Celecoxib versus ibuprofen in the prevention of heterotopic ossification following total hip replacement: a prospective randomised trial

Efficacy of ibuprofen and indomethacin as prophylaxis of heterotopic ossification: a comparative study

The prophylactic action of non-steroidal anti-inflammatory drugs (NSAIDs) in heterotopic ossification (HO) was first described following analgesic therapy with indomethacin. Following that evidence, several compounds have been successfully used for prophylaxes of HO. Ibuprofen has been also proposed for the prevention of HO following THA. The present study compared the administration of ibuprofen for three weeks versus indomethacin as prophylaxis for HO following primary THA. In all THA procedures, pre- and post-operative protocols were conducted in a highly standardized fashion. The type of HO prophylaxis (indomethacin 100 mg/daily or ibuprofen 100 mg/daily) was chosen according to a chronological criterion: from 2017 to 2019 indomethacin was used, whereas from 2019 to 2022 ibuprofen was administered. In case of allergy or intolerance to NSAIDs, no prophylaxis was performed, and patients were included as a control group. All patients who underwent an anteroposterior radiography of the pelvis at a minimum of 12 months following THA were considered for inclusion. On admission, the age and sex of the patients were recorded. Moreover, the causes of osteoarthritis and the date of surgery were recorded. The grade of HO was assigned by a blinded assessor who was not involved in the clinical management of the patients. The modified Brooker Staging System was used to rate the efficacy of the interventions. Data from 1248 patients were collected. 62% (767 of 1248 patients) were women. The mean age was 67.0 ± 2.9 years. The mean follow-up was 21.1 ± 10.8 months. In the ibuprofen group, 73% of patients evidenced Brooker 0, 17% Brooker I, and 10% Brooker II. In the indomethacin group, 77% of patients evidenced Brooker 0, 16% Brooker I, 6% Brooker II. No patient in the ibuprofen and indomethacin group developed Brooker III or IV. In the control group, 64% of patients evidenced Brooker 0, 21% Brooker I, 3% Brooker II, and 12% Brooker III. No patient in the control group developed Brooker IV HO. Concluding, three weeks of administration of ibuprofen demonstrated similar efficacy to indomethacin in preventing HO following primary THA. The prophylaxis with ibuprofen or indomethacin was more effective in preventing HO compared to a control group who did not receive any pharmacological prophylaxis.

A Short Course of Celecoxib Prevents Heterotopic Ossification Following Cementless Total Hip Arthroplasty

Heterotopic ossification (HO) is a common complication after total hip arthroplasty (THA) and can result in pain and loss of motion of the hip. This is the first study in the literature to determine if a short course of Celecoxib is effective in the prevention of HO in patients undergoing cementless THA. In this retrospective study of prospectively collected data, consecutive patients undergoing a primary cementless THA were reviewed at a 2-year follow-up. The Control group consisted of 104 hips that did not receive Celecoxib (Control group), while the 208 hips in the Celecoxib group received 100 mg twice daily for 10 days. Radiographs, patient-recorded outcome measures and range of motion (ROM) were evaluated. Overall, there was a significantly decreased incidence of HO in the Celecoxib group (18.7%) than in the Control group (31.7%) (p = 0.01). The odds that a patient developed HO using Celecoxib were 0.4965 times the odds that a patient developed HO without treatment. Clinically, the Celecoxib group demonstrated significantly greater improvement in their mean WOMAC stiffness (0.35 vs. 0.17, p = 0.02) and physical function scores (3.26 vs. 1.83, p = 0.03) compared to those in the Control group, but there was no difference in the ROM between the two groups. This study is the first to demonstrate that the lowest dose of Celecoxib for a short course of only 10 days is a simple and effective prophylactic treatment option that can significantly reduce the incidence of HO following cementless THA.

Efficacy of NSAIDs versus radiotherapy for heterotopic ossification prophylaxis following total hip arthroplasty in high-risk patients: a systematic review and meta-analysis

BACKGROUND

The aims of this systematic review were: (1) to investigate the prophylactic effect of radiotherapy (RT) and NSAIDs in high-risk patients following total hip arthroplasty (THA); and (2) to compare the efficacy of non-selective and COX-II selective NSAIDs in preventing post-THA HO, utilising a meta-analysis of randomised control studies.

METHODS

The PubMed, Embase, and Cochrane Databases were searched for articles regarding HO following THA in March 2019. Studies were included if they contained data regarding HO incidence after THA or contained data regarding HO prophylaxis comparison of NSAIDs and/or RT in terms of dosage or duration.

RESULTS

24 studies reported on populations that were not at high-risk for HO. These studies reported between 47.3% and 90.4% of their patient populations had no HO formation; between 2.8% and 52.7% had mild formation; and between 0.0% and 10.4% had severe formation. A total of 13 studies reported on populations at high-risk for HO. Studies analysing RT in high-risk patients reported between 28.6% and 97.4% of patients developed no HO formation; between 1.9% and 66.7% developed mild HO formation; and between 0.0% and 11.9% developed severe HO formation. Studies analysing NSAID treatment among high-risk populations reported between 76.6% and 88.9% had no HO formation; between 11.1% and 23.4% had mild HO formation, and between 0.0% and 1.8% had severe HO formation. 9 studies were identified as randomised control trials and subsequently used for meta-analysis. The relative risk for COX-II in developing any HO after THA was not significantly different compared to non-selective NSAIDs (RR 1.00; CI, 0.801-1.256; p = 0.489).

CONCLUSIONS

NSAIDs prophylaxis for HO may have better efficacy than RT in high-risk patients following THA. Non-selective and COX-II selective NSAIDs have comparable efficacy in preventing HO. Factors such as medical comorbidities and side-effect profile should dictate the prophylaxis recommendation.

Selective versus non-selective NSAIDs as prophylaxis for heterotopic ossification following hip arthroplasty: a meta-analysis

Background

Some patients have demonstrated evidence of heterotopic ossification (HO) following total hip arthroplasty (THA). Selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) are used as prophylaxis for HO following THA. This meta-analysis compared selective versus non-selective NSAIDs as prophylaxis for HO following THA.

Material and methods

The present study was conducted according to the PRISMA 2020 guidelines. All the clinical investigations comparing selective versus non-selective NSAIDs as prophylaxis for HO following THA were accessed in February 2022. An assessment of the methodological quality and statistical analyses were performed through the risk of bias summary tool of the Review Manager 5.3 software (Cochrane Collaboration, Copenhagen). The modified Brooker staging system was used to rate the efficacies of the interventions.

Results

Data from 8 studies and 1526 patients were collected. 60.8% were female. No difference was found in the sample size, mean age, and percentage of females between the two groups at baseline. No statistically significant difference was found between selective and non-selective NSAIDs in term of efficacy. 72% (1078 of 1502) of the patients were classified as Brooker 0, 21% (322 of 1502) as Brooker I, 5% (80 of 1502) as Brooker II, 1% (16 of 1502) as Brooker III, and 0.1% (2 of 1502) as Brooker IV.

Conclusion

Selective and non-selective NSAIDs were equally effective when used as prophylaxis for HO following THA.

Level of evidence

Level III, systematic review and meta-analysis.

A comprehensive update on the pharmacological management of heterotopic ossification following hip arthroplasty: a level I evidenced based expert opinion

INTRODUCTION

Heterotopic ossification (HO) of the hip joint may happen accompanying skeletal muscle trauma or surgical procedures. The pharmacological prophylaxis of heterotopic ossification (HO) following total hip arthroplasty (THA) is debated.

AREAS COVERED

This expert opinion aims to systematically investigate the efficacy of current pharmacological options as prophylaxis for HO following THA.

EXPERT OPINION

The current evidence identified celecoxib, naproxen, and diclofenac as best option for the prevention of HO in patients who undergo primary THA. The most appropriate pharmacotherapy for the prevention of HO is still debated and should be customized according to patients' comorbidities and medical history. For patients with cardiovascular comorbidities, naproxen, or diclofenac should be considered along with proton pump inhibitors to prevent gastrointestinal complications. For patients with history of gastrointestinal disease, celecoxib can be recommended. These conclusions must be considered within the limitations of the present investigation. Between studies, heterogeneities in the administration protocols were evident. In some RCTs, the length of the follow-up was shorter than 12 months. The current clinical practice would benefit of high-quality recommendations and the development of the shared official guidelines.

The efficacy of nonsteroidal anti-inflammatories in the prevention of heterotopic ossification following elbow trauma surgery

Background

Heterotopic ossification (HO) is common following surgery for elbow trauma and can have a significant impact on elbow function. The use of nonsteroidal anti-inflammatories (NSAIDs) for HO prophylaxis following total hip arthroplasty is well described, with the gold standard of indomethacin 25 mg tid for 6 weeks. However, there is sparse evidence relating to the elbow joint, particularly after elbow trauma surgery. We aim to investigate the efficacy of NSAIDs in the primary prevention of HO amongst all adult patients undergoing surgery for elbow trauma and identify risk factors for HO formation.

Methods

A search of the Fiona Stanley Hospital electronic theater database for procedures undertaken for elbow trauma from January 2015 to June 2020 was performed. Electronic medical records and radiographs were reviewed to determine the incidence of HO, prescription of NSAIDs, biographical data, and complications.

Results

One hundred and fifty-three patients were identified of which 78 patients received NSAIDs postoperatively, compared to 72 who did not. The prescribing history of the remaining 3 patients was unknown. In the NSAID group, the typical patient was prescribed 3-7 days of NSAIDs. Ten patients received a prophylactic course (4-6 weeks). The incidence of HO was similar in both groups (24% in those taking NSAIDs vs. 21% in those not taking NSAIDs). Of those specifically prescribed a prophylactic course, 50% developed HO and 50% did not. Statistical analysis demonstrated that patients with increased body mass index and high energy injuries were more likely to develop HO. Overall complications were low within the cohort. Only 1 patient, who was prescribed NSAIDs, suffered a fracture nonunion (1.3%).

Conclusion

NSAIDs did not affect the incidence of HO about the elbow following surgery for trauma amongst our cohort. There was no appreciable difference in the rates of HO amongst those prescribed NSAIDs and those who were not. Increased body mass index and high energy trauma were predictive for higher incidence of HO. Risks of NSAID therapy were low, with only 1 (1.3%) patient suffering a nonunion.

Cytokine "fine tuning" of enthesis tissue homeostasis as a pointer to spondyloarthritis pathogenesis with a focus on relevant TNF and IL-17 targeted therapies

A curious feature of axial disease in ankylosing spondylitis (AS) and related non-radiographic axial spondyloarthropathy (nrAxSpA) is that spinal inflammation may ultimately be associated with excessive entheseal tissue repair with new bone formation. Other SpA associated target tissues including the gut and the skin have well established paradigms on how local tissue immune responses and proven disease relevant cytokines including TNF and the IL-23/17 axis contribute to tissue repair. Normal skeletal homeostasis including the highly mechanically stressed entheseal sites is subject to tissue microdamage, micro-inflammation and ultimately repair. Like the skin and gut, healthy enthesis has resident immune cells including ILCs, γδ T cells, conventional CD4+ and CD8+ T cells and myeloid lineage cells capable of cytokine induction involving prostaglandins, growth factors and cytokines including TNF and IL-17 that regulate these responses. We discuss how human genetic studies, animal models and translational human immunology around TNF and IL-17 suggest a largely redundant role for these pathways in physiological tissue repair and homeostasis. However, disease associated immune system overactivity of these cytokines with loss of tissue repair “fine tuning” is eventually associated with exuberant tissue repair responses in AS. Conversely, excessive biomechanical stress at spinal enthesis or peripheral enthesis with mechanically related or degenerative conditions is associated with a normal immune system attempts at cytokine fine tuning, but in this setting, it is commensurate to sustained abnormal biomechanical stressing. Unlike SpA, where restoration of aberrant and excessive cytokine “fine tuning” is efficacious, antagonism of these pathways in biomechanically related disease may be of limited or even no value.

NSAIDs for Prophylaxis for Heterotopic Ossification After Total Hip Arthroplasty: A Bayesian Network Meta-analysis

Non-steroidal anti-inflammatory drugs (NSAID) have been recommended to prevent of heterotopic ossification (HO) after total hip arthroplasty (THA), but debates are still ongoing. The present Bayesian network meta-analysis of randomized clinical trials (RCTs) compared all available pathways of NSAID treatment as prophylaxis for HO after THA. The present Bayesian network meta-analysis was conducted according to The PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions guidelines. All randomized clinical trials comparing two or more interventions to prevent HO after THA were considered for analysis. HO was classified according to Brooker. The quality of the methodological assessment was performed through the risk of bias summary tool of the Review Manager Software 5.3 (The Cochrane Collaboration, Copenhagen). The network meta-analysis was performed through a STATA routine for Bayesian hierarchical random-effects model analysis, with log odd ratio (LOR) effect measure. Data from 26 studies (6396 THAs; 58% females) were collected. The mean follow-up was 10.50 ± 5.7 months. ANOVA showed good comparability among mean age and gender (P > 0.5). Celecoxib demonstrated the highest rate of Brooker class 0 (LOR 6.96), followed by diclofenac (LOR 6.94). Naproxen demonstrated the lowest rate of Brooker I HO (LOR 2.82), followed by celecoxib (LOR 3.52). Celecoxib demonstrated lowest rate of Brooker class II HO (LOR 1.66), class III (LOR), and class IV (LOR 0.25). The equation for global linearity detected no statistically significant inconsistency (P > 0.5) in all the comparisons. The present Bayesian network meta-analysis encourages the use of celecoxib as a prophylaxis for HO. These conclusions must be interpreted in light of the limitations of the present study. Future investigations are required to establish more definitely the role of celecoxib.Level of Evidence: I, Bayesian network analysis of RCTs.

The effect of celecoxib in traumatic heterotopic ossification around temporomandibular joint in mice

OBJECTIVE

In this study, the role of inflammation in traumatic heterotopic ossification around temporomandibular joint (THO-TMJ), as well as the preventive and treatment effect of celecoxib in THO-TMJ both in vivo and in vitro were explored.

DESIGN

A surgically-induced THO-TMJ mouse model and a co-culture model of ATDC-5 or MC3T3-E1 and RAW-264.7 cells were used in this study for in vivo and in vitro research.

RESULTS

A series of inflammatory factors, such as CD3, CD68, CD20, IL-10, IL-6 and TNF-α, were activated 48 h after trauma in a THO-TMJ model. Local trauma initiated systemic inflammatory responses as well as T cell- and macrophage-mediated local inflammatory responses around TMJ. In addition, expression of COX-2 was significantly elevated. The findings also showed that local injection of celecoxib could effectively alleviate the inflammatory response around TMJ at the early stage of trauma and inhibit the formation of THO-TMJ in vivo. Meanwhile, celecoxib could inhibit chondrogenic differentiation of ATDC-5 and osteogenic differentiation of MC3T3-E1 under inflammatory condition in vitro. Furthermore, celecoxib could inhibit the expression of Bmpr1b in the injured condylar cartilage at the initiation stage of THO-TMJ, which implied that Bmpr1b expressed by the residual condylar cartilage might be related to the pathogenesis of THO-TMJ.

CONCLUSIONS

Inflammation played a crucial role in the pathogenesis of THO-TMJ, and anti-inflammation might be a possible choice to inhibit THO-TMJ, which provided scientific clues for the mechanisms, pharmacotherapy and molecular intervention of THO-TMJ.

Celecoxib cannot inhibit the progression of initiated traumatic heterotopic ossification

BACKGROUND AND HYPOTHESIS

Heterotopic ossification (HO) is a recognized sequela after trauma and arthroplasty. The purpose of this study was to evaluate the therapeutic effect of celecoxib on HO. We hypothesized that celecoxib may inhibit the progression of initiated HO.

METHODS

We performed a retrospective review of 37 patients who underwent elbow joint surgery between January 2014 and June 2018. Seventeen patients were prescribed orally administered celecoxib (200 mg/dose, twice daily) for 2 months after the diagnosis of HO, whereas the remaining 20 patients were administered celecoxib for 1 month starting immediately after surgery. HO progression was evaluated by plain radiographs. By use of an Achilles tendon puncture-induced HO mouse model, the curative effect of celecoxib was illustrated at different HO progression stages. The mice were assigned to 1 of 4 groups: sham group, vehicle group, group receiving celecoxib on day 1, and group receiving celecoxib in week 6. Achilles tendons were analyzed by micro-computed tomography and histochemistry after 12 weeks.

RESULTS

Celecoxib did not inhibit the progression of initiated HO in the patients in whom HO was diagnosed, whereas those who received celecoxib after surgery had lower morbidity. Achilles tendon puncture effectively induced typical HO in mice. The ectopic bone volume was significantly reduced in the day 1 celecoxib group compared with the vehicle group; however, the difference was not statistically significant in the week 6 celecoxib group.

CONCLUSIONS

Administration of celecoxib starting immediately after surgery can significantly inhibit the formation of HO. Once HO is visible on plain radiographs or micro-computed tomography, celecoxib cannot effectively attenuate further progression of HO in humans and mice.

Long-term follow-up outcomes for patients undergoing primary total hip arthroplasty with uncemented versus cemented femoral components: a retrospective observational study with a 5-year minimum follow-up

BACKGROUND

This retrospective analysis compared the long-term outcomes for patients with a femoral neck fracture (AO/OTA type 31B) treated with a primary unilateral total hip arthroplasty with uncemented or cemented femoral components (UTHA or CTHA, respectively).

METHODS

We conducted a retrospective cohort study using the South China Hip Arthroplasty Database. We identified 422 patients with femoral neck fracture (AO/OTA type 31B) who were previously treated with primary unilateral UTHA or CTHA between 2007 and 2015, with follow-up until 2019. Follow-up occurred 1, 3, 6 and 12 months postoperatively and yearly thereafter. The primary outcome was the Harris hip score (HHS). The secondary outcome was the orthopaedic complication rate.

RESULTS

In total, 324 patients (UTHA n = 160, mean age 68.61 ± 7.49 years; CTHA n = 164, mean age 68.75 ± 7.04 years) were evaluated for study eligibility. The median follow-up was 73.3 months (range, 11.6-89.2 months). At the final follow-up, HHS was 74.09 ± 6.23 vs 79.01 ± 10.21 (UTHA vs CTHA, p = 0.012). Significant differences were detected in the incidence of prosthetic revision, loosening, and periprosthetic fracture between the UTHA and CTHA groups (7.5% for UTHA vs 1.8% for CTHA, p = 0.015; 17.5% for UTHA vs 8.5% for CTHA, p = 0.016; 11.9% for UTHA vs 4.9% for CTHA, p = 0.021, respectively).

CONCLUSION

In this setting, CTHA demonstrated superiority to UTHA by improving functional outcomes and decreasing complication rates.

Heterotopic Ossification: A Challenging Complication of Total Hip Arthroplasty: Risk Factors, Diagnosis, Prophylaxis, and Treatment

Background

This review is intended to summarize the risk factors, classification, diagnosis, and treatment of heterotopic ossification (HO) of previously published studies.

Results

Heterotopic ossification is a common complication of total hip arthroplasty. Its prevalence is not the same in all of the patient groups. Frequency of HO varies from 15 to 90%. Hip ankylosis, male gender, and previous history of HO are said to be risk factors with a significant level. Diagnosis is based on a single AP radiograph: the Brooker classification that divides HO into four grades is the most commonly used. The confirmation test that can be used is a bone scan. A great amount of bone metabolic turnover markers have been tested, but none of them seems to be relevant in case of prevention or diagnosis of HO. The most effective prophylactic treatment is radiotherapy or administration of nonsteroidal anti-inflammatory drugs. Over the years a lot of different RT protocols have been tested. Nowadays the most often used regimen is 7 Gy given postoperatively in a single dose. The most commonly prescribed drug in prophylaxis of HO is indomethacin. Also, the efficacy of ibuprofen and diclofenac was proven. Recently researchers focused on selective COX-2 inhibitors. They appear to be as effective as nonselective NSAIDs having less side effects. The one and only treatment of HO is a revision arthroplasty.

Optimal strategies for the prevention of heterotopic ossification after total hip arthroplasty: A network meta-analysis

BACKGROUND

Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), selective NSAIDs, and radiation are widely used for the prevention of heterotopic ossification (HO) after total hip arthroplasty (THA). Previous studies have suggested that nonselective NSAIDs, selective NSAIDs and radiation can prevent HO after THA, though the results are conflicting. In this network meta-analysis, we aimed to comprehensively analyze the efficacy and safety of three strategies for preventing HO after THA compared to a placebo.

PATIENTS AND METHODS

Relevant studies about nonselective NSAIDs, selective NSAIDs, radiation and controls that were used to prevent HO after THA were collected. Data were extracted independently by two reviewers. Network meta-analysis was applied to assess treatment efficacy and safety. The surface under the cumulative ranking curve (SUCRA) method was used to assess which treatment was ranked the highest. The node-splitting method was used to calculate inconsistency.

RESULTS

Radiation was found to be the most efficient option for preventing overall incidence of HO and Brooker IV, I, II and III HO after THA. Selective NSAIDs were the safest option, and radiation was ranked second for preventing HO after THA, as the treatments were ranked taking discontinuation caused by nongastrointestinal side effects (DNGSE) and the incidence of complications into consideration.

CONCLUSIONS

A network meta-analysis concluded that radiation is the most efficacious method for preventing HO after THA.

Prophylactic Celecoxib Administration Is Associated With Decreased Incidence and Severity of Heterotopic Ossification After Hip Resurfacing by Direct Lateral Approach in Male Patients

Heterotopic ossification is a potential complication that may have a particularly higher association with hip resurfacing. The 2 current mainstays for heterotopic ossification treatment and prophylaxis are administration of nonsteroidal anti-inflammatory drugs and radiotherapy. Recent studies have determined that celecoxib is effective in heterotopic ossification prophylaxis after total hip arthroplasty. However, considering the reportedly higher incidence and severity of heterotopic ossification in these patients, relatively few studies have evaluated its role in hip resurfacing. Therefore, the authors assessed the incidence, severity, and risk factors of heterotopic ossification in patients who had hip resurfacing and did or did not receive celecoxib. Of the 198 patients, 83 received celecoxib and 115 did not. Radiographs were examined to grade heterotopic ossification using the Brooker classification system. The rate of heterotopic ossification differed between patients who did and patients who did not receive celecoxib prophylaxis (25% vs 65%, P<.001). Celecoxib was an independent predictor of decreased heterotopic ossification (odds ratio, 0.16; 95% confidence interval, 0.08-0.35). Celecoxib administration is associated with decreased incidence and severity of heterotopic ossification after hip resurfacing performed using the direct lateral approach in male patients. [Orthopedics. 2018; 41(6):e807-e812.].

Selective COX-2 inhibitor versus non-selective COX-2 inhibitor for the prevention of heterotopic ossification after total hip arthroplasty: A meta-analysis

BACKGROUND

Whether selective non-steroidal anti-inflammatory drugs (NSAIDs) has equally efficacy with non-selective NSAIDs in preventing heterotopic ossification (HO) after total hip arthroplasty (THA) was controversial. The purpose of this meta-analysis was to assess the efficacy and safety of selective NSAID versus non-selective NSAIDs for the prevention of HO after THA.

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Google Search Engine, and China National Knowledge Infrastructure databases was searched for randomized controlled trials (RCTs) were comparing selective NSAID versus non-selective NSAIDs for preventing HO after THA. The primary outcomes were overall HO incidence, Brooker classification HO incidence, gastrointestinal side effects, the occurrence of excessive bleeding and discontinuation caused by gastrointestinal side effects (DGSE). Data were analyzed using Stata 12.0.

RESULTS

A total of 8 RCTs involving 1636 patients were included in the meta-analysis. There was no significant difference between the nonselective NSAIDs group and the selective NSAIDs group in the overall incidence of HO (relative risk, RR = 0.91, 95% confidence intervals, CI 0.78-1.06, P = .203), Brooker I HO (RR = 1.02, 95% CI 0.85-1.23, P = .794), Brooker II HO (RR = 1.00, 95% CI 0.66-1.52, P = .996). Brooker III HO (RR = 0.98, 95% CI 0.37-2.62, P = .971). And the occurrence of excessive bleeding (RR = 0.67, 95% CI 0.24-1.92, P = .458). The selective NSAIDs group was associated with a significant decrease in gastrointestinal side effects (RR = 0.35, 95% CI 0.18-0.71, P = .004) and discontinuation caused by gastrointestinal side effects compared with the nonselective NSAIDs group (RR = 0.28, 95% CI 0.11-0.66, P = .004).

CONCLUSION

The available evidence indicates selective NSAIDs were as effective as non-selective NSAIDs in preventing HO after THA. And selective NSAIDs were associated with less gastrointestinal side effects than non-selective NSAIDs. Considering the limitation of current meta-analysis, more RCTs need to identify the optimal NSAIDs drug for HO after THA.

Non-steroidal anti-inflammatory drugs for heterotopic ossification prophylaxis after total hip arthroplasty: a systematic review and meta-analysis

Aims

The aim of this study was to assess the efficacy of non-selective and selective non-steroidal anti-inflammatory drugs (NSAIDs) in preventing heterotopic ossification (HO) after total hip arthroplasty (THA).

Methods

A thorough and systematic literature search was conducted and 29 studies were found that met inclusion criteria. Data were extracted and statistical analysis was carried out generating forest plots.

Results

Non-selective NSAIDs showed a significant decrease in the odds for forming HO after THA (odds ratio (OR) -1.35, confidence interval (CI) -1.83 to -0.86) when compared with placebo. Selective NSAIDs also showed a significant decrease in the odds for forming HO after THA when compared with placebo (OR -1.58, CI -2.41 to -0.75). When comparing non-selective NSAIDs with selective NSAIDs, there was no significant change in the odds for forming HO after THA (OR 0.22, CI -0.36 to 0.79).

Conclusion

Our meta-analyses of all available data suggest that both non-selective and selective NSAIDs are effective HO prophylaxis and can be used routinely after THA for pain control as well as prevention of HO. Indomethacin may serve as the benchmark among non-selective NSAIDs and celecoxib among selective NSAIDs. There was no difference in the incidence of HO between non-selective and selective NSAIDs, allowing physicians to choose either based on the clinical scenario and patient-specific factors. Cite this article: Bone Joint J 2018;100-B:915-22.

Heterotopic ossification and the elucidation of pathologic differentiation

Tissue regeneration following acute or persistent inflammation can manifest a spectrum of phenotypes ranging from the adaptive to the pathologic. Heterotopic Ossification (HO), the endochondral formation of bone within soft-tissue structures following severe injury serves as a prominent example of pathologic differentiation; and remains a persistent clinical issue incurring significant patient morbidity and expense to adequately diagnose and treat. The pathogenesis of HO provides an intriguing opportunity to better characterize the cellular and cell-signaling contributors to aberrant differentiation. Indeed, recent work has continued to resolve the unique cellular lineages, and causative pathways responsible for ectopic bone development yielding promising avenues for the development of novel therapeutic strategies shown to be successful in analogous animal models of HO development. This review details advances in the understanding of HO in the context of inciting inflammation, and explains how these advances inform the current standards of diagnosis and treatment.

Incidence of Heterotopic Ossification Following a Multimodal Pain Protocol in Total Hip Arthroplasty With the Posterior Approach

Heterotopic ossification (HO) is prevalent after total hip arthroplasty (THA). Oral nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors have reduced the incidence of HO; however, to the authors' knowledge, no studies have reported the incidence and severity of HO with a pain protocol highlighted by celecoxib in the pre- and postoperative period with a posterolateral approach. Between October 2014 and October 2015, a retrospective study was conducted of 687 consecutive primary THAs with minimum 1-year follow-up performed between January 2009 and December 2013. All patients underwent a posterolateral THA with a multimodal pain protocol consisting of preoperative celecoxib; local steroid infiltration intraoperatively; postoperative celecoxib, dexamethasone, and ketorolac; and aspirin or warfarin thromboprophylaxis. For all patients, pre- and postoperative radiographs were examined and classified for HO using the Brooker classification. Interobserver reliability was calculated for both incidence of HO and Brooker classification. Overall, HO was present around 98 (14.3%) THAs. The incidence of Brooker I, II, and III HO was 38 (5.5%), 47 (6.8%), and 12 (1.7%), respectively. No patients required surgical excision or had radiographic evidence of Brooker IV HO. Multivariate logistic regression identified male sex and hypertrophic osteoarthritis as significant risk factors. The use of aspirin for thromboprophylaxis significantly reduced the incidence of HO. This study found the overall incidence of HO when using celecoxib during a posterior THA to be 14.3%, which is similar to what others have reported with the direct lateral approach and with other COX-2 inhibitors for a posterior approach. Risk factors include male sex and preoperative hypertrophic osteoarthritis. [Orthopedics. 2018; 41(1):e92-e97.].

Strategic Targeting of Multiple BMP Receptors Prevents Trauma-Induced Heterotopic Ossification

Trauma-induced heterotopic ossification (tHO) is a condition of pathologic wound healing, defined by the progressive formation of ectopic bone in soft tissue following severe burns or trauma. Because previous studies have shown that genetic variants of HO, such as fibrodysplasia ossificans progressiva (FOP), are caused by hyperactivating mutations of the type I bone morphogenetic protein receptor (T1-BMPR) ACVR1/ALK2, studies evaluating therapies for HO have been directed primarily toward drugs for this specific receptor. However, patients with tHO do not carry known T1-BMPR mutations. Here we show that, although BMP signaling is required for tHO, no single T1-BMPR (ACVR1/ALK2, BMPR1a/ALK3, or BMPR1b/ALK6) alone is necessary for this disease, suggesting that these receptors have functional redundancy in the setting of tHO. By utilizing two different classes of BMP signaling inhibitors, we developed a translational approach to treatment, integrating treatment choice with existing diagnostic options. Our treatment paradigm balances either immediate therapy with reduced risk for adverse effects (Alk3-Fc) or delayed therapy with improved patient selection but greater risk for adverse effects (LDN-212854).

Leptin accelerates the pathogenesis of heterotopic ossification in rat tendon tissues via mTORC1 signaling

Leptin, an adipocyte-derived cytokine associated with bone metabolism, is believed to play a critical role in the pathogenesis of heterotopic ossification (HO). The effect and underlying action mechanism of leptin were investigated on osteogenic differentiation of tendon-derived stem cells (TDSCs) in vitro and the HO formation in rat tendons. Isolated rat TDSCs were treated with various concentrations of leptin in the presence or absence of mTORC1 signaling specific inhibitor rapamycin in vitro. A rat model with Achilles tenotomy was employed to evaluate the effect of leptin on HO formation together with or without rapamycin treatment. In vitro studies with TDSCs showed that leptin increased the expression of osteogenic biomarkers (alkaline phosphatase, runt-related transcription factor 2, osterix, osteocalcin) and enhanced mineralization of TDSCs via activating the mTORC1 signal pathway (as indicated by phosphorylation of p70 ribosomal S6 kinase 1 and p70 ribosomal S6). However, mTORC1 signaling blockade with rapamycin treatment suppressed leptin-induced osteogenic differentiation and mineralization. In vivo studies showed that leptin promoted HO formation in the Achilles tendon after tenotomy, and rapamycin treatment blocked leptin-induced HO formation. In conclusion, leptin can promote TDSC osteogenic differentiation and heterotopic bone formation via mTORC1 signaling in both vitro and vivo model, which provides a new potential therapeutic target for HO prevention.

The efficacy of celecoxib in preventing heterotopic ossification recurrence after open arthrolysis for post-traumatic elbow stiffness in adults

BACKGROUND

Heterotopic ossification (HO) recurrence after joint surgery is always a disturbing problem for patients and surgeons. Our study was performed to assess the efficacy and safety of celecoxib in preventing the recurrence of HO after open arthrolysis for post-traumatic elbow stiffness.

METHODS

We retrospectively studied 152 patients with stiff elbows caused by post-traumatic HO. After surgery, 77 patients received celecoxib (200 mg once daily) for 28 days, whereas 75 did not. Radiographic evaluation was performed at 3, 6, and 9 months postoperatively. Univariate and multivariate analyses were performed to determine which factors affected HO recurrence.

RESULTS

HO was both more common and more severe in the no-celecoxib group than in the celecoxib group at 3, 6, and 9 months after surgery. A significant difference was observed between the 2 groups in terms of postoperative extension (P = .030), flexion (P = .008), and pronation (P = .005); however, no significant difference in postoperative supination was noted (P = .622). Logistic regression analysis showed that taking celecoxib was the protective factor for HO recurrence, whereas overweight (body mass index > 25) and male gender were the risk factors.

CONCLUSIONS

A short course of celecoxib aids in the prevention of HO recurrence after open arthrolysis for elbow stiffness in adults and could be an effective and safe option.

Heterotopic Ossification: Basic-Science Principles and Clinical Correlates

➤ Heterotopic ossification occurs most commonly after joint arthroplasty, spinal cord injury, traumatic brain injury, blast trauma, elbow and acetabular fractures, and thermal injury.➤ The conversion of progenitor cells to osteogenic precursor cells as a result of cell-mediated interactions with the local tissue environment is affected by oxygen tension, pH, availability of micronutrients, and mechanical stimuli, and leads to heterotopic ossification.➤ Radiation and certain nonsteroidal anti-inflammatory medications are important methods of prophylaxis against heterotopic ossification.➤ Well-planned surgical excision can improve patient outcomes regardless of the joint involved or the initial cause of injury.➤ Future therapeutic strategies are focused on targeted inhibition of local factors and signaling pathways that catalyze ectopic bone formation.

Nonsteroidal Anti-inflammatory Drugs as Prophylaxis for Heterotopic Ossification after Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Heterotopic ossification (HO) is a frequent complication after total hip arthroplasty (THA). Nonsteroidal anti-inflammatory drugs (NSAIDs) have been used as routine prophylaxis for HO after THA. However, the efficacy of NSAIDs on HO, particularly selective NSAIDs versus nonselective NSAIDs, is uncertain.We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov to identify randomized controlled trials with respect to HO after THA. Two reviewers extracted the data and estimated the risk of bias. For the ordered data, we followed the Bayesian framework to calculate the odds ratio (OR) with a 95% credible interval (CrI). For the dichotomous data, the OR and 95% confidence interval (CI) were calculated using Stata version 12.0. The subgroup analyses and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach were used.A total of 1856 articles were identified, and 21 studies (5995 patients) were included. In the NSAIDs versus placebo analysis, NSAIDs could decrease the incidence of HO, according to the Brooker scale (OR = 2.786, 95% CrI 1.879-3.993) and Delee scale (OR = 9.987, 95% CrI 5.592-16.17). In the selective NSAIDs versus nonselective NSAIDs analysis, there was no significant difference (OR = 0.7989, 95% CrI 0.5506-1.125) in the prevention of HO. NSAIDs could increase discontinuation caused by gastrointestinal side effects (DGSE) (OR = 1.28, 95% CI 1.00-1.63, P = 0.046) more than a placebo. Selective NSAIDs could decrease DGSE (OR = 0.48, 95% CI 0.24-0.97, P = 0.042) compared with the nonselective NSAIDs. There was no significant difference with respect to discontinuation caused by non-gastrointestinal side effects (DNGSE) in NSAIDs versus a placebo (OR = 1.16, 95% CI 0.88-1.53, P = 0.297) and in selective NSAIDs versus nonselective NSAIDs (OR = 0.83, 95% CI 0.50-1.37, P = 0.462).NSAIDs might reduce the incidence of HO and increase DGSE in the short-term.

Effect of a selective COX-2 inhibitor, celecoxib, on heterotopic ossification after total hip arthroplasty: a case-controlled study

Heterotopic ossification (HO) is a well-known complication of total hip arthroplasty (THA), especially when the direct lateral approach is used. In this study, we examined the effect of the selective COX-2 inhibitor, celecoxib, on the rates of HO after THA. A control group consisting of 108 patients that did not receive celecoxib was compared with a study group consisting of 106 patients that did receive celecoxib. We assessed the presence and grade of HO using the Brooker classification and Harris hip scores were determined pre- and postoperatively to better quantify clinical outcomes. In this retrospective study of prospectively collected data, celecoxib is associated with a significant reduction in the incidence of HO in patients undergoing THA.

Repercussions of NSAIDS drugs on bone tissue: the osteoblast

Non-steroidal anti-inflammatory drugs (NSAIDs) can act by modulating the behavior of osteoblasts, including their proliferation, differentiation, adhesion, and migration, but not all NSAIDs have these effects. Our objective was to update the information on this issue in a review of the literature in order to offer guidance on the prescription of the appropriate NSAID(s) to patients requiring bone tissue repair. To review current knowledge of this issue by searching for all relevant publications since 2001 in the MEDLINE, EMBASE and Cochrane Library databases, we used the following descriptors: bone tissue, osteoblast, NSAIDs, Anti-inflammatory drugs. Published studies show that most NSAIDs have an adverse effect on osteoblast growth by cell cycle arrest and apoptosis induction. The effect on differentiation varies according to the drug, dose, and treatment time. Osteoblast adhesion is increased and migration decreased by some NSAIDs, such as indomethacin and diclofenac. The antigenic profile or phagocytic function can also be modulated by NSAIDs. In general, NSAIDs have an adverse effect on bone tissue and given the routine administration of NSAIDs to individuals requiring bone repair, in which the osteoblast has an essential role, this effect on bone should be borne in mind.

Celecoxib and heterotopic bone formation after total hip arthroplasty

We assessed the effectiveness of celecoxib in the prevention of heterotopic ossification (HO) following primary total hip replacement (THR). We studied 170 consecutive THRs. Sixty-three patients received celecoxib after surgery (200mg twice/daily) for 28 days and 84 did not. HO was more common in non-celecoxib patients than in the celecoxib-group at 3, 6, and 12 months (P =0.005, 0.004 and 0.01, respectively). At 1 year, fewer celecoxib recipients had Brooker classes II or III. None of the celecoxib patients developed HO Brooker class IV, while 2% in the non-celecoxib group did. No patient discontinued treatment or had revision for aseptic loosening. A short course of celecoxib for pain aids in the prevention of HO after primary THR, and could be a useful and safe option that does not interfere with anticoagulation.

NSAID therapy effects on healing of bone, tendon, and the enthesis

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for the treatment of skeletal injuries. The ability of NSAIDs to reduce pain and inflammation is well-established. However, the effects of NSAID therapy on healing of skeletal injuries is less defined. NSAIDs inhibit cyclooxygenase activity to reduce synthesis of prostaglandins, which are proinflammatory, lipid-signaling molecules. Inhibition of cyclooxygenase activity can impact many physiological processes. The effects of NSAID therapy on healing of bone, tendon, and the tendon-to-bone junction (enthesis) have been studied in animal and cell culture models, but human studies are few. Use of different NSAIDs with different pharmacological properties, differences in dosing regimens, and differences in study models and outcome measures have complicated comparisons between studies. In this review, we summarize the mechanisms by which bone, tendon, and enthesis healing occurs, and describe the effects of NSAID therapy on each of these processes. Determining the impact of NSAID therapy on healing of skeletal tissues will enable clinicians to appropriately manage the patient's condition and improve healing outcomes.

Use of imatinib in the prevention of heterotopic ossification

BACKGROUND

Heterotopic ossification (HO) is a common complication following orthopedic and trauma surgery, which may have substantial negative effects on the postoperative outcome. Angiogenesis appears to play a critical role in heterotopic ossification. One of the involved signaling molecules is platelet-derived growth factor (PDGF) which may be inhibited by imatinib.

QUESTIONS/PURPOSES

Our goal was to prevent HO by pharmacologically interfering with the molecular signaling pathways involved in the developmental process. We hypothesized that by administering a proven inhibitor of PDGF expression, heterotopic bone formation may be prevented.

METHODS

The effect of imatinib on HO formation was studied in a murine model which reliably produces islets of HO within the soft tissue following Achilles tenotomy. The control group underwent Achilles tenotomy only. The imatinib group received imatinib mesylate. After trial completion, the limbs were harvested and scanned by micro-CT. Heterotopic bone volume was then identified and quantified.

RESULTS

The mean volume of heterotopic bone formed in the control group was 0.976mm(3) compared to 0.221 mm(3) in the imatinib group. The volume of HO in the treatment group was reduced by 85% compared to the control group.

CONCLUSIONS

The administration of imatinib was associated with a significantly reduced volume of HO. This may be due to the inhibitory effect of imatinib on the PDGF signaling pathway during development of HO.

CLINICAL RELEVANCE

The successful reduction of HO formation following imatinib administration has led to further insight concerning the pathogenesis of HO which in the future may lead to new clinical approaches towards the prevention of HO.

Could heterotopic ossification be prevented by varying dietary n-3/n-6 polyunsaturated fatty acid ratio: a novel perspective to its treatment?

Heterotopic ossification (HO) is a common complication following with musculoskeletal trauma and surgical procedures. It usually decreases joint mobility and eventually causes loss of joint function. Despite nonsteroidal anti-inflammatory drugs (NSAIDs), the inhibitor of cyclooxygenase(COX), have been proven to prevent HO effectively via prostaglandin E2 synthesis regulation and modulation of tissue responsiveness to pro-inflammatory signaling, HO prevention is still a matter of debate for clinicians to avoid the side effect of NSAIDs. Interestingly, it is suggested that PGE2 production and pro-inflammatory microenvironment in body could be modified by varying the ratio of the precursor fatty acids in the diet. On account of the effect of dietary (n-6)/(n-3) PUFAs ratio on both COX metabolism and pro-inflammatory cytokines mediated biological responsiveness, we hypothesized lowering dietary (n-6)/(n-3) PUFAs ratio may not only directly reduce the substrate of COX-2 and COX-2 activity, but also partially ameliorate tissue inflammatory responsiveness to cytokines correlated with HO development,exerting an inhibitory effect on PGE2 synthesis to prevent HO formation. The negative role of lowering dietary (n-6)/(n-3) PUFAs ratio on angiogenesis, cytokines-induced apoptosis, inflammatory responsiveness and osteogenesis could also contribute to its action on HO development. If our hypothesis is proved to be corrected, it could be an innovative method to treat HO.

Heterotopic ossification of the elbows in a major petrol burn

A case of a young man who developed heterotopic ossification (HO) in his elbows following an accident where he sustained petrol burns to over 60% of his body. His injuries necessitated intubation, escharotomies and a protracted intensive care unit stay that was complicated by septicaemia. Several weeks after the injury, he was diagnosed with HO in his right elbow, followed by the left elbow a week later. He was commenced on an non-steroidal anti-inflammatory drug, a long-term course of a bisphosphonate and regular physiotherapy. He is now waiting for the HO bone to mature before having definitive excision of his lesions in 12-18 months time.

Blast injuries and heterotopic ossification

Heterotopic ossification (HO) is perhaps the single most significant obstacle to independence, functional mobility, and return to duty for combat-injured veterans of Operation Enduring Freedom and Operation Iraqi Freedom. Recent research into the cause(s) of HO has been driven by a markedly higher prevalence seen in these wounded warriors than encountered in previous wars or following civilian trauma. To that end, research in both civilian and military laboratories continues to shed light onto the complex mechanisms behind HO formation, including systemic and wound specific factors, cell lineage, and neurogenic inflammation. Of particular interest, non-invasive in vivo testing using Raman spectroscopy may become a feasible modality for early detection, and a wound-specific model designed to detect the early gene transcript signatures associated with HO is being tested. Through a combined effort, the goals of early detection, risk stratification, and development of novel systemic and local prophylaxis may soon be attainable.

Pharmacological treatment of heterotopic ossification following hip surgery: an update

Heterotopic ossification is a frequent complication following total hip arthroplasty and acetabular surgery. Formation of ectopic lamellar bone in tissues that exhibit no potential for ossification can lead to associated pain and decrease in function. Prophylaxis and treatment protocols aim to reduce the incidence, by both the use of nonsteroidal anti-inflammatory drug (NSAID) regimens and localized radiotherapy. New therapeutic modalities including bone morphogenetic proteins (BMP) inhibitors like Noggin, BMP type 1 receptor inhibition, nuclear retinoic acid receptor-gamma agonists (RAR-γ), and free radical scavengers are currently under investigation.

Adherence to routine use of pharmacological prophylaxis of heterotopic ossification after total hip arthroplasty: results from an Italian multicenter, prospective, observational survey

BACKGROUND

In spite of the proven efficacy of pharmacological prophylaxis of heterotopic ossification following total hip arthroplasty, its routine use is still debated, and no data are available regarding the adherence to its administration in clinical practice.

MATERIALS AND METHODS

In this prospective, observational, multicenter study, 480 consecutive patients operated on for primary total hip arthroplasty during the year 2009 were followed radiographically for 12 months after surgery in order to assess the incidence of periprosthetic heterotopic ossification. Surgeons were free to choose whether to administer pharmacological prophylaxis, and were asked to keep a record of the duration of the prophylaxis (if used) or the reasons for not using it. To facilitate the statistical analysis, all of the participating centers agreed to use only one drug (celecoxib) that had already proven to be effective.

RESULTS

368 patients were administered celecoxib and 112 patients did not receive any prophylaxis. Reported reasons for not administering celecoxib prophylaxis were the surgeon's opinion that prophylaxis was not needed on a routine basis (84/112 patients, 75%), previous history of gastrointestinal bleeding (17.8%), and concomitant cardiorenal pathologies (7.1%). The overall incidence of heterotopic ossification in the celecoxib-treated patients was 23% (no cases of Brooker grade 3 or 4 ossifications), compared to 55% in the untreated patients (Brooker grade 3 and 4: 8.9%). Multivariate analysis showed that celecoxib prophylaxis was the single most important variable when predicting the occurrence of heterotopic ossification.

CONCLUSIONS

This study confirms the efficacy and tolerability of celecoxib for the prophylaxis of heterotopic ossification after total hip arthroplasty, and shows how the surgeon's belief that routine prevention is not required still plays an important role in the determination of this complication, together with the fear of possible unwanted side effects.

Celecoxib inhibits the heterotopic ossification in the rat model with Achilles tenotomy

Celecoxib, a selective cox-2 inhibitor, has been shown to prevent the heterotopic ossification following total hip arthroplasty. However, the effects of celecoxib on heterotopic ossification at other locations remain unclear. This study aimed to investigate the effect of celecoxib on heterotopic ossification in the rat model with Achilles tenotomy. Forty male Sprague-Dawley rats, which were randomly divided into 2 groups (n = 20), underwent midpoint Achilles tenotomy on left legs through a posterior approach under aseptic condition. Experimental group was treated with the saline solution of celecoxib (10 mg/kg) per day, while control group was treated by normal saline (0.9%). At 3, 5 and 10 postoperative weeks, all animals were examined by X-ray to assess new bone formation in the Achilles tendon. At 10 weeks after surgery, all animals were killed and Achilles tendons were taken for hematoxylin-eosin (HE) and immunohistochemical staining. Heterotopic ossification developed in 3 rats (15%) in experimental group and 20 rats (100%) in control group by postoperative 10 weeks. The incidence of heterotopic ossification was significantly lower in experimental group than in control group (P < 0.05). Our findings suggest that celecoxib inhibits HO development in rat model with Achilles tenotomy.

COX-2 inhibitors for the prevention of heterotopic ossification after THA

Nonsteroidal anti-inflammatory drugs (NSAIDs) may prevent heterotopic ossification after total hip arthroplasty (THA). Cyclooxygenase 2 (COX-2) inhibitors may minimize side effects. The goal of this review was to compare the effectiveness and side effects of the perioperative use of selective COX-2 inhibitors with those of conventional NSAIDs in patients undergoing THA. We followed the systematic reviews' updated methods of the Cochrane Collaboration Back Review Group and searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. We identified all randomized controlled trials until April 2009 enrolling THA patients and comparing COX-2 inhibitors to NSAIDs. We assessed their methodological quality and extracted data. Five randomized controlled trials were included. Prevention of heterotopic ossification and side effects with COX-2 inhibitors were significant in 2 studies. Discontinuation for side effects was not significant. COX-2 inhibitors do not prevent heterotopic ossification after THA significantly better than conventional NSAIDs, while they are advantageous regarding side effects.

Total hip replacement in patients with multiple epiphyseal dysplasia with a mean follow-up of 15 years and survival analysis

The hip joint is commonly involved in multiple epiphyseal dysplasia and patients may require total hip replacement before the age of 30 years.

We retrospectively reviewed nine patients (16 hips) from four families. The diagnosis of multiple epiphyseal dysplasia was based on a family history, genetic counselling, clinical features and radiological findings. The mean age at surgery was 32 years (17 to 63), with a mean follow-up of 15.9 years (5.5 to 24).

Of the 16 hips, ten required revision at a mean of 12.5 years (5 to 15) consisting of complete revision of the acetabular component in three hips and isolated exchange of the liner in seven. No femoral component has loosened or required revision during the period of follow-up.

With revision for any reason, the 15-year survival was only 11.4% (95% confidence interval 1.4 to 21.4). However, when considering revision of the acetabular shell in isolation the survival at ten years was 93.7% (95% confidence interval 87.7 to 99.7), reducing to 76.7% (95% confidence interval 87.7 to 98.7) at 15 and 20 years, respectively.

Selective COX-2 inhibitor versus nonselective COX-1 and COX-2 inhibitor in the prevention of heterotopic ossification after total hip arthroplasty: a meta-analysis of randomised trials

Whether selective cyclo-oxygenase-2 (COX-2) inhibitors are equally effective compared to nonselective NSAIDs for the prevention of heterotopic ossification (HO) after total hip arthroplasty (THA) is still unclear. We carried out a comprehensive search strategy, in which only randomised controlled trials were included. Two reviewers independently assessed methodological quality and extracted outcome data. Analyses were performed using Stata version 10.0. Four eligible randomised controlled trials totalling 808 patients were included. Meta-analysis results showed that no statistically significant difference was found in overall incidence of HO (RR 1.08; 95% CI 0.71-1.64), incidence of moderate severe HO (Brooker II and III) (RR 0.83; 95% CI 0.48-1.42) and any grade of Brooker classification between two groups. In summary, the selective COX-2 inhibitors are equally effective as nonselective NSAIDs for the prevention of HO after THA. Considering the gastrointestinal side effects of nonselective NSAIDs, we recommend selective COX-2 inhibitors for the prevention of HO after THA. However, future well-designed, randomised controlled trials are still needed to further confirm our results.

Heterotopic ossification in burns: our experience and literature reviews

PURPOSES

Heterotopic ossification (HO) is an uncommon, but high profile complication of burns. In this paper, a retrospective study was undertaken to evaluate our treatment and results of HO. Relevant literature was also reviewed to search for new advances in prevention and management for patients with HO after burns.

MATERIALS AND METHODS

A retrospective study was undertaken in Chang Gung Memorial Hospital, Linkou. We collected 12 patients who suffered from HO after burn and received operation in our hospital between June 2000 and September 2007. The data was expressed as mean.

RESULTS

Patients' gender distribution was 10 males and 2 females. The mean age was 43 years old (range, 30-59). Causes of burn were flame burn (75%), scald burn (8%), contact burn (8%), and high-voltage electrical burn (8%). Mean TBSA was 39% (range, 8-90%). Nine of 12 patients (75%) were admitted to intensive care unit (ICU) and 6 (50%) received mechanical ventilator support. The mean ICU stay was 82 days (range, 26-240 days). The elbow was the most commonly affected joint (92%). The outcome of surgery was acceptable in all elbows at the time of surgery. The mean ROMs before surgery were 31 degrees (range, 0-75 degrees). The mean ROMs after surgery were 99 degrees (range, 70-115 degrees); mean gain was 68 degrees (range, 35-115 degrees). One (8%) patients had recurrent HO after operation. The mean outpatient department follow-up time was 14.6 months (range, 1-40 months). The incidence of HO in our burn center is 0.15%.

CONCLUSION

Although HO after burn is uncommon, physicians should keep the complication in mind. When burn patients complain decreased ROM or "locking sign" in their joints, X-ray examination is indicated to rule out HO. Surgery is the treatment of choice when the diagnosis of HO is confirmed.

Prophylaxis of heterotopic ossification - an updated review

Heterotopic ossification (HO) is defined as the process by which trabecular bone forms outside of the skeletal structure, occupying space in soft tissue where it does not normally exist. The current popular prophylactic treatment modalities include non-steroidal anti-inflammatory drugs (NSAIDs) and radiation therapy, although the literature remains inconclusive as to which is superior. Additionally, both treatments can lead to adverse effects to the patient. Recently there have been several studies attempting to identify new aspects of the etiology of heterotopic bone formation and introduce new prophylactic modalities with increased efficacy and fewer side effects. For this review, we selectively retrieved articles from Medline published from 1958–2008 on the prophylaxis of HO with the aim of assisting readers in quickly grasping the current status of research and clinical aspects of HO prophylaxis.

Celecoxib does not appear to affect prosthesis fixation in total knee replacement: A randomized study using radiostereometry in 50 patients

BACKGROUND AND PURPOSE

After joint replacement, a repair process starts at the interface between bone and cement. If this process is disturbed, the prosthesis may never become rigidly fixed to the bone, leading to migration-and with time, loosening. Cox-2 inhibitors are widely used as postoperative analgesics, and have adverse effects on bone healing. This could tamper prosthesis fixation. We investigated whether celecoxib, a selective Cox-2 inhibitor, increases prosthesis migration in total knee replacement (TKR).

METHODS

50 patients were randomized to either placebo or celecoxib treatment, 200 mg twice daily, for 3 weeks after TKR (NexGen; Zimmer). Maximum total point motion (MTPM) of the tibial component was measured after 2 years using radiostereometric analysis (RSA). In addition, range of motion, pain, and, subjective outcome were evaluated.

RESULTS

No differences in prosthesis migration, pain scores, range of motion, and subjective outcome were found after 2 years. Confidence intervals were narrow.

INTERPRETATION

It is unlikely that Celecoxib increases the risk of loosening, and it may be used safely in conjunction with TKR.

Aspirin decreases the prevalence and severity of heterotopic ossification after 1-stage bilateral total hip arthroplasty for osteoarthrosis

Heterotopic ossification (HO) is a frequent complication after total hip arthroplasty (THA). We retrospectively evaluated the prevalence and severity of HO in patients with osteoarthrosis who underwent 1-stage bilateral THA (OSBTHA) and compared those who received aspirin with those who received Coumadin for postoperative chemothromboprophylaxis. The aspirin group consisted of 66 patients (132 hips), with a mean age of 64 years (SD, 8.5). The Coumadin group consisted of 67 patients (134 hips), with a mean age of 60 years (SD, 10.2). Overall, HO was detected in 124 hips (46.6%). There were 43 hips (32.5%) with HO in the aspirin group and 81 (60.4%) in the Coumadin group (P < .00005). Aspirin significantly decreases the prevalence and severity of HO in comparison to Coumadin after OSBTHA.