Personalizing Prophylactic Radiotherapy for Hip Heterotopic Ossification: An AMSTAR-2 Compliant Review of Meta-analyses.

BACKGROUND/AIM: Heterotopic ossification (HO) is a common complication following total hip arthroplasty. Various prophylactic treatments have been proposed, including radiotherapy (RT). This review summarizes the evidence from meta-analyses on the efficacy of RT in preventing hip HO. MATERIALS AND METHODS: A literature search was conducted on PubMed. The quality of the meta-analyses was assessed using the AMSTAR-2 tool. RESULTS: Seven meta-analyses were included. One meta-analysis reported a significant reduction in HO occurrence after RT compared to the control group. Comparing RT and non-steroidal anti-inflammatory drugs, one and two meta-analyses showed significantly greater efficacy of RT in preventing severe HO and better outcomes in patients receiving drugs, respectively. Regarding RT settings, the postoperative and preoperative RT were each supported by one meta-analysis. Furthermore, two meta-analyses showed an advantage of multi-fractionated RT over single fraction RT. The overall confidence rate of the meta-analyses was moderate, low, and critically low in one, three, and three meta-analyses, respectively. CONCLUSION: RT is a confirmed prophylactic intervention for HO. However, the precise optimization of timing, dosage, and fractionation requires elucidation. Future research should focus on the development of predictive models through large-scale data collection and advanced analytics to refine individualized treatment strategies and assess RT comparative effectiveness with drugs.

Fifteen years' experience of radiation therapy for resected advanced heterotopic ossification following motor vehicle accidents: outcome and side effects.

BACKGROUND: Surgical resection is the primary treatment for advanced-stage heterotopic ossification (HO), with a high incidence of local recurrence reaching up to 50%. Postoperative radiotherapy (PORT) and indomethacin are commonly used prophylactic strategies following surgery. The study aims to assess the safety and effectiveness of PORT in advanced-stage HO patients having motor vehicle accidents (MVA). METHODS: Medical records of patients having HO following MVA between 2006 and 2021 were retrospectively reviewed. Thirty-nine patients with advanced disease (35 had hip HO and 4 had elbow HO) were included in the study. RESULTS: Excision of HO with joint preservation was performed for 82% of patients, while 18% had a joint replacement. Seven to 8 Gy radiation was given to all patients within 3 days postoperatively. A ninty seven percent of patients regained partially the movement range. The mean follow-up time was 74 months. Six patients had treatment failure, with only one having a recurrence of HO. The 8-year treatment failure-free rate (8-y TFFR) was 79.3±9%, and the 5-year HO failure-free rate (5y-HOFFR) was 97.2±3%. Acute side effects were experienced in 13% of patients but resolved without any consequences. Despite the relatively long follow-up time, we did not report any absolute infertility or secondary malignancies related to the radiation. The testicular mean calculated dose was 33±44 cGy, and the mean measured dose was 58±40 cGy. Of the 35 patients who received radiation to the pelvis, 26 were married, and all did not experience infertility post-treatment. CONCLUSION: PORT proved an effective and safe treatment for advanced-stage HO disease. The treatment failure is mainly related to surgical difficulties due to advanced disease. Treatment using a 3-dimensional or intensity-modulated radiation therapy is not associated with serious side effects like second malignancy or absolute infertility.

Single-Dose Radiation Therapy Without Additional Surgery as a Treatment for Heterotopic Ossification Developing After Transfemoral Amputation.

ABSTRACT: Heterotopic ossification is the development of mature lamellar bone in soft tissues. Heterotopic ossification can occur in up to 23% of patients after amputation. Heterotopic ossification is often painful, causing significant dysfunction. While radiotherapy is used to prevent heterotopic ossification before formation, there is a dearth of literature on using radiotherapy to treat existing heterotopic ossification. This case report describes the use of late radiotherapy for the management of existing heterotopic ossification that developed after a transfemoral amputation. A 61-yr-old woman with peripheral artery disease of her bilateral lower limbs status post stenting and ultimately left transfemoral amputation was diagnosed with symptomatic heterotopic ossification limiting her function. Another surgery was not felt to be warranted. She was not improving with medical therapy and was prescribed 800 cGy in one fraction. After treatment, she experienced significant relief in her pain, allowing her to resume physical therapy and use of her prosthesis. There are no other published examples of using radiation alone for treatment of heterotopic ossification formation after transfemoral amputation without surgical revision of the bone formation. Our case shows possible utility in single-dose radiation as a treatment to prevent progression of heterotopic ossification, especially when limiting functional progress.

Prophylactic Radiotherapy of Hip Heterotopic Ossification: A Narrative Mini Review.

Evidence on prophylactic radiotherapy (RT) in hip heterotopic ossification (HO) is sparse and conflicting. The aim of this literature review was to collect and summarize the available data on RT efficacy in preventing hip HO. The results of this review show that RT is effective in the prevention of hip HO, albeit with large variability across series. Effective prophylactic RT requires optimal treatment fields and time intervals with surgery. On the contrary, there is no clear evidence on the optimal timing (post-operative versus pre-operative RT). Comparisons between prophylactic RT and use of non-steroidal anti-inflammatory drugs showed conflicting results, although most were in favor of RT. In conclusion, RT is an established prophylactic treatment for hip HO. However, optimal dose, technique and timing remain unclear, as does the usefulness of combining RT with drugs.

Primary Versus Secondary Radiotherapy for Heterotopic Ossification Prevention About the Elbow.

OBJECTIVES: To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred and twenty-nine patients who received prophylactic radiotherapy (XRT) over a 15-year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow-up after XRT. Fifty-four patients were ultimately included. INTERVENTION: All patients were treated with a single dose of 7 Gy. Ninety-eight percentage of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery. MAIN OUTCOMES MEASUREMENTS: The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint. RESULTS: Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT and 11.1% required surgery to resect the heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT and 5.5% required resection surgery. No secondary malignancies were identified. CONCLUSIONS: Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow-up is required to better characterize populations at high risk for development of HO and secondary malignancy. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radiotherapy for the prophylaxis of heterotopic ossification after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trails.

Heterotopic ossification (HO) refers to the formation of lamellar bone in soft tissues and is a significant complication after total hip arthroplasty (THA). Radiotherapy has been proven as an effective prophylaxis especially for those patients with high risk of HO after THA. However the dose, timing, and frequency of radiation have yet to be determined. To compare HO progressions with different radiotherapy strategies and explore an optimal radiation option. We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trails (through December 1, 2019; no language restrictions) collecting patients who accepted prophylaxis radiation for whom HO progression outcomes were reported. Of 87 identified studies, 10 randomized controlled trails including 1203 patients and 1268 hips were taken to this analysis. Compared with the low biologically effective radiation dose group (biologically effective dose [BED] < 20 Gy), the medium biologically effective radiation dose group (20 Gy ≤ BED ≤ 24 Gy) had statistically significant difference on the prophylaxis of HO (p = 0.003). But for overall incidence of HO, there was no statistically significant difference between low BED group and high BED group (BED > 24, p = 0.21). There was statistically significant reduction in the prophylaxis of HO progression with multiple fractions as opposed to single fraction radiotherapy (p = 0.04). Hips with preoperative radiation were no more likely to observe HO progression than those with postoperative radiotherapy (p = 0.43). Radiotherapy with medium dose (20 Gy ≤ BED ≤ 24 Gy) after THA is an effective dose for preventing HO. In the prophylaxis of HO, multiple fractions seem to be more effective than single fraction radiation. Preoperative radiotherapy could prevent HO progression with the same efficacy postoperative.

Effectiveness of radiotherapy to prevent recurrence of heterotopic ossification in patients with spinal cord injury and traumatic head injury: A retrospective case-controlled study.

OBJECTIVE: To evaluate recurrence and early postoperative complications (sepsis) following surgical excision combined with radiotherapy for troublesome hip heterotopic ossification in patients with spinal cord injury and traumatic brain injury. DESIGN: Retrospective case-control study. SETTING: Data relating to patients with spinal cord injury or traumatic brain injury who underwent surgical excision of hip heterotopic ossification were retrieved from the BANKHO database. Case patients underwent excision + radiotherapy and controls underwent excision only. Control patients were matched to case patients according to sex and age (± 4 years). PARTICIPANTS: Data from 19 case patients and 76 controls were analysed. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The primary end-point was recurrence of heterotopic ossification. Secondary end-points were postoperative complications and, more specifically, sepsis that required surgical revision. RESULTS: There was no difference between the odds ratios (OR) for recurrence for each group (OR case group = 0.63, OR spinal cord injury subgroup = 0.45 and OR head injury subgroup = 1.04). The rate of sepsis requiring surgical revision was significantly higher in the case group (p < 0.05). CONCLUSION: Based on the results of this case-control study, we suggest that radiotherapy should not be combined with surgery in patients with troublesome hip heterotopic ossification undergoing excision. Radiotherapy does not appear to prevent recurrence and, moreover, it is associated with an increased risk of postoperative sepsis.

[A survey of Belgian practice for non-malignant diseases]. / Une enquête de l'utilisation en Belgique de la radiothérapie pour des affections bénignes, non-tumorales.

Two prior surveys were carried out in 1995 and 1999 to evaluate the use of radiotherapy in the treatment of non-malignant disease. In 2016, the same questionnaire was used and sent to the 24 centers of the country: 22 responded. A major decrease was observed in the number of patients treated: 360 in 2016 in contrast to 954 in 1999 and 1113 in 1995. The most frequent indications remain the prevention of heterotopic bone formation, keloids or gynecomastia. A new indication was observed: trigeminal nevralgia treated with radiosurgery. Two frequent indications in the past disappeared: the prevention of coronary restenosis and the macular degeneration. A great agreement was observed regarding the possible indications for radiotherapy but also to avoid it for inflammatory pathologies.

Hypofractionated Radiation Therapy for Progressive Heterotopic Ossification: The Relationship between Dose and Efficacy.

PURPOSE: We sought to evaluate treatment outcomes after hypofractionated short-course radiation therapy (RT) for progressive heterotopic ossification (HO). METHODS AND MATERIALS: Nine consecutive patients were treated between January 2016 and December 2018. None had received previous preventive RT. RT was performed to prevent further HO progression with one of the following dose-fractionation regimens: 7 Gy × 2 fractions, 9 Gy × 1 fraction, 6 Gy × 2 fractions, 6 Gy × 3 fractions, 8 Gy × 2 fractions, or 7 Gy × 3 fractions. RESULTS: All patients were male, with a median age of 30 years (range, 16-55). Eight patients presented with grade III Brooker classification. The most commonly involved site was the hip, followed by femur and knee. With a median assessment time of 7.1 (range, 5.1-23.1) months, eight patients achieved decreased HO, with five showing a dramatic (≥50%) reduction. Among the five excellent responders, a 21 Gy with 7 Gy per fraction schedule was used in four patients. HO status was maintained at the final median follow-up of 11.6 months (range, 6.2-36.1), and Brooker's grade was improved in three patients. No significant RT-related toxicity was noted. CONCLUSIONS: The current RT scheme was effective for the management of progressive HO. It is speculated that higher RT doses could result in the superior efficacy of progressive HO.

Is prophylaxis for heterotopic ossification with radiation therapy after THR associated with early loosening or carcinogenesis?

INTRODUCTION: Heterotopic ossification may develop after major hip surgeries, thus preventive strategies including radiation therapy and non steroid anti-inflammatory drugs are commonly employed. There are certain concerns regarding the effects of radiation therapy on implant loosening and carcinogenesis. Our study aims to evaluate whether radiation therapy results in implant loosening or radiation-induced tumours in the long term. PATIENTS AND METHODS: This was a prospective study including 97 high-risk patients for heterotopic ossification who underwent total hip arthroplasty. Patients were divided into 2 groups and received either a combination of radiation therapy and indomethacin (Group A), or indomethacin alone (Group B). Evaluated outcomes included implant loosening or development of radiation-induced tumours during the follow-up period. RESULTS: The follow-up period of the study was 10 years. Group A consisted of 50 patients, while Group B consisted of 47 patients. 3 patients died during the follow-up. There were 2 cases of implant loosening, 1 from each of the 2 groups at 9 and 10 years after surgery respectively; thus, no statistically significant difference regarding implant loosening was found (p < 0.05). During the follow-up period no cases of radiation-induced tumours were identified. CONCLUSION: Our results are consistent with those of other studies supporting the safety of radiation therapy as a preventive strategy for heterotopic ossification following major surgeries in high risk patients. Further studies with even longer follow-up may be required to definitely exclude the possibility of adverse outcomes linked with radiation therapy.

Radiation Therapy for Benign Disease: Arteriovenous Malformations, Desmoid Tumor, Dupuytren Contracture, Graves Ophthalmopathy, Gynecomastia, Heterotopic Ossification, Histiocytosis.

Although the use of ionizing radiation in malignant conditions has been well established, its application in benign conditions has not been fully accepted and has been inadequately recognized by health care providers outside of radiation therapy. Most frequently, radiation therapy in these benign conditions is used along with other treatment modalities, such as surgery, in instances where the condition causes significant disability or could even lead to death. Radiation therapy can be helpful for inflammatory/proliferative disorders. This article discusses the current use of radiation therapy in some of the more common benign conditions.

Outcomes of Preoperative Versus Postoperative Radiation for Heterotopic Ossification Prevention in Children With Neuromuscular Hip Dysplasia Undergoing Proximal Femoral Resection.

BACKGROUND: Few studies exist to inform the extrapolated practice of irradiating children for heterotopic ossification (HO) prevention. We report the incidence of HO formation following prophylactic preoperative compared with postoperative radiation therapy (RT) in children with neuromuscular hip dysplasia (NHD) following proximal femoral resection (PFR). METHODS: A retrospective, 2-institution chart review was performed. Eligibility was limited to patients with at least 1 year of follow-up. Evaluation included radiographic HO grading by a combined severity scale, assessment of synchronous symptoms of pain or decreased range of motion, and stratification by preoperative versus postoperative reception of RT. A control cohort included 4 nonirradiated hips with NHD after PFR. RESULTS: Twenty-five hips in 20 children met eligibility criteria. Eleven hips were irradiated preoperatively and 14 postoperatively. Radiographic evidence of post-RT development of radiographic evidence of heterotopic ossification (rHO) was found in all 25 hips and earlier in patients irradiated preoperatively (median time to rHO was 4.0 vs. 15.7 mo, P=0.03, 95% confidence interval, 0.24-21.5). There was no statistically significant difference in the development of symptomatic HO (P=0.62) between the preoperative (45.5%) and postoperative (35.7%) groups, nor in HO grade (P=0.34). Seven (28%) of the 25 hips (5 preoperative and 2 postoperative) had documentation of rHO-free intervals after surgery, with an average duration of 5.6 months, while the remaining presented with rHO at first follow-up visit. All eligible control hips (100%) developed rHO and symptomatic heterotopic ossification. CONCLUSIONS: Perioperative RT did not prevent the formation of HO in any child with NHD after PFR. Extrapolation of evidence of the efficacy of RT for HO prevention in ambulatory adults after traumatic hip injury to a population of children with central nervous system injury and NHD may be premature. Additional studies are needed to clarify optimal prevention of HO in this population. LEVEL OF EVIDENCE: Level III-therapeutic retrospective comparative study.

Radiation Prophylaxis for Hip Salvage Surgery in Cerebral Palsy: Can We Reduce the Incidence of Heterotopic Ossification?

BACKGROUND: Heterotopic ossification (HO) is a well-recognized complication of proximal femoral resection (PFR) surgery in children with cerebral palsy (CP). Although single-dose radiation prophylaxis (SDRP) has been shown to be effective at lowering the rates of HO following adult total hip arthroplasty; there has been limited study examining the efficacy of SDRP for HO prevention in children with CP undergoing PFR. The purpose of this study was to assess the efficacy of SDRP in children with CP undergoing PFR. METHODS: This retrospective case control series identified all patients from one tertiary children's hospital undergoing PFHR. Patients were dichotomized into (1) SDRP and (2) non-SDRP groups. In SDRP, radiation was delivered preoperatively at a dose of 7.5 Gy utilizing a 6 MV photon beam. The incidence of HO in the SDRP cohort was compared to historic data using binomial testing. The size of HO lesions was compared using Wilcoxon signed-rank test. McCarthy, Brooker, and Anatomic Classifications of HO were compared using repeated measures logistic regression. RESULTS: Twenty-three patients (mean age, 15.5) and 35 hips (17 SDRP, 18 Non-SDRP) were included in the analysis. There were 17 females and 6 males in the cohort with the majority classified as GMFCS V, 21/23 (91%). HO was seen in 6 of the SDRP cohort (6/17, 35%) and 15 of the non-SDRP cohort (15/18, 83%) (P=0.015). The average size of HO at maturity was 282.7 mm in the SDRP cohort compared with 1221.5 mm in the Non-SDRP cohort (P=0.026). Radiation treatment was associated with a 938.9 mm decrease in HO size at maturity (P= 0.026). Multivariate repeated measures logistic regression analysis found that non-SDRP hips had 13 times higher odds of developing HO (P=0.015). There were no significant differences in infection rates between the 2 cohorts and there were no radiation-associated complications. CONCLUSIONS: Short-term follow up demonstrates that SDRP is a safe and efficacious intervention in decreasing the incidence and size of HO in children with CP undergoing PFR. LEVELS OF EVIDENCE: Level III-Case control cohort study.

The effect of late radiotherapy on the progression of heterotopic ossification following total hip arthroplasty.

INTRODUCTION: Heterotopic ossification (HO) is a known complication after total hip arthroplasty (THA). Radiotherapy is an effective prophylactic treatment for high-risk patients. However, there is no treatment for patients who did not receive prophylactic treatment and subsequently develop HO postoperatively. This study was to determine whether late radiotherapy treatment can prevent the progression of HO following THA. METHODS: A chart review was performed to identify patients who developed HO following THA and were treated with late radiotherapy. All these patients received radiotherapy after their 6- or 12-week postoperative follow-up. Patients were evaluated radiographically pre- and 2 years post-radiotherapy using ImageJ software to measure the difference in the area of HO that formed. RESULTS: Nine patients with a mean age of 64.5 years were identified. All patients developed HO within 6- or 12-week postsurgery and received later radiotherapy. Eight of the nine hips (89%) treated with late radiotherapy demonstrated no further progression in the amount of bone formed. Overall, there was an increase in the mean total area of HO by 19 mm2 (2%), (p = 0.12). CONCLUSION: Late, low-dose radiotherapy is effective in preventing the progression of HO in patients who unexpectedly develop significant HO following THA.

Heterotopic ossifications: role of radiotherapy as prophylactic treatment.

BACKGROUND: Heterotopic ossification (HO) is abnormal formation of lamellar bone in soft tissue; the most frequent causes are total hip arthroplasty and trauma. Severe cases can lead to ankilosis with important impact on quality of life. Surgery is the elective treatment, but, especially in high-risk patients, it is important to prevent the re-formation of HO and, in these cases, radiotherapy (RT) can play an important role. MATERIALS AND METHODS: we retrospectively analyzed a mono-institutional casistic of 30 patients (31 sites) at high risk for HO development, treated with surgery and pre- or postoperative RT. The majority of patients received a single RT fraction of 7 Gy, median age was 62, with a prevalence of male and hip as most frequently involved site. Radiological studies and clinical examination were performed in all patients during the follow-up period to evaluate both treatment efficacy and acute or late toxicity. RESULTS: With a median follow up of 67 months, 23 patients had a complete response (CR) with excellent results in term of joint mobility. Two patients with CR showed a relapse of HO in the same site 19 and 12 months after treatment, respectively. Seven patients (22,6%) had a partial response (PR) to RT. One patient who reached CR had a history of previous irradiation in the same site 16 years before. No acute or late reactions have been reported. CONCLUSION: Our data confirm safety and efficacy of RT in preventing HO, especially in high-risk patients, preferring a single fraction of 7 Gy.

Symptomatic palliation with radiotherapy in extensive heterotopic ossifications.

Heterotopic ossification (HTO) is the dystrophic formation of mature lamellar bone outside the confines of normal osseous tissues. It is frequently a complication which occurs following traumatic insult, both iatrogenic and non-iatrogenic, and neurological compromise. While mild degree of disease is often asymptomatic, significant pain and mobility limitations may result in reduced quality of life in advanced cases. Currently, the commonly accepted management for patients experiencing significant symptomatic HTOs is a combination therapy of surgical excision with prophylactic radiotherapy in the immediate perioperative period. In this article, we present a patient who achieved satisfactory pain relief and improvements in overall quality of life with the sole use of external beam radiation to illustrate the possibility of using radiotherapy alone for symptomatic management of HTO.

Testicular Dose During Prophylaxis of Heterotopic Ossification with Radiation Therapy.

AIM: A single-institution, retrospective study was performed to investigate potential techniques to minimize radiation exposure to the testicles during heterotopic ossification (HO) prophylaxis. We report the impact of split-beam technique (SBT) and different photon energies on the total dose of radiation received by the testicles during prophylaxis of HO. MATERIALS AND METHODS: Between 2008 and 2010, we identified 64 patients with traumatic acetabular fractures who underwent surgery followed by radiation therapy (RT) without testicular shielding. Postoperative RT was delivered within 72 h in a single fraction of 700 cGy using 6-18 MV photons, without testicular shielding due to patient refusal. All patients underwent 3-D RT planning in which the testicles were contoured as a region of interest and dose-volume histograms (DVH) were generated. Additional treatment planning trials were created for each patient by utilizing a SBT medially and by using different photon energies (6, 10 and 18 MV) to study the effects of these maneuvers on the delivered dose to the testicles. RESULTS: In reviewing the DVH, it was noted that the mean dose delivered to the testicles was 10 cGy (range=3-40). The maximum dose was 31 cGy (range=7-430). When SBT was utilized, a significant reduction in the mean (44%) and maximum (47%) doses delivered to the testicles was noted. Further reductions in the mean (26%) and maximum (14%) doses were achieved by using higher-energy (10-18 MV) beams. The radiation doses to the testicles from the CT simulation and the two portal images were estimated to be 4 and 1.5 cGy, respectively. CONCLUSION: Low-dose prophylactic RT to prevent HO around the hip causes a low, but likely biologically meaningful, radiation dose to be delivered to the testicles. This dose could be further reduced by using a medial SBT and photon energies above 6 MV. Testicular shielding should be offered to all male patients receiving such RT. In addition, all patients should be informed about the consequences of testicular radiation as part of their informed consent.

In-hospital outcomes following single-dose radiation therapy in the treatment of heterotopic ossification of the hip following spinal cord injury-an analysis of 444 cases.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The objective of the study was to analyse the efficacy of single-dose radiation therapy in the treatment of heterotopic ossification (HO) following spinal cord injury (SCI). SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: Patients who were treated for HO around the hips following SCI at our institution between January 2003 and December 2013 were included in this retrospective cohort study. A total of 444 HO cases around the hip were treated with single-dose radiation therapy after a mean time interval of 4.9 days (0-97 days; s.d.=8.1) after HO diagnosis. Primary outcome measures were the number of HO relapses and the occurrence of adverse side effects related to the radiation therapy. RESULTS: After a mean time interval of 63.2 days (8-295 days; s.d.=39.6) subsequent to SCI HO occurred in 207 male (84.8%) and 37 female (15.2%) patients with a mean age of 46.4 years (18-81 years, s.d.=18.2). In 200 patients both hips were affected, whereas the remaining 44 HO occurred unilateral. None of the patients suffered primary side effects due to the radiation therapy. However, in 13 out of 244 patients (5.3%), HO relapse occurred. After repeated single-dose radiotherapy, one patient suffered joint ankylosis and therefore required surgical resection. CONCLUSION: Our results present that single-dose radiation therapy is a safe option in the treatment for spinal cord-injured patients suffering from HOs of the hips.

[Effect of radiotherapy and indomethacin together in the prevention of recurrence of ectopic ossification around the elbow after resection].

OBJECTIVE: To discuss the effect of single low dose local radiotherapy and indomethacin together in the prevention of recurrence of ectopic ossification around the elbow after resection. METHODS: From Jun. 2009 to Dec. 2011, we performed excision of ectopic ossification around the elbow in 78 stiff elbows. For each case, we used both medial and lateral approaches, and we performed both anterior and posterior capsulectomies and removal of ectopic ossification. In the lateral approach, we started proximally, the lateral supracondylar ridge of the humerus was exposed from the interval between extensor carpi radialis longus (ECRL) and triceps, and then distally passed the interval between ECRL and extensor carpi radialis brevis (ECRB). With the medial approach, after releasing the ulnar nerve, the pronator teres muscle origin was reflected from the medial epicondyle, and then the common flexor-pronator tendon was split longitudinally distally and the brachalis and the anterior portion of the flexor-pronator group were dissected off the anterior humerus. If there was forearm rotation dysfunction, we used extensive lateral approach, the anconeus muscle was reflected from the ulna and the scar tissue and ectopic ossification around the proximal radioulnar joint were resected. The important structures, such as the lateral ulnar collateral ligament (LUCL) and the anterior part of the medial collateral ligament (AMCL), should be carefully protected, because they were important for the elbow stability. Anterior transposition of the ulnar nerve depended on the patients' condition. We performed low dose radiotherapy 4 hours before operation, and we used indomethacin for 6 weeks after operation. In these patients, there were 46 males and 32 females, whose age averaged (35.8±7.9) years (16-65 years). According to Hastings-Graham classification, there were 56 IIA, 5 IIB, 6 IIC and 11 III before operation. RESULTS: We followed up these patients for 26 months with an average of 24-36 months, all the patients improved their elbow function, and no recurrence of ectopic ossification appeared except for 1 patient. For this patient, his elbow function was excellent, and according to Hastings-Graham classification, his ectopic ossification was of type I. CONCLUSION: Single low dose local radiotherapy and indomethacin together are effective in the prevention of recurrence of ectopic ossification around the elbow after excision.