In Reply to Dr. Azoury et al.

Abstract

We would like to thank Azoury et al. ( 1 Robinson C.G. Polster J.M. Reddy C.A. et al. Postoperative single-fraction radiation for prevention of heterotopic ossification of the elbow. Int J Radiat Oncol Biol Phys. 2010; 77: 1493-1499 Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar ) for their interest in our article. We agree that although intuition would dictate that prevention of de novo heterotopic ossification (HO) after surgery to the elbow should be more successful than prevention of recurrent HO after the excision of established HO, the data reported to date cannot justify such an assumption. Our colleagues interestingly reported that primary prophylaxis resulted in superior radiologic success rates compared with secondary prophylaxis (86% vs. 57%, respectively) ( 2 Nasr E. Nehme R. Ghanem I. et al. [Role of radiotherapy in heterotopic ossification.]. Cancer Radiother. 2009; 13: 42-46 Crossref PubMed Scopus (4) Google Scholar ). However, no descriptive statistics were used to justify such a statement, which no doubt reflects the small numbers of patients that all current studies suffer from (including our own). Furthermore, the study by Azoury et al. included only 5 elbows of the 26 joints treated. Finally, the statement that “the data from studies of the elbow have generally shown that primary prophylaxis is used in cases with a high risk of HO formation” cannot be supported by the report by Heyd et al. ( 3 Heyd R. Buhleier T. Zamboglou N. Radiation therapy for prevention of heterotopic ossification about the elbow. Strahlenther Onkol. 2009; 185: 506-511 Crossref PubMed Scopus (25) Google Scholar ), as suggested by Dr. Azoury, because 15 of the 20 patients in that study had evidence of HO before surgical resection and adjuvant radiotherapy. In fact, the results of our study fall in line quite nicely with those reported by Heyd et al. ( 3 Heyd R. Buhleier T. Zamboglou N. Radiation therapy for prevention of heterotopic ossification about the elbow. Strahlenther Onkol. 2009; 185: 506-511 Crossref PubMed Scopus (25) Google Scholar ); of 20 patients (75% with HO before surgery), only 2 (10%) developed new HO. In our study, of 36 patients (72% with HO before surgery), only 3 (8%) developed new HO. The only study to date analyzing data exclusively from patients without previous HO reported a 27% (3 of 11) rate of failure ( 4 Stein D.A. Patel R. Egol K.A. et al. Prevention of heterotopic ossification at the elbow following trauma using radiation therapy. Bull Hosp Jt Dis. 2003; 61: 151-154 PubMed Google Scholar ). Whether adjuvant radiotherapy to prevent HO about the elbow is best delivered to a potentially large number of patients without previous HO or should be restricted to the smaller number of patients with documented symptomatic HO remains in question. Perhaps a meta-analysis with individual patient data would be helpful, given the limited numbers of patients reported to date. We would happily contribute to such a study. Postoperative Radiation for Prevention of Heterotopic Ossification of the Elbow: Primary or Secondary Prophylaxis? In Regard to Robinson CG et al. (Int J Radiat Oncol Biol Phys 2010;77:1493–1499)International Journal of Radiation Oncology, Biology, PhysicsVol. 79Issue 2PreviewTo the Editor: We read the report by Robinson et al. (1) reporting the experience of the Clevelend Clinic in the prevention of heterotopic ossification (HO) with a lot of interest. One fact worthy of discussion is the value of primary prevention of HO. The data shown have concerned mainly secondary prevention (72% of the patients had evidence of HO before surgery). The data from studies of the elbow have generally shown that secondary prophylaxis is used in cases with a high risk of HO formation (2). Full-Text PDF