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Postoperative NSAID Prophylaxis for Elbow Heterotopic Ossification: A Systematic Review and Meta-Analysis Comparing COX-2 Selective vs. Non-Selective Inhibitors
Areeb Ahmad, B.S.
1,2, Khorram Roya, MD
1, Kassem Ghayyad, MD
1, Vraj Amin, BS
2, Amir R Kachooei, MD PhD
1, G. Russell Huffman, MD
1, Daryl C. Osbahr, MD
1; Luke Oh, MD
1(1)Rothman Orthopaedics Florida at AdventHealth, Orlando, FL, (2)University of Central Florida College of Medicine, Orlando, FL
Introduction: Heterotopic ossification (HO) is a significant complication causing pain, stiffness, and functional impairment following traumatic elbow surgery. While Nonsteroidal anti-inflammatory drugs (NSAIDs) have been extensively investigated for HO prophylaxis, their effectiveness in preventing postoperative HO in the elbow remains unclear. This study aims to compare the efficacy of selective versus non-selective COX-2 inhibitor non-steroidal NSAIDS in reducing postoperative HO rates after traumatic elbow surgeries.
Methods: This systematic review and meta-analysis were conducted following PRISMA guidelines. A comprehensive search was performed in PubMed, Embase, Cochrane Library, and Web of Science from January 2004 to January 10, 2025. Level I-III studies were included if they examined patients who underwent elbow surgery following trauma and compared a specific selective or non-selective COX-2 inhibitor to no pharmacological prophylaxis, with reported postoperative HO formation rates.
Results: A total of 2,429 articles were identified across the four databases. Following full-text review, 1 randomized control trial and 5 retrospective studies were included in the quantitative synthesis. Celecoxib as a selective NSAID showed a more favorable trend in HO risk reduction compared to indomethacin (36% vs. 13%), although neither reached statistical significance. Non-selective (Indomethacin and Ibuprofen) and selective (Celecoxib) NSAID prophylaxis significantly reduced HO incidence compared to controls (
P = 0.007), demonstrating a 27% relative risk reduction.
Conclusion: Both selective (Celecoxib) and non-selective (Indomethacin and Ibuprofen) NSAIDs effectively reduce the risk of HO following elbow trauma surgery. Although we did not reach statistical significance, Celecoxib (selective) showed a greater potential benefit compared to Indomethacin (non-selective). Given their comparable efficacy and more favorable safety profile, selective COX-2 inhibitors may represent a preferable prophylactic option, though future randomized studies are warranted to validate this finding.
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