Heterotopic ossification treatment question

[BobbyHeenan]

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I have a patient at just 6 weeks post op that developed HO after ORIF from a traumatic fracture. The patient did not have pre op radiation and can't have NSAIDs. Given the rarity of this case/question, for medical/legal reasons..., I'll keep some details vague

Anyway, 6 week post op patient is developing early HO noted on radiographs. The orthopod is very good in my experience working with him/her and reasonably suggests we do a late course of XRT to prevent progression to avoid eventually needing another operation, which can be fraught with problems.

There are actually a number of well done series showing this has merit.
My questions is dose, because if this radiation fails and she needs an excision of this HO she's going to need another course of peri op radiation, so cumulative dose matters here to me.

One study used 7 Gy X 1.

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

Late, low-dose radiotherapy is effective in preventing the progression of HO in patients who unexpectedly develop significant HO following THA.

pubmed.ncbi.nlm.nih.gov

Another study suggesting a whiff of possible dose escalation benefit using doses like 6 Gy X 3 or even 7 Gy X 3.

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

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.

pubmed.ncbi.nlm.nih.gov

DEFINE_ME

Any thoughts here?

 

[TheWallnerus]

Patient age?

Better irradiate her today/right now. I think single fx, would use 8 Gy. Can re-RT another 7-8 Gy in future after re-op if need be just fine.

 

[BobbyHeenan]

Patient age?

Better irradiate her today/right now. I think single fx, would use 8 Gy. Can re-RT another 7-8 Gy in future after re-op if need be just fine.

50's.

Yeah I like maybe 8 X 1 now, 7 Gy later if need be.

I saw a really old series of 20 Gy in 10 fractions of hips, but most of the HO lit obviously moved away from protracted courses.

 

[TheWallnerus]

50's.

Yeah I like maybe 8 X 1 now, 7 Gy later if need be.

50's... just do the single fx. Risk/benefit and all that.

 

[Palex80]

Data from the HOP-2 trial support postoperative RT given fractionated.

Prevention of heterotopic ossification about the hip: final results of two randomized trials in 410 patients using either preoperative or postoperative radiation therapy - PubMed

With the exception of a small subgroup of patients with ipsilateral high Brooker Grade III and IV, pre- and postoperative radiotherapy are equally effective to prevent heterotopic ossification about the hip after hip surgery and total hip arthroplasty. Fractionated medium dose radiotherapy...

pubmed.ncbi.nlm.nih.gov

The so called HOP2-trial.

 

[BobbyHeenan]

Data from the HOP-2 trial support postoperative RT given fractionated.

Prevention of heterotopic ossification about the hip: final results of two randomized trials in 410 patients using either preoperative or postoperative radiation therapy - PubMed

With the exception of a small subgroup of patients with ipsilateral high Brooker Grade III and IV, pre- and postoperative radiotherapy are equally effective to prevent heterotopic ossification about the hip after hip surgery and total hip arthroplasty. Fractionated medium dose radiotherapy...

pubmed.ncbi.nlm.nih.gov

The so called HOP2-trial.
View attachment 343701

Yes, I was thinking about 5 X 3.5 Gy too.

Though that dosing is in immediate post op period. I was trying to find more studies about treating existing/developing HO.

My usual is pre op 7 Gy X 1 (I work closely with a hip guru orthopod that likes this. It works out well for both of us for work flow).

 

[Mandelin Rain]

Pre-op 7 Gy x 1 for me. Not that it matters for the case presented. But pre-op definitely the way to go if possible (non-traumatic). Better to get everyone there at 6:00 AM to beat the OR schedule than keep everyone past 6:00 PM with the surprise consult and treat.

 

[BobbyHeenan]

Pre-op 7 Gy x 1 for me. Not that it matters for the case presented. But pre-op definitely the way to go if possible (non-traumatic). Better to get everyone there at 6:00 AM to beat the OR schedule than keep everyone past 6:00 PM with the surprise consult and treat.

I was so pumped when the hip team agreed to go pre op.

No more "oh we forgot to consult you and case mgmt needs this guy discharged, please come up and treat we need to send him home sorry it's 5PM and I'm just now calling you."

 

[seper]

I would be a contrarian here. Do not treat now, wait until HO becomes symptomatic and let the patient have debulking then.

 

[Mandelin Rain]

I would be a contrarian here. Do not treat now, wait until HO becomes symptomatic and let the patient have debulking then.

My thought as well.

 

[BobbyHeenan]

I would be a contrarian here. Do not treat now, wait until HO becomes symptomatic and let the patient have debulking then.

I think that's reasonable.

I discussed that with ortho and they didn't like that at all. Though I presented it as an option to patient.

I really defer to ortho here because they just have more experience with this sort of thing. I think as long as I felt comfortable with radiation dose (knowing two courses possible), I was comfortable treating now.

 

[evilbooyaa]

Will RT for HO even work at 6 weeks post-op?? The post-op RT you're seeing is like, immediately or within maybe 1 week post-op, right? Even in HOP-2 linked by Palex above, it was < 96 hours post-op to start the RT, which is 4 days.

Asking about RT for HO at 6 weeks (42 days), when the normal time is within 4 days post-op, is like asking about adjuvant breast cancer treatment (assuming adjuvant breast RT should be given within say 8 weeks post-op) at 84 weeks post-op. That's ~21 months. 1.75 years from lumpectomy. That's kinda what we're talking about. Which I think most would put in a category of "completely ****ing bonkers"

If anyone has a link suggesting efficiacy of RT for HO at anything at more than say a 1 week post-op time period... please link.

 

[Palex80]

Asking about RT for HO at 6 weeks (42 days), when the normal time is within 4 days post-op, is like asking about adjuvant breast cancer treatment (assuming adjuvant breast RT should be given within say 8 weeks post-op) at 84 weeks post-op. That's ~21 months. 1.75 years from lumpectomy. That's kinda what we're talking about. Which I think most would put in a category of "completely ****ing bonkers"

Will still eliminate DCIS. 🤣

(I'm just trolling you)

 

[Surf Rx]

Looking for some advice. I have a 30yo female who was in a bad car accident with multiple pelvic fractures including a comminuted fracture of the acetabulum extending into the joint. Ortho wants me to radiate for heterotopic ppx.

What is your age cut off for these bad fractures? Obviously worried about risk of malignancy and fertility, but her risk of a debilitating HO would be quite high. Also, compliance would likely be an issue, so no indomethacin.

 

[communitydoc13]

What is your age cut off for these bad fractures?

Never radiated a kid but was present for several HO tx in patients this young at program associated with large trauma center.

2nd malignancy risk is very low and per my understanding, essentially at the case report level in terms of risk.

With proper fields, dose to ovaries should be very low.

 

[RickyScott]

Looking for some advice. I have a 30yo female who was in a bad car accident with multiple pelvic fractures including a comminuted fracture of the acetabulum extending into the joint. Ortho wants me to radiate for heterotopic ppx.

What is your age cut off for these bad fractures? Obviously worried about risk of malignancy and fertility, but her risk of a debilitating HO would be quite high. Also, compliance would likely be an issue, so no indomethacin.

treated several kids as a resident (counted towards peds quota) w/some horrible contractures and multiple surgeries.

 

[elementaryschooleconomics]

Never radiated a kid but was present for several HO tx in patients this young at program associated with large trauma center.

2nd malignancy risk is very low and per my understanding, essentially at the case report level in terms of risk.

With proper fields, dose to ovaries should be very low.

Same, I distinctly remember a 23-24 year old in a terrible motorcycle accident we treated for HO PPx. I never seriously considered getting a motorcycle license after that.

 

[madchemist89]

In residency, we treated lots of ho. Mostly it was young guys who had crashed cars or motorcycles in the middle of the night whilst enebriated. We saw a few gunshots to the hip to.

 

[TheWallnerus]

In residency, we treated lots of ho.

 

[seper]

Looking for some advice. I have a 30yo female who was in a bad car accident with multiple pelvic fractures including a comminuted fracture of the acetabulum extending into the joint. Ortho wants me to radiate for heterotopic ppx.

What is your age cut off for these bad fractures? Obviously worried about risk of malignancy and fertility, but her risk of a debilitating HO would be quite high. Also, compliance would likely be an issue, so no indomethacin.

I would treat. there are risks, but therapeutic ratio is good