Download PDF
J Hand Microsurg 2021; 13(03): 189-195
DOI: 10.1055/s-0040-1721880
Survey or Meta-Analysis

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Jeffrey M. Henstenburg
1   Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
,
Matthew Sherman
1   Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
,
Asif M. Ilyas
1   Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
› Author Affiliations
Subject Editor:
› Further Information
    Permissions and Reprints

Abstract

Introduction Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury.

Materials and Methods We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis.

Results Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up.

Conclusion There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference.

Level of Evidence Level III.

Keywords

elbow - trauma - heterotopic ossification - prophylaxis - radiation therapy - NSAID - review


Publication History

Article published online:
31 December 2020

© 2020. Society of Indian Hand & Microsurgeons. All rights reserved. Thieme Medical and Scientific Publishers Pvt. Ltd., A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India

 

  • References

  • 1 Ilahi OA, Strausser DW, Gabel GT. Post-traumatic heterotopic ossification about the elbow. Orthopedics 1998; 21 (03) 265-268
    CrossrefPubMedGoogle Scholar
  • 2 Hamid N, Ashraf N, Bosse MJ. et al Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study. J Bone Joint Surg Am 2010; 92 (11) 2032-2038
    CrossrefPubMedGoogle Scholar
  • 3 Sun Z, Cui H, Ruan J, Li J, Wang W, Fan C. What range of motion and functional results can be expected after open arthrolysis with hinged external fixation for severe posttraumatic elbow stiffness?. Clin Orthop Relat Res 2019; 477 (10) 2319-2328
    CrossrefPubMedGoogle Scholar
  • 4 Brouwer KM, Lindenhovius ALC, de PB Witte, Jupiter JB, Ring D. Resection of heterotopic ossification of the elbow: a comparison of ankylosis and partial restriction. J Hand Surg Am 2010; 35 (07) 1115-1119
    CrossrefPubMedGoogle Scholar
  • 5 Balboni TA, Gobezie R, Mamon HJ. Heterotopic ossification: pathophysiology, clinical features, and the role of radiotherapy for prophylaxis. Int J Radiat Oncol Biol Phys 2006; 65 (05) 1289-1299
    CrossrefPubMedGoogle Scholar
  • 6 Agarwal S, Loder S, Levi B. Heterotopic ossification following upper extremity injury. Hand Clin 2017; 33 (02) 363-373
    CrossrefPubMedGoogle Scholar
  • 7 Ploumis A, Belbasis L, Ntzani E, Tsekeris P, Xenakis T. Radiotherapy for prevention of heterotopic ossification of the elbow: a systematic review of the literature. J Shoulder Elbow Surg 2013; 22 (11) 1580-1588
    CrossrefPubMedGoogle Scholar
  • 8 Garland DEM. A clinical perspective on common forms of acquired heterotopic ossification. Clin Orthop Relat Res 1991; 263: 13-29
    PubMedGoogle Scholar
  • 9 Baldwin K, Hosalkar HS, Donegan DJ, Rendon N, Ramsey M, Keenan MAE. Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies. J Hand Surg Am 2011; 36 (05) 798-803
    CrossrefPubMedGoogle Scholar
  • 10 Giannicola G, Spinello P, Villani C, Cinotti G. Post-traumatic proximal radioulnar synostosis: results of surgical treatment and review of the literature. J Shoulder Elbow Surg 2020; 29 (02) 329-339
    CrossrefPubMedGoogle Scholar
  • 11 Mishra MV, Austin L, Parvizi J, Ramsey M, Showalter TN. Safety and efficacy of radiation therapy as secondary prophylaxis for heterotopic ossification of non-hip joints. J Med Imaging Radiat Oncol 2011; 55 (03) 333-336
    CrossrefPubMedGoogle Scholar
  • 12 Sonderegger J, Gidwani S, Ross M. Preventing recurrence of radioulnar synostosis with pedicled adipofascial flaps. J Hand Surg Eur Vol 2012; 37 (03) 244-250
    CrossrefPubMedGoogle Scholar
  • 13 Chen S, Yu SY, Yan H. et al The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise. J Shoulder Elbow Surg 2015; 24 (08) 1165-1171
    CrossrefPubMedGoogle Scholar
  • 14 Zhou Y, Cai J-Y, Chen S, Liu S, Wang W, Fan C-Y. Application of distal radius-positioned hinged external fixator in complete open release for severe elbow stiffness. J Shoulder Elbow Surg 2017; 26 (02) e44-e51
    CrossrefPubMedGoogle Scholar
  • 15 Kamrani RS, Ahangar P, Nabian MH. Mehrpour SR, Oryadi Zanjani L. Proximal radial diaphyseal segment resection for posttraumatic proximal radioulnar synostosis: a prospective study of 15 cases. J Shoulder Elbow Surg 2014; 23 (06) 855-860
    CrossrefPubMedGoogle Scholar
  • 16 Zhang C, Zhong B, Luo C-F. Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People’s Hospital. Injury 2014; 45 (06) 942-948
    CrossrefPubMedGoogle Scholar
  • 17 Kayalar M, Özerkan F, Bal E, Toros T, Ademoğlu Y, Ada S. Elbow arthrolysis in severely stiff elbows. Arch Orthop Trauma Surg 2008; 128 (010) 1055-1063
    CrossrefPubMedGoogle Scholar
  • 18 Durakbasa MO, Gumussuyu G, Gungor M, Ermis MN. Distal humeral coronal plane fractures: management, complications and outcome. J Shoulder Elbow Surg 2013; 22 (04) 560-566
    CrossrefPubMedGoogle Scholar
  • 19 Vavken P, Castellani L, Sculco TP. Prophylaxis of heterotopic ossification of the hip: systematic review and meta-analysis. Clin Orthop Relat Res 2009; 467 (012) 3283-3289
    CrossrefPubMedGoogle Scholar
  • 20 Iorio R, Healy WL. Heterotopic ossification after hip and knee arthroplasty: risk factors, prevention, and treatment. J Am Acad Orthop Surg 2002; 10 (06) 409-416
    CrossrefPubMedGoogle Scholar
  • 21 Whelan DB, Dold AP, Trajkovski T, Chahal J. Risk factors for the development of heterotopic ossification after knee dislocation. Clin Orthop Relat Res 2014; 472 (09) 2698-2704
    CrossrefPubMedGoogle Scholar
  • 22 Manegold S, Springer A, Landvoigt K, Tsitsilonis S. Heterotopic ossification after total ankle replacement: The role of prosthesis alignment. Foot Ankle Surg 2017; 23 (02) 122-127
    CrossrefPubMedGoogle Scholar
  • 23 Jung H-G, Lee S-H, Shin M-H, Lee D-O, Eom J-S, Lee J-S. Anterior heterotopic ossification at the talar neck after total ankle arthroplasty. Foot Ankle Int 2016; 37 (07) 703-708
    CrossrefPubMedGoogle Scholar
  • 24 Cullen JP, Pellegrini VD Jr, Miller RJ, Jones JA. Treatment of traumatic radioulnar synostosis by excision and postoperative low-dose irradiation. J Hand Surg Am 1994; 19 (03) 394-401
    CrossrefPubMedGoogle Scholar
  • 25 Robinson CG, Polster JM, Reddy CA. et al Postoperative single-fraction radiation for prevention of heterotopic ossification of the elbow. Int J Radiat Oncol Biol Phys 2010; 77 (05) 1493-1499
    CrossrefPubMedGoogle Scholar
  • 26 Koh KH, Lim TK, Lee HI, Park MJ. Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification. J Shoulder Elbow Surg 2013; 22 (08) 1128-1134
    CrossrefPubMedGoogle Scholar
  • 27 McAuliffe JA, Wolfson AH. Early excision of heterotopic ossification about the elbow followed by radiation therapy. J Bone Joint Surg Am 1997; 79 (05) 749-755
    CrossrefPubMedGoogle Scholar
  • 28 Stein DA, Patel R, Egol KA, Kaplan FT, Tejwani NC, Koval KJ. Prevention of heterotopic ossification at the elbow following trauma using radiation therapy. Bull Hosp Jt Dis 2003; 61 (3-4) 151-154
    PubMedGoogle Scholar
  • 29 Lo TCM, Pfeifer BA, Smiley PM, Gumley GJ. Case report: radiation prevention of heterotopic ossification after bone and joint surgery in sites other than hips. Br J Radiol 1996; 69 823 673-677
    CrossrefPubMedGoogle Scholar
  • 30 Heyd R, Buhleier T, Zamboglou N. Radiation therapy for prevention of heterotopic ossification about the elbow. Strahlenther Onkol 2009; 185 (08) 506-511
    CrossrefPubMedGoogle Scholar
  • 31 Abrams RA, Simmons BP, Brown RA, Botte MJ. Treatment of posttraumatic radioulnar synostosis with excision and low-dose radiation. J Hand Surg Am 1993; 18 (04) 703-707
    CrossrefPubMedGoogle Scholar
  • 32 Yang KH, Park HW, Park SJ, Jung SH. Lateral J-plate fixation in comminuted intercondylar fracture of the humerus. Arch Orthop Trauma Surg 2003; 123 (05) 234-238
    CrossrefPubMedGoogle Scholar
  • 33 Henket M, van PJ Duijn, Doornberg JN, Ring D, Jupiter JB. A comparison of proximal radioulnar synostosis excision after trauma and distal biceps reattachment. J Shoulder Elbow Surg 2007; 16 (05) 626-630
    CrossrefPubMedGoogle Scholar
  • 34 Haglin JM, Kugelman DN, Christiano A, Konda SR, Paksima N, Egol KA. Open surgical elbow contracture release after trauma: results and recommendations. J Shoulder Elbow Surg 2018; 27 (03) 418-426
    CrossrefPubMedGoogle Scholar
  • 35 Poggi MM, Thomas BE, Johnstone PA. Excision and radiotherapy for heterotopic ossification of the elbow. Orthopedics 1999; 22 (011) 1059-1061
    CrossrefPubMedGoogle Scholar
  • 36 Lindenhovius ALC, Linzel DS, Doornberg JN, Ring DC, Jupiter JB. Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion. J Shoulder Elbow Surg 2007; 16 (05) 621-625
    CrossrefPubMedGoogle Scholar
  • 37 Kamineni S, Maritz NG, Morrey BF. Proximal radial resection for posttraumatic radioulnar synostosis: a new technique to improve forearm rotation. J Bone Joint Surg Am 2002; 84 (05) 745-751
    CrossrefPubMedGoogle Scholar
  • 38 Sun Y, Cai J, Li F, Liu S, Ruan H, Fan C. The efficacy of celecoxib in preventing heterotopic ossification recurrence after open arthrolysis for post-traumatic elbow stiffness in adults. J Shoulder Elbow Surg 2015; 24 (011) 1735-1740
    CrossrefPubMedGoogle Scholar
  • 39 Li F, Mao D, Pan X, Zhang X, Mi J, Rui Y. Celecoxib cannot inhibit the progression of initiated traumatic heterotopic ossification. J Shoulder Elbow Surg 2019; 28 (012) 2379-2385
    CrossrefPubMedGoogle Scholar
  • 40 Bimmel R, van Riet RP, Sys J. Heterotopic ossification causing proximal radioulnar synostosis after insertion of a radial head prosthesis. J Hand Surg [Br] 2006; 31 (04) 383-384
    CrossrefPubMedGoogle Scholar
  • 41 Viola RW, Hanel DP. Early “simple” release of posttraumatic elbow contracture associated with heterotopic ossification. J Hand Surg Am 1999; 24 (02) 370-380
    CrossrefPubMedGoogle Scholar
  • 42 Bell SN, Benger D. Management of radioulnar synostosis with mobilization, anconeus interposition, and a forearm rotation assist splint. J Shoulder Elbow Surg 1999; 8 (06) 621-624
    CrossrefPubMedGoogle Scholar
  • 43 He S-K, Yi M, Zhong G, Cen S-Q, Chen J-L, Huang F-G. Appropriate excision time of heterotopic ossification in elbow caused by trauma. Acta Orthop Traumatol Turc 2018; 52 (01) 27-31
    CrossrefPubMedGoogle Scholar
  • 44 Ahmed SI, Burns TC, Landt C, Hayda R. Heterotopic ossification in high-grade open fractures sustained in combat: risk factors and prevalence. J Orthop Trauma 2013; 27 (03) 162-169
    CrossrefPubMedGoogle Scholar
  • 45 Tarallo L, Mugnai R, Rocchi M, Capra F, Catani F. Mason type III radial head fractures treated by anatomic radial head arthroplasty: Is this a safe treatment option?. Orthop Traumatol Surg Res 2017; 103 (02) 183-189
    CrossrefPubMedGoogle Scholar
  • 46 Wang P, Kandemir U, Zhang K. et al Treatment of capitellar and trochlear fractures with posterior comminution: minimum 2-year follow-up. J Shoulder Elbow Surg 2019; 28 (05) 931-938
    CrossrefPubMedGoogle Scholar
  • 47 Sreenivas T, Menon J, Nataraj AR. Heterotopic ossification of the elbow after closed reduction and retrograde intramedullary nailing for radial neck fracture treated by anconeus interposition. Musculoskelet Surg 2013; 97 (03) 267-271
    CrossrefPubMedGoogle Scholar
  • 48 Sandeep KN, Suresh G, Gopisankar B, Abhishek N, Sujiv A. Does excision of heterotopic ossification of the elbow result in satisfactory patient-rated outcomes?. Malays Orthop J 2017; 11 (01) 35-40
    CrossrefPubMedGoogle Scholar
  • 49 Chen H-W, Liu GD, Ou S. et al Operative treatment of terrible triad of the elbow via posterolateral and anteromedial approaches. PLoS One 2015; 10 (04) 0124821
    PubMedGoogle Scholar
  • 50 Rex C, Suresh PM Kumar, Srimannarayana A, Chugh S, Ravichandran M, Harish DN. Analysis of results of surgical treatment of posttraumatic stiff elbow. Indian J Orthop 2008; 42 (02) 192-200
    CrossrefPubMedGoogle Scholar