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Treatment of Heterotopic Ossification

The published literature on treatment of HO provides evidence for non-steroidal anti-inflammatory drugs, warfarin, bisphosphonates, pulse low-intensity electromagnetic field therapy, radiation and surgical excision.

Table 1. Reviews examining the effectiveness of pharmacological, non-pharmacological and surgical management of HO after SCI

Author(s)

Country

Date included in the review

AMSTAR score

Number of articles

Method:

Level of evidence

Questions

Conclusions
Aubut et al. 2011

Canada

Review of published articles between 1980-2010

AMSTAR=8

N=26

 

Method: Comprehensive literature search of English RCT, Cohort studies, case series, and review articles of traumatic SCI in adult age group (≥18 yr).

Databases: MEDLINE, EMBASE, CINAHL, PsycInfo.

Level of evidence: Moderate quality: Downgraded high quality studies, non-randomized trials, prospective cohort studies; Low quality: Retrospective observational, retrospective cohort and case-control studies; Very low quality: Case series, case reports, reviews and others.

Questions/measures/hypothesis:

1.     Examine the effectiveness of pharmacological, non-pharmacological and surgical management of HO after ABI and SCI.

1.     ABI population usually required multicomponent treatments compared to the SCI population.

2.     There are more level 1 and level 2 evidence for the SCI literature in supporting HO treatment, while the literature for the ABI population is weaker with mainly level 4 evidence.

3.      HO in SCI patients was mostly seen in the hip while the ABI patients had more varied location of HO including hip, knee and elbow.

4.     Etidronate and indomethacin post-surgery suggested for both populations to reduce the risk for HO.

Teasell et al.

2010

Canada

Review of published articles between 1980-2009

AMSTAR=8

N=13

Method: Comprehensive literature search of English RCT, Cohort studies, case series, and review articles of traumatic SCI in adult age group (≥18yr).

Databases: MEDLINE, EMBASE, CINAHL, PsycInfo.

Level of evidence: Moderate quality: Downgraded high quality studies, non-randomized trials, prospective cohort studies; Low quality: Retrospective observational, retrospective cohort and case-control studies; Very low quality: Case series, case reports, reviews and others.

Questions/measures/hypothesis:

Examine the effectiveness of pharmacological, non-pharmacological and surgical management of HO after SCI.

1.     There was strong evidence that early prophylactic treatment was efficacious in preventing HO, in which NSAIDs showed greatest effectiveness (level 1 evidence).

2.     Bisphosphonates had the strongest evidence for treatment of HO (level)

3.     There is some evidence for the use of Pulse low intensity electromagnetic field therapy (PLIMF), however, further research is needed.

Two systematic reviews examined the effectiveness of HO management interventions. Aubut et al. (2011) found that pharmacological interventions were effective in the prophylaxis of HO. Teasell et al. (2010) also found that rofecoxib and indomethacin were effective in preventing HO after SCI. However, only limited evidence supported the use of radiotherapy, warfarin, or Pulse low intensity electromagnetic field therapy (PLIMF) for the prevention of HO after SCI. Once HO developed, only surgical resection was found to be effective, while bisphosphonates such as Etidronate Disodium and pamindronate were supported by limited evidence.