Prophylaxis of heterotopic ossification – an updated review

Abstract

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.

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

“…Following procedures that may be complicated by HO, recommendations indicate that prophylaxis should be given in the form of NSAIDs, such as indomethacin, or aspirin-like drugs that act as non-specific cyclooxygenase inhibitors [70,71]. The duration of treatment is controversial.…”

Treatments and Preventative Measures for Trauma‐Induced Heterotopic Ossification: A Review

“…Although the use of systemic NSAIDs has been shown to reduce inflammation and the risk for HO manifestation and proliferation, they have garnered notoriety for their propensity to impede fracture healing, especially with the use of indomethacin 64, 65, 66, 67. Because indomethacin is a COX2 nonselective inhibitor, it works by inhibiting prostaglandin‐mediated bone remodeling and also by directly inhibiting the differentiation of osteoprogenitor cells 63, 66. Local administration of NSAIDs for the prevention of HO is currently under investigation.…”

“…Preoperatively, RT delivery has shown varied reports of effectiveness 2. Some animal studies suggest that the inhibiting effect on bone healing after the use RT is more pronounced if it is administered closer to the time of the actual injury 63. However, high and frequent doses have the potential to cause cell death and be carcinogenic 63, 69.…”

“…However, high and frequent doses have the potential to cause cell death and be carcinogenic 63, 69. As there may not be enough data to support RT's long‐term effects, especially on young individuals, it may be worth reconsidering it as an option when deciding to use it on patients 63. To date, there is no standard time frame, whether pre‐operatively or postoperatively, that is universally accepted by all surgeons opting to initiate RT 18, 63…”

A Rare Case of Heterotopic Ossification in a Newborn: A Case Report

“…HO was first described by Reidel in 1883, followed by Dejerne and Ceiller who observed HO in soldiers who sustained spinal cord injuries during the First World War 2 . Although the pathophysiology of heterotopic bone formation is not fully understood, the aetiology of HO is divided into neurogenic, genetic and traumatic causes 1,3 . The disorder is very rare in the paediatric population and almost unheard of in the newborn.…”