AF Brooker

Alberto Aliprandi

B Neal

C Berndt

CL Romano

CM Larson

EE Berg

Filippo Randelli

HF Riegler

J Charnley

JG Grohs

JM Glick

JW Byrd

Lorenzo Banci

Luca Pierannunzii

MA Ritter

MD Boynton

MJ Pagnani

MJ Philippon

Robert Buly

S Rosendahl

S Sodha

SA Schmidt

TG Sampson

Vincenza Ragone

Journal of Orthopaedics and Traumatology

English

PubMed

Springer - Publisher Connector

Heterotopic ossifications after arthroscopic management of femoroacetabular impingement: the role of NSAID prophylaxis

BRIEF COMMUNICATION
Heterotopic ossifications after arthroscopic management
of femoroacetabular impingement: the role of NSAID prophylaxis
Filippo Randelli • Luca Pierannunzii •
Lorenzo Banci • Vincenza Ragone •
Alberto Aliprandi • Robert Buly
Received: 18 May 2010 / Accepted: 8 November 2010 / Published online: 30 November 2010
 The Author(s) 2010. This article is published with open access at Springerlink.com
Abstract
Background Open hip surgery is known to be a risk for
heterotopic ossification (HO), and nonsteroidal anti-
inflammatory drugs (NSAIDs) have been widely recog-
nized as an effective prevention. Hip arthroscopy is gaining
popularity thanks to the possibility of treating femoroace-
tabular impingement (FAI) with a minimally invasive
technique, however little is known about its rate of post-
operative HO. The aim of the present study is to evaluate
HO prevalence after hip arthroscopy for FAI and its rela-
tionship with NSAID prophylaxis.
Materials and methods We retrospectively reviewed 300
FAI cases who have been managed with hip arthroscopy in
two different hospitals from April 2006 to May 2009. All
medical records and indications at discharge were ana-
lyzed, focusing on administration of NSAIDs, as well as
follow-up roentgenograms with regard to presence of HO
around the hip joint. The patients were divided into two
groups: a treatment group of 285 hips which received
NSAID prophylaxis and a control group of 15 hips which
did not.
Results Five hips presented HO, with overall prevalence
of 1.6%. All five patients with HO belonged to the control
group. No HO was observed in the treatment group. Thus,
HO rate turned out to be significantly higher (P \ 0.001) in
patients who did not receive NSAIDs after surgery.
Conclusion Arthroscopic treatment of FAI is not
exempt from potential development of HO. NSAIDs after
arthroscopic FAI treatment seem to be an effective
prevention.
Keywords Hip arthroscopy  Femoroacetabular
impingement  Heterotopic ossification  NSAIDs
Introduction
Heterotopic ossification (HO) or ectopic bone formation is
the formation of bone in soft tissue where bone normally
does not exist. HO is a well-known complication after open
hip surgery such as total hip replacement, open reduction
and internal fixation of hip and pelvic fractures, and joint-
sparing reconstructive surgery (i.e., surgical dislocation)
[1]. An increasing number of reports have been presented
since the 1970s [2, 3]. In previous reports, prevalence of
ectopic ossification after total hip replacement (THR)
varied widely between 5% [4] and 90% [5].
Nonsteroidal anti-inflammatory drugs (NSAIDs), con-
ventional cyclooxygenase (COX) inhibitors, and, most
recently, selective COX-2 inhibitors (COXIB), have been
shown to be effective in lowering incidence of HO after
total hip replacement [6–9].
However, although much has been reported and
described in literature about ectopic bone formation after
open hip surgery, little is known and documented about this
complication after hip arthroscopy. This procedure has
recently gained popularity thanks to the possibility of
managing femoroacetabular impingement (FAI) [10–13].
F. Randelli  L. Banci (&)  V. Ragone  A. Aliprandi
Policlinico San Donato, P.zza Malan, 2,
20097 San Donato Milanese, Milan, Italy
e-mail: lorenzo.banci@tiscali.it
L. Pierannunzii
Istituto Ortopedico Gaetano Pini, P.zza Cardinal Ferrari,
1, 20122 Milan, Italy
R. Buly
Hospital for Special Surgery, New York, NY, USA
123
J Orthopaed Traumatol (2010) 11:245–250
DOI 10.1007/s10195-010-0121-z
Despite several case reports of HO after arthroscopic
surgeries in different joints [14–17], HO development after
hip arthroscopy has not been deeply investigated so far.
Only one recent study reported HO as one of the possible
complications following hip arthroscopy [18].
The aim of the present retrospective study is to report
the HO rate from a consecutive series of patients who
underwent hip arthroscopy for FAI, and to evaluate its
association with NSAID prophylaxis. The hypothesis is
that the risk of developing HO is higher if NSAID pro-
phylaxis is not administered.
Materials and methods
All hip arthroscopies performed for FAI correction in two
different hospitals between April 2006 and May 2009 were
included. Cases whose medical records were not com-
pletely available were ruled out of the study, as were all
cases that had follow-up shorter than 6 months. Three
hundred hips, in 300 patients, could be included: 51 pro-
cedures were performed in hospital A; the remaining 249
procedures were performed in hospital B. All patients gave
informed consent prior to being included in the study. The
study was authorized by the local ethical committee and
was performed in accordance with the ethical standards of
the 1964 Declaration of Helsinki as revised in 2000.
The study population was composed of 180 males and
120 females, with mean age of 37.4 years (range
16–66 years). Average follow-up was 17.9 months (range
6 months–3 years).
All cases were operated by senior surgeons experienced
in hip arthroscopy. Anteroposterior (AP) radiographs and
cross-table or Dunn view were obtained preoperatively in
all patients. These images were evaluated to rule out any
pre-existing calcium deposits around the joint. Two or
three standard arthroscopic portals were always employed:
a paratrochanteric anterolateral portal, an anterior or mid-
anterior portal, and rarely a distal accessory anterolateral
portal. Routinely the anterolateral portal was established
first with the aid of a C-arm image intensifier. The (mid-)
anterior portal was subsequently performed in an out–in
fashion under direct visualization. Traction was used to
access the central compartment. Capsulotomy was always
performed, while true capsulectomy rarely occurred.
Patient position was supine in hospital A, and lateral in
hospital B, but procedures did not differ significantly.
All medical records were reviewed from hospital com-
puter databases; age, gender, weight, diagnosis, date of
surgery, operative report, and prescriptions at discharge
were recorded. A full description of NSAID prophylaxis, if
any, was recorded (drug, dose and duration). All patients
whose compliance with NSAID regimen was not clearly
recorded in follow-up reports were contacted by telephone
to ascertain it.
Follow-up radiographs were evaluated with regard to
presence of ectopic bone formation around the hip joint. Any
HO was classified according to Brooker grading system [19].
We defined the treatment group as patients who received
NSAID prophylaxis on a regular basis for at least 7 days,
starting within 24 h after surgery, and the control group as
patients who did not. Heterotopic ossifications rates and 95%
confidence interval (CI) were calculated for all the arthros-
copies and separately for treatment and control groups.
Treatment and control groups were compared according to the
main independent variables and the main predisposing factors
for HO formation using Fisher’s exact test and independent-
samples t test to assess their comparability. Significance of
associations between HO complication and pharmacological
prophylaxis was assessed using Fisher’s exact test. P-value
\0.05 was considered statistically significant for all analyses.
Statistical computations were performed using SPSS release
10.0 (SPSS Inc., Chicago, IL, USA) for Windows.
Results
Fifteen of the 300 reviewed patients received no NSAID
prophylaxis nor other medications against heterotopic bone
formation (control group), because of allergy towards
multiple NSAIDs or because of lack of compliance. The
remaining 285 patients received NSAIDs after surgery
(treatment group): 15 patients received COX-2-selective
NSAIDs (etoricoxib 90 mg) once a day for 3 weeks, and
270 patients received nonselective NSAIDs (248 patients
with naproxen 500 mg twice a day for 3 weeks, and the
other 22 patients with other NSAIDs such as aceclofenac,
indomethacin or ketoprofen for 3 weeks).
Of 300 hips, 5 cases (4 males, 1 female) presented HO
after hip arthroscopy, with overall prevalence of 1.6%
(95% CI 0.2–3.0%). All HO cases are summarized in
Table 1. Treatment and control groups resulted comparable
regarding the main independent variables and the main
predisposing factors for HO formation (Table 2).
All five patients (Figs. 1, 2, 3, 4) with HO belonged to
the control group, with prevalence of 33% (95% CI
8–54%). No HO was observed within the treatment group.
HO occurred in a significantly higher percentage
(P \ 0.001) in patients who did not receive any prophy-
laxis compared with patients who received NSAIDs.
Discussion
There are several case reports in the literature describing
HO complication after different joint arthroscopic
246 J Orthopaed Traumatol (2010) 11:245–250
123
T
a
b
le
1
H
O
ca
se
s
C
as
e
G
en
d
er
A
g
e
(y
ea
rs
)
W
ei
g
h
t
(k
g
)
D
ia
g
n
o
si
s
F
o
ll
o
w
-u
p
(m
o
n
th
s)
O
p
er
at
iv
e
p
o
si
ti
o
n
A
rt
h
ro
sc
o
p
ic
p
ro
ce
d
u
re
B
ro
o
k
er
g
ra
d
e
H
O
p
o
si
ti
o
n
T
im
e
o
f
H
O
d
ia
g
n
o
si
s
(m
o
n
th
s
af
te
r
su
rg
er
y
)
S
y
m
p
to
m
s
1
M
3
1
6
5
F
A
I
m
ix
ed
-t
y
p
e
w
it
h
la
b
ra
l
te
ar
1
4
S
u
p
in
e
C
ap
su
le
ct
o
m
y
,
la
b
ra
l
d
eb
ri
d
em
en
t,
ri
m
tr
im
m
in
g
,
fe
m
o
ra
l
o
st
eo
ch
o
n
d
ro
p
la
st
y
1
L
at
er
al
2
A
sy
m
p
to
m
at
ic
,
n
o
ar
ti
cu
la
r
m
o
ti
o
n
li
m
it
at
io
n
2
M
6
6
7
0
F
A
I
m
ix
ed
ty
p
e
w
it
h
la
b
ra
l
te
ar
1
2
S
u
p
in
e
C
ap
su
le
ct
o
m
y
,
la
b
ra
l
d
eb
ri
d
em
en
t,
ri
m
tr
im
m
in
g
,
fe
m
o
ra
l
o
st
eo
ch
o
n
d
ro
p
la
st
y
1
L
at
er
al
2
A
sy
m
p
to
m
at
ic
,
n
o
ar
ti
cu
la
r
m
o
ti
o
n
li
m
it
at
io
n
3
F
1
7
6
2
F
A
I
m
ix
ed
ty
p
e
w
it
h
la
b
ra
l
te
ar
1
5
S
u
p
in
e
C
ap
su
le
ct
o
m
y
,
la
b
ra
l
d
eb
ri
d
em
en
t,
ri
m
tr
im
m
in
g
,
fe
m
o
ra
l
o
st
eo
ch
o
n
d
ro
p
la
st
y
2
A
n
te
ro
la
te
ra
l
2
D
ec
re
as
in
g
p
ai
n
,
n
o
ar
ti
cu
la
r
m
o
ti
o
n
li
m
it
at
io
n
4
M
4
5
7
3
F
A
I
ca
m
ty
p
e
w
it
h
la
b
ra
l
te
ar
2
4
L
at
er
al
d
ec
u
b
it
u
s
N
o
ca
p
su
le
ct
o
m
y
,
la
b
ra
l
d
eb
ri
d
em
en
t,
fe
m
o
ra
l
o
st
eo
ch
o
n
d
ro
p
la
st
y
3
A
n
te
ro
la
te
ra
l
1
2
M
in
im
al
p
ai
n
fl
ex
in
g
th
e
h
ip
[
1
0
0

A
rt
ic
u
la
r
R
O
M
:
fl
ex
io
n
1
0
0
,
in
te
rn
al
ro
ta
ti
o
n
5
,
ex
te
rn
al
ro
ta
ti
o
n
1
5
,
ab
d
u
ct
io
n
3
5
,
ad
d
u
ct
io
n
2
5

5
M
5
0
6
1
F
A
I
ca
m
ty
p
e
w
it
h
la
b
ra
l
te
ar
6
L
at
er
al
d
ec
u
b
it
u
s
N
o
ca
p
su
le
ct
o
m
y
,
la
b
ra
l
d
eb
ri
d
em
en
t,
ac
et
ab
u
la
r
m
ic
ro
fr
ac
tu
re
,
fe
m
o
ra
l
o
st
eo
ch
o
n
d
ro
p
la
st
y
1
A
n
te
ri
o
r
(r
ec
tu
s-
p
so
as
)
2
L
it
tl
e
st
if
fn
es
s,
so
re
w
it
h
fl
ex
io
n
an
d
in
te
rn
al
ro
ta
ti
o
n
A
rt
ic
u
la
r
R
O
M
:
fl
ex
io
n
9
0
,
in
te
rn
al
ro
ta
ti
o
n
0
,
ex
te
rn
al
ro
ta
ti
o
n
1
5
,
ab
d
u
ct
io
n
2
5
,
ad
d
u
ct
io
n
2
0

R
O
M
,
ra
n
g
e
o
f
m
o
ti
o
n
J Orthopaed Traumatol (2010) 11:245–250 247
123
procedures [14–17]. A common element in these reports is
the absence of any prophylactic administration of NSAIDs
or other medications against ectopic bone formation. In
Table 2 Comparison between treatment group (postoperative NSAID prophylaxis) and control group (no postoperative NSAID prophylaxis)
regarding the main independent variables and the predisposing factors for HO formation
Treatment group (n = 285) Control group (n = 15) P value
Male 171 (60%) 9 (60%) 0.50
Age, mean ± SD (years) 38.1 ± 13.2 37.1 ± 12.4 0.79
Weight, mean ± SD (kg) 71.0 ± 12.7 71.4 ± 10.2 0.91
Anterolateral capsulectomy 172 (60%) 10 (67%) 0.75
Rim trimming 122 (43%) 5 (33%) 0.41
Head–neck junction osteoplasty 179 (63%) 12 (80%) 0.054
SD, standard deviation
Fig. 1 Case 1: detail of axial radiograph showing grade 1 HO at
2 months after surgery
Fig. 4 Case 4: detail of anteroposterior radiograph showing grade 3
anterolateral HO 1 year after arthroscopic treatment
Fig. 2 Case 3: detail of anteroposterior radiograph showing grade 2
HO at 1 year after surgery
Fig. 3 Case 3: detail of axial radiograph at 1-year follow-up
248 J Orthopaed Traumatol (2010) 11:245–250
123
fact, HO prophylaxis is not routinely employed after
arthroscopy, as HO represents an exceptional complication
for this kind of surgery.
HO within an arthroscopic hip portal was once described
by Thomas-Byrd [20]. Larson [18] reported HO among the
complications following his consecutive series of hip ar-
throscopies. The author reported incidence of 6% (six
hips), with one case of significant motion limitation
resulting from ossification of the iliopsoas tendon, but no
prophylaxis was mentioned.
Historically, the paucity of reports of HO following hip
arthroscopy may be explained considering that most hip
arthroscopies were performed to address labral, chondral,
and synovial diseases until the last decade, when FAI
gained popularity and extended the indications to include
acetabular and femoral osteochondroplasties. Arthroscopic
treatment of FAI may present increased risk for HO for-
mation due to the additional manipulation of soft tissues
(capsulotomy or capsulectomy). In addition, bony debris
after milling might collect within periarticular soft tissues,
there triggering further local bone formation.
Often arthroplasty patients complain about HO only if
the lesion is bulky (grade 3 or 4), but hip arthroscopy
patients are generally younger, more active, and motivated
to return to sport activities, even at competitive levels.
Since this population is definitely more demanding than
usual candidates for total hip replacement, even small
ossifications might affect overall satisfaction. For this
reason, and on the basis of this study, we believe that
prophylaxis should be considered.
To the best of our knowledge, this is the first study
reporting prevalence of HO in a large consecutive series of
arthroscopic femoroacetabular osteochondroplasties and its
association with NSAID administration. Our analysis has
shown a significant difference in the frequency of such
complications between patients who received NSAIDs
postoperatively and patients who did not.
This study presents several limitations. Its most impor-
tant weakness is the small sample size of the control group.
The strong asymmetry between treatment and control
groups may have biased their comparison. However, given
the large difference we observed, a randomized controlled
trial could hardly be acceptable from an ethical point of
view.
Moreover, the prophylaxis regimen is heterogeneous.
Different drugs may be differently effective for HO pre-
vention. Nevertheless, this study has the purpose of veri-
fying the association between any NSAID prophylaxis,
considered as the main independent variable, and HO.
Further studies are needed to evaluate the specific effec-
tiveness of any single medication.
Several factors are also known or supposed to be asso-
ciated with increased risk for formation of heterotopic bone
[2]. Referring to hip arthroscopy, capsular incision and
resection to expose the peripheral cam deformity, extensive
rim trimming, anchor placement, and male gender might be
the most relevant predisposing factors. Due to the relevant
limitations of this study, a systematic and comprehensive
analysis of these multiple risk factors was not possible.
In conclusion, arthroscopic treatment of FAI is not
exempt from potential formation of HO. This study eval-
uated the effects of NSAIDs on HO development and
observed a significantly higher complication rate in those
patients who did not receive prophylaxis. Thus, the authors
suggest NSAID prophylaxis after hip arthroscopy when
FAI is addressed.
Conflict of interest None.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
References
1. Neal B, Gray H, MacMahon S, Dunn L (2002) Incidence of
heterotopic bone formation after major hip surgery. ANZ J Surg
72:808–821
2. Ritter MA, Vaughan RB (1977) Ectopic ossification after total
hip arthroplasty. Predisposing factors, frequency, and effect on
results. J Bone Joint Surg Am 59:345–351
3. Riegler HF, Harris CM (1976) Heterotopic bone formation after
total hip arthroplasty. Clin Orthop Relat Res 117:209–216
4. Charnley J (1972) The long term results of low friction arthro-
plasty of the hip performed as a primary intervention. J Bone
Joint Surg 54B:61–76
5. Rosendahl S, Christoffersen K, Norgaard M (1973) Para-articular
ossification after total hip replacement. Acta Orthop Scand
43:400
6. Schmidt SA, Kjaersgaard-Andersen P, Pedersen NW, Kristensen
SS, Pedersen P, Nielsen JB (1988) The use of indomethacin to
prevent the formation of heterotopic bone after total hip
replacement. A randomized, double-blind clinical trial. J Bone
Joint Surg Am 70:834–838
7. Pagnani MJ, Pellicci PM, Salvati EA (1991) Effect of aspirin on
heterotopic ossification after total hip arthroplasty in men who
have osteoarthrosis. J Bone Joint Surg Am 73:924–929
8. Romano CL, Duci D, Romano D, Mazza M, Meani E (2004)
Celecoxib versus indomethacin in the prevention of heterotopic
ossification after total hip arthroplasty. J Arthroplasty 19(1):
14–18
9. Grohs JG, Schmidt M, Wanivenhaus A (2007) Selective COX-2
inhibitor versus indomethacin for the prevention of heterotopic
ossification after hip replacement: a double-blind randomized
trial of 100 patients with 1-year follow-up. Acta Orthop 78(1):
95–98
10. Glick JM, Sampson TG, Gordon RB, Behr JT, Schmidt E (1987)
Hip arthroscopy by the lateral approach. Arthroscopy 3:4–12
11. Byrd JW (1994) Hip arthroscopy utilizing the supine position.
Arthroscopy 10:275–280
12. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA (2009)
Outcomes following hip arthroscopy for femoroacetabular
J Orthopaed Traumatol (2010) 11:245–250 249
123
impingement with associated chondrolabral dysfunction: mini-
mum two-year follow-up. J Bone Joint Surg Br 91(1):16–23
13. Sampson TG (2008) Arthroscopic treatment of femoroacetabular
impingement. Am J Orthop 37(12):608–612
14. Berndt C, Ganko A, Whitehouse SL, Crawford RW (2008) Het-
erotopic ossification within an arthroscopic portal after unevent-
ful partial meniscectomy. Knee 15(5):416–418
15. Sodha S, Nagda SH, Sennett BJ (2006) Heterotopic ossification in
a throwing athlete after elbow arthroscopy. Arthroscopy
22(7):802e1–802e3
16. Boynton MD, Enders TJ (1999) Severe heterotopic ossification
after arthroscopic acromioplasty: a case report. J Shoulder Elbow
Surg 8(5):495–497
17. Berg EE, Ciullo JV, Oglesby JW (1994) Failure of arthroscopic
decompression by subacromial heterotopic ossification causing
recurrent impingement. Arthroscopy 10(2):158–161
18. Larson CM, Giveans MR (2008) Arthroscopic management of
femoroacetabular impingement: Early outcomes measures.
Arthroscopy 24(5):540–546
19. Brooker AF, Bowerman JW, Robinson RA, Riley LH (1973)
Ectopic ossification following total hip replacement. Incidence
and a method of classification. J Bone Joint Surg 55A:1629–1632
20. Thomas-Byrd JW (1998) Complications associated with hip
arthroscopy. In: Operative hip arthroscopy, chap 12. Thieme
Medical Publisher Inc., New York, pp 171–176
250 J Orthopaed Traumatol (2010) 11:245–250
123


Crossref

Arthroscopic management of femoroacetabular impingement: Early outcomes measures.

Arthroscopic treatment of femoroacetabular impingement.

Celecoxib versus indomethacin in the prevention of heterotopic ossiﬁcation after total hip arthroplasty.

Complications associated with hip arthroscopy. In: Operative hip arthroscopy, chap 12.

Ectopic ossiﬁcation after total hip arthroplasty. Predisposing factors, frequency, and effect on results.

Ectopic ossiﬁcation following total hip replacement. Incidence and a method of classiﬁcation.

Effect of aspirin on heterotopic ossiﬁcation after total hip arthroplasty in men who have osteoarthrosis.

Failure of arthroscopic decompression by subacromial heterotopic ossiﬁcation causing recurrent impingement.

Heterotopic bone formation after total hip arthroplasty.

Heterotopic ossiﬁcation in a throwing athlete after elbow arthroscopy.

Heterotopic ossiﬁcation within an arthroscopic portal after uneventful partial meniscectomy.

Hip arthroscopy by the lateral approach.

Hip arthroscopy utilizing the supine position.

Incidence of heterotopic bone formation after major hip surgery.

Outcomes following hip arthroscopy for femoroacetabular J Orthopaed Traumatol

Para-articular ossiﬁcation after total hip replacement.

Severe heterotopic ossiﬁcation after arthroscopic acromioplasty: a case report.

The long term results of low friction arthroplasty of the hip performed as a primary intervention.

The use of indomethacin to prevent the formation of heterotopic bone after total hip replacement. A randomized, double-blind clinical trial.

Wanivenhaus A

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3014465

Heterotopic ossifications after arthroscopic management of femoroacetabular impingement: the role of NSAID prophylaxis

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Springer - Publisher Connector

Crossref