Efficacy of naproxen prophylaxis for the prevention of heterotopic ossification after hip surgery: a meta-analysis

Classification and Incidence of Heterotopic Ossifications in Relation to NSAID Prophylaxis after Elbow Trauma

Heterotopic ossification (HO) after elbow trauma can be responsible for significant motion restrictions. The study's primary aim was to develop a new X-ray-based classification for HO of the elbow. This retrospective study analyzed elbow injury radiographs from 138 patients aged 6-85 years (mean 45.9 ± 18) who underwent operative treatment. The new classification was applied at 6 weeks, 12 weeks, and 6 months postoperatively. The severity of HO was graded from 0 to 4 and localization was defined as r (radial), p (posterior), u (ulnar) or a (anterior) by two observers. The patients were categorized based on injury location and use of non-steroidal anti-inflammatory drugs (NSAIDs) for HO prophylaxis. The correlations between the generated data sets were analyzed using Chi-square tests (χ2) with a significance level of p < 0.05. The inter- and intraobserver reliability was assessed using Cohen's Kappa. In 50.7% of the evaluated X-rays, the formation of HO could be detected after 12 weeks, and in 60% after 6 months. The analysis showed a significant correlation between the injury's location and the HO's location after 12 weeks (p = 0.003). The use of an NSAID prophylaxis did not show a significant correlation with the severity of HO. The classification showed nearly perfect inter- (κ = 0.951, p < 0.001) and intrareliability (κ = 0.946, p < 0.001) according to the criteria of Landis and Koch. Based on the presented classification, the dimension and localization of HO in the X-ray image can be described in more detail compared to previously established classifications and, thus, can increase the comparability of results across studies.

Is Heterotopic Ossification Associated With Surgical Approach in Total Hip Arthroplasty?

BACKGROUND

Although risk factors for heterotopic ossification (HO) have been defined, the effect from surgical approach is not fully understood. The primary objective of our study was to evaluate the effect that surgical approach has on the risk for developing severe HO after total hip arthroplasty (THA) and compare this with other known risk factors. We hypothesized that there would be no difference in HO formation based on the surgical approach.

METHODS

We retrospectively reviewed all patients who underwent primary THA at our hospital between March 2011 and March 2021. Patients with HO documented in the radiology reports were cross-referenced with our THA data set and manually reviewed to determine Brooker classification. Patient demographics, medical comorbidities, surgical details, and medication information were collected from the electronic medical record and compared.

RESULTS

Of 3,427 patients who underwent THA, 677 (19.8%) developed HO postoperatively. A multivariable analysis confirmed that surgical approach was independently associated with increased odds for HO development. The anterolateral (odds ratio [OR], 3.43; P < 0.001) and posterior (OR, 2.24; P < 0.001) approaches had increased odds for developing HO compared with the direct anterior approach. However, only the anterolateral approach (OR, 1.85; P = 0.033) demonstrated an increased association with the development of severe HO (Brooker 3, 4) postoperatively.

CONCLUSION

Although the use of the direct anterior approach had the lowest overall OR for developing HO after THA, this is likely only clinically notable when compared with the anterolateral approach.

LEVEL OF EVIDENCE

III.

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.

Heterotopic Ossification Following Arthroplasty for Femoral Neck Fracture

BACKGROUND

Heterotopic ossification (HO) is a frequent complication following hip surgery. Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we aimed to (1) determine the prevalence of HO following total hip arthroplasty (THA) for femoral neck fracture in patients ≥50 years of age, (2) identify whether HO is associated with an increased risk of revision surgery within 24 months after the fracture, and (3) determine the impact of HO on functional outcomes.

METHODS

We performed a multivariable Cox regression analysis using revision surgery as the dependent variable and HO as the independent variable. We compared Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between participants with and those without HO at 24 months.

RESULTS

Of 1,441 participants in the study, 287 (19.9%) developed HO within 24 months. HO was not associated with subsequent revision surgery. Grade-III HO was associated with statistically significant and clinically relevant deterioration in the total WOMAC score, which was mainly related to the function component of the score, compared with grade I or II.

CONCLUSIONS

The impact of grade-III HO on the functional outcomes and quality of life after THA for hip fracture is clinically important, and HO prophylaxis for selected high-risk patients may be appropriate.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Low-Dose Aspirin Administered for Venous Thromboembolism Prophylaxis Reduces the Incidence of Heterotopic Ossification in Total Joint Arthroplasty

BACKGROUND

Heterotopic ossification (HO) is a common complication following total joint arthroplasty (TJA). However, the pathophysiology of HO is not entirely understood. Inflammation may play a significant role in the pathogenesis of HO as nonsteroidal anti-inflammatory drugs are effective in the prevention of HO. The purpose of this study is to examine if aspirin (ASA), when used as venous thromboembolism (VTE) prophylaxis, influenced the rate of HO formation following TJA.

METHODS

We queried our longitudinally maintained database to identify all patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) for osteoarthritis between January 2016 and June 2018 with at least 3-month radiographic follow-up. In total, 1238 THAs and 1051 TKAs were included for analysis. Radiographs were reviewed and HO formation graded according to the Brooker classification. Patient demographic and VTE prophylaxis data were collected and reviewed for accuracy. Univariate and multivariate analysis was performed to evaluate the effect of ASA on HO formation.

RESULTS

The overall rate of HO was 37.5% after THA and 17.4% after TKA. Patients receiving ASA were less likely to develop HO after THA (34.8% vs 45.5%; P < .001), as well as HO after TKA (13.4% vs 18.4%; P = .047) compared to patients receiving non-ASA VTE prophylaxis. The rate of HO formation trended to be lower, albeit not statistically significantly, in patients receiving low-dose ASA (81 mg) vs high-dose ASA (325 mg).

CONCLUSION

Patients undergoing primary TJA receiving ASA for VTE prophylaxis were less likely to develop HO compared to patients who were administered non-ASA VTE prophylaxis.

Nonsteroidal Antiinflammatory Drugs as Potential Disease-Modifying Medications in Axial Spondyloarthritis

Nonsteroidal antiinflammatory drugs (NSAIDs) are the first-line pharmacotherapy for patients with axial spondyloarthritis (SpA). In recent years, treatment options have expanded with the availability of biologic agents, including tumor necrosis factor inhibitors and interleukin-17 inhibitors. However, a treatment strategy that clearly prevents syndesmophyte formation has not been established. Observational studies of patients with ankylosing spondylitis indicated potential disease-modifying effects of NSAIDs, but two randomized trials came to different conclusions. More broadly, whether any of the currently available medications for axial SpA have an effect on spine radiographic progression, beyond symptom control, remains inconclusive. In this article, we will review clinical studies of the disease modification effects of NSAIDs and biologics in axial SpA; examine genetic, animal, and clinical evidence of the effects of NSAIDs on bone formation; and discuss how future studies may investigate the question of disease modification in axial SpA.

The hypoxic microenvironment: a driving force for heterotopic ossification progression

Heterotopic ossification (HO) refers to the formation of bone tissue outside the normal skeletal system. According to its pathogenesis, HO is divided into hereditary HO and acquired HO. There currently lack effective approaches for HO prevention or treatment. A deep understanding of its pathogenesis will provide promising strategies to prevent and treat HO. Studies have shown that the hypoxia-adaptive microenvironment generated after trauma is a potent stimulus of HO. The hypoxic microenvironment enhances the stability of hypoxia-inducible factor-1α (HIF-1α), which regulates a complex network including bone morphogenetic proteins (BMPs), vascular endothelial growth factor (VEGF), and neuropilin-1 (NRP-1), which are implicated in the formation of ectopic bone. In this review, we summarize the current understanding of the triggering role and underlying molecular mechanisms of the hypoxic microenvironment in the initiation and progression of HO, focusing mainly on HIF-1 and it's influenced genes  BMP, VEGF, and NRP-1. A better understanding of the role of hypoxia in HO unveils novel therapeutic targets for HO that reduce the local hypoxic microenvironment and inhibit HIF-1α activity.

Lollipop Sign - Ossification at Wire Ends after Osteosynthesis?

Introduction:

Heterotopic ossification (HO) is abnormal formation of new bone in the soft tissue. HO occurs outside the normal bone within soft tissues such as muscles and tendons, and histologically, it is no different from skeletal bone. It is still not clear what factors stimulate HO. The soft tissue around the hip joint has been identified as the most common location for HO. Patients with HO usually have no clinical symptoms; however, it can become very painful and lead to severe functional limitations. The standard diagnostic procedure consists of conventional X-ray diagnostics and/or skeletal scintigraphy. Local radiation and nonsteroidal anti-inflammatory drugs are the classical options for treatment and prophylaxis of HO. We describe two pediatric patients with “lollipop-like” HO at the end of Kirschner wires (K-wires, steel) and titanium elastic nails (TENs, titanium).

Case Report:

A 9-year-old girl, 1 year after Salter and Pemberton osteotomy with K-wires, and a 15-year-old boy, 1 year after fracture of the right femur treated by osteosynthesis with TENs, were treated in our department due to HO. The girl did not report any symptoms, while the boy had pain in the location where the ossification had formed. However, examination of the girl’s hip showed that the range of motion in the hip affected by HO was limited in comparison with the opposite unaffected hip.

Conclusion:

To the best of our knowledge, lollipop-like HO around protruding K-wires or TENs has not yet been described. According to literature, HO is mainly located in the pelvic region and at the elbow. Most studies investigating HO describe cases which have occurred after cemented or uncemented hip replacement surgery. In the cases presented here, HO might have been stimulated by repetitive muscle trauma above the protruding K-wire and TENs, the trauma caused by the operation, bone marrow cells dispersed intraoperatively, or by a combination of these and other factors. There are numerous studies on strategies to prevent HO after joint replacement. We suggest “lollipop sign” as a name for this rare type of HO around the end of K-wires/TENs in pediatric patients.

A systematic review and meta-analysis of naproxen for prevention heterotopic ossification after hip surgery

BACKGROUND

The aim of this study was to assess the efficacy of naproxen in preventing heterotopic ossification (HO) after hip surgery (total hip arthroplasty [THA] and hip arthroscopy).

METHODS

Using databases (PubMed, EMBASE, and Web of Science), we conducted an electronic, systematic search of randomized controlled trials (RCTs) comparing naproxen versus placebo on HO after hip surgery. The risk ratio (RR) of the dichotomous data, weighted mean difference (WMD) of continuous data, and 95% confidence intervals (CIs) were calculated to assess the effects of naproxen in patients with hip surgery.

RESULTS

A total of 4 studies including 269 patients were analyzed. Risk of bias was relatively high in allocation concealment and blinding. Compared with control group, administration naproxen was associated with a significantly reduction of the occurrence of HO at final follow-up after hip surgery (P < .05). What's more, naproxen was associated with a reduction of the Brooker I and II HO (P < .05). However, there was no significant difference between the Brooker III HO between naproxen and control groups (P > .05). Furthermore, there was no significant difference between the complications (P > .05) between naproxen and control groups.

CONCLUSION

Naproxen has a beneficial role in reducing the total occurrence of HO, Brooker I and II HO after hip surgery. However, conclusions are limited due to the lack of high-quality studies. More high quality studies may help in a more reliable therapy for HO.