Radiation Oncology Journal

The Korean Society for Radiation Oncology (대한방사선종양학회)
권호 표지

Prophylactic Radiotherapy to Prevent the Recurrence of Heterotopic Ossification after Surgical Intervention of the Elbow

주관절에서 이소성 골형성의 재발방지를 위한 예방적 방사선 치료

  • Kim, Hak-Jae (Departments of Radiation Oncology, Seoul National University College of Medicine) ;
  • Kim, Jin-Ho (Departments of Radiation Oncology, Seoul National University College of Medicine) ;
  • Kim, Kyu-Bo (Departments of Radiation Oncology, Seoul National University College of Medicine) ;
  • Choi, Ja-Young (Departments of Radiology, Seoul National University College of Medicine) ;
  • Chung, Moon-Sang (Departments of Orthopedic Surgery, Seoul National University College of Medicine) ;
  • Kim, Il-Han (Departments of Radiation Oncology, Seoul National University College of Medicine)
  • 김학재 (서울대학교 의과대학 방사선종양학교실) ;
  • 김진호 (서울대학교 의과대학 방사선종양학교실) ;
  • 김규보 (서울대학교 의과대학 방사선종양학교실) ;
  • 최자영 (서울대학교 의과대학 영상의학교실) ;
  • 정문상 (서울대학교 의과대학 정형외과학교실) ;
  • 김일한 (서울대학교 의과대학 방사선종양학교실)
  • Published : 2007.12.30
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: Heterotopic ossification is a well-known postoperative and post-traumatic complication of the elbow. We reviewed the treatment outcome for the use of low-dose radiation after surgical intervention of the elbow to prevent recurrence of heterotopic ossification (HO). Materials and Methods: Forty-five patients with HO underwent surgical intervention and postoperative radiotherapy of the elbow. The median age of the patients was 29 years ($16{\sim}75$ years), and 27 of the patients were men and 18 were women. The occurrence of HO was mainly due to surgery after fracture (24/45) and traumatic injury (21/45). Limitation of the range of motion (ROM) was the most common symptom of the patients. Thirty-four patients received postoperative radiotherapy with a dose of 8 Gy in 2 fractions; 5 patients received a dose of 10 Gy in 5 fractions and 6 patients received a dose of 7 Gy in 1 fraction. Postoperative radiotherapy was given on the first two postoperative days for most of the patients. Sixteen patients were not given anti-inflammatory medication and 29 patients were given NSAIDs for $1{\sim}8$ months. Results: After a median follow-up period of 18 months (range $6{\sim}72$ months), 41 patients showed clinical improvement and two patients did not show improvement. Assessment of the ROM showed a mean improvement from $0{\sim}135^{\circ}$ to $60{\sim}145^{\circ}$ (p=0.028), and assessment of the functional outcome according to MEPI was from ($15{\sim}95$) to ($80{\sim}100$) (p<0.0001). Two of the 34 patients that were followed-up with radiography had mild radiological recurrence of heterotopic ossification. No complications were observed after the radiotherapy. Conclusion: These results suggested that low-dose radiation administered after surgical intervention is safe and effective to prevent the recurrence of HO in the elbow.

목적: 주관절의 이소성 골형성은 수술이나 외상 후에 발생하는 흔한 합병증으로 알려져 있다. 본 연구는 주관절에서 발생하는 이소성 골형성의 재발 방지를 위해 예방적 방사선 치료를 시행한 환자들을 대상으로 후향적 분석을 시행하였다. 대상 및 방법: 주관절에 이소성 골형성으로 진단된 45명의 환자가 수술 후 방사선 치료를 시행 받았다. 이소성 골형성의 주된 원인은 골절과 외상이었고 수술 전 주된 증상은 가동관절범위의 제한이었다. 방사선 치료는 대부분의 환자에서 수술 후 2일 안에 시작하였고 1일 조사선량을 4 Gy씩 2회에 걸쳐 총 8 Gy를 조사하였다. 29명의 환자에서 $1{\sim}8$개월 동안 NSAID를 투약 받았다. 치료 후($60{\sim}145^{\circ}$) 측정한 가동관절범위에서 치료 전($0{\sim}135^{\circ}$)보다 통계적으로 유의한 향상을 보였고(p=0.028), MEPI를 이용한 기능지수 평가에서도 치료 전($15{\sim}90$)보다 치료 후($80{\sim}100$)에서 통계적으로 유의하게 증가하였다. 추적 관찰 시 방사선 사진의 판독이 가능했던 34명의 환자 중 2명에서 경미한 이소성 골형성의 재발이 있는 것으로 나타났다. 치료 후 합병증은 관찰되지 않았다. 결 론: 주관절의 이소성 골형성의 경우 수술 후 예방적 방사선 치료를 시행하는 것은 재발 방지를 위해 유용한 치료로 선택될 수 있고, 향후 더 많은 환자를 대상으로 연구가 진행되어야 할 것으로 생각된다.

Keywords

References

  1. Hastings II H, Graham TJ. The classification and treatment of heterotopic ossification about the elbow and forearm. Hand Clinic 1994;10:417-437
  2. Connor JM, Evans DA. Fibrodysplasia ossificans progressiva: the clinical features and natural history of 34 patients. J Bone Joint Surg Br 1982;64:76-83
  3. Bisla RS, Ranawat CS, Inglis AE. Total hip replacement in patients with ankylosing spondylitis with involvement of the hip. J Bone Joint Surg Am 1975;58:233-238
  4. Dicaprio MR, Huo MH, Zatorski LE, et al. Incidence of heterotopic ossification following total hip arthroplasty in patients with prior stroke. Orthopedics 2004;27:41-43
  5. Burd TA, Lowry KJ, Anglen JO. Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures. J Bone Joint Surg Am 2001;83:1783-1788 https://doi.org/10.2106/00004623-200112000-00003
  6. Nilsson OS, Persson PE. Heterotopic bone formation after joint replacement. Curr Opin Rheumatol 1999;11:127-131 https://doi.org/10.1097/00002281-199903000-00008
  7. Coventry MB, Scanlon PW. The use of radiation to discourage ectopic bone (a nine‐year study in surgery about the hip). J Bone Joint Surg 1981;63A:201-208
  8. Lindsay HB, Bert JT, Luu T, et al. Postoperative irradiation for the prevention of heterotopic bone: Analysis of different dose schedules and shielding considerations. Int J Radiat Oncol Biol Phys 1990;19:577-581 https://doi.org/10.1016/0360-3016(90)90483-Z
  9. David AK, Nicholas SM. Preoperative vs. postoperative radiation prophylaxis of heterotopic ossification: a rural community hospital's experience. Int J Radiat Oncol Biol Phys 1998;40: 171-176 https://doi.org/10.1016/S0360-3016(97)00547-6
  10. Seegenschmiedt MH, Keilholz L, Martus P, et al. Prevention of heterotopic ossification about the hip: final results of two randomized trials in 410 patients using either preoperative or postoperative radiation therapy. Int J Radiat Oncol Biol Phys 1997;39:161-171
  11. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, ed. The Elbow and Its Disorders. Philadelphia: W B Saunders Company. 1985:73-91
  12. Park CI, Park WY, Kim IH. Postoperative irradiation in the prevention of hterotopic bone formation. J Korean Soc Ther Radiol Oncol 1985;3:145-149
  13. Thompson HC, Garcia A. Mositis ossificans: aftermath of elbow injuries. Clin Orthop 1967;50:129-134
  14. Mikic ZD, Vukadinovic SM. Late results in fractures of the radial head treated by excision. Clin Orthop 1983;181:220-228
  15. Poggi MM, Thomas BE, Johnstone PA. Excision and radiotherapy for heterotopic ossification of the elbow. Orthopedics 1999;22:1059-1061
  16. McAuriffe JA, Lauderdale F, Wolfson AH. Early excision of heterotopic ossification about the elbow followed by radiation therapy. J Bone Joint Surg Am 1997;79:749-755 https://doi.org/10.2106/00004623-199705000-00015
  17. Heyd R, Strassmann G, Schopohl B, et al. Radiation therapy for the prevention of heterotopic ossification at the elbow. J Bone Joint Surg Br 2001;83:332-334 https://doi.org/10.1302/0301-620X.83B3.11428
  18. Anthony P, Keys HM, Evarts CM, et al. Prevention of heterotopic bone formation with early postoperative irradiation in high risk patients undergoing total hip arthroplasty: comparison of 10 Gy vs. 20 Gy schedules. Int J Radiat Oncol Biol Phys 1987;13:365-369 https://doi.org/10.1016/0360-3016(87)90010-1
  19. Konski AA, Pelligrini VD, Poulter C, et al. Randomized trial comparing single dose vs. fractionated irradiation for prevention of heterotopic bone. Int J Radiat Oncol Biol Phys 1990;18:1139-1142 https://doi.org/10.1016/0360-3016(90)90450-X
  20. Padgett DE, Holley KG, Cummings M, et al. The efficacy of 500 cGy radiation in the prevention of heterotopic ossification after total hip arthroplasty: a prospective, randomized, pilot study. J Arthroplasty 2003;18:677-686 https://doi.org/10.1016/S0883-5403(03)00265-1
  21. Esenwein SA, Sell S, Herr G, et al. Superior efficacy in suppression of heterotopic bone formation using fractionated irradiation of $5\times2$ Gy compared to a single dose of 7 Gy. An experimental study in rats. Acta Orthop Belg 2003;69:119-126
  22. Seegenschmiedt MH, Martus P, Goldmann A, et al. Pre- and postoperative radiotherapy to prevent heterotopic ossification of the hip joint. Strahlenther Onkol 1994;170:2819- 2291
  23. Kolbl O, Knelles D, Barthel T, et al. Randomized trial comparing early postoperative irradiation vs. the use of nonsteroidal anti‐inflammatory drugs for prevention of hterotopic ossification following prosthetic total hip replacement. Int J Radiat Oncol Biol Phys 1997;39:961-966 https://doi.org/10.1016/S0360-3016(97)00496-3
  24. Pakos EE, Ioannidis JP. Radiotherapy vs. nonsteroidal antiinflammatory drugs for the prevention of hterotopic ossification after major hip procedures: a meta‐analysis of randomized trials. Int J Radiat Oncol Biol Phys 2004;60:888-895 https://doi.org/10.1016/j.ijrobp.2003.11.015
  25. Dickens P, Wei WI, Sham JS. Osteosarcoma of the maxilla in Hong Kong Chinese post irradiation for nasopharangeal carcinoma. A report of four cases. Cancer 1999;66:1924-1926 https://doi.org/10.1002/1097-0142(19901101)66:9<1924::AID-CNCR2820660912>3.0.CO;2-9
  26. Kim JH, Chu FC, Woodard HQ, Melamed MP, Huvos A, Cantin J. Radiaton‐induced soft‐tissue and bone sarcoma. Radiology 1978;129:201-208