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Radiation therapy or radiotherapy, which is the use of ionizing radiation for therapeutic ends, has been proposed as a possible adjunct treatment for HO.

 

Table 6 Radiation Therapy for Treatment of Heterotopic Ossification

Author Year

Country

Research Design

Score

Total Sample Size

MethodsResults
Museler et al., 2017

Germany

Case Series

N=244

Population: Mean age: 46.4 yr; Gender: males=207, females=37; Severity of injury: AIS: A=220, B=8, C=12, D=4.

Interventions: Single-dose radiation therapy at the hip for HO. Mean time of treatment was 4.9 days. Treatment was administered with either 15 MV or 6 MV.

Outcome Measures: HO recurrence, side effect due to radiation.

1.     Of the 244 patients, 13 experienced recurrence of HO. All 13 patients initially experienced HO in both hips. Of the 444 initial cases of HO, there were 26 instances of recurrence.

2.     No patients experienced negative side-effects as a result of radiation treatment.

Sautter-Bihl et al. 2001

Germany

Case Series

N=52

Population: Mean age: 33 yr; Gender: males=44, females=8;

Treatment: Patients received a single dose of radiotherapy 2-10Gy through a linear accelerator at 6-8 MV photons.

Outcome Measures: Efficacy, Brooker classification, adverse effects.

1.     Prevention of HO was seen in 71% of (41 primarily treated, 9 resected) joints.

2.     Radiotherapy treatment did not result in a regression of the Brooker score in any patient.

3.     An increase in two Brooker score grades was seen in two joints (1 knee, 1 hip)

4.     No adverse effects due to therapy occurred.

5.     16 of 32 hips treated only with radiotherapy (50%) did not show any abnormalities on follow-up.

6.     No progression of HO was noted in 30/36 subjects (83%).

7.     Re-ossification after therapy which led to a decrease in joint mobility was noted in three subjects.

Sautter-Bihl et al. 2000

Germany

Case Series

N=36

Population: Age range: 17-59 yr; Gender: males=32, females=4; Follow-up range: 4-98mo.

Treatment: 25/36 subjects received 10 Gy radiotherapy in fraction of 2-2.5 Gy, while four patients received higher doses. In phase 2 seven subjects received a single does of irradiation with 8Gy. In total, 46 joints were irradiated.

Outcome Measures: Progression of HO and complications.

1.     No statistically significant results were reported.

2.     16 of the 32 hips treated with radiotherapy only did not show any abnormalities on follow-up.

3.     No progression of HO was noted in 30/36 subjects.

4.     Re-ossification after therapy, which led to a decrease in joint mobility was noted in three subjects.

Discussion

Sautter-Bihl et al. (2000) studied 36 patients with HO of whom 27 patients (32 joints) received radiotherapy when ossification was minimal. 11 patients (13 joints) had obvious ossifications, which had to be resected. Post-op radiotherapy was performed 24-36 hours post-operatively. Two patients received radiotherapy both before and after surgery. Mean duration of follow-up was 23.6 months. 30 of the 36 irradiated patients showed no progression of HO. In three patients, reossification after therapy resulted in a moderate decrease in joint mobility.

In the follow-up case series by Sautter-Bihl et al. (2001), the authors examined the effectiveness of radiotherapy administered to 52 SCI patients. Radiotherapy effectively prevented primary and secondary HO post-surgical excision in 71% of patients. However, treatment did not result in regression of HO once developed, as measured by the Brooker scale. Two joints increased in Brooker score, although neither of them developed any functional impairment. Another case series by Museler et al. (2017) used either 15 MV or 6 MV radiotherapy to target HO at the hip in 244 patients. Recurrence of HO was found to be very low (5.3%), and of those that experienced recurrence HO was initially present in both hips.

A case study by Cramarossa et al. (2013) reported on the use of radiation therapy on a patient who had previously experienced an SCI at the C5-C6 level and had been diagnosed with dysphagia due to HO-induced osteophytes. One day after surgical intervention which involved anterior cervical decompression and drilling of the osteophytes, the patient received a single treatment of radiation at 8 Gy. At follow-up, the patient reported that they were not experiencing any recurrence of dysphagic symptoms. The authors add that radiation should only be considered for patients at high risk of HO due to the risk of creating a radiotherapy-induced malignancy and that an expansion of the literature is required to better assist treatment decisions.

Conclusion

There is moderate Level 4 evidence (from three case series studies; Sautter-Bihl et al. 2000; Sautter-Bihl et al. 2001; Museler et al. 2017) that radiotherapy reduces the progression of heterotopic ossification.

  • Radiotherapy can reduce the progression of heterotopic ossification.