The Reduction of Heterotopic Ossification Incidence After Hip Arthroscopy in Patients Treated With Selective Cyclooxygenase 2 Inhibitor (Celecoxib)

Chemoprophylaxis for heterotopic ossification following hip arthroscopy: A systematic review

INTRODUCTION

Heterotopic ossification (HO) is a known complication diagnosed following hip arthroscopy.

PURPOSE/HYPOTHESIS

This study sought to review the current literature on chemoprophylaxis for HO following hip arthroscopy and to describe what agents and doses are being utilized.

STUDY DESIGN

Systematic Review.

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines on the use of chemoprophylactic medications for HO prevention following hip arthroscopy. Mechanical and radiation prophylaxis were not included in the current analysis.

RESULTS

A total of 203 studies were identified, of which 15 were included with 6463 patients. There was one randomized control trial (RCT) and 4 additional comparative studies. The most commonly utilized chemoprophylactic agents were the following: naproxen (n ​= ​8), celecoxib (n ​= ​3), indomethacin (n ​= ​3), aspirin (n ​= ​1), etoricoxib (n ​= ​1), and etodolac (n ​= ​1), and non-specific non-steroidal anti-inflammatory drugs (NSAIDs) (n ​= ​1). Naproxen was either given at a dose of 500 ​mg once or twice daily for 2-4 weeks. RCTs and additional comparative studies showed significant HO prevention using chemoprophylactic agents following hip arthroscopy.

CONCLUSIONS

HO is a known and common complication following hip arthroscopy. The current systematic review found significant heterogeneity across the literature with respect to specific chemoprophylactic agents and their dosing regimens aimed to reduce the incidence and severity of HO following hip arthroscopy. Additionally, this review demonstrates that most studies that utilize chemoprophylaxis use NSAIDs with successful reduction in the incidence of HO.

LEVEL OF EVIDENCE

Level IV Evidence.

Low-dose prophylaxis protocol for heterotopic ossification after hip preservation surgery in a sport participants cohort

BACKGROUND

Heterotopic ossification (HO) is a well-known complication of arthroscopic and open surgical treatment of femoroacetabular impingement (FAI). Incidence of heterotopic ossification has been reported in the literature between 0% and 44% after hip arthroscopy and between 18.2% and 25% after anterior mini-open surgery. Currently, pharmacological prophylaxis with NSAIDs and selective COX-2 inhibitors are commonly used and their effectiveness is well documented in literature.

HYPOTHESIS

We hypothesized that the low-dose prophylaxis protocol with selective cox-2 inhibitors decreases the risk of heterotopic ossification in open or arthroscopic hip preservation surgery in athletes.

METHODS

This study is an analysis of prospectively gathered data on 98 sport participant patients who underwent arthroscopic or anterior mini-open treatment for FAI between April 2008 and April 2018. All the patients received postoperative oral prophylaxis with 60 mg etoricoxib once daily for two weeks. Post-operative X-rays were performed at 1, 3, and 12 months after surgery and reviewed by two orthopedic surgeons blinded to the type and side of surgery. HO were graded according to the Brooker classification. Descriptive statistics was used to analyze demographic data. Bivariate analysis was performed to analyze the association of HO with each of the following variables: type of surgery, physical activity, time of evolution of symptoms, age at surgery, and sex. Finally, a regression model analysis was performed to determine the presence of confounding effects between variables.

RESULTS

The study cohort was composed of 54 patients in the arthroscopic treatment group and 44 patients in the anterior mini-open group. HO was identified in 6 (13.6%) patients in the mini-open group. No HO was identified in the arthroscopic group. In the bivariate analysis, "type of surgery" was the only variable that showed a statistically significant association with HO (p = 0.007).

CONCLUSION

Results of this study suggest that anterior mini-open treatment was characterized by a higher risk of HO development compared to hip arthroscopy for femoroacetabular impingement treatment regardless of pharmacological prophylaxis. The treatment regimen of 60 mg etoricoxib daily for two weeks was an effective prophylaxis for HO formation in sport participant patients compared with data available in the literature.

Heterotopic Ossification in Hip Arthroscopy

Introduction  Hip arthroscopy is a rising surgical technique due to the increase in hip diseases, especially femoroacetabular impingement. One of the several complications related to such procedures is heterotopic ossifications (HO). The aim of this study is to describe the prevalence of HO after hip arthroscopy in a series of patients with femoroacetabular impingement and to compare its preoperative and intraoperative variables with a matched control group of patients without HO. Methods  All patients who underwent hip arthroscopy for femoroacetabular impingement between 2010 and 2017 with a minimum follow-up of 2 years were included in this analysis. Radiographic examinations were recorded to select cases with HO. A case-control analysis was performed comparing preoperative and intraoperative variables between cases with HO and a matched control group without HO. Results  A total of 700 cases were included in the analysis. HO was found in 15 (2.14%) of subjects. Cases with HO showed more severe cartilage injuries, less cam morphology ratio, and a higher proportion of partial labrectomies than the control group. No significant differences were observed in preoperative hip pain or function between groups. Conclusions  The prevalence of HO after hip arthroscopy in subjects with femoroacetabular impingement was 2.14%. Cases with HO had more severe cartilage injuries, lower ratio of cam morphology, and higher proportion of partial labrectomies than the control cases without HO. Level of Evidence  Level III.

Safety and Efficacy of Postoperative Nonsteroidal Anti-inflammatory Drugs in Sports Medicine

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for multimodal pain control after surgery. These medications work by selective or nonselective inhibition of cyclooxygenase, which has downstream effects on thromboxanes, prostaglandins, and prostacyclins. Clinical studies have shown beneficial effects for alleviating pain and reducing opioid consumption after surgery. Within hip arthroscopy, there is evidence that postoperative NSAIDs can also reduce the risk of symptomatic heterotopic bone formation. However, preclinical and animal studies have raised concern over the effect of NSAIDs on bone and soft-tissue healing. In addition, selective and nonselective cyclooxygenase 2 inhibitors may have different safety profiles regarding postoperative soft-tissue healing. The purpose of this review was to outline the mechanisms of action, efficacy, and effect on soft-tissue healing of postoperative NSAIDs and to provide evidence-based recommendations for appropriate use.

Sustained local ionic homeostatic imbalance caused by calcification modulates inflammation to trigger heterotopic ossification

Heterotopic ossification (HO) is a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues. Despite being a frequent complication of orthopedic and trauma surgery, brain and spinal injury, the etiology of HO is poorly understood. The aim of this study is to evaluate the hypothesis that a sustained local ionic homeostatic imbalance (SLIHI) created by mineral formation during tissue calcification modulates inflammation to trigger HO. This evaluation also considers the role SLIHI could play for the design of cell-free, drug-free osteoinductive bone graft substitutes. The evaluation contains five main sections. The first section defines relevant concepts in the context of HO and provides a summary of proposed causes of HO. The second section starts with a detailed analysis of the occurrence and involvement of calcification in HO. It is followed by an explanation of the causes of calcification and its consequences. This allows to speculate on the potential chemical modulators of inflammation and triggers of HO. The end of this second section is devoted to in vitro mineralization tests used to predict the ectopic potential of materials. The third section reviews the biological cascade of events occurring during pathological and material-induced HO, and attempts to propose a quantitative timeline of HO formation. The fourth section looks at potential ways to control HO formation, either acting on SLIHI or on inflammation. Chemical, physical, and drug-based approaches are considered. Finally, the evaluation finishes with a critical assessment of the definition of osteoinduction. STATEMENT OF SIGNIFICANCE: The ability to regenerate bone in a spatially controlled and reproducible manner is an essential prerequisite for the treatment of large bone defects. As such, understanding the mechanism leading to heterotopic ossification (HO), a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues, would be very useful. Unfortunately, the mechanism(s) behind HO is(are) poorly understood. The present study reviews the literature on HO and based on it, proposes that HO can be caused by a combination of inflammation and calcification. This mechanism helps to better understand current strategies to prevent and treat HO. It also shows new opportunities to improve the treatment of bone defects in orthopedic and dental procedures.

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

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.

Heterotopic Ossification After Arthroscopic Procedures: A Scoping Review of the Literature

Background:

Heterotopic ossification (HO) is the formation of bone in soft tissue resultant from inflammatory processes. Lesion formation after arthroscopic procedures is an uncommon but challenging complication. Optimal prophylaxis and management strategies have not been clearly defined.

Purpose:

To present a scoping review of the pathophysiology, risk factors, diagnostic modalities, prophylaxis recommendations, and current treatment practices concerning HO after arthroscopic management of orthopaedic injuries.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

A scoping review via a PubMed search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The search strategy was based on the terms “heterotopic ossification” AND “arthroscopy.” The clinical outcomes review included studies on the arthroscopic management of orthopaedic injuries in which the primary subject matter or a secondary outcome was the development of HO. An analysis of the pathophysiology, diagnostic modalities, and management options was reported.

Results:

A total of 43 studies (33,065 patients) reported on HO after hip arthroscopy, while 21 (83 patients) collectively reported on HO after arthroscopic procedures to the shoulder, elbow, knee, or ankle; however, management techniques were not standardized. Identified risk factors for HO included male sex and mixed impingement pathology, while intraoperative capsular management was not suggested as a contributing factor. Diagnosis of ossification foci was performed using radiography and computed tomography. The rate of HO after hip arthroscopy procedures approached 46% without prophylaxis, and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) decreased occurrence rates to 4% but carries associated risks. External beam radiation has not been exclusively studied for use after arthroscopic procedures.

Conclusion:

HO is a known complication after arthroscopic management of orthopaedic injuries. NSAID prophylaxis has been demonstrated to be effective after hip arthroscopy procedures. Patients with persistent symptoms and mature lesions may be indicated for surgical excision, although variability is present in patient-reported outcome scores postoperatively.

Incidence of Heterotopic Ossification with NSAID Prophylaxis Is Low After Open and Arthroscopic Hip Preservation Surgery

Purpose

We evaluate the incidence of heterotopic ossification (HO) development with nonsteroidal anti-inflammatory drug (NSAID) prophylaxis in patients after open and arthroscopic hip preservation surgery.

Methods

A retrospective review identified patients who underwent hip preservation surgery at a single institution within the past 3 years. Patients who underwent hip arthroscopy with or without periacetabular osteotomy (PAO) or femoral osteotomy (FO) were included. Those who did not receive 3-month postoperative radiographs were excluded. The incidence and Brooker classification (BC) of HO in patients taking Naproxen or another NSAID (meloxicam, celecoxib, indomethacin, or aspirin alone) was assessed using AP radiographs available from 3-, 6-, and 12-month follow-up appointments. Univariate analysis was conducted to compare numerical means and categorical data (significance level P = .05).

Results

A total of 328 hips (284 patients) were included. All patients received hip arthroscopy, while 71 patients (21.6%) received concurrent periacetabular osteotomy (PAO; n = 65) or femoral osteotomy (FO; n = 6). Overall, 276 hips (84.4%) received Naproxen for HO prophylaxis. In total, 5 of 328 hips (1.5%) developed HO (4, BC I; 1, BC III). The rate of HO development was significantly higher in males versus females (4 of 121 (3.31%) vs 1 of 207 (.48%), P = .0441). All 5 patients received arthroscopic cam resection and labral repair, and 1 patient also received PAO. Three patients in the Naproxen group (.91%) developed HO, which was not statistically different from those taking a different NSAID (.61%, P = .1797).

Conclusion

The incidence of HO development was low with NSAID prophylaxis after hip preservation surgery.

Large Heterogeneity Among Minimal Clinically Important Differences for Hip Arthroscopy Outcomes: A Systematic Review of Reporting Trends and Quantification Methods

PURPOSE

To perform a systematic review of reporting trends and quantification methods for the minimal clinically important difference (MCID) within the hip arthroscopy literature.

METHODS

Cochrane, PubMed, and OVID/MEDLINE databases were queried for hip arthroscopy articles that reported the MCID. Studies were classified as (1) calculating new MCID values for their specific study-population or (2) referencing previously established MCID values. Data pertaining to patient demographics, study characteristics, outcome measures, method of MCID quantification, MCID value, anchor questions, measurement error, and study from which referenced MCID values were obtained were extracted.

RESULTS

A total of 59 articles with 18,830 patients (19,867 hips) was included. A total of 19 unique outcome measures was reported. A total of 33 (n = 55.9%) studies (follow-up range 6-60 months) used previously established MCID values to assess their study population (MCID values established at a follow-up range 6-31 months). The remaining 26 studies (44.1%) performed new MCID calculations. The MCID values were inconsistent and varied widely (Hip Outcome Score-Activities of Daily Living: 5.0-15.4; Hip Outcome Score-Sports Subscale: 6-25; modified Harris hip score: 2.4-20.9). Among the 33 studies that used previously established MCID values, 10 different studies were cited as the reference. Among the remaining 26 studies that calculated a new MCID value, the most common method was 0.5 standard deviation method (n = 21, 80.8%). Only 3 of 26 (11.5%) studies reported a measurement of error in conjunction with their MCID values.

CONCLUSIONS

Inconsistencies in MCID reporting and quantification methods led to a wide range of MCID values for commonly administered outcome measures within the hip arthroscopy literature-even for the same outcome measures. The majority of studies referenced previously established MCID values with variable ranges of follow-up and applied those values to assess their specific study population at varying follow-ups.

LEVEL OF EVIDENCE

IV, systematic review.

Editorial Commentary: The Curious Incident of the Bone in the Soft Tissue: Is Heterotopic Ossification After Hip Arthroscopy an Interesting Finding or Is It a Complication?

Heterotopic ossification (HO) following hip arthroscopy is a common finding. Naproxen and celecoxib have both been found to decrease the incidence of HO. Whether this makes a clinical difference to outcomes is unclear at this time. A critical weighing of risks and benefits with regard to HO prophylaxis is warranted. Although the authors will personally continue to use nonsteroidal anti-inflammatory drugs for HO prophylaxis, it is up to the discerning reader to draw her/his own conclusion.