title: Prophylactic radiotherapy against heterotopic ossification following internal fixation of acetabular fractures: a comparative estimate of risk.
abstract: OBJECTIVE
  Radiotherapy (RT) is effective in preventing heterotopic ossification (HO) around acetabular fractures requiring surgical reconstruction. We audited outcomes and estimated risks from RT prophylaxis, and alternatives of indometacin or no prophylaxis.
  
  
  METHODS
  34 patients underwent reconstruction of acetabular fractures through a posterior approach, followed by a 8-Gy single fraction. The mean age was 44 years. The mean time from surgery to RT was 1.1 days. The major RT risk is radiation-induced fatal cancer. The International Commission on Radiological Protection (ICRP) method was used to estimate risk, and compared with a method (Trott and Kemprad) specifically for estimating RT risk for benign disease. These were compared with risks associated with indometacin and no prophylaxis.
  
  
  RESULTS
  28 patients (82%) developed no HO; 6 developed Brooker Class I; and none developed Class II-IV HO. The ICRP method suggests a risk of fatal cancer in the range of 1 in 1000 to 1 in 10,000; the Trott and Kemprad method suggests 1 in 3000. For younger patients, this may rise to 1 in 2000; and for elderly patients, it may fall to 1 in 6000. The risk of death from gastric bleeding or perforation from indometacin is 1 in 180 to 1 in 900 in older patients. Without prophylaxis risk of death from reoperation to remove HO is 1 in 4000 to 1 in 30,000.
  
  
  CONCLUSIONS
  These results are encouraging, consistent with much larger series and endorse our multidisciplinary management. Risk estimates can be used in discussion with patients.
  
  
  CONCLUSIONS
  The risk from RT prophylaxis is small, it is safer than indometacin and substantially overlaps with the range for no prophylaxis.
authors.affiliation: 1 Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: N G
authors.initials: NG
authors.lastname: Burnet
authors.forename: P
authors.initials: P
authors.lastname: Nasr
authors.forename: G
authors.initials: G
authors.lastname: Yip
authors.forename: J E
authors.initials: JE
authors.lastname: Scaife
authors.forename: T
authors.initials: T
authors.lastname: House
authors.forename: S J
authors.initials: SJ
authors.lastname: Thomas
authors.forename: F
authors.initials: F
authors.lastname: Harris
authors.forename: P J
authors.initials: PJ
authors.lastname: Owen
authors.forename: P
authors.initials: P
authors.lastname: Hull
mesh_terms: D065526:Acetabuloplasty / Q000009:adverse effects; D000077:Acetabulum / Q000000981:diagnostic imaging / Q000293:injuries* / Q000528:radiation effects; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007213:Indomethacin / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009999:Ossification, Heterotopic / Q000000981:diagnostic imaging / Q000209:etiology / Q000517:prevention & control / Q000532:radiotherapy*; D011183:Postoperative Complications / Q000517:prevention & control / Q000532:radiotherapy; D011859:Radiography; D012086:Reoperation; D018570:Risk Assessment; D055815:Young Adult
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D007213:Indomethacin
references.citation: J Bone Joint Surg Br. 2006 Dec;88(12):1618-24
references.pmid: 17159175
references.citation: Ann ICRP. 2007;37(2-4):1-332
references.pmid: 18082557
references.citation: Radiology. 1988 Sep;168(3):851-4
references.pmid: 3136510
references.citation: Injury. 2002 Nov;33(9):751-6
references.pmid: 12379382
references.citation: Cochrane Database Syst Rev. 2004;(3):CD001160
references.pmid: 15266441
references.citation: Strahlenther Onkol. 2005 Aug;181(8):529-33
references.pmid: 16044221
references.citation: Med Phys. 2013 Oct;40(10):101702
references.pmid: 24089892
references.citation: Lancet. 2013 Aug 31;382(9894):769-79
references.pmid: 23726390
references.citation: J Bone Joint Surg Am. 1981 Feb;63(2):201-8
references.pmid: 6780568
references.citation: Ann Intern Med. 1991 Nov 15;115(10):787-96
references.pmid: 1834002
references.citation: Int J Radiat Oncol Biol Phys. 2000 Jul 15;47(5):1347-52
references.pmid: 10889389
references.citation: Clin Orthop Relat Res. 1994 Aug;(305):96-105
references.pmid: 8050252
references.citation: J Bone Joint Surg Am. 1996 Nov;78(11):1632-45
references.pmid: 8934477
references.citation: J Bone Joint Surg Am. 2001 Dec;83(12):1783-8
references.pmid: 11741055
references.citation: Int J Radiat Oncol Biol Phys. 2012 Mar 1;82(3):e339-44
references.pmid: 22019241
references.citation: J Bone Joint Surg Br. 2006 Dec;88(12):1613-7
references.pmid: 17159174
references.citation: Lancet. 2012 Sep 22;380(9847):1075-81
references.pmid: 22998717
references.citation: Scand J Rheumatol Suppl. 1996;102:3-8
references.pmid: 8628980
references.citation: Clin Orthop Relat Res. 2013 Sep;471(9):2776-82
references.pmid: 23440617
references.citation: J Orthop Surg Res. 2009 Apr 20;4:12
references.pmid: 19379483
references.citation: Int J Radiat Oncol Biol Phys. 2007 Apr 1;67(5):1499-505
references.pmid: 17234358
references.citation: J Bone Joint Surg Br. 2003 Jul;85(5):700-5
references.pmid: 12892193
references.citation: Int J Radiat Oncol Biol Phys. 1997 Dec 1;39(5):961-6
references.pmid: 9392532
references.citation: Radiat Oncol. 2012 Aug 21;7:140
references.pmid: 22908888
references.citation: Expert Opin Pharmacother. 2008 Apr;9(5):767-86
references.pmid: 18345954
references.citation: J Bone Joint Surg Br. 1997 Nov;79(6):959-63
references.pmid: 9393912
references.citation: J Surg Oncol. 2012 May;105(6):570-6
references.pmid: 22012601
references.citation: Clin Orthop Relat Res. 2009 Feb;467(2):526-30
references.pmid: 18820982
references.citation: J Bone Joint Surg Br. 2005 Jul;87(7):969-73
references.pmid: 15972913
references.citation: Pract Radiat Oncol. 2012 Apr-Jun;2(2):151-4
references.pmid: 24674090
references.citation: J Bone Joint Surg Br. 2005 Jan;87(1):2-9
references.pmid: 15686228
references.citation: J Bone Joint Surg Am. 1973 Dec;55(8):1629-32
references.pmid: 4217797
references.citation: Radiology. 1978 Nov;129(2):501-8
references.pmid: 279941
references.citation: Am J Clin Oncol. 1989 Oct;12(5):411-5
references.pmid: 2508462
references.citation: Crit Rev Oncol Hematol. 2012 Sep;83(3):393-406
references.pmid: 22138059
references.citation: BMJ. 2013 Jun 11;346:f3195
references.pmid: 23757736
references.citation: J Bone Joint Surg Br. 2004 Aug;86(6):783-7
references.pmid: 15330014
references.citation: J Bone Joint Surg Br. 2011 Feb;93(2):229-36
references.pmid: 21282764
references.citation: Semin Immunopathol. 2011 May;33(3):273-86
references.pmid: 21240489
references.citation: Ann Intern Med. 1988 Sep 1;109(5):359-63
references.pmid: 3261560
references.citation: Strahlenther Onkol. 2006 Aug;182(8):431-6
references.pmid: 16896588
references.citation: Int J Radiat Oncol Biol Phys. 1988 Mar;14(3):471-6
references.pmid: 3343154
references.citation: Int J Radiat Oncol Biol Phys. 1997 Aug 1;39(1):161-71
references.pmid: 9300751
references.citation: Ann Intern Med. 1991 Feb 15;114(4):257-63
references.pmid: 1987872
references.citation: J Bone Joint Surg Br. 1998 Mar;80(2):259-63
references.pmid: 9546456
references.citation: Ann R Coll Surg Engl. 2006 Mar;88(2):151-6
references.pmid: 16551406