From the Research
The first-line treatment for heterotopic ossification (HO) around the hip in an elderly, immobile, wheelchair-bound patient post-TBI is conservative management focused on pain control and maintaining functional status. NSAIDs, particularly indomethacin 25mg three times daily for 3-6 weeks, are the mainstay medication therapy, as supported by 1. This should be accompanied by gentle range of motion exercises to preserve joint mobility, without forcing movement that causes pain. Physical therapy should be initiated to prevent further contractures and maintain existing function. Pain management may also include acetaminophen up to 3000mg daily in divided doses and, if necessary, low-dose opioids for breakthrough pain. Prophylactic measures against gastric irritation from NSAIDs, such as proton pump inhibitors (e.g., omeprazole 20mg daily), are important in elderly patients, as noted in 2. Surgery is generally avoided in this population due to the high risk of complications and limited functional benefit for wheelchair-bound patients, as discussed in 3. NSAIDs work by inhibiting prostaglandin synthesis, which plays a role in the inflammatory cascade that contributes to HO formation. The goal of treatment is to manage symptoms and prevent further functional decline rather than complete resolution of the ossification, as the risk-benefit ratio of aggressive interventions is unfavorable in this patient population. Key considerations in managing HO include:
- Preventing further contractures and maintaining existing function through physical therapy
- Managing pain effectively with NSAIDs, acetaminophen, and low-dose opioids as needed
- Protecting against gastric irritation with proton pump inhibitors
- Avoiding surgery due to its high risk of complications in this patient population, as highlighted in 4 and 5.