术前与术后放疗对接受股骨近端切除术的神经肌肉性髋关节发育不良儿童预防异位骨化的效果
Outcomes of Preoperative Versus Postoperative Radiation for Heterotopic Ossification Prevention in Children With Neuromuscular Hip Dysplasia Undergoing Proximal Femoral Resection.
作者信息
Hess Clayton B, Stein-Wexler Rebecca, Qi LiHong, Davids Jon R, Fragoso Ruben C
机构信息
Department of Radiation Oncology, Francis H. Burr Proton Therapy Center, Massachusetts General Hospital, Harvard University, Boston, MA.
Department of Radiation Oncology, UC Davis NCI-Designated Comprehensive Cancer Center, Sacramento, CA.
出版信息
J Pediatr Orthop. 2019 Feb;39(2):e102-e107. doi: 10.1097/BPO.0000000000001018.
BACKGROUND
Few studies exist to inform the extrapolated practice of irradiating children for heterotopic ossification (HO) prevention. We report the incidence of HO formation following prophylactic preoperative compared with postoperative radiation therapy (RT) in children with neuromuscular hip dysplasia (NHD) following proximal femoral resection (PFR).
METHODS
A retrospective, 2-institution chart review was performed. Eligibility was limited to patients with at least 1 year of follow-up. Evaluation included radiographic HO grading by a combined severity scale, assessment of synchronous symptoms of pain or decreased range of motion, and stratification by preoperative versus postoperative reception of RT. A control cohort included 4 nonirradiated hips with NHD after PFR.
RESULTS
Twenty-five hips in 20 children met eligibility criteria. Eleven hips were irradiated preoperatively and 14 postoperatively. Radiographic evidence of post-RT development of radiographic evidence of heterotopic ossification (rHO) was found in all 25 hips and earlier in patients irradiated preoperatively (median time to rHO was 4.0 vs. 15.7 mo, P=0.03, 95% confidence interval, 0.24-21.5). There was no statistically significant difference in the development of symptomatic HO (P=0.62) between the preoperative (45.5%) and postoperative (35.7%) groups, nor in HO grade (P=0.34). Seven (28%) of the 25 hips (5 preoperative and 2 postoperative) had documentation of rHO-free intervals after surgery, with an average duration of 5.6 months, while the remaining presented with rHO at first follow-up visit. All eligible control hips (100%) developed rHO and symptomatic heterotopic ossification.
CONCLUSIONS
Perioperative RT did not prevent the formation of HO in any child with NHD after PFR. Extrapolation of evidence of the efficacy of RT for HO prevention in ambulatory adults after traumatic hip injury to a population of children with central nervous system injury and NHD may be premature. Additional studies are needed to clarify optimal prevention of HO in this population.
LEVEL OF EVIDENCE
Level III-therapeutic retrospective comparative study.
背景
关于预防性照射儿童以预防异位骨化（HO）的推断性实践的研究很少。我们报告了在近端股骨切除（PFR）后患有神经肌肉性髋关节发育不良（NHD）的儿童中，术前预防性放疗与术后放疗（RT）后HO形成的发生率。
方法
进行了一项回顾性的、涉及两个机构的病历审查。纳入标准仅限于至少随访1年的患者。评估包括通过综合严重程度量表进行的放射学HO分级、对疼痛或活动范围减小等同步症状的评估，以及根据术前与术后接受RT进行分层。一个对照组包括4例PFR后未接受放疗的NHD髋关节。
结果
20名儿童的25个髋关节符合纳入标准。11个髋关节术前接受放疗，14个术后接受放疗。在所有25个髋关节中均发现了放疗后异位骨化（rHO）的放射学证据，且术前放疗的患者出现得更早（rHO的中位时间为4.0个月对15.7个月，P = 0.03，95%置信区间，0.24 - 21.5）。术前组（45.5%）和术后组（35.7%）之间有症状的HO发生情况（P = 0.62）以及HO分级（P = 0.34）均无统计学显著差异。25个髋关节中有7个（28%）（5个术前和2个术后）有术后无rHO间隔的记录，平均持续时间为5.6个月，而其余在首次随访时出现rHO。所有符合条件的对照髋关节（100%）均出现了rHO和有症状的异位骨化。
结论
围手术期放疗并不能预防任何PFR后NHD儿童HO的形成。将创伤性髋关节损伤后门诊成人中放疗预防HO的有效性证据外推至中枢神经系统损伤和NHD儿童人群可能为时过早。需要更多研究来明确该人群中HO的最佳预防方法。
证据水平
III级 - 治疗性回顾性比较研究。
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