy and indomethacin for the first 15 postoperative days or indomethacin alone for the same period. A historical group of 50 patients that received indomethacin alone served as control. Primary endpoint was the radiographic evidence of HO at 6 months. Secondary endpoints were the evaluation of factors related to HO development, side effects from each treatment, and group differences in the clinical assessment with the Merle d’Aubigné Score.

Results:

Four patients in the combined-therapy group developed HO compared to 13 patients in the indomethacin group (p < 0.05) and 13 patients in the historical group (p < 0.05). One patient each in the combined group and the historical group developed Brooker III HO (nonsignificant difference). Duration of surgery and congenital hip disease were associated with HO development in the indomethacin groups, while age and congenital hip disease showed such an association in the combined-therapy group. The side effects and mean Merle d’Aubigné Score did not differ significantly between the three groups.

Conclusion:

Combined radiotherapy and indomethacin was more efficacious in preventing HO after total hip arthroplasty compared to indomethacin alone and should be considered for future investigation.

Hintergrund und Ziel:

Heterotope Ossifikationen (HO) sind eine häufige Komplikation nach Implantation einer Hüfttotalendoprothese. In dieser Studie wurde die Wirksamkeit der Kombination von Radiotherapie und Indometacin im Vergleich mit alleinigem Indometacin zur HO-Prävention nach endoprothetischem Hüftgelenkersatz evaluiert.

Patienten und Methodik:

96 Patienten wurden prospektiv eingeschlossen und erhielten in den ersten 15 Tagen nach dem Eingriff entweder eine postoperative Radiotherapie mit einer Einzeldosis von 7,0 Gy und Indometacin oder nur Indometacin. Eine historische Gruppe von 50 nur mit Indometacin behandelten Patienten diente als Kontrolle. Primärer Endpunkt war die radiologische Evidenz von HO nach 6 Monaten. Sekundäre Endpunkte umfassten die Evaluierung von die HO-Entwicklung begünstigenden Faktoren, von Nebenwirkungen der jeweiligen Behandlung und von Gruppenunterschieden in der klinischen Beurteilung mit dem Score nach Merle d’Aubigné.

Ergebnisse:

Vier Patienten in der kombinierten Therapiegruppe entwickelten HO im Vergleich zu 13 Patienten in der Indometacingruppe (p < 0,05) und 13 Patienten in der historischen Gruppe (p < 0,05). Je ein Patient in der kombinierter und der historischen Gruppe entwickelte HO Brooker III (nichtsignifikanter Unterschied). Operationsdauer und kongenitale Hüftdysplasie waren in den Indometacingruppen mit der Entwicklung von HO assoziiert, während Alter und kongenitale Hüftdysplasie in der kombinierten Therapiegruppe eine solche Assoziation zeigte. Die Nebenwirkungen und der durchschnittliche Score nach Merle d’Aubigné zeigten keine signifikanten Unterschiede zwischen den drei Gruppen.

Schlussfolgerung:

Die Kombination von Radiotherapie und Indometacin war zur HO-Prävention nach Implantation einer Hüfttotalendoprothese effektiver als alleiniges Indometacin und erfordert weitere Untersuchungen.

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References

  1. Adamietz B, Sauer R, Keilholz L. Bestrahlung beim Impingementsyndrom des Schultergelenks. Strahlenther Onkol 2008;184:245–50.

    Article  PubMed  Google Scholar 

  2. Ashton LA, Bruce W, Goldberg J, et al. Prevention of heterotopic bone formation in high risk patients post-total hip arthroplasty. J Orthop Surg (Hong Kong) 2000;8:53–7.

    Google Scholar 

  3. Barthel T, Baumann B, Nöth U, et al. Prophylaxis of heterotopic ossification after total hip arthroplasty: a prospective randomized study comparing indomethacin and meloxicam. Acta Orthop Scand 2002;73:611–4.

    Article  PubMed  Google Scholar 

  4. Brooker AF, Bowerman JW, Robinson RA, et al. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629–32.

    PubMed  CAS  Google Scholar 

  5. Chalmers J, Gray DH, Rush J. Observations on the induction of bone in soft tissues. J Bone Joint Surg Br 1975;57:36–45.

    PubMed  CAS  Google Scholar 

  6. Craven PL, Urist MR. Osteogenesis by radioisotope labelled cell populations in implants of bone matrix under the influence of ionizing radiation. Clin Orthop 1971;76:231–3.

    Article  PubMed  CAS  Google Scholar 

  7. Eggli S, Woo A. Risk factors for heterotopic ossification in total hip arthroplasty. Arch Orthop Trauma Surg 2001;121:531–5.

    Article  PubMed  CAS  Google Scholar 

  8. Fransen M, Neal B. Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty. Cochrane Database Syst Rev 2004;3:CD001160.

    PubMed  Google Scholar 

  9. Grohs JG, Schmidt M, Wanivenhaus A. Selective COX-2 inhibitor versus indomethacin for the prevention of heterotopic ossification after hip replacement: a double-blind randomized trial of 100 patients with 1-year follow-up. Acta Orthop 2007;78:95–8.

    Article  PubMed  Google Scholar 

  10. Handel M, Brettschneider J, Kock FX, et al. Risk factors associated with heterotopic ossifications in primary total hip arthroplasty. Z Orthop Ihre Grenzgeb 2004;142:564–70.

    Article  PubMed  CAS  Google Scholar 

  11. Healy WL, Lo TC, Covall DJ, et al. Single-dose radiation therapy for prevention of heterotopic ossification after total hip arthroplasty. J Arthroplasty 1990;5:369–75.

    PubMed  CAS  Google Scholar 

  12. Healy WL, Lo TC, DeSimone AA, et al. Single-dose irradiation for the prevention of heterotopic ossification after total hip arthroplasty. A comparison of doses of five hundred and fifty and seven hundred centigray. J Bone Joint Surg Am 1995;77:590–5.

    PubMed  CAS  Google Scholar 

  13. Heyd R, Tselis N, Ackermann H, et al. Radiation therapy for painful heel spurs. Results of a prospective randomized study. Strahlenther Onkol 2007;183:3–9.

    Article  PubMed  Google Scholar 

  14. Hofmann S, Trnka HJ, Metzenroth H, et al. General short-term indomethacin prophylaxis to prevent heterotopic ossification in total hip arthroplasty. Orthopedics 1999;22:207–11.

    PubMed  CAS  Google Scholar 

  15. Iorio R, Healy WL. Heterotopic ossification after hip and knee arthroplasty: risk factors, prevention, and treatment. J Am Acad Orthop Surg 2002;10:409–16.

    PubMed  Google Scholar 

  16. Kienapfel H, Koller M, Wüst A, et al. Prevention of heterotopic bone formation after total hip arthroplasty: a prospective randomised study comparing postoperative radiation therapy with indomethacin medication. Arch Orthop Trauma Surg 1999;119:296–302.

    Article  PubMed  CAS  Google Scholar 

  17. Knahr K, Salzer M, Eyb R, et al. Heterotopic ossification with total hip endoprostheses in various models of thrombosis prophylaxis. J Arthroplasty 1988;3:1–8.

    Article  PubMed  CAS  Google Scholar 

  18. Kölbl O, Flentje M, Eulert J, et al. Prospective study on the prevention of heterotopic ossification after total hip replacement. Non-steroidal anti-inflammatory agents versus radiation therapy. Strahlenther Onkol 1997;173:677–82.

    Article  PubMed  Google Scholar 

  19. Kölbl O, Knelles D, Barthel T, et al. Randomized trial comparing early postoperative irradiation vs. the use of nonsteroidal antiinflammatory drugs for prevention of heterotopic ossification following prosthetic total hip replacement. Int J Radiat Oncol Biol Phys 1997;39:961–6.

    PubMed  Google Scholar 

  20. Kölbl O, Seufert J, Pohl F, et al. Preoperative irradiation for prevention of heterotopic ossification following prosthetic total hip replacement: results of a prospective study in 462 hips. Strahlenther Onkol 2003;179:767–73.

    Article  Google Scholar 

  21. Langsenlehner T, Stiegler C, Quehenberger F, et al. Long-term follow-up of patients with pituitary macroadenomas after postoperative radiation therapy. Analysis of tumor control and functional outcome. Strahlenther Onkol 2007;183:241–7.

    Article  PubMed  Google Scholar 

  22. Lo TC. Radiation therapy for heterotopic ossification. Semin Radiat Oncol 1999;9:163–70.

    Article  PubMed  CAS  Google Scholar 

  23. Merle d’Aubigné R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954;36:451–75.

    Google Scholar 

  24. Moore KD, Goss K, Anglen JO. Indomethacin versus radiation therapy for prophylaxis against heterotopic ossification in acetabular fractures: a randomised, prospective study. J Bone Joint Surg Br 1998;80:259–63.

    Article  PubMed  CAS  Google Scholar 

  25. Oertel S, Schneider U, Keel M, et al. Prophylaxis of heterotopic ossification in patients sedated after polytrauma. Medical and ethical considerations. Strahlenther Onkol 2008;184:212–7.

    Article  PubMed  Google Scholar 

  26. Padgett DE, Holley KG, Cummings M, et al. The efficacy of 500 CentiGray radiation in the prevention of heterotopic ossification after total hip arthroplasty: a prospective, randomized, pilot study. J Arthroplasty 2003;18:677–86.

    Article  PubMed  Google Scholar 

  27. Pagnani MJ, Pellicci PM, Salvati EA. Effect of aspirin on heterotopic ossification after total hip arthroplasty in men who have osteoarthrosis. J Bone Joint Surg Am 1991;73:924–9.

    PubMed  CAS  Google Scholar 

  28. Pakos EE, Ioannidis JP. Radiotherapy vs. nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip procedures: a meta-analysis of randomized trials. Int J Radiat Oncol Biol Phys 2004;60:888–95.

    PubMed  CAS  Google Scholar 

  29. Pakos EE, Pitouli EJ, Tsekeris PG, et al. Prevention of heterotopic ossification in high-risk patients with total hip arthroplasty: the experience of a combined therapeutic protocol. Int Orthop 2006;30:79–83.

    Article  PubMed  Google Scholar 

  30. Pellegrini VD Jr, Gregoritch SJ. Preoperative irradiation for prevention of heterotopic ossification following total hip arthroplasty. J Bone Joint Surg Am 1996;78:870–81.

    PubMed  Google Scholar 

  31. Pohl F, Seufert J, Tauscher A, et al. The influence of heterotopic ossification on functional status of hip joint following total hip arthroplasty. Strahlenther Onkol 2005;181:529–33.

    Article  PubMed  Google Scholar 

  32. Ritter MA, Vaughan RB. Ectopic ossification after total hip arthroplasty. Predisposing factors, frequency, and effect on results. J Bone Joint Surg Am 1977;59:345–51.

    PubMed  CAS  Google Scholar 

  33. Saudan M, Saudan P, Perneger T, et al. Celecoxib versus ibuprofen in the prevention of heterotopic ossification following total hip replacement: a prospective randomised trial. J Bone Joint Surg Br 2007;89:155–9.

    PubMed  CAS  Google Scholar 

  34. Sauer R, Seegenschmiedt MH, Goldmann A, et al. Prevention of periarticular ossification following endoprosthetic hip replacement using postoperative irradiation. Strahlenther Onkol 1992;168:89–99.

    PubMed  CAS  Google Scholar 

  35. Seegenschmiedt MH, Keilholz L, Martus P, et al. Prevention of heterotopic ossification about the hip: final results of two randomized trials in 410 patients using either preoperative or postoperative radiation therapy. Int J Radiat Oncol Biol Phys 1997;39:161–71.

    PubMed  CAS  Google Scholar 

  36. Seegenschmiedt MH, Makoski HB, Micke O, German Cooperative Group on Radiotherapy for Benign Diseases. Radiation prophylaxis for heterotopic ossification about the hip joint — a multicenter study. Int J Radiat Oncol Biol Phys 2001;51:756–65.

    PubMed  CAS  Google Scholar 

  37. Seegenschmiedt MH, Martus P, Goldmann AR, et al. Pre- and postoperative radiotherapy to prevent heterotopic ossification of the hip joint. Strahlenther Onkol 1994;170:281–91.

    PubMed  CAS  Google Scholar 

  38. Sell S, Gaissmaier C, Fritz J, et al. Different behavior of human osteoblast-like cells isolated from normal and heterotopic bone in vitro. Calcif Tissue Int 1998;62:51–9.

    Article  PubMed  CAS  Google Scholar 

  39. Shehab D, Elgazzar AH, Collier BD. Heterotopic ossification. J Nucl Med 2002;43:346–53.

    PubMed  Google Scholar 

  40. Sodemann B, Persson PE, Nilsson OS. Prevention of heterotopic ossification by nonsteroid antiinflammatory drugs after total hip arthroplasty. Clin Orthop 1988;237:158–63.

    PubMed  Google Scholar 

  41. Trott KR, Kamprad F. Estimation of cancer risks from radiotherapy of benign diseases. Strahlenther Onkol 2006;182:431–6.

    Article  PubMed  Google Scholar 

  42. Vanden Bossche L, Vanderstraeten G. Heterotopic ossification: a review. J Rehabil Med 2005;37:129–36.

    Article  PubMed  Google Scholar 

  43. van der Heide HJ, Rijnberg WJ, Van Sorge A, et al. Similar effects of rofecoxib and indomethacin on the incidence of heterotopic ossification after hip arthroplasty. Acta Orthop 2007;78:90–4.

    Article  PubMed  Google Scholar 

  44. Zehetgruber H, Grübl A, Goll A, et al. Prevention of heterotopic ossification after THA with indomethacin: analysis of risk factors. Z Orthop Ihre Grenzgeb 2005;143:631–7.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedic Surgery, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece

    Emilios E. Pakos MD, Kosmas S. Stafilas, Aggelos N. Politis, Gregory Mitsionis & Theodore A. Xenakis

  2. Department of Radiation Therapy, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece

    Pericles G. Tsekeris

  3. Neohoropoulo, 243, Ioannina, 45500, Greece

    Emilios E. Pakos MD

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  1. Emilios E. Pakos MD
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Correspondence to Emilios E. Pakos MD.

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Pakos, E.E., Stafilas, K.S., Tsekeris, P.G. et al. Combined Radiotherapy and Indomethacin for the Prevention of Heterotopic Ossification after Total Hip Arthroplasty. Strahlenther Onkol 185, 500–505 (2009). https://doi.org/10.1007/s00066-009-1954-3

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