Comparing Heterotopic Ossification Prophylaxis Options for Elbow Trauma: A Meta-Analysis
Jeffrey Henstenburg, MD1; Clay Townsend, BS2; Asif Ilyas, MD3
1Thomas Jefferson University, Philadelphia, PA; 2Rothman Institute at Thomas Jefferson University Hopsital, Philadelphia, PA; 3Orthopaedics, Rothman Institute at Thomas Jefferson University, Philadelphia, PA
Introduction
Heterotopic ossification (HO) can be a serious complication following traumatic elbow injury, with rates of elbow HO quoted as high as 10-30%. HO prophylaxis options include non-steroidal anti-inflammatory (NSAID) medications and radiation treatment, however little consensus exists on the most effective option. Even less evidence exists on long term functional outcomes following either prophylaxis method. The purpose of this review is to compare effectiveness and outcomes between NSAID and radiation prophylaxis for elbow HO following a traumatic injury.
Methods
We performed a systematic review of PubMed and Cochrane Library for HO prophylaxis following elbow trauma (Figure 1). HO prophylaxis was primary (prior to development of HO) or secondary (after excision of previously developed HO). Articles were excluded for HO etiology other than elbow fracture or in subjects that received both prophylactic interventions. A total of 36 articles were included in final analysis. Separate analyses were performed for range of motion (ROM) at final follow up in flexion and extension arcs (n = 20) and pronation and supination arcs (n = 10). Mayo Elbow Performance Index (MEPI) means were calculated but not compared due to underreporting in studies. Continuous variables were examined using weighted means and Walds test for p values. Categorical variables were examined via proportions testing.
Results
826 elbows were included in the final analysis. 203 elbows received radiation prophylaxis, and 623 elbows received NSAID prophylaxis (Table 1). The average age was 41.6 in the radiation group and 36.9 in the NSAID group (p = 0.220). 68.5% of the radiation group is male and 64.7% of the NSAID group is male (p = 0.693). Average follow up duration is 20.7 months in the radiation group and 29.4 months in the NSAID group (p = 0.109) 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 NSAID, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs 134.7 degrees NSAID, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAID group at final follow up.
Conclusion
There are no statistical differences in HO development, recurrence, or final ROM when using NSAID or radiation prophylaxis following elbow trauma. We recommend the use of either technique based on patient characteristics and surgeon preference.
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