The Journal of Bone and Joint Surgery (American) 83:1783-1788 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.
Indomethacin Compared with Localized Irradiation for the Prevention of Heterotopic Ossification Following Surgical Treatment of Acetabular Fractures
Timothy A. Burd, MD,
Kent J. Lowry, MD and
Jeffrey O. Anglen, MD
Investigation performed at the Department of Orthopaedic
Surgery, University of Missouri-Columbia Hospital and Clinics, Columbia,
Missouri
Timothy A. Burd, MD
Kent J. Lowry, MD
Jeffrey O. Anglen, MD
Department of Orthopaedic Surgery, University of Missouri-Columbia
Hospital and Clinics, MC213, One Hospital Drive, Columbia, MO 65212.
E-mail address for J.O. Anglen: anglenj{at}health.missouri.edu
The authors did not receive grants or outside funding in support
of their research or preparation of this manuscript. They did not
receive payments or other benefits or a commitment or agreement
to provide such benefits from a commercial entity. No commercial
entity paid or directed, or agreed to pay or direct, any benefits
to any research fund, foundation, educational institution, or other
charitable or nonprofit organization with which the authors are
affiliated or associated.
A commentary is available with the electronic versions of this
article, on our web site (www.jbjs.org) and on our quarterly CD-ROM
(call our subscription department, at 781-449-9780, to order the
CD-ROM).
Background: There is controversy surrounding
the relative effectiveness of local irradiation and oral indomethacin
for prophylaxis against heterotopic ossification following surgical
treatment of acetabular fractures. The purpose of this study was
to compare the efficacy of these two commonly used methods in a
prospective, randomized trial.
Methods: From July 1992 to June 1999, 166 patients
in whom a fracture of the acetabulum was treated surgically through
a posterior, extensile, or combination approach were randomized
to receive either indomethacin or radiation therapy postoperatively.
Seventy-eight patients received 800 cGy of local radiation therapy
within seventy-two hours after surgery, and seventy-two patients received
a six-week course of indomethacin (25 mg three times a day) beginning
within twenty-four hours after surgery. Sixteen additional patients
were randomized but did not receive treatment with either prophylactic
regimen. At an average of fourteen months, the extent of heterotopic
ossification was assessed on plain radiographs with use of the classification
of Brooker et al. The grade of ossification was correlated with
hip motion.
Results: There was no significant difference between
treatment groups with regard to patient age, gender, Glasgow Coma
Scale, operative time, estimated operative blood loss, duration
of follow-up, or presence of closed head injury. The Injury Severity
Score appeared to be the only covariate that was significantly different
between the groups (p = 0.019). Grade-III or IV ossification
developed in eight (11%) of the patients in the indomethacin group
and three (4%) in the radiation therapy group. The difference
was not significant (p = 0.22; 95% confidence
interval, -1.1%, +15.7%). No complications related
to the prophylaxis were noted in either group. Heterotopic ossification
developed in all sixteen patients who did not receive prophylaxis,
with six demonstrating grade-III or IV changes. The overall prevalence
of grade-III or IV heterotopic ossification was 7% (eleven of
150) in the treated groups and 38% (six of sixteen) in the
untreated group.
We did not find any association between the prevalence of heterotopic
ossification and fracture type (p = 0.296) or posterior
hip dislocation (p = 0.306). Grade-I, II, and III heterotopic
ossification did not decrease the range of motion of the hip except
in flexion.
Conclusions: Both local radiation therapy and indomethacin
were found to provide effective prophylaxis against heterotopic
ossification following surgical treatment of acetabular fractures
through a posterior or extensile approach. We detected no significant
difference in efficacy between the two prophylactic regimens.
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