Increased Risk of Heterotopic Ossification Following Revision Hip Arthroplasty for Periprosthetic Joint Infection

Document Type : RESEARCH PAPER

Authors

Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA

Abstract

Purpose: To investigate whether surgery for PJI of the hip, the number of procedures and their duration contribute to risk of HO formation.
Methods: 56 patients with hip PJI undergoing one-stage (10) or two-stage (46) exchange arthroplasty were matched to 112 patients undergoing revision arthroplasty for aseptic failure based on age, gender, body mass index (BMI), surgical approach (all direct lateral) and date of surgery (2006-2013). Patients with Paget’s disease and ankylosing spondylitis, or preoperative HO were excluded. Perioperative pain management included use of the anti-inflammatory medications in all patients without prophylactic radiotherapy. Six-month postoperative radiographs were reviewed based on Brooker classification.
Results: The incidence of overall HO in PJI and aseptic groups was 84% (47/56) and 11% (12/112), respectively. High grade HO (grades 3 and 4) in PJI and aseptic groups were 25% (24/56) and 4% (4/112), respectively. PJI was an independent risk factor for HO in the multivariate analysis (odds ratio of 9.3, 95% CI: 2.9-29.9, p<0.001).
Conclusions: Patients undergoing surgical treatment of hip PJI seem to be at increased risk of developing HO compared to aseptic failure. HO prophylaxis regimens may be recommendable in eligible patients undergoing surgical intervention for PJI of the hip.

Keywords

Main Subjects


1. Board TN, Karva A, Board RE, Gambhir AK, Porter
ML. The prophylaxis and treatment of heterotopic
ossification following lower limb arthroplasty. J Bone
Joint Surg Br. 2007; 89(4):434-40.
2. Garland DE. A clinical perspective on common forms
of acquired heterotopic ossification. Clin Orthop Relat
Res. 1991; 263(1):13-29.
3. Iorio R, Healy WL. Heterotopic ossification after hip
and knee arthroplasty: risk factors, prevention, and
treatment. J Am Acad Orthop Surg. 2002; 10(6):409-16.
4. Neal B, Gray H, MacMahon S, Dunn L. Incidence of
heterotopic bone formation after major hip surgery.
ANZ J Surg. 2002; 72(11):808-21.
5. Ahrengart L. Periarticular heterotopic ossification after
total hip arthroplasty. Risk factors and consequences.
Clin Orthop Relat Res. 1991; 263(1):49-58.
6. Smith TO, Nichols R, Donell ST, Hing CB. The clinical
and radiological outcomes of hip resurfacing versus
total hip arthroplasty: a meta-analysis and systematic
review. Acta Orthop. 2010; 81(6):684-95.
7. Pape HC, Marsh S, Morley JR, Krettek C, Giannoudis PV.
Current concepts in the development of heterotopic
ossification. J Bone Joint Surg Br. 2004; 86(6):783-7.
8. Parvizi J, Gehrke T; The International Consensus
Group on Periprosthetic Joint Infection. Definition of
periprosthetic joint infection. J Arthroplasty. 2014;
29(7):1331.
9. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr.
Ectopic ossification following total hip replacement.
Incidence and a method of classification. J Bone Joint
Surg Am. 1973; 55(8):1629-32.
10. Francés A, Moro E, Cebrian JL, Marco F, Garcí􀆴a-López
A, Serfaty D, et al. Reconstruction of bone defects with
impacted allograft in femoral stem revision surgery.
Int Orthop. 2007; 31(4):457-64.
11. Fransen M, Neal B, Cameron ID, Crawford R,
Tregonning G, Winstanley J, et al. Determinants of
heterotopic ossification after total hip replacement
surgery. Hip Int. 2009; 19(1):41-6.
12. Eggli S, Woo A. Risk factors for heterotopic ossification
in total hip arthroplasty. Arch Orthop Trauma Surg.
2001; 121(9):531-5.
13. Barrack RL, Brumfield CS, Rorabeck CH, Cleland D,
Myers L. Heterotopic ossification after revision total
knee arthroplasty. Clin Orthop. 2002; 404(1):208-13.
14. Tomas X, Bori G, Garcia S, Garcia-Diez AI, Pomes J,
Soriano A, et al. Accuracy of CT-guided joint aspiration
in patients with suspected infection status post-total
hip arthroplasty. Skeletal Radiol. 2011; 40(1):57-64.
15. Ahrengart L, Lindgren U. Heterotopic bone after hip
arthroplasty. Defining the patient at risk. Clin Orthop.
1993; 293(1):153-9.
16. Bozic KJ, Ward DT, Lau EC, Chan V, Wetters NG, Naziri
Q, et al. Risk factors for periprosthetic joint infection
following primary total hip arthroplasty: a case
control study. J Arthroplasty. 2014; 29(1):154-6.
17. Handel M, Brettschneider J, Köck FX, Anders S, Perlick
L, Sell S. Risk factors associated with heterotopic
ossifications in primary total hip arthroplasty. Z
Orthop Ihre Grenzgeb. 2004; 142(5):564-70.
18. Freeman TA, Parvizi J, Della Valle CJ, Steinbeck
MJ. Reactive oxygen and nitrogen species induce
protein and DNA modifications driving arthrofibrosis
following total knee arthroplasty. Fibrogenesis Tissue
Repair. 2009; 2(1):5.
19. Yu PB, Deng DY, Lai CS, Hong CC, Cuny GD, Bouxsein
ML, et al. BMP type I receptor inhibition reduces
heterotopic [corrected] ossification. Nat Med. 2008;
14(12):1363-9.
20. Balboni TA, Gobezie R, Mamon HJ. Heterotopic
ossification: pathophysiology, clinical features, and
the role of radiotherapy for prophylaxis. Int J Radiat
Oncol Biol Phys. 2006; 65(5):1289-99.
21. Tsuji K, Bandyopadhyay A, Harfe BD, Cox K, Kakar
S, Gerstenfeld L, et al. BMP2 activity, although
dispensable for bone formation, is required for
the initiation of fracture healing. Nat Genet. 2006;
38(12):1424-9.
22. Corriere MA, Rogers CM, Eliason JL, Faulk J, Kume
T, Hogan BL, et al. Endothelial Bmp4 is induced
during arterial remodeling: effects on smooth muscle
cell migration and proliferation. J Surg Res. 2008;
145(1):142-9.
23. Miyazono K, Maeda S, Imamura T. BMP receptor
signaling: transcriptional targets, regulation of
signals, and signaling cross-talk. Cytokine Growth
Factor Rev. 2005; 16(3):251-63.
24. Vasileiadis GI, Amanatullah DF, Crenshaw JR, Taunton
MJ, Kaufman KR. Effect of heterotopic ossification
on hip range of motion and clinical outcome. J
Arthroplasty. 2015; 30(3):461-4.
25. Schwarzkopf R, Cohn RM, Skoda EC, Walsh M, Jaffe
F. The predictive power of preoperative hip range
of motion for the development of heterotopic
ossification. Orthopedics. 2011; 34(3):169.