British Journal of Radiology 74 (2001),503-506 © 2001 The British Institute of Radiology
Re-irradiation for prophylaxis of heterotopic ossification after hip surgery
T C M Lo, MD
1 and
W L Healy, MD
2
Departments of 1Radiation Oncology and 2Orthopaedic Surgery, Lahey Clinic Medical Center, Burlington, MA, USA
Correspondence: T C M Lo, MD, Department of Radiation Oncology, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805, USA
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Abstract
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Heterotopic ossification (HO) may occur after total hip arthroplasty, but fortunately most patients are asymptomatic. Rick factors for HO include previous HO, hypertrophic osteoarthritis, diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, Paget's disease and post-traumatic arthritis. Both pre-operative and post-operative radiotherapy are effective in the prevention of HO in 85–95% of high-risk patients treated. In the few patients who needed re-operation for a variety of reasons, we found that re-irradiation is possible and safe. These case reports present our experience with single dose re-irradiation of the hip in an attempt to prevent post-operative HO.
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Introduction
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Heterotopic ossification (HO) is a well known occurrence after total hip arthroplasty (THA). Brooker's grading system (Table 1
) has generally been accepted for classifying the extent of ossification [1]. When HO occurs after THA, it is usually asymptomatic. However, if Brooker's grade IV ossification develops, the associated pain and stiffness of the affected hip may defeat the original goal of surgery. Surgical excision of HO without adjuvant preventive therapy is associated with a high incidence of recurrence [2–8]. The best treatment for HO about the hip is peri-operative prophylaxis for high-risk patients.
Two prophylactic treatment regimens have been found to be effective in preventing HO after hip surgery: oral non-steroidal anti-inflammatory drugs (NSAIDs) and external beam photon irradiation. Drawbacks to the use of NSAIDs are side effects and patient compliance [9]. Radiation has been applied in single dose and multidose protocols. Single dose post-operative radiotherapy [10–13] is preferred by many surgeons in the prophylaxis of HO owing to its simplicity, safety and compliance. Several studies [11–15] have confirmed the efficacy of single dose irradiation in the prevention of HO after THA.
From time to time, it may be necessary to re-operate on a hip that was treated with radiation to prevent HO at the time of previous hip surgery. We are not aware of any reports in the literature regarding prophylactic re-irradiation after re-operation on a hip treated with prophylactic radiation after the index hip surgery. This report discusses treatment of four patients who received a second course of post-operative single dose radiotherapy after re-operation.
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Case 1
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In 1981 a 39-year-old man with Marie–Strumpell arthritis underwent left hip replacement because of symptomatic osteoarthritis. On post-operative day 2, a single dose of 7 Gy radiation, calculated to midplane, was given to the surgical site. A 4 MV photon beam was used with a single anteroposterior field. The field size was 16 cm x 20 cm covering the entire hip. Ipsilateral revision THA was performed in 1988 because of aseptic loosening. On post-operative day 1 the hip was treated again with a single dose of 7 Gy. In this instance, a 10 MV photon beam was used and opposed anteroposterior and posteroanterior (AP–PA) fields were used. The reference point was at the midplane. The field size was 6 cm x 14 cm and the target volume was the soft tissue around the neck of the prosthesis. Follow-up radiography of the pelvis 10 years after the second radiation treatment showed no evidence of HO around the left hip. The patient encountered no problems from the second dose of prophylactic irradiation.
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Case 2
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In 1983 a 71-year-old man fell from a ladder and sustained a subcapital fracture of the left hip. He underwent reconstruction with a Moore endoprosthesis (Figure 1). Post-operatively, Brooker's grade III HO developed in the affected hip. The HO was associated with pain, progressive limp and restricted range of motion. Conversion THA with excision of HO was performed in 1984 (Figure 2). A single midplane dose of 7 Gy was delivered to the operative site on post-operative day 1. A 10 MV photon beam was used with a field size of 14 cm x 16 cm and opposed AP–PA technique. Ipsilateral revision THA was performed in 1991 for aseptic loosening (Figure 3). Again, a single midplane dose of 7 Gy radiation was delivered on post-operative day 1, using a 10 MV photon beam and AP–PA technique. The field size was 5 cm x 14 cm covering the soft tissue plane around the metal prosthetic neck. The patient is currently asymptomatic and radiography shows no significant bone growth more than 8 years after the last operation. No problems or complications were encountered from radiation treatment.
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Figure 2. Case 2. Residual ectopic bone after conversion total hip arthroplasty with excision of heterotopic ossification.
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Case 3
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In 1988 a 69-year-old man underwent right total hip replacement because of degenerative arthritis. 1 month after operation, he fell and sustained a fracture of the right greater trochanter, which was treated non-operatively. Extensive HO developed by the 5th month after fracture, causing significant restriction of range of motion as well as hip pain. A large mass of heterotopic bone about the greater trochanter was removed. A single midplane dose of 7 Gy was delivered to the surgical site on post-operative day 1. The patient was treated with a 10 MV photon beam with AP–PA technique and a field size of 5 cm x 14 cm with a 25° collimator angle to cover the soft tissue plane around the neck of the hip prosthesis. Unfortunately, the patient's symptoms were not completely relieved. In 1990 he underwent further excision of ectopic bone around the hip. A single midplane dose of 7 Gy was again delivered on post-operative day 1. The same field size and technique was used and the patient was treated with a 10 MV photon beam. The patient is currently doing well, with no radiographic evidence of new ectopic bone formation at 8-year follow-up. No problems were encountered from radiation treatment.
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Case 4
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In 1994 a 67-year-old man was seen because of symptomatic severe osteoarthritis of the right hip and Paget's disease. Right THA was performed. On post-operative day 1, a single midplane dose of 7 Gy radiotherapy was given using a 10 MV photon beam, AP–PA technique, a field size of 5 cm x 14 cm with appropriate collimator angulation to cover the soft tissue plane around the neck of the prosthesis [12]. Revision THA was performed 1 year later for pain and aseptic loosening. HO was found outside the radiation field at the time of surgery. Post-operative radiotherapy was recommended, and again a single dose of 7 Gy was delivered uneventfully on post-operative day 2. A 10 MV photon beam was used with opposed AP–PA technique. The target dose was calculated at the midplane and the field size was 5 cm x 14 cm with appropriate collimator angulation to cover the soft tissue plane around the neck of the metal prosthesis. The patient has done well since that time, with last follow-up at 34 months. No problems were encountered with radiation treatment.
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Discussion
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HO is a well known occurrence after hip surgery. Knelles et al [15] summarized the literature and reported an incidence of HO of 8–90%. Among the largest series, it is generally accepted that HO develops in high-risk patients at a rate of 35–57% [16, 17] (Table 2). Fortunately, symptomatic HO develops in less than 10% of these patients and only a few of them require re-operation solely because of HO [18].
The exact activating factors of the condition remain unknown. However, it is believed that the likely cells of origin are the non-circulating connective tissue cells with fibroblastic features, and HO is a result of inappropriate differentiation of these pluripotential mesenchymal cells into osteoblastic stem cells [4, 6, 18–23].
The first use of radiation therapy to prevent HO after THA was at Mayo Clinic, with delivery of 20 Gy in 10 fractions [23]. Subsequently, other investigators [24, 25] showed that 10 Gy given in five fractions yielded successful prophylaxis. Investigations at the Lahey Clinic [26] demonstrated equal success in the prophylaxis of HO using a single dose of 7 Gy after THA. Subsequently, in a randomized trial conducted by Pellegrini et al [27] comparing single dose with fractionated irradiation, single dose was confirmed to be as effective as fractionated radiotherapy. Recently, Lo [28] reviewed the literature and summarized the results of post-operative radiation therapy for prophylaxis of HO after hip surgery.
Experience with re-irradiation of hips to prevent HO is rare. In this report, we have presented four patients who required hip re-operation after a previous single post-operative dose of radiotherapy to the hip for HO prophylaxis. We found that a second treatment was effective in preventing HO. It was expected that soft tissue could tolerate 14 Gy given in two fractions, particularly with such long intervals between the two fractions as in our patients. We encountered no acute or chronic complications.
Received for publication November 28, 2000.
Revision received February 26, 2001.
Accepted for publication April 4, 2001.
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References
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Abstract
Introduction
