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

Severe heterotopic ossification after total hip arthroplasty in male patients under 70 years of age: effectiveness of prophylactic protocol

BACKGROUND

This study aims to evaluate the incidence of clinically significant heterotopic ossification (HO) in primary total hip arthroplasty (THA), comparing outcomes with and without the adoption of an HO prophylactic protocol in male patients under 70 years of age.

METHODS

The prophylactic protocol involved the administration of 50 mg of Indomethacin twice daily for 3 weeks. HO presence was classified according to the Brooker classification system, considering "severe" clinically significant HO (Brooker grade 3 and 4).

RESULTS

Two hundred and seventy-nine patients were included in our study, and an overall HO rate of 68.2% versus a rate of 61.5% was found respectively in patients not subjected and subjected to prophylactic protocol, without significant difference (PR 0.062). However, patients not subjected to the HO prophylactic protocol exhibited a severe HO rate of 22.4% compared to 7.7% in the prophylactic group, with a statistically significant difference (P = 0.008).

CONCLUSIONS

Our study demonstrated that prophylactic protocol adoption is significantly associated with lower rate of severe HO in male patients under 70 years of age. Currently, there are no orthopedic guidelines for the prevention and management of HO after THA, but in the absence of contraindications, the adoption of a prophylactic protocol for HO should always be considered in high-risk patients.

The role of Bisphosphonates in the prevention and treatment of Heterotopic Ossification following Spinal Cord Injury: A systematic review

Heterotopic ossification (HO) is a frequent complication following spinal cord injury (SCI), yet evidence regarding the efficacy of bisphosphonates in managing this condition remains limited. This systematic review aims to evaluate the role of bisphosphonates in the prevention and treatment of HO in patients with SCI. A comprehensive search of PubMed, CINAHL, ScienceDirect, Cochrane Library, and the Centre for Reviews and Dissemination databases was conducted to identify studies meeting predefined inclusion criteria. Relevant articles were also identified through bibliographic references. A total of 11 studies were included: nine investigating etidronate, one on alendronate, and one on pamidronate. Bisphosphonate administration varied, with oral etidronate provided for a minimum of 12 weeks and intravenous pamidronate given for up to 14 days. Bisphosphonates were used either prophylactically or therapeutically to delay the progression of HO. Findings across all studies highlighted the preventive role of bisphosphonates in reducing the occurrence of HO in SCI patients and demonstrated their therapeutic potential, as evidenced by less extensive heterotopic bone formation. However, the available evidence remains insufficient to draw definitive conclusions about the optimal use of bisphosphonates in this population. Further well-designed clinical trials are required to elucidate their preventive and therapeutic efficacy in managing HO after SCI.

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.

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.

Abdominal wall heterotopic ossification following damage control laparotomy: an unusual bone to pick

BACKGROUND

Heterotopic ossification (HO) refers to the development of extra-skeletal bone in muscle and soft tissues, following tissue insult secondary to surgery or trauma. This pathological process is considered as the result of severe inflammatory cell cascade initiated after local trauma and subsequent attempt at tissue repair involving resident mesenchymal cells. We present a series of 12 cases of abdominal HO (AHO), over 8 years, following damage control laparotomies (DCLs).

METHODS

Medical records of 50 patients who underwent DCLs at Alice Springs Hospital between 2010 and 2018 were retrospectively reviewed for AHO. Demographic data were extracted. Abdominal X-rays and computed tomography scans of 47 patients were reviewed for AHO.

RESULTS

Twelve patients (25%) developed AHO of varying diversity ranging from small insignificant lesions to clinically palpable lesions in the abdominal wall. Data revealed relatively younger male preponderance. DCL for severe acute pancreatitis (SAP) was associated with AHO (P < 0.1, 90% CI). Longer periods of ventilation, intensive care unit stay and admission to hospital were strongly associated with AHO (P < 0.01, 95% CI). Occurrence of AHO with SAP was significantly higher compared to patients without SAP (relative risk 3.54, P < 0.001). Only two patients required surgical excision of HO prior to definitive closure of the abdomen.

CONCLUSION

The authors conclude that AHO occurred more frequently in younger males. DCL for SAP was a significant risk factor. Extended periods of ventilation, intensive care unit stay and hospital admission were strongly associated with the development of AHO. Preoperative detection of HO is essential prior to planning definitive closure of the abdomen.

When the Nervous System Turns Skeletal Muscles into Bones: How to Solve the Conundrum of Neurogenic Heterotopic Ossification

PURPOSE OF REVIEW

Neurogenic heterotopic ossification (NHO) is the abnormal formation of extra-skeletal bones in periarticular muscles after damage to the central nervous system (CNS) such as spinal cord injury (SCI), traumatic brain injury (TBI), stroke, or cerebral anoxia. The purpose of this review is to summarize recent developments in the understanding of NHO pathophysiology and pathogenesis. Recent animal models of NHO and recent findings investigating the communication between CNS injury, tissue inflammation, and upcoming NHO therapeutics are discussed.

RECENT FINDINGS

Animal models of NHO following TBI or SCI have shown that NHO requires the combined effects of a severe CNS injury and soft tissue damage, in particular muscular inflammation and the infiltration of macrophages into damaged muscles plays a key role. In the context of a CNS injury, the inflammatory response to soft tissue damage is exaggerated and persistent with excessive signaling via substance P-, oncostatin M-, and TGF-β1-mediated pathways. This review provides an overview of the known animal models and mechanisms of NHO and current therapeutic interventions for NHO patients. While some of the inflammatory mechanisms leading to NHO are common with other forms of traumatic and genetic heterotopic ossifications (HO), NHOs uniquely involve systemic changes in response to CNS injury. Future research into these CNS-mediated mechanisms is likely to reveal new targetable pathways to prevent NHO development in patients.

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.

Heterotopic Ossification: A Comprehensive Review

Heterotopic ossification (HO) is a diverse pathologic process, defined as the formation of extraskeletal bone in muscle and soft tissues. HO can be conceptualized as a tissue repair process gone awry and is a common complication of trauma and surgery. This comprehensive review seeks to synthesize the clinical, pathoetiologic, and basic biologic features of HO, including nongenetic and genetic forms. First, the clinical features, radiographic appearance, histopathologic diagnosis, and current methods of treatment are discussed. Next, current concepts regarding the mechanistic bases for HO are discussed, including the putative cell types responsible for HO formation, the inflammatory milieu and other prerequisite “niche” factors for HO initiation and propagation, and currently available animal models for the study of HO of this common and potentially devastating condition. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

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.

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).

Heterotopic Ossification and Hypertrophic Scars

Burns and trauma cause superficial and deep soft tissue wounds that cannot heal to the preinjury state. Healing requires cell proliferation and differentiation into the injured tissue type, laying down extracellular matrix, often as collagens. Heterotopic ossification causes severe pain, nonhealing wounds, and restricted range of motion. Treatment includes radiation therapy, nonsteroidal anti-inflammatory drugs, bisphosphonates, and possibly surgical excision and prophylactic measures. Hypertrophic scars, nonosseous lesions caused by excessive collagen deposition, are often painful, functionally limiting, and aesthetically displeasing. Treatment includes CO2 laser application, steroid injections, and excision with skin grafting. This article reviews the management of these pathologic wounds.

Serum biomarkers in patients with ossification of the posterior longitudinal ligament (OPLL): Inflammation in OPLL

BACKGROUD

Ossification of the posterior longitudinal ligament (OPLL) is characterized by replacement of ligamentous tissue by ectopic new bone formation. OPLL causes narrowing of the spinal canal, resulting in neurological impairment. However, the pathogenesis of OPLL has not been fully elucidated. We investigated whether inflammation occurs in OPLL or not using high-sensitivity CRP (hs-CRP) in a case-control study.

METHODS AND FINDINGS

This study included 103 patients with OPLL in the patient group and 95 age- and sex-matched volunteers with degenerative spinal disease in the control group. Of the 103 OPLL patients, 88 patients who were available for more than 2 years follow-up were checked for OPLL progression. A blood sample was obtained and Hs-CRP, and other routine data, including total protein (TP), albumin (ALB), lactate dehydrogenase (LDH), alkaline phosphatase (ALP), glucose (Glu), calcium (Ca), inorganic phosphate (Pi), white blood cell count (WBC), hemoglobin (Hb) and platelet (PLT), were analyzed. The data were compared between the patients with OPLL and the controls. The severity of the ossified lesions in the whole spine were evaluated by the ossification index (OS index) in patients with OPLL. The data were also compared between the patients with OPLL progression (the progression group) and the patients without OPLL progression (the non-progression group). In the results, the mean hs-CRP in the OPLL group was higher than that in the controls. The Pi in the OPLL group was lower than that in the control group. A negative correlation was found between the Pi and the OS index. The mean hs-CRP in the progression group was higher than that in the non-progression group. There was a positive correlation between the average length of the OPLL progression per year and the hs-CRP.

CONCLUSIONS

The results may suggest the occurrence of local inflammation in OPLL and the inflammation might cause OPLL progression. These facts are important for understanding the pathology of OPLL.

Heterotopic Ossification Following Upper Extremity Injury

Heterotopic ossification (HO) presents a substantial barrier to rehabilitation for patients with severe burns or trauma. Although surgical excision is a mainstay of management for this condition, this is unable to address the chronic sequelae of HO, including chronic pain, joint contractures, nerve dysfunction, and open wounds. Current therapeutic modalities are aimed at excision and the prevention of recurrence using nonsteroidal antiinflammatory drugs (NSAIDs) or radiation therapy. Research is now focused on identifying alternative strategies to prevent the initial occurrence of HO through NSAIDs and novel inhibitors of the bone morphogenetic protein signaling pathway.

Celecoxib treatment of fibrous dysplasia (FD) in a human FD cell line and FD-like lesions in mice with protein kinase A (PKA) defects

Osteochondromyxomas (OMX) in the context of Carney complex (CNC) and fibrous dysplasia (FD)-like lesions (FDLL) in mice, as well as isolated myxomas in humans may be caused by inactivation of PRKAR1A, the gene coding for the type 1a regulatory subunit (R1α) of cAMP-dependent protein kinase (PKA). OMXs and FDLL in mice lacking Prkar1a grow from abnormal proliferation of adult bone stromal cells (aBSCs). Prkar1a and Prkaca (coding for Cα) haploinsufficiency leads to COX2 activation and prostaglandin E2 (PGE2) production that, in turn, activates proliferation of aBSCs. Celecoxib is a cyclooxygenase-2 (COX2) inhibitor. We hypothesized that COX-2 inhibition may have an effect in FD and FDLL. In vitro treatment of a human cell line prepared from a FD patient with Celecoxib resulted in decreased PGE2 and cell proliferation. Treatment of mice haploinsufficient for R1α and Cα with 1500 mg/kg Celecoxib led to decreased PGE2 and proliferation and increased apoptosis, with a corresponding gene expression profile, resulting in dramatic reduction of tumor growth. Furthermore, the treatment improved the organization of cortical bone that was adjacent to the tumor. We conclude that, in vitro and in vivo, Celecoxib had an inhibitory effect on FD cell proliferation and in mouse FDLL structure, respectively. We speculate that COX-2 inhibitors offer an attractive alternative to current treatments for benign tumors such as OMX and FD that, apart from tumor suppression, may mechanically stabilize affected bones.

Comparative clinical study of the prophylaxis of heterotopic ossifications after total hip arthroplasty using etoricoxib or diclofenac

PURPOSE

This study investigated whether etoricoxib (COX-II blocker) has a superior efficacy of preventing heterotopic ossification (HO) after total hip arthroplasty (THA) compared to diclofenac (non-selective NSAID).

METHODS

One hundred patients were included (50 in each group) in this single centre, prospective, double-blinded, randomized, controlled trial. Etoricoxib (90 mg) was administered once and diclofenac (75 mg) twice per day for a perioperative period of nine days. The incidence of HO was evaluated on radiographs of the pelvis six months after surgery.

RESULTS

Eighty nine of 100 (89 %) patients could be analysed. The overall HO incidence was 37.8 %. There was no significant difference between both study groups. Twelve patients (27.3 %) of the DIC group and 13 patients (28.9 %) of the ETO group showed Brooker grade I ossifications. Five patients (11.4 %) of the DIC and four patients of the ETO (8.9 %) group showed grade II HO formations. No class III or IV HO formations occured in both groups. Ad hoc analysis detected a negative correlation between HO incidence and limited abduction and internal rotation of the hip.

CONCLUSIONS

Etoricoxib and diclofenac are equally effective for oral HO prophylaxis after primary cementless THA when given for nine peri-operative days to ensure a full recovery and high patient satisfaction.

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.

Heterotopic ossification after hemiarthroplasty of the hip - A comparison of three common approaches

OBJECTIVE

Heterotopic ossification (HO) about the hip after total hip arthroplasty and internal fixation of the hip, pelvis, and acetabulum has been linked to surgical approach. However, no study has investigated surgical approach and HO in patients undergoing hemiarthroplasty. We therefore aimed to explore the influence of operative approach in patients undergoing hemiarthroplasty.

METHODS

Through a retrospective case series at an Urban level I trauma center, we found 80 patients over the age of 60 undergoing hemiarthroplasty for femoral neck fractures from 2000 to 2009. Patient charts, operative notes, and radiographs were reviewed for demographics, operative approach (anterior: A, anterior-lateral: AL, posterior: P), and any development of HO. Fisher's exact test compared rates of HO among the three approaches. Student's t-tests compared Brooker Classification levels of HO among the approaches.

RESULTS

82 hemiarthroplasties (26 A, 32 AL, 24 P) were included for analysis. 22 patients (27%) had HO. There was no significant difference in the development of HO based upon surgical approach: A: 19% (n = 5); AL: 34% (n = 11); P: 25% (n = 6). There was a significant difference in the grade of HO based on Brooker Classification (BC) with the posterior approach resulting in significantly lower grade of HO: A (BC: 2.60); AL (BC: 2.64); P (BC: 1.50) (p = 0.012).

CONCLUSIONS

Our data is the first to evaluate surgical approach and HO in patients with hemiarthroplasty. Patients have a significant risk of developing higher grade HO based on surgical approach (A or AL). Orthopedists should be mindful of these risks when considering A or AL approaches.