Preoperative, single-fraction irradiation for prophylaxis of heterotopic ossification after total hip arthroplasty

Surgical treatment of anterior cervical osteophytes causing dysphagia

PURPOSE

Dysphagia due to anterior cervical osteophytes is a rare condition. However, it can become serious enough to permanently impair the quality of life up to making normal food intake impossible. If conservative treatment fails, there is the option of surgical resection of the osteophytes. The objective of this study was to assess the outcomes of resections of anterior cervical osteophytes causing spondylogenic dysphagia, taking literature into consideration.

METHOD

Resection of anterior cervical osteophytes using a standard anterior approach was performed in 14 consecutive patients with spondylogenic dysphagia between 2009 and 2015. Indomethacin or radiation was used to prevent recurrence. Imaging and clinical data were collected in follow-up examinations over an average of 50 months.

RESULTS

The osteophytes were sufficiently resected in all cases. Anterior plates were placed in three patients due to pronounced segmental mobility. Five patients were given recurrence prevention in the form of indomethacin, nine with radiation. One patient required revision surgery for a hematoma. No other serious complications were observed. All patients had significant improvement of their symptoms. No recurrences or signs of increasing instability were found during the follow-up period.

CONCLUSION

When conservative treatment fails, surgical resection of cervical osteophytes is a sufficient method for treating spondylogenic dysphagia. High patient satisfaction and improvement of the quality of life are achieved with a low complication rate. Routine additional stabilization has been discussed as recurrence prevention. Prophylaxis using indomethacin or radiation, known primarily from hip replacement, also appears to be an option.

Heterotopic ossifications: role of radiotherapy as prophylactic treatment

BACKGROUND

Heterotopic ossification (HO) is abnormal formation of lamellar bone in soft tissue; the most frequent causes are total hip arthroplasty and trauma. Severe cases can lead to ankilosis with important impact on quality of life. Surgery is the elective treatment, but, especially in high-risk patients, it is important to prevent the re-formation of HO and, in these cases, radiotherapy (RT) can play an important role.

MATERIALS AND METHODS

we retrospectively analyzed a mono-institutional casistic of 30 patients (31 sites) at high risk for HO development, treated with surgery and pre- or postoperative RT. The majority of patients received a single RT fraction of 7 Gy, median age was 62, with a prevalence of male and hip as most frequently involved site. Radiological studies and clinical examination were performed in all patients during the follow-up period to evaluate both treatment efficacy and acute or late toxicity.

RESULTS

With a median follow up of 67 months, 23 patients had a complete response (CR) with excellent results in term of joint mobility. Two patients with CR showed a relapse of HO in the same site 19 and 12 months after treatment, respectively. Seven patients (22,6%) had a partial response (PR) to RT. One patient who reached CR had a history of previous irradiation in the same site 16 years before. No acute or late reactions have been reported.

CONCLUSION

Our data confirm safety and efficacy of RT in preventing HO, especially in high-risk patients, preferring a single fraction of 7 Gy.

Testicular Dose During Prophylaxis of Heterotopic Ossification with Radiation Therapy

AIM

A single-institution, retrospective study was performed to investigate potential techniques to minimize radiation exposure to the testicles during heterotopic ossification (HO) prophylaxis. We report the impact of split-beam technique (SBT) and different photon energies on the total dose of radiation received by the testicles during prophylaxis of HO.

MATERIALS AND METHODS

Between 2008 and 2010, we identified 64 patients with traumatic acetabular fractures who underwent surgery followed by radiation therapy (RT) without testicular shielding. Postoperative RT was delivered within 72 h in a single fraction of 700 cGy using 6-18 MV photons, without testicular shielding due to patient refusal. All patients underwent 3-D RT planning in which the testicles were contoured as a region of interest and dose-volume histograms (DVH) were generated. Additional treatment planning trials were created for each patient by utilizing a SBT medially and by using different photon energies (6, 10 and 18 MV) to study the effects of these maneuvers on the delivered dose to the testicles.

RESULTS

In reviewing the DVH, it was noted that the mean dose delivered to the testicles was 10 cGy (range=3-40). The maximum dose was 31 cGy (range=7-430). When SBT was utilized, a significant reduction in the mean (44%) and maximum (47%) doses delivered to the testicles was noted. Further reductions in the mean (26%) and maximum (14%) doses were achieved by using higher-energy (10-18 MV) beams. The radiation doses to the testicles from the CT simulation and the two portal images were estimated to be 4 and 1.5 cGy, respectively.

CONCLUSION

Low-dose prophylactic RT to prevent HO around the hip causes a low, but likely biologically meaningful, radiation dose to be delivered to the testicles. This dose could be further reduced by using a medial SBT and photon energies above 6 MV. Testicular shielding should be offered to all male patients receiving such RT. In addition, all patients should be informed about the consequences of testicular radiation as part of their informed consent.

Heterotopic ossification following hip arthroplasty: a comparative radiographic study about its development with the use of three different kinds of implants

Background

Our purpose was to record the incidence of heterotopic ossification (HO) following hip replacement by different variables to identify patient groups that are likely to develop HO in the absence of a prophylactic protocol.

Methods

Radiographically, we studied 651 patients having undergone hip joint replacement, evaluating three kinds of implants: ceramic-ceramic-coupled total hip replacement (THR), TriboFit^® with polycarbonate urethane-ceramic coupling and endoprosthesis. Each patient was analysed for HO development by age, gender, diagnosis, presence of previous ossifications, surgical approach and kind of implant. Within the population that developed HO, data were assessed for correlation with severity of ossification graded according to Brooker classification.

Results

The overall incidence of HOs was 59.91 %. The factors increasing their incidence in the univariate analysis were as follows: lower age of the patients with HO (mean 77.6 years, p = 0.0018) than those subjects who did not develop HO (mean 80.2 years); male gender (64.4 %, p = 0.1011); diagnosis of coxarthrosis (72.7 %, p = 0.0001) compared to femur neck fracture (55.9 %, p = 0.0001); presence of previous HO (76.2 %, p = 0.0260); lateral approach (65.5 %) as opposed to anterior-lateral approach (55.6 %, p = 0.0163); and ceramic-ceramic THR (68.1 %) and TriboFit^® (67.0 %) compared to endoprosthesis (51.3 %, p = 0.0001).

During multivariate analysis, the presence of HO after previous hip surgery (p = 0.0324) and the kind of implant (p = 0.0004) showed to be independent risk factors for the development of HO. Analysing the population that developed HO, we found that the severity of ossification by Brooker classification was influenced by gender (p = 0.0478) and kind of implant (p = 0.0093).

Conclusions

In agreement with the literature, our radiographic study confirms the following risk factors of HO development in absence of any prophylactic treatment: male gender, diagnosis of coxarthrosis compared to femur neck fracture, previous HO, surgical approach and kind of implant. In particular, Hardinge-Bauer and Watson-Jones surgical approaches, characterized by a wide exposure of the coxofemoral joint, and ceramic-ceramic THR and TriboFit^® implants significantly increase the development of HO.

Is preoperative radiation therapy as effective as postoperative radiation therapy for heterotopic ossification prevention in acetabular fractures?

BACKGROUND

Prophylactic approaches to prevent heterotopic ossification after acetabular fracture surgery have included indomethacin and/or single-dose external beam radiation therapy administered after surgery. Although preoperative radiation has been used for heterotopic ossification prophylaxis in the THA population, to our knowledge, no studies have compared preoperative and postoperative radiation therapy in the acetabular fracture population.

QUESTIONS/PURPOSES

We determined whether heterotopic ossification frequency and severity were different between patients with acetabular fracture treated with prophylactic radiation therapy preoperatively and postoperatively.

METHODS

Between January 2002 and December 2009, we treated 320 patients with a Kocher-Langenbeck approach for acetabular fractures, of whom 50 (34%) were treated with radiation therapy preoperatively and 96 (66%) postoperatively. Thirty-four (68%) and 71 (74%), respectively, had 6-month radiographs available for review and were included. For hospital logistical reasons, patients who underwent operative treatment on a Friday or Saturday received radiation therapy preoperatively, and all others received it postoperatively. The treatment groups were comparable in terms of most demographic parameters, injury severity, and fracture patterns. Six-month postoperative radiographs were reviewed and graded according to Brooker. Followup ranged from 6 to 93 months and 6 to 97 months for the preoperative and postoperative groups, respectively. Post hoc power analysis showed our study was powered to detect a difference of 22% or more between patients with severe heterotopic ossification. Sample size calculations showed 915 subjects would be needed to detect a 5% relative difference in severe heterotopic ossification status between groups.

RESULTS

We detected no difference in heterotopic ossification frequency between the preoperative (eight of 36, 22%) and postoperative (19 of 71, 27%) groups (p=0.609). There was also no difference in heterotopic ossification severity between groups (p=0.666). Two of 36 (6%) in the preoperative group and three of 71 (4%) in the postoperative group developed clinically significant Grade III heterotopic ossification. No patients developed Grade IV heterotopic ossification.

CONCLUSIONS

We found no difference in heterotopic ossification frequency or severity when comparing preoperative and postoperative radiation therapy. However, given the relatively low frequency of heterotopic ossification in this population, in particular the frequency of severe or symptomatic heterotopic ossification, the possibility of a Type II error must be considered. Larger, prospective studies are required to confirm our no-difference finding, but insofar as the result in this fracture population mirrors that of the THA population, unless our finding is disproven, we believe radiation therapy can be given either before or after surgery, as dictated by the clinical scenario.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Radiotherapy for the prophylaxis of heterotopic ossification: a systematic review and meta-analysis of published data

INTRODUCTION

Following surgery, the formation of heterotopic ossification (HTO) can limit mobility and impair quality of life. Radiotherapy has been proven to provide efficacious prophylaxis against HTO, especially in high-risk settings.

PURPOSE

The current review aims to determine the factors influencing HTO formation in patients receiving prophylactic radiotherapy.

METHODS

A systematic search of the literature was conducted on Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials. Studies were included if they reported the percentage of sites developing heterotopic ossification after receiving a specified dose of prophylactic radiotherapy. Weighted linear regression analysis was conducted for continuous or categorical predictors.

RESULTS

Extracted from 61 articles, a total of 5464 treatment sites were included, spanning 85 separate study arms. Most sites were from the hip (97.7%), from United States patients (55.2%), and had radiation prescribed postoperatively (61.6%) at a dose of 700cGy (61.0%). After adjusting for radiation site, there was no statistically significant relationship between the percentage of sites developing HTO and radiation dose (p=0.1) or whether radiation was administered preoperatively or postoperatively (p=0.1). Sites with previous HTO formation were more likely to develop recurrent HTO than those without previous HTO formation (p=0.04). There was a statistically significant negative relationship between the HTO development and the cohort mean year of treatment (p=0.007).

CONCLUSION

Decreases in rates of HTO over time in this patient population may be a function of more efficacious surgical regimens and prophylactic radiotherapy.

Computerized tomography-based radiotherapy improves heterotopic ossification outcomes

PURPOSE

To report the impact of computerized tomography (CT) based radiotherapy (RT) on heterotopic ossification (HO) outcomes.

METHODS

This is a single institution, retrospective study of 532 patients who were treated for traumatic acetabular fractures (TAF). All patients underwent open-reduction internal-fixation (ORIF) of the TAF followed by RT for HO prophylaxis. Postoperative RT was delivered within 72h, in a single fraction of 7Gy. The patients were divided into 2 groups based on RT planning: CT (A) vs. clinical setup (B).

RESULTS

At a median follow up of 8years the incidence of HO was 21.6%. Multivariate regression analysis revealed that group (A) vs. (B) had HO incidence of 6.6% vs. 24.6% (p<0.001), respectively. Furthermore, HO Brooker grade ≥3 was observed in 2.2% vs. 10.8% (p=0.007) in group (A) vs. (B), respectively. Thus, the odds of developing HO and Brooker grades ≥3 were 4.7 and 4.5 times higher, respectively, in patients who underwent clinical setup.

CONCLUSION

Our data suggest that using CT based RT allowed more accurate delineation of the tissues and better clinical outcomes. Although CT-based RT is associated with additional cost the efficacy of CT-based RT reduces the risk of HO, thereby decreasing the need for additional surgical interventions.

[Methods of the physical medicine therapy in prevention of heterotopic ossification after total hip arthroplasty]

BACKGROUND/AIM

In the prevention of periarticular heterotopic ossification (HO), a common complication after total hip arthroplasty (THA), nonsteroidal antiinflammatory drugs (NSAID) and irradiation are used. Some theories presume that local hypoxia of the soft tissue causes HO. The aim of this study was to investigate if the early use of pulsed electromagnetic fields (PEMF) could prevent this ossification since it accelerates the circulation and oxigenation of soft tissue.

METHODS

The study included three groups of the patients with primary THA. The group C consisted of 66 patients/79 hips who had only kinesitherapy in postoperative rehabilitation. The group B consisted of 117 patients/131 hips who had PEMF and interferential current (IC) which, on average, started on the 14th day after the surgery combined with the standard kinesitherapy. The group A consisted of 117 patients/131 hips who had PEMF from the third postoperative day and IC from, on average, the 14th postoperative day with the standard kinesitherapy. The classification of HO was done on a standard AP roentgenograms of the hips, taken at least one year after the surgery.

RESULTS

The overall HO was seen in 50.63% of the group C patients, in 43.51% of the B group and in 16.67% of the group A. Severe HO (III and IV class according to Brooker) was seen in 26.58% of the group C patients and in 6.10% of the group B, but none in the group A.

CONCLUSION

According to the obtained results an early treatment with PEMF could prevent severe HO and reduce the overall HO.

Prevention of heterotopic ossification in high-risk patients with total hip arthroplasty: the experience of a combined therapeutic protocol

The combination of radiotherapy and indomethacin for the prevention of heterotopic ossification (HO) in high-risk patients undergoing total hip arthroplasty (THA) has not been reported. The aim of the present study was to present the experience of our department with this combined therapeutic protocol. Fifty-four patients who underwent THA received a single dose of 7 Gy of postoperative radiotherapy and 75 mg of indomethacin for 15 days. Patients were analyzed for clinical and radiographical evidence of HO development at 1 year postoperatively. The overall radiographical incidence of HO was 20.4% (95% CI 10.6-33.5%), while only 1 patient with clinically significant HO was seen. Patients with secondary arthritis due to congenital hip disease had a statistically significantly higher incidence of HO compared with those with osteoarthrosis. The clinical assessment with the Merle d'Aubigné score showed that patients with radiographic documentation of HO had a lower mean score compared with those with no evidence of HO. No treatment-related side effects were seen. Combined radiotherapy and indomethacin was effective in preventing heterotopic ossification after total hip arthroplasty. The evaluation of this efficacy compared with radiotherapy or NSAIDs alone should be the future target of larger randomized designs.