Indomethacin for Heterotopic Ossification Prophylaxis Following Surgical Treatment of Elbow Trauma: A Randomized Controlled Trial

Description

In this presentation, Yousif Atwan discusses a randomized control trial investigating the effectiveness of indomethacin in preventing heterotopic ossification (HO) after elbow surgery for trauma. Atwan begins by explaining that HO, characterized by the formation of extra bone in connective tissues, is a frequent complication following elbow trauma and surgery, leading to diminished range of motion and functional disability in affected patients. The underlying causes of HO remain poorly understood but relate to inflammatory responses following soft tissue injuries.



Indomethacin, a non-steroidal anti-inflammatory drug, has shown promise in preventing HO formation in the lower extremities by inhibiting cyclooxygenase and the differentiation of osteoprogenitor cells. The study referenced also notes that a prior Cochrane review found a significant reduction in HO formation associated with indomethacin during total hip arthroplasty. However, existing literature presents mixed results, particularly regarding its use in elbow trauma. Previous studies showed high rates of adverse effects, including non-union fractures when coupled with radiation therapy, which has prompted further investigation.



This study aims to ascertain whether postoperative indomethacin reduces HO incidence following surgical treatment of elbow trauma. A double-blinded randomized trial was conducted with patients aged 16 to 85 who had sustained elbow injuries requiring surgical fixation. The trial excluded patients at enhanced risk for developing HO and involved a treatment group receiving indomethacin alongside pantoprazole for gastric protection, while the control group received a placebo.



Data was collected to analyze the incidence and classification of HO using the Brooker classification system, identifying the stage of HO formation based on severity. The study followed 164 randomized patients, ultimately evaluating 75 from the indomethacin group and 83 from the control group. Atwan reports that incidences of HO were present in 49% of the indomethacin group compared to 55% of the control group, but no statistically significant difference was found between groups. Similarly, reoperation rates and complications were comparable across both groups.



Atwan concludes that the trial finds no significant differences in HO formation or clinical outcomes, marking it as the first randomized controlled trial on indomethacin for elbow trauma. Although the study yielded no radiographic differences, future investigations will focus on patient-reported outcomes and range of motion assessments to uncover potential clinical differences between treatment regimens. He acknowledges collaborators and expresses gratitude for the opportunity to share the findings.

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