Heterotopic ossification (HO) prophylaxis after distal biceps repair

Abstract

Hypothesis and Background

A potential complication of distal biceps repair is heterotopic ossification (HO), which impacts both limb function and overall patient outcomes. Common HO prophylaxis methods include nonsteroidal anti-inflammatory drugs or localized radiation therapy. The purpose of this systematic review was to determine an effective means of providing HO prophylaxis following distal biceps repair.

Methods

A systematic review of the literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched for studies published after 1998: PubMed, Embase, and Cochrane Library. Studies were included if they compared patients who were placed on HO prophylaxis following distal biceps repair compared to those that were not placed on HO prophylaxis, were prospective randomized controlled trials or retrospective case-control studies, and evaluated HO prophylaxis regimens. Studies that were not written in English, analyzed animals or cadavers, and did not directly evaluate patients undergoing distal biceps repair, did not study HO rophylaxis, or had alternative study designs were excluded.

Results

The initial search identified 134 studies, 4 of which met the inclusion criteria and were included in the study. Each of these 4 (100%) studies evaluated indomethacin, and 1 (25%) study evaluated both indomethacin and meloxicam. The included studies evaluated HO prophylaxis in the setting of both one- and two-incision distal biceps repairs. Overall, 2 of the 4 (50%) studies supported the use of indomethacin as HO prophylaxis, 1 of 4 (25%) did not support the use of indomethacin for HO prophylaxis, and 1 of 4 (25%) studies reported that indomethacin and meloxicam are similarly effective HO prophylaxis drugs. None of the studies meeting the inclusion criteria analyzed radiation therapy as a potential method for HO prophylaxis.

Discussion and Conclusion

Indomethacin is commonly used as a prophylactic measure for HO following distal biceps repair; however, based on the results of this study, it is not necessary to use this routinely due to its limited efficacy in preventing HO and potential risks (eg, gastrointestinal upset, bleeding) associated with the medication. Future randomized studies should evaluate the use of other nonsteroidal anti-inflammatory drugs (eg, meloxicam) for HO prophylaxis in addition to not using any HO prophylaxis following either one- or two-incision distal biceps repairs.