Heterotopic Ossification Prophylaxis Research Articles

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations.

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF. A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis. A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic. The literature supports the use of radiation therapy for HO prophylaxis, early (< 5days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Limited Field Radiation Therapy for Prophylaxis of Heterotopic Ossification of the Hip

Conventional prophylaxis for heterotopic ossification (HO) of the hip with radiotherapy (RT) includes treatment of the prosthesis, adductor, and abductor compartments. To limit RT effects on neovascularization and healing after surgery, we routinely used a limited-field RT (LF-RT), which only includes the affected compartment guided by pre-operative imaging. This study aims to examine whether LF-RT was as effective in preventing local recurrence as CF-RT.We retrospectively reviewed the charts of 85 consecutive patients who underwent post-operative RT for HO from March 2005 to June 2019. Patients treated to non-hip sites or without radiographic follow-up were excluded. RT fields were reviewed to determine whether they fall under CF-RT defined as inclusion of the prosthesis, adductor, and abductor compartments or LF-RT which was defined as the adductor compartment alone.A total of 48 patients were eligible. Most patients were male (60.4%), with a median age of 65 years (interquartile range (IQR) 60-75 years), and a median follow-up of 23.8 months (IQR 12.6-53.1 months). Most patients received 7 Gray (81.3%), with the most common technique being 2-dimensional RT (70.8 %). Thirty-six patients (75%) received LF-RT to the abductor compartment, whereas twelve patients (25%) received CF-RT. There was no significant difference in local recurrence between LF-RT (0%) and CF-RT (8.3%) (P = 0.4). No ipsilateral re-treatment was required in LF-RT patients compared to one CF-RT patient (8.3 %). The single recurrence in the CF-RT group was retreated with CF-RT. There were no recorded acute or late adverse events related to either field. No patient in either group required non-radiation secondary interventions such as hip injections or surgical revision for HO.Within this limited cohort, LF-RT was similarly efficacious as CF-RT in prophylaxis for HO of the hip with no added toxicity. Future centers that are interested in adopting LF-RT should routinely acquire pre-operative images to aid in the creation of treatment volumes.

Incidence of Heterotopic Ossification with NSAID Prophylaxis Is Low After Open and Arthroscopic Hip Preservation Surgery

PurposeWe evaluate the incidence of heterotopic ossification (HO) development with nonsteroidal anti-inflammatory drug (NSAID) prophylaxis in patients after open and arthroscopic hip preservation surgery.MethodsA retrospective review identified patients who underwent hip preservation surgery at a single institution within the past 3 years. Patients who underwent hip arthroscopy with or without periacetabular osteotomy (PAO) or femoral osteotomy (FO) were included. Those who did not receive 3-month postoperative radiographs were excluded. The incidence and Brooker classification (BC) of HO in patients taking Naproxen or another NSAID (meloxicam, celecoxib, indomethacin, or aspirin alone) was assessed using AP radiographs available from 3-, 6-, and 12-month follow-up appointments. Univariate analysis was conducted to compare numerical means and categorical data (significance level P = .05).ResultsA total of 328 hips (284 patients) were included. All patients received hip arthroscopy, while 71 patients (21.6%) received concurrent periacetabular osteotomy (PAO; n = 65) or femoral osteotomy (FO; n = 6). Overall, 276 hips (84.4%) received Naproxen for HO prophylaxis. In total, 5 of 328 hips (1.5%) developed HO (4, BC I; 1, BC III). The rate of HO development was significantly higher in males versus females (4 of 121 (3.31%) vs 1 of 207 (.48%), P = .0441). All 5 patients received arthroscopic cam resection and labral repair, and 1 patient also received PAO. Three patients in the Naproxen group (.91%) developed HO, which was not statistically different from those taking a different NSAID (.61%, P = .1797).ConclusionThe incidence of HO development was low with NSAID prophylaxis after hip preservation surgery.

Prophylaxis for Heterotopic Ossification Following Distal Biceps Tendon Repair.

Heterotopic ossification (HO) is a possible complication of distal biceps tendon repair (DBTR). Several agents can prevent HO formation, although relatively few studies have investigated prophylaxis specifically after DBTR. The purposes of this study were to survey members of the American Shoulder and Elbow Surgeons (ASES) to determine (1) what percentage use HO prophylaxis after DBTR; (2) type, dosage, and duration of prophylaxis used; and (3) use of single-incision or double-incision surgical technique. An anonymous electronic survey was distributed to ASES members to determine the use of HO prophylaxis and DBTR technique. The survey included questions regarding the number of DBTRs performed annually; preferred surgical technique and implants; and type, dosage, and duration of HO prophylaxis used before, during, and after surgery. Descriptive statistics were used to analyze the results. Of 173 respondents, 98 (56.6%) performed 1 to 10 DBTRs per year, 65 (37.6%) performed 11 to 25 DBTRs per year, and 10 (5.8%) performed 26 to 50 DBTRs per year. A total of 131 (75.7%) preferred the single-incision technique, whereas 42 (24.3%) preferred the double-incision technique. A total of 94 (54.3%) performed DBTR using a metal button and interference screw, 35 (20.2%) through drill holes, 25 (14.5%) with suture anchors, and 19 (11.0%) with a metal button alone. A total of 132 (76.3%) respondents did not use HO prophylaxis, and 41 (23.7%) used nonsteroidal anti-inflammatory drugs following surgery. A total of 35 (85.4%) used indomethacin, 18 (51.4%) of whom preferred 75 mg/d for 3 to 4 weeks. Heterotopic ossification is a commonly reported complication following DBTR, especially with the double-incision technique. Prophylaxis with anti-inflammatory medications and suppressive modalities (radiation therapy) appear to reduce the incidence of HO. Despite these data, most surgeons (76.3%) do not use HO prophylaxis. Low annual volume of cases, lack of large-volume studies with outcome data, and the dominant use of the single-incision repair technique may explain this. [Orthopedics. 2021;44(4):e588-e592.].

Heterotopic Ossification Following Arthroplasty for Femoral Neck Fracture.

Heterotopic ossification (HO) is a frequent complication following hip surgery. Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we aimed to (1) determine the prevalence of HO following total hip arthroplasty (THA) for femoral neck fracture in patients ≥50 years of age, (2) identify whether HO is associated with an increased risk of revision surgery within 24 months after the fracture, and (3) determine the impact of HO on functional outcomes. We performed a multivariable Cox regression analysis using revision surgery as the dependent variable and HO as the independent variable. We compared Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between participants with and those without HO at 24 months. Of 1,441 participants in the study, 287 (19.9%) developed HO within 24 months. HO was not associated with subsequent revision surgery. Grade-III HO was associated with statistically significant and clinically relevant deterioration in the total WOMAC score, which was mainly related to the function component of the score, compared with grade I or II. The impact of grade-III HO on the functional outcomes and quality of life after THA for hip fracture is clinically important, and HO prophylaxis for selected high-risk patients may be appropriate. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of NSAIDs versus radiotherapy for heterotopic ossification prophylaxis following total hip arthroplasty in high-risk patients: a systematic review and meta-analysis

The aims of this systematic review were: (1) to investigate the prophylactic effect of radiotherapy (RT) and NSAIDs in high-risk patients following total hip arthroplasty (THA); and (2) to compare the efficacy of non-selective and COX-II selective NSAIDs in preventing post-THA HO, utilising a meta-analysis of randomised control studies. The PubMed, Embase, and Cochrane Databases were searched for articles regarding HO following THA in March 2019. Studies were included if they contained data regarding HO incidence after THA or contained data regarding HO prophylaxis comparison of NSAIDs and/or RT in terms of dosage or duration. 24 studies reported on populations that were not at high-risk for HO. These studies reported between 47.3% and 90.4% of their patient populations had no HO formation; between 2.8% and 52.7% had mild formation; and between 0.0% and 10.4% had severe formation. A total of 13 studies reported on populations at high-risk for HO. Studies analysing RT in high-risk patients reported between 28.6% and 97.4% of patients developed no HO formation; between 1.9% and 66.7% developed mild HO formation; and between 0.0% and 11.9% developed severe HO formation. Studies analysing NSAID treatment among high-risk populations reported between 76.6% and 88.9% had no HO formation; between 11.1% and 23.4% had mild HO formation, and between 0.0% and 1.8% had severe HO formation. 9 studies were identified as randomised control trials and subsequently used for meta-analysis. The relative risk for COX-II in developing any HO after THA was not significantly different compared to non-selective NSAIDs (RR 1.00; CI, 0.801-1.256; p = 0.489). NSAIDs prophylaxis for HO may have better efficacy than RT in high-risk patients following THA. Non-selective and COX-II selective NSAIDs have comparable efficacy in preventing HO. Factors such as medical comorbidities and side-effect profile should dictate the prophylaxis recommendation.

Primary Prevention of Heterotopic Ossifications After Total Hip Replacement: Electromyotomy Technique

We compared the benefit of modification in surgical technique in relation to primary prophylaxis of heterotopic ossifications after total hip replacement with straight stem. This modification contains the so-called electromyotomy technique and was compared versus standard „cold blade“ technique. Two groups were assessed and matched by BMI, sex, age and arthrosis type undergoing hip replacement. Traumatic, dysplastic and rheumatic hips were excluded. A total of 682 patients were evaluated, 262 cemented, 402 uncemented and 18 hybrid types with minimum of 1 year follow-up (average 5.6 years). The standard “sharp blade” technique contained 313 hips, the alternative contained 369 hips. Surgeries were performed according to the same protocols and by one team via anterolateral approach. Patients with risk factors for heterotopical ossifications and administration of secondary prophylaxis modalities were excluded. The development of heterotopic ossification were assessed with blind control of radiologic specialists (Brooker´s grades). Heterotopic ossification (HO) developed in 32.69%, totally in 223 patients. Of those clinically relevant (Brooker III and IV grades) were 8.94%, in 61 patients. In standard group there were 137 HO in 313 hips (43.76%), clinically relevant in 12.78%, 40 patients. In this group there were 123 cemented hips with 53 HO, 174 uncemented with 74 HO and 16 hybrid prostheses with 10 HO. Average age was 68.53 years, 153 males, 160 females. In alternative electromyotomy group there were 369 hips with 86 HO (23.30%), clinically relevant HO cases developed in 5.69%, 21 patients. HO in particular types: 139 cemented hips with 43 HO, uncemented 228 with 42 HO and hybrid 2 with 1 HO. Average age was 70.56y, males 171, females 198. Statistic values of HO occurence between these groups favourising the electromyotomy group were significant, such as comparing the particular Brooker grades distribution and prosthesis type (cemented, uncemented). Significant decrease was observed mainly in uncemented joint replacements and in clinically relevant grades in electromyotomy group. A novel perspective on primary prophylaxis of heterotopic hip ossification after straight femoral stem total hip replacement with engagement of modification in surgical technique so called electromyotomy is presented. Statistical analysis of results in ossification development significantly favorising modified technique in all types of prosthesis fixation, notably in uncemented prosthesis types. The main drop in counts of clinicaly relevant grades of osifications is also statistically relevant. According to these findings this surgical step is routinely implemented in our technique of straight stem implantations nowadays.

Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures.

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification. (www.actabiomedica.it)

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

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.

Heterotopic Ossification in Polytrauma

Background: Heterotopic ossification (HO) is the pathologic development of ectopic bone in muscle and soft tissue. HO is a known complication that can arise in cases of fracture, surgery, burn injury, and nervous system injury. The co-occurrence of traumatic brain injury (TBI) and fracture increases the risk of HO development by 37-50%. This review aims to examine and synthesize the mechanisms involved in HO development after polytrauma, available animal models to study these mechanisms, and possible treatment options for patients. &#x0D; &#x0D; Project Methods: A literature search was conducted using PubMed and EMBASE with search terms: heterotopic ossification, fracture, and traumatic brain injury. This search produced 33 unique articles. &#x0D; &#x0D; Results: TBI and fracture contribute to HO development by triggering the release of inflammatory cytokines, neuropeptides, and hormones in response to nervous system and bone damage. Bone morphogenetic protein (BMP), vascular endothelial growth factor (VEGF), and Substance P (SP) are among the known contributors to HO formation. Damage to the blood brain barrier and release of nervous system factors may also contribute to the osteogenic environment that promotes ectopic bone development. Rodent modeling of the biologic mechanisms underlying HO can be exploited to better understand the molecular causes of the condition. There are also options for both prophylaxis and treatment of HO. Prophylaxis options include radiation treatment, non-steroidal anti-inflammatory drugs (NSAIDs), and bisphosphonates. Treatment options include physical therapy and surgical resection. &#x0D; &#x0D; Potential Impact: HO has a high occurrence rate in military personnel exposed to combat trauma and can lead to restriction of joint movement, pain, and infections in soft tissue. There are limited options for treatment, pointing to a need for further study.

Diclofenac for prophylaxis of heterotopic ossification after hip arthroplasty: a systematic review.

Heterotopic ossification (HO) is defined as the formation of lamellar bone in extraskeletal soft tissues. HO can be a severe complication after hip arthroplasty but can possibly be prevented by postoperative treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or radiotherapy. Diclofenac is 1 of the most used drugs in HO prophylaxis because it is effective and long established. However, there is still no uniform therapy regimen in terms of duration, dose and side effect profile regarding the application of diclofenac in HO prevention. We have, therefore, conducted the first systematic review investigating diclofenac for HO prophylaxis after hip arthroplasty. The aim of this study is to assess the efficacy, dose and duration of diclofenac therapy in preventing HO after total hip arthroplasty (THA). According to the PRISMA Guidelines we performed a systematic literature search in EMBASE via Ovid, in MEDLINE via PubMed and in the Cochrane Library addressing all studies in English and German regarding the prophylaxis of HO with diclofenac after THA. We identified 731 potential studies and included 6 randomised controlled trials with 957 patients. The studies were heterogeneous with regard to duration of therapy, dose, comparative group and follow-up period. The therapy duration ranged from 9 to 42 days, the applied diclofenac doses ranged from 75 mg to 150 mg daily. Patients treated with diclofenac showed a significant reduction in the total incidence of HO regarding to the Brooker Classification compared to placebo and no clinically relevant ossifications occured (Brooker III and IV). Diclofenac is efficacious in the prevention of HO and can be used routinely after THA. The existing data indicates that a minimum dose of 75 mg diclofenac per day started on the first postoperative day for a minimum of 9 days is needed to prevent HO with an acceptable incidence of side effects, such as gastrointestinal symptoms.

Pharmacologic Prophylaxis for Heterotopic Ossification Following Spinal Cord Injury

Yolcu, Yagiz U MD; Wahood, Waseem; Goyal, Anshit MBBS; Alvi, Mohammed A MD; Reeves, Ronald; Qu, Wenchun; Gerberi, Danielle; Bydon, Mohamad MD Author Information

A 2-Week Course of Naproxen for Heterotopic Ossification Prophylaxis Is Effective Following Hip Arthroscopy for Femoroacetabular Impingement

PurposeTo evaluate the effectiveness of 2 weeks of naproxen prophylaxis for heterotopic ossification (HO) after primary hip arthroscopy for femoroacetabular impingement (FAI).MethodsAll consecutive hip arthroscopy cases by a single surgeon from January 1, 2015, to December 31, 2016, were retrospectively reviewed. Cases were included if they met the following criteria: (1) Primary hip arthroscopy, including femoral neck osteoplasty, for FAI; (2) naproxen prophylaxis for 2 weeks’ duration; and (3) radiographic follow-up at a minimum of 3 months postoperatively. Radiographic imaging for each patient was evaluated for the presence of HO, and independent radiology reports were used to confirm patients with HO. Maximal size of HO was measured and classified according to the Brooker criteria. Demographic and operative variables of the patients included in this study who received naproxen prophylaxis for 2 weeks were formally compared with a cohort of patients who received naproxen prophylaxis for 3 weeks in a previous randomized controlled trial.ResultsA total of 185 patients who received naproxen prophylaxis for 2 weeks were included in the study, 5 of whom developed HO (3%). A total of 48 patients who received naproxen prophylaxis for 3 weeks were included for comparison, 2 of whom developed HO (4%). There was no significant difference in the rate of HO formation between 2 weeks and 3 weeks of naproxen prophylaxis (P = .597). All 7 cases of HO were classified as Brooker class 1.ConclusionsThe observed rate of postoperative heterotopic ossification after 2 weeks of naproxen prophylaxis in this study was equivalent to that observed after 3 weeks’ prophylaxis in a previously published study. Two weeks of naproxen prophylaxis may be a sufficient treatment course for the prevention of heterotopic ossification after primary hip arthroscopy for FAI.Level of EvidenceLevel III – Retrospective Comparative Study.

NSAIDs for Prophylaxis for Heterotopic Ossification After Total Hip Arthroplasty: A Bayesian Network Meta-analysis

Non-steroidal anti-inflammatory drugs (NSAID) have been recommended to prevent of heterotopic ossification (HO) after total hip arthroplasty (THA), but debates are still ongoing. The present Bayesian network meta-analysis of randomized clinical trials (RCTs) compared all available pathways of NSAID treatment as prophylaxis for HO after THA. The present Bayesian network meta-analysis was conducted according to The PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions guidelines. All randomized clinical trials comparing two or more interventions to prevent HO after THA were considered for analysis. HO was classified according to Brooker. The quality of the methodological assessment was performed through the risk of bias summary tool of the Review Manager Software 5.3 (The Cochrane Collaboration, Copenhagen). The network meta-analysis was performed through a STATA routine for Bayesian hierarchical random-effects model analysis, with log odd ratio (LOR) effect measure. Data from 26 studies (6396 THAs; 58% females) were collected. The mean follow-up was 10.50 ± 5.7 months. ANOVA showed good comparability among mean age and gender (P > 0.5). Celecoxib demonstrated the highest rate of Brooker class 0 (LOR 6.96), followed by diclofenac (LOR 6.94). Naproxen demonstrated the lowest rate of Brooker I HO (LOR 2.82), followed by celecoxib (LOR 3.52). Celecoxib demonstrated lowest rate of Brooker class II HO (LOR 1.66), class III (LOR), and class IV (LOR 0.25). The equation for global linearity detected no statistically significant inconsistency (P > 0.5) in all the comparisons. The present Bayesian network meta-analysis encourages the use of celecoxib as a prophylaxis for HO. These conclusions must be interpreted in light of the limitations of the present study. Future investigations are required to establish more definitely the role of celecoxib.Level of Evidence: I, Bayesian network analysis of RCTs.

Abstract PO-034: Prospective planning of radiation treatment at new patient conference during the COVID-19 Pandemic: The University of Mississippi Medical Center experience

Abstract Objective: To evaluate patterns of patient management in an academic Radiation Oncology department between 3/17/20 and 5/8/20 during the COVID-19 pandemic. Background: As a response to the worldwide COVID-19 pandemic, our Radiation Oncology department instituted a number of measures to limit spread of the disease to our patients and staff. This included prospectively evaluating all new referrals for radiation treatment and determining an appropriate course of action, which if appropriate included delaying the start of radiation, hypofractionation, or using other modalities of treatment prior to start of radiation. Methods: We analyzed data for 82 patients between 3/17/20-5/8/20 to evaluate patterns of management. The chi-squared test was used to evaluate the descriptive characteristics of the study population, with P values ≤ 0.05 considered statistically significant. One sample t-test was used to compare the statistical mean difference between sample variables. Data were analyzed using SPSS 24.0 software (IBM, Armonk, NY, USA). Results: The data set comprised 38% Caucasians and 59% African Americans. An age breakdown revealed 12.3% below age 30, 42% between ages 30-60, and 45.7% over age of 60. When the data were analyzed by gender, we noted a significant difference by site of treatment (p=0.005) and whether immediate treatment was required or not (p=0.029). This likely reflects gender-driven differences in cancer site with patients diagnosed with prostate cancer getting LHRH agonist therapy prior to start of radiation. Hypofractionated radiation schedules were used in 2 patients with cord compression early during the study period compared to 3 patients who received standard fractionation later, and one person elected to go straight to hospice care (p=0.002). Of patients for heterotopic ossification prophylaxis, 3/14 declined radiation and one was over the weight limit of the radiation table (p=0.000). 41% of patients were inpatients. No patients developed COVID-19 during our study period. Conclusion: A prospective evaluation of new patient referrals may have helped mitigate the spread of COVID-19 at our Radiation Oncology facility. This is one of several prospective measures that our department took to protect patients and staff. Citation Format: Sanjay Joseph, Mary Nittala, Paul Roberts, Maurice King, Hiba Ahmed, Ashley Albert, Toms Thomas, Robert Allbright, Satyaseelan Packianathan, Eswarkumar Mundra, Srinivasan Vijayakumar. Prospective planning of radiation treatment at new patient conference during the COVID-19 Pandemic: The University of Mississippi Medical Center experience [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-034.

Do Indomethacin or Radiation for Heterotopic Ossification Prophylaxis Increase the Rates of Infection or Wound Complications After Acetabular Fracture Surgery?

To compare the rates of infection and wound complications in patients undergoing operative fixation (ORIF) of acetabular fractures receiving heterotopic ossification (HO) prophylaxis using indomethacin or external beam radiation therapy (XRT) versus no prophylaxis. Retrospective cohort. Level I trauma center. We reviewed 473 patients undergoing ORIF of acetabular fractures through posterior, combined, or extensile surgical approaches from 2012 to 2017, with a median follow-up of 13 months (0.5-77 months). Rates of infection and wound complications were stratified according to their HO prophylaxis method into three groups as indomethacin, XRT, and no prophylaxis. Overall, 167 patients (35.3%) received indomethacin, 104 patients (22.0%) received postoperative XRT, and 202 patients (42.7%) received no prophylactic treatment. There was no difference between the 3 groups for the risk of surgical site infection (P = 0.280). The XRT group had a significantly increased risk of noninfectious wound complications (20.2%) compared with the indomethacin group (6.6%, P = 0.002) and the no prophylaxis group (5.0%, P < 0.0001). Multivariate analysis revealed XRT remained a significant risk factor for noninfectious wound complications compared with no prophylaxis (odds ratio 5.39; 95% confidence interval 2.37-12.22; P < 0.0001). Although there is no difference between XRT, indomethacin, and no HO prophylaxis for the risk of surgical site infection, the use of XRT results in more than 5 times increased risk of noninfectious wound complications compared with no prophylaxis. This increased risk should be considered when contemplating XRT for HO prophylaxis in acetabular fracture patients. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Thrombin Hemostatic Matrix Reduces Heterotopic Ossification in Acetabular Fractures Fixed Through the Kocher-Langenbeck Approach.

To determine whether an injectable thrombin product [thrombin hemostatic matrix (THM)] at closure of a Kocher-Langenbeck approach reduces the risk of heterotopic ossification (HO) formation after an acetabular fracture. Case control. Two Level 1 trauma centers. Patients with operatively treated acetabulum fractures fixed through Kocher-Langenbeck from 2013 to 2018. Records were reviewed for demographics, history of traumatic brain injury, HO medication or radiation prophylaxis, THM (Surgiflo, Ethicon, Bridgewater New Jersey) administration, and length of follow-up. Radiographs were reviewed for dislocation, fracture, Letournel and Orthopaedic Trauma Association classifications, HO, and Brooker grade if applicable. Patients receiving HO prophylaxis (eg, nonsteroidal anti-inflammatory drugs and radiation) were excluded. Remaining patients were divided into 2 groups: THM administration (intervention) and no THM. Continuous variables were compared using t-tests and categorical variables with chi-square or Fisher's exact tests. Risk ratios for the association between HO occurrence and THM administration. Three-hundred and twenty-eight acetabular fractures met inclusion criteria (126 intervention, 202 control) in patients with a mean age of 38.7 ± 15.9 years; 62.2% were male, and 42.1% were African American. Traumatic brain injury and posterior dislocation rates were equivalent between groups (P = 0.505, 0.754, respectively). HO rate in the control group was 42.6% compared with 21.4% in the THM group (P < 0.001). Booker grade 3/4 in control group was 17.3% versus 3.2% in the THM group (P < 0.001). Patients receiving THM had a 50% reduced risk of HO (95% confidence interval 0.35-0.73) compared to those who did not; adjustment for age, gender, ethnicity, and traumatic brain injury did not meaningfully change the association (risk ratio 0.46; 95% confidence interval 0.29-0.73; P < 0.001). The use of a surgiflo product at closure of a KO approach may reduce the risk of HO formation by 50% after an acetabular fracture. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Heterotopic Ossification After Spinal Cord Injury: Current Clinical Approaches

Heterotopic ossification (HO) is a frequent complication after spinal cord injury (SCI). This review article critically analyzes the scientific literature of HO after SCI and offers expert opinion on how past research translates to clinical practice. Triple-phase bone scintigraphy has been the gold standard for diagnosing HO; however, recent research suggests diagnostic ultrasound may be more convenient, cost-effective, and safe. Currently, routine pharmaceutical prophylaxis for HO after SCI is not recommended. Range of motion exercises are advised to prevent and treat HO. Etidronate was approved for HO treatment, but it is no longer available in the USA. Evidence to support the use of alternate bisphosphonates is lacking. Surgical resection is reserved for select cases where the primary goal is improving function. HO is a common complication after SCI, and continued research is needed to improve diagnosis, prevention, and treatment.

Trochanteric-sparing Proximal Femoral Resection for Arthritic Spastic Hips

Progressive hip subluxation or dislocation leading to degenerative disease, in neuromuscular disease, is a significant cause of morbidity to the patient and burden to the caretaker. Surgical salvage procedures have unpredictable success. We hypothesized that modifying the Castle-type proximal femoral resection by securing a retained greater trochanter with its musculature to the capsular arthroplasty and femoral shaft would compartmentalize the femur to decrease proximal femoral migration and heterotopic ossification (HO), thereby precluding the need for traction and HO prophylaxis while improving pain and caretaker satisfaction. The purpose of this report is to describe the novel trochanteric-sparing proximal femoral resection (TS-PFR) technique. Seventeen hips in 13 patients were treated by the TS-PFR procedure. Twelve of 13 patients experienced complete pain relief, and all had improved sitting tolerance and perineal care. These results represent an improvement from prior salvage operations, without increase in blood loss, length of stay, proximal femoral migration, or HO. One patient underwent revision for failed soft tissue envelope. A retrospective review of patients treated at 2 institutions identified those who underwent TS-PFR for arthritic spastic hip. Perioperative course, radiologic evaluation for migration and HO, and caretaker satisfaction were compared with prior published surgical techniques. The TS-PFR technique is a safe alternative to previously described spastic hip salvage procedures and may improve upon them by creating a compartment for the proximal femur that precludes the need for traction and decreases HO. The technique improves patients’ pain, sitting tolerance, perineal hygiene, and caretaker satisfaction.

Acetabular revision arthroplasty with anovel cementless augment-and-modular-cage system (MRS-C) : Surgical technique and preliminary clinical results

Optimal reconstruction of acetabular anatomy and primarily stable bridging even of large bone defects in hip revision surgery by intraoperative cementless application of highly modular components of the MRS-TITAN Comfort (MRS-C) system according to the augment-and-modular-cage principle. Acetabular defect situations in hip revision surgery, hereditary/acquired acetabular deformities, severe secondary hip osteoarthritis. Extended periacetabular defects of the dorsal pillar, pelvic discontinuities, persisting posttraumatic or periprosthetic infections, lack of intraoperative bony anchorage options. Conventional positioning. Flexible selection of approach (posterolateral, anterolateral or transgluteal) to the hip joint, if possible using aprevious approach. Implant removal, preparation and intraoperative acetabular defect evaluation. Optional impaction bone grafting for biological downsizing. Selection of modular components and augments depending on the defect. Preparation of the obturator foramen for anchorage of the caudal flange. Optional preparation of the os ilium for additional fixation of the cage with flanges. Fixation with polyaxial screws and selection of version/inclination of the cup component. Selection of the inlay (polyethylene/ceramic). Partial weight-bearing with 20 kg body-weight for 6weeks with crutches. Prophylaxis for deep vein thrombosis and heterotopic ossification. Additional adapted antibiotic therapy in cases of infection. Aminimum 1‑year follow-up of 42patients showed significant improvements of Harris Hip Scores (p < 0.0001), adequate reconstruction of the physiologic center of rotation (x-ray controlled in the vertical plane, referenced to the contralateral side), and aclear reduction of preoperative leg length discrepancies. No significant changes in range of motion. No implant-associated complications noted. Based on the short follow-up results, the implant proves as suitable for reconstruction of even large acetabular bone defects.