Dear Editor,

We have read the article entitled “Is etoricoxib effective in preventing heterotopic ossification after primary total hip arthroplasty?” by Brunnekreef et al. [1] published in International Orthopaedics with great interest.

In this study, the authors proved that etoricoxib, a selective cyclo-oxygenase-2 (COX-2) inhibitor, was effective for the prevention of heterotopic ossification (HO) following total hip arthroplasty (THA). However, we have several opinions which we would like to communicate with the authors.

  1. 1.

    Different orthopaedic surgeons may have different operative skills, which may result in varied incidence of HO following THA. Therefore, we would like to know whether all of the patients were managed by one doctor.

  2. 2.

    The follow-up time was only six months, which seems to be a little short. We suggest that longer follow-up time (at least one year) should be carried out to assess the long-term efficacy of etoricoxib for the prevention of HO.

  3. 3.

    With regard to radiograph assessment, the authors used a blinding and randomised strategy. We appreciated that this may reduce subjective bias. In addition, we suggest that at least two radiologists or orthopaedic surgeons should be included and the evaluation procedure should be performed independently.

  4. 4.

    The quality of antero-posterior pelvic radiographs is also very important for HO evaluation. Therefore, effective measures should be taken (such as patient education, experienced radiologist, etc.) to ensure the radiograph quality.

  5. 5.

    As the authors stated that the small sample size and the lack of a control group might affect the outcome, a future large scale of patients and a controlled method should be taken. Furthermore, we advise that future trials should also focus on different strategies of etoricoxib dosage and timing for HO prevention. Moreover, special attention should be paid to the adverse effects of etoricoxib.