Editorial Commentary: The Efficacy of Nonsteroidal Anti-inflammatory Drugs for Prophylaxis of Heterotopic Ossification in Hip Arthroscopy--Do We Treat Patients or X-rays?

Incidence and Risk Factors for Heterotopic Ossification in a Matched Cohort Adolescent Population Undergoing Hip Arthroscopy

BACKGROUND

Heterotopic ossification (HO) is a known complication after hip arthroscopy in adults, positively associated with larger cam resection, male sex, older age, and obesity, and negatively associated with nonsteroidal anti-inflammatory drug (NSAID) use and capsular closure. However, it has not been well-documented in adolescents. The purpose of this study was to determine the incidence and risk factors for the development of HO in adolescent patients undergoing hip arthroscopy.

METHODS

Clinical and operative records from a pediatric institution were queried to identify patients aged 21 years or younger who underwent hip arthroscopy between 2008 and 2018. The 27 cases that developed HO were matched 1:4 on age and sex with 107 controls. The bivariate analysis assessed the relationship between demographic and perioperative factors on the development of HO. Multivariable logistic regression evaluated the association between prophylactic NSAID use (indomethacin 75 mg, 3 wk) and HO, controlling for surgeon and extent of cam resection (change in alpha angle).

RESULTS

Twenty-seven of 595 (4.5%) hips that underwent hip arthroscopy developed HO within 2 years of surgery. Prophylactic indomethacin was not significantly associated with developing HO [30% (8/27), P=0.83], after controlling for surgeon and extent of cam resection-nor were age, sex, and body mass index percentile. Of patients who developed HO, a smaller proportion underwent reoperation for HO excision among those who received prophylactic indomethacin than those who did not [13% (1/8) vs. 63% (12/19), P=0.03].

CONCLUSIONS

The incidence of HO within 2 years of hip arthroscopy in this adolescent population was 4.5%. Although studies in the adult hip arthroscopy population have pointed to a protective role of NSAIDs (eg, indomethacin) in radiographic HO, the effect was less certain in this adolescent sample. Larger studies are important to further evaluate the role of prophylactic NSAIDs and variations in arthroscopic technique in developing HO.

LEVEL OF EVIDENCE

Level III-therapeutic, case-control study.

Risk Factors for High-Grade Heterotopic Ossification After Total Disc Replacement: A Single-Center Experience of 394 Cases

BACKGROUND

Heterotopic ossification (HO) is a common complication following total disc replacement (TDR). High-grade HO is a clinically relevant complication, however, only a few studies have evaluated risk factors for high-grade HO.

OBJECTIVE

To evaluate potential risk factors for HO and high-grade HO and their impact on clinical outcomes.

METHODS

We retrospectively reviewed patients who underwent TDR or hybrid surgery (HS) with Prestige-LP (Medtronic), Discover (Depuy), and Prodisc-C (Synthes). Clinical outcomes were assessed using Japanese Orthopaedic Association, Visual Analogue Scale, and Neck Disability Index scores. Radiological variables, including preoperative ossification, global and segmental range of motion (ROM), HO, and adjacent segment degeneration (ASD) were reviewed.

RESULTS

A total of 394 patients were evaluated. HO and high-grade HO occurred in 67.77% and 11.17% patients, respectively. Preoperative ossification was significantly associated with the occurrence of HO (P < .001, OR: 3.507, 95%CI: 2.211-5.562) and high-grade HO (P = .019, OR: 2.176, 95%CI: 1.137-4.166). The ROM of replacement levels and C2-7 were significantly lower in the high-grade HO group compared to those without high-grade HO: (3.80° vs 10.18°, P < .001) and (42.81° vs 54.00°, P < .001), respectively. The incidence of ASD was significantly higher in patients with high-grade HO than those without high-grade HO (22.73% vs 11.14%, P = .048).

CONCLUSION

Preoperative ossification was identified as a potential risk factor for HO and high-grade HO. Patients with high-grade HO had limited ROM of replacement levels and the cervical spine and had a high incidence of ASD compared to those without high-grade HO.

Heterotopic Ossification in Hip Arthroscopy: an Updated Review

PURPOSE OF REVIEW

Heterotopic ossification (HO) in hip arthroscopy is a common post-operative complication. This review was undertaken to provide an update (2014 present) on the current literature regarding HO in hip arthroscopy.

RECENT FINDINGS

Risk factors for HO post-hip arthroscopy include male gender, mixed impingement, picture, and the size of CAM resection. HO prophylaxis with NSAIDs has been proven to decrease the rate of HO post-hip arthroscopy; however, there is inherent risk to long-standing NSAIDs therapy. HO post-hip arthroscopy is not uncommon as a radiological finding, but symptomatic HO post-hip arthroscopy requiring revision surgery is a rare event, at < 1%. The outcomes for revision surgery for HO excision have fair outcomes. The hip arthroscopist should stratify their patients based on known risk factors, and determine whether NSAIDs prophylaxis is warranted.

Are Controversial Issues in Cervical Total Disc Replacement Resolved or Unresolved?: A Review of Literature and Recent Updates

Since the launch of cervical total disc replacement (CTDR) in the early 2000s, many clinical studies have reported better outcomes of CTDR compared to those of anterior cervical discectomy and fusion. However, CTDR is still a new and innovative procedure with limited indications for clinical application in spinal surgery, particularly, for young patients presenting with soft disc herniation with radiculopathy and/or myelopathy. In addition, some controversial issues related to the assessment of clinical outcomes of CTDR remain unresolved. These issues, including surgical outcomes, adjacent segment degeneration (ASD), heterotopic ossification (HO), wear debris and tissue reaction, and multilevel total disc replacement (TDR) and hybrid surgeries are a common concern of spine surgeons and need to be resolved. Among them, the effect of CTDR on patient outcomes and ASD is theoretically and clinically important; however, this issue remains disputable. Additionally, HO, wear debris, multilevel TDR, and hybrid surgery tend to favor CTDR in terms of their effects on outcomes, but the potential of these factors for jeopardizing patients' safety postoperatively and/or to exert harmful effects on surgical outcomes in longer-term follow-up cannot be ignored. Consequently, it is too early to determine the therapeutic efficacy and cost-effectiveness of CTDR and will require considerable time and studies to provide appropriate answers regarding the same. For these reasons, CTDR requires longer-term follow-up data.

Incidence and factors associated with development of heterotopic ossification after damage control laparotomy

INTRODUCTION

The incidence of heterotopic ossification (HO) following damage control laparotomy (DCL) is unknown. Abdominal wall reconstruction may prove more challenging in patients with HO. This study examines the incidence and factors associated with HO in patients with an open abdomen following DCL.

METHODS

A retrospective review of all patients with an open abdomen after DCL at a level 1 trauma centre from 2009 to 2015 was conducted. Demographics and peri-operative outcomes of patients with and without HO were compared. Univariate and multivariable binary logistic regression models were used to determine the association of peri-operative factors with the development of HO.

RESULTS

68 patients were included, of which 36 (53%) developed HO. On univariate analysis, development of HO was significantly associated with hollow viscus injury (OR, 3.89; CI 1.42-10.7), greater number of abdominal surgeries prior to definitive closure (OR, 1.84; CI, 1.10-3.05), non-fascial closure (OR, 4.33; CI, 1.44-13.1) and higher peak ALP (OR 1.01; CI, 1.00-1.02). The presence of a hollow viscus injury remained an independent predictor of HO on multivariable analysis after adjusting for covariates (OR, 3.77; CI, 1.22-11.6).

CONCLUSION

Heterotopic ossification develops in a high proportion of trauma patients following damage control laparotomy, particularly in the presence of hollow viscus injury. Its impact on delayed abdominal wall reconstruction and the efficacy of prophylaxis strategies merit further investigation.