Pathogenesis and prevention strategies of heterotopic ossification in total hip arthroplasty: a narrative literature review and results of a survey in Germany

Heterotopic ossification (HO) after THA can lead to pain, impaired range of motion and possibly revision surgery. This article summarizes current literature on the pathogenesis of HO in THA and trauma. Second, it presents the results of a survey on prophylactic concepts for HO in Germany. A narrative literature review was conducted by searching three databases (Pubmed, ScienceDirect, the Cochrane library) on the aetiology of HO. Between 2013 and 2014, a questionnaire was sent to 119 orthopaedic and trauma surgery departments in Germany. The acquired form of HO seems to develop after tissue trauma, which induces a local inflammation. A change in tissue conditions, multiple signalling pathways and involvement of several different cell types seem to promote enchondral ossification and finally HO formation. The feed back rate of the survey was 67 %. Eighty-seven percent of all departments currently administer NSAIDs with a mean time span of 3 weeks after surgery for oral prophylaxis. Prophylactic perioperative irradiation is performed in 64 % of trauma/orthopaedic departments if the patient is at risk for HO with a mean dosage of 7 Gy. Basic research detected new pathways and cell signalling mechanisms of HO pathogenesis, which could offer new treatment and prophylaxis options in the near future. So far, there is no uniform strategy for the clinical prophylaxis of HO in THA. Guidelines and new clinical trials need to be developed to further reduce HO rates in THA.