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Incidence of Heterotopic Ossification Following a Multimodal Pain Protocol in Total Hip Arthroplasty With the
Insights
Heterotopic ossification (HO) after total hip arthroplasty (THA) occurred in 14.3% of patients. Celecoxib-based pain management and aspirin thromboprophylaxis did not significantly alter HO incidence, but male sex and osteoarthritis were risk factors.
Area of Science:
- Orthopedics
- Arthroplasty Surgery
- Pharmacology
Background:
- Heterotopic ossification (HO) is a common complication following total hip arthroplasty (THA).
- Existing pharmacologic interventions, including nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors, aim to mitigate HO incidence.
- The specific impact of a celecoxib-centric multimodal pain protocol combined with a posterolateral approach on HO rates remains under-investigated.
Purpose of the Study:
- To determine the incidence and severity of HO in patients undergoing primary THA with a posterolateral approach.
- To evaluate the effectiveness of a specific multimodal pain management protocol, including preoperative and postoperative celecoxib, on HO development.
- To identify potential risk factors associated with HO in this patient cohort.
Main Methods:
- Retrospective analysis of 687 primary THA cases performed between January 2009 and December 2013 with a minimum 1-year follow-up.
- All patients received a posterolateral THA and a multimodal pain protocol involving celecoxib, local steroids, dexamethasone, ketorolac, and thromboprophylaxis (aspirin or warfarin).
- Pre- and postoperative radiographs were assessed for HO using the Brooker classification, with interobserver reliability calculated.
Main Results:
- Overall HO incidence was 14.3% (98/687 patients), with Brooker classifications I, II, and III observed in 5.5%, 6.8%, and 1.7% of cases, respectively.
- No cases of Brooker IV HO requiring surgical excision were reported.
- Multivariate logistic regression identified male sex and hypertrophic osteoarthritis as significant risk factors for HO. Aspirin thromboprophylaxis was associated with a reduced HO incidence.
Conclusions:
- The incidence of HO (14.3%) in THA patients managed with a celecoxib-based pain protocol and a posterolateral approach is comparable to findings with other COX-2 inhibitors and surgical approaches.
- Male sex and preoperative hypertrophic osteoarthritis are significant risk factors for HO development after THA.
- While the studied pain protocol did not dramatically alter HO rates, aspirin use for thromboprophylaxis showed a protective effect.
Abstract:
Heterotopic ossification (HO) is prevalent after total hip arthroplasty (THA). Oral nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors have reduced the incidence of HO; however, to the authors' knowledge, no studies have reported the incidence and severity of HO with a pain protocol highlighted by celecoxib in the pre- and postoperative period with a posterolateral approach. Between October 2014 and October 2015, a retrospective study was conducted of 687 consecutive primary THAs with minimum 1-year follow-up performed between January 2009 and December 2013. All patients underwent a posterolateral THA with a multimodal pain protocol consisting of preoperative celecoxib; local steroid infiltration intraoperatively; postoperative celecoxib, dexamethasone, and ketorolac; and aspirin or warfarin thromboprophylaxis. For all patients, pre- and postoperative radiographs were examined and classified for HO using the Brooker classification. Interobserver reliability was calculated for both incidence of HO and Brooker classification. Overall, HO was present around 98 (14.3%) THAs. The incidence of Brooker I, II, and III HO was 38 (5.5%), 47 (6.8%), and 12 (1.7%), respectively. No patients required surgical excision or had radiographic evidence of Brooker IV HO. Multivariate logistic regression identified male sex and hypertrophic osteoarthritis as significant risk factors. The use of aspirin for thromboprophylaxis significantly reduced the incidence of HO. This study found the overall incidence of HO when using celecoxib during a posterior THA to be 14.3%, which is similar to what others have reported with the direct lateral approach and with other COX-2 inhibitors for a posterior approach. Risk factors include male sex and preoperative hypertrophic osteoarthritis. [Orthopedics. 2018; 41(1):e92-e97.].
