Reconstruction of the proximal radius with 3D-printed personalized prosthesis after tumor resection: case series.

BACKGROUND: Giant cell tumor of bone (GCTB) (Campanacci III) or malignant tumors extend to the epiphyseal region of the proximal radius, and intra-articular resection of the proximal radius is often needed. In the present study, we present the patients who underwent reconstruction of the proximal radius with 3D-printed personalized prosthesis after tumor resection, aiming to describe the prosthesis design and surgical technique and evaluate the clinical outcomes of this method. METHODS: Between November 2018 and January 2021, 9 patients received radial hemiarthroplasty with 3D-printed personalized prostheses after tumor resection. The pathologic diagnosis was GCTB (Campanacci III) in 7 patients, osteosarcoma (IIB) in 1 patient, and synovial sarcoma (IIB) in 1 patient. The range of motion (ROM) and strength in terms of elbow flexion/extension and forearm supination/pronation were evaluated. Pain was assessed by the visual analog scale (VAS) preoperatively and at each follow-up visit. To evaluate the functional outcome, the Mayo Elbow Performance Score (MEPS) system and the Musculoskeletal Tumor Society (MSTS) scoring system were administered at each follow-up visit. Complications and oncological outcomes were recorded. RESULTS: The patients were followed from 24 to 51 months, with a median follow-up of 35 months. No patients were lost to follow-up. During the follow-up, local recurrence and metastasis were not observed. The VAS score improved from a median of 5 points (range 4-7) preoperatively to 1 point (range 0-2) at the last follow-up visit. The mean MEPS score was 88.5% (83-93), and the mean MSTS score was 25.3 (24-27) at the last follow-up visit. No complications such as infection and aseptic loosening were detected. CONCLUSIONS: The implantation of a 3D-printed personalized prosthesis after proximal radial resection showed excellent oncologic outcomes and postoperative function at short-term follow-up and is a viable alternative method for reconstruction of the proximal radius bone defect after tumor resection.

Arteriovenous Malformation Presenting With Bone Destruction of the Proximal Radius: A Case Report.

Erosive bony lesions are a frequent manifestation of numerous etiologies, spanning from malignancy and metabolic disorders to chronic inflammatory conditions like sarcoidosis. However, arteriovenous malformations (AVM) are a less prevalent etiology for this condition. The presentation of erosive bony lesions is diverse, influenced by factors such as age, gender, size, and extent of the lesion. Multiple imaging modalities are employed to achieve a diagnosis, including plain radiograph, Doppler ultrasound, computed tomography, angiography, and magnetic resonance imaging.

Clinical and radiological evaluation of radial neck factures in children and adolescents treated by percutaneous leverage reduction with Kirschner wire stabilization.

PURPOSE: The aim of the study was to evaluate the clinical and radiological results of surgical treatment of radial neck fractures in children and adolescents by percutaneous leverage with Kirschner wire stabilization. METHODS: A retrospective clinical and radiographical evaluation was performed on a cohort of 61 patients (mean age 9.7 years; range 3 to 15) with isolated, unilateral radial neck fractures treated between 2009 and 2019. The mean duration of follow-up was 4.2 years (range 2 to 9 years). All fractures were types III and IV according to Judet's classification. RESULTS: After mean follow-up, the radiographic results according to Metaizeau were rated as excellent in 70.5% of respondents, good in 27.9%, satisfactory in 1.6%. According to Mayo Elbow Performance Score, 95.1% of respondents obtained a very good result, 3.3% good, and 1.6% satisfactory. The mean radial neck-shaft angle changed from a mean 51.5° before operation to 3.8° postoperatively (p<0.001). The mean translation was 3.1mm before surgery and 0.5mm postoperatively (p<0.001). No limb axis deviation, elbow joint instability, and infection of the implant insertion site were observed. No statistically significant differences were noted between girls and boys (p>0.05). CONCLUSIONS: Our findings indicate that percutaneous leverage with Kirschner wire stabilization is an effective and safe method for treating isolated radial neck fractures, characterized by a low risk of iatrogenic complications.

Functional Postoperative Outcome for 92 Cases of Radial Head Fractures: A PROM-Based Retrospective Study.

Background: Fractures of the radial head are common injuries, whereas, in the case of displaced fractures, surgical treatment using screw or plate osteosynthesis, excision, or replacement of the radial head is required. However, data about patient-related outcomes (PROM) for different types of radial head fractures is limited in the current literature. Therefore, this study was conducted to evaluate the functional outcome after operatively treated radial head fractures and to further correlate these results with the initial modified Mason classification. Methods: In this retrospective study, all suitable patients with surgical treatment of a radial head fracture were identified. Only patients with Mason II-IV fractures were included. All patients completed the Elbow Self-Assessment Score (ESAS) questionnaire. Data on fracture classification, type of surgery, and revision operations (if needed) were assessed. Results: A total of 92 patients suffering from fractures of the radial head (57 Mason II, 35 Mason III-fractures) who were operatively treated at our institution were enrolled. There were 42 (47.7%) female and 50 (54.3%) male patients with an average age of 47.5 ± 14.1 years. Screw osteosynthesis was performed in 67 patients, plate osteosynthesis in 20 patients, and five patients received radial head arthroplasty. The average ESAS score accounted for 89.7 ± 16.7. Mason II fractures showed significantly better functional results with higher ESAS scores (92.3 ± 13.9 vs. 85.4 ± 20.1) as well as significantly lower rates of necessary implant removal (0 vs. 5 (14.3%) than Mason III fractures. Screw osteosynthesis showed significantly better functional ESAS scores, 91.0 ± 16.5, than plate osteosynthesis, with 85.3 ± 17.6 (p = 0.041), but was predominantly used in Mason II fractures. Conclusions: Surgical treatment using screw- and plate osteosynthesis of radial head fractures provides a good overall outcome. The postoperative function is associated with the initial Mason classification as the patients' reported outcome was worse in Mason III fractures compared to Mason type II fractures. In this context, the ESAS score can be considered a useful tool for the assessment of the patient-based functional outcome.

Anthropometric Study of Proximal Radius in Below-Average Height Thai Women and Its Correlation with Commercially Available Radial Head Prostheses.

Background: Most radial head prostheses were designed in Western countries based on the anatomical characteristics of Western populations. We hypothesised that these prostheses are too large for below-average height Thai women. The objective of this study is to evaluate the anthropometric parameters of the proximal radius in such a population and its correlation with commercially available prostheses. Methods: Dominant elbows of 124 Thai women whose height was <155 cm were studied. Using the standard anteroposterior and lateral radiographic images, the head diameter and thickness, the distance between the articular surface and radial tuberosity, the narrowest intra-medullary canal diameter and the narrowest outer diameter of the radial neck were measured. Correlations between body height and each radiographic parameter were assessed using the Pearson correlation coefficient (PCC). The specifications of the commercial metallic radial head implants were reviewed and used to evaluate the relevant radiographic parameters. Results: Mean of the minimum and maximum head diameter was 18.54 ± 1.11 mm and 19.13 ± 1.17 mm, respectively; the thickness was 7.43 ± 0.69 mm, the distance between the articular surface and tuberosity was 19.05 ± 1.45 mm, the intra-medullary canal diameter was 7.63 ± 1.2 mm and the outer diameter of the radial neck was 11.13 ± 1.26 mm. There is a poor correlation between the participant's height and each parameter (PCC ≤ 0.50). In 24.2% of the participants, the smallest size of prosthetic designs with a head diameter of 20 mm is larger than +2 mm in reference to minor diameter. The minimum prosthetic head thickness is greater than the average value of the participants in 12 out of 15 designs. One participant has an outer neck diameter smaller than the smallest stem diameter of three designs. Conclusions: Surgeons must be aware that commercially available radial head replacement implants may be too large for below-average height Thai women. Level of Evidence: Level IV (Prognostic).

Diagnosis, treatment and complications of radial head and neck fractures in the pediatric patient.

Radial head and neck fractures represent up to 14% of all pediatric elbow fractures and can be a difficult challenge in the pediatric patient. In up to 39% of proximal radius fractures, there is a concomitant fracture, which can easily be overlooked on the initial standard radiographs. The treatment options for proximal radius fractures in children range from non-surgical treatment, such as immobilization alone and closed reduction followed by immobilization, to more invasive options, including closed reduction with percutaneous pinning and open reduction with internal fixation. The choice of treatment depends on the degree of angulation and displacement of the fracture and the age of the patient; an angulation of less than 30 degrees and translation of less than 50% is generally accepted, whereas a higher degree of displacement is considered an indication for surgical intervention. Fractures with limited displacement and non-surgical treatment generally result in superior outcomes in terms of patient-reported outcome measures, range of motion and complications compared to severely displaced fractures requiring surgical intervention. With proper management, good to excellent results are achieved in most cases, and long-term sequelae are rare. However, severe complications do occur, including radio-ulnar synostosis, osteonecrosis, rotational impairment, and premature physeal closure with a malformation of the radial head as a result, especially after more invasive procedures. Adequate follow-up is therefore warranted.

Chondrosarcoma of the proximal radius treated by wide resection and reconstructed by 3D printed implant: A case report and description of surgical technique.

INTRODUCTION: Chondrosarcoma is the second most common primary malignancy of bone that can occur in multiple locations in the skeleton. It has been rarely reported in the proximal radius. While surgical resection is the primary treatment modality for individuals with localized disease, reconstruction can be challenging in the elbow joint due to its complex anatomy. 3D printing technology can be used in such complex cases to restore the normal anatomy after resection. CASE PRESENTATION: We present a case of mesenchymal chondrosarcoma in a 33-year-old male occurring in the proximal radius, restricting his elbow motion. That was resected and reconstructed using 3D modeling. Restoring a functional range of motion without instability. DISCUSSION: Many surgical options for chondrosarcoma presented over the years including en bloc resection, resection with or without reconstruction, or amputation. Usage of 3D modeling in the orthopedic surgery field is relatively new and it can be used in pre-operative planning and shortens surgical time. 3D printing in our case helped in obtaining a full range of motion (flexion, extension, pronation, and supination) for the patient. CONCLUSION: It's important to reconstruct elbow joint support structure and function after resection of such a large malignant tumor in young patients. We used 3D printed implant to maintain a functional limb and it was an excellent alternative treatment.

Fractures of the proximal radius in children: management and results of 100 consecutive cases.

INTRODUCTION: Pediatric radial neck and head fractures are rare, accounting for only 1% of all fractures in children. The aim of this study is to describe the management and results of the respective fracture types and different injury characteristics. MATERIALS AND METHODS: This study performs a retrospective data analysis of 100 consecutive patients with a fracture of the proximal radius treated in a single high-volume pediatric trauma center. RESULTS: One hundred patients [mean age 7.5 years (1-15)] were documented with a fracture of the proximal radius between 3/2011 and 12/2019. The gender distribution was 62 girls and 38 boys. Twenty-seven patients had concomitant injuries. Conservative treatment was performed in 63 patients (Judet I = 27; II = 30; III = 6; Mason I = 2) using an above-the-elbow cast for 21 days (6-35). Surgical treatment was performed in 37 patients (Judet II = 3; III = 22; IV = 5; V = 7) using elastic stable intramedullary nailing (ESIN). Open reduction was necessary in five cases, and additional immobilization was performed in 32 cases. Six complications occurred: loss of implant stability (n = 2), healing in malalignment, pseudarthrosis, radioulnar synostosis, and a persisting hypoesthesia at the thumb. As a result, two ESIN osteosynthesis were revised, and one radial head resection was performed. Loss of movement was seen in 11% of cases, overall Mayo elbow performance index (MEPI) was 99.8 (90-100), and none of the patients experienced negative impacts on activities of daily life. CONCLUSIONS: Proximal radial fractures occur predominately without dislocation. Good results are obtained with conservative treatment throughout. In cases with displacement exceeding growth-related correction, ESIN is the undisputed treatment of choice. Open surgery and long immobilization periods should be avoided whenever possible.

Estudio morfométrico del radio proximal en una población chilena / Morphometric study of the proximal radius in a Chilean population

RESUMEN: El objetivo de esta investigación fue determinar la morfometría del extremo proximal del radio, mediante mediciones efectuadas en la cabeza, cuello y tuberosidad del radio, en una población chilena y compararlas según sexo. Se efectuó un estudio transversal analizando exámenes de Tomografía Computarizada (TC) de codo, realizados entre enero de 2014 y diciembre de 2018. Se incluyó 32 TC, correspondientes a 16 hombres y 16 mujeres. Se transfirió las imágenes formateadas al software RadiAnt, para efectuar las mediciones en el radio proximal. El análisis estadístico de los resultados se realizó mediante el software SPSS 22. El diámetro de la cabeza del radio en hombres osciló entre 22,8±1,3 y 25,0±1,7 mm; en mujeres osciló entre 19,4±1,4 y 20,7±1,4 mm. El diámetro del cuello del radio proximal en hombres osciló entre 14,0±0,8 y 15,6±0,7 mm; en mujeres osciló entre 11,7±0,8 y 13,3±1,3 mm. El diámetro del cuello del radio distal en hombres osciló entre 14,4±1,0 y 16,0±1,2 mm; en mujeres osciló entre 12,5±1,0 y 13,8±1,5 mm. El diámetro de la tuberosidad radial en hombres osciló entre 15,1±1,5 y 17,7±1,8 mm; en mujeres osciló entre 13,2±1,1 y 15,5±1,8 mm. El promedio de altura de la cabeza del radio fue de 11,2±1,2 mm en hombres y de 9,5+0,8 mm en mujeres. El análisis comparativo entre sexos mostró diferencias estadísticamente significativas en todas las mediciones precedentes. El promedio de altura del cuello del radio fue de 11,2±1,2 mm en hombres y 10,1±1,6 mm en mujeres, sin diferencia significativa (p= 0,15). Los valores promedios de la morfometría del radio proximal de la población chilena difieren de los descritos para la población europea y presentan algunas similitudes con la población china. Nuestros resultados pueden ser de utilidad para el diseño de implantes y prótesis para el extremo proximal del radio y para una correcta planificación quirúrgica en ortopedia y traumatología.

SUMMARY: The aim of this research was to determine the morphometry of the proximal radius in a Chilean population, by means of measurements made in head of radius, neck of radius and radial tuberosity, and to compare them according to sex. A cross-sectional study was conducted analyzing Computed Tomography scans (CT) of elbows, performed between January 2014 and December 2018. Thirty-two CT corresponding to 16 men and 16 women were included. The formatted images were transferred to the RadiAnt software in order to perform measurements in the proximal radius. The statistical analysis of the results was performed using the SPSS 22 software. The diameter of the head of radius in men ranged between 22.8±1.3 and 25.0±1.7 mm; in women it ranged between 19.4±1.4 and 20.7±1.4 mm. The diameter of the proximal neck of radius in men ranged between 14.0±0.8 and 15.6±0.7 mm; in women, it ranged between 11.7±0.8 and 13.3±1.3 mm. The diameter of the distal neck of radius in men ranged between 14.4±1.0 and 16.0±1.2 mm; in women, it ranged between 12.5±1.0 and 13.8±1.5 mm. The diameter of radial tuberosty in men ranged between 15.1±1.5 and 17.7±1.8 mm; in women, it ranged between 13.2±1.1 and 15.5±1.8 mm. The mean height of the head of radius was 11.2±1.2 mm in men and 9.5±0.8 mm in women. Statistically significant sex differences were revealed in all the preceding measurements. The mean height of the neck of radius was 11.2±1.2 mm in men and 10.1±1.6 mm in women, with no significant difference (p= 0.15). The average values of morphometry of the proximal radius of the Chilean population differ from those describing the European population, and show some similarities with the Chinese population. Our results may be useful to design of implants and prostheses for the proximal radius, and to correct surgical planning in orthopedics and traumatology.

Impinging exostoses of the proximal radius: a report of two cases with distinct clinical features.

Owing to the rotatory motion of proximal radius and the closely apposed anatomic structures, cortically based osseous lesions at the level of the proximal forearm may produce symptomatic impingement. While osseous impingement onto the adjacent proximal ulna may result in limited forearm rotation, impingement on the surrounding soft-tissue structures may produce symptoms as well. Here, we describe two cases of symptomatic proximal radius exostosis, each of which produced distinct clinical symptoms. In the first case, impingement on the posterior interosseous nerve produced symptoms of radiating forearm pain and paresthesia resembling radial tunnel syndrome. In the second case, impingement of the exostosis on the distal biceps tendon resulted in painful mechanical snapping with rotation of the forearm. In both cases, symptoms rapidly improved after surgical excision.

Corrective osteotomy for a malunited proximal radius fracture causing radio-capitellar dislocation in a paediatric patient: A case report.

BACKGROUND: Malunited proximal radius fractures causing dislocation of the radio-capitellar joint are rare. We present a case of a two-year-old female patient with such an injury who was treated with a proximal radius osteotomy with good long-term outcomes. METHOD/RESULTS: Case study of a single patient with a malunited proximal radius fracture which was identified as causing radio-capitellar dislocation who underwent corrective osteotomy with a good result. CONCLUSION: Our opinion is that a corrective osteotomy for a malunited proximal radius fracture causing radio-capitellar dislocation is a sound treatment option and that no supplementary soft tissue reconstruction such as annular ligament exploration/reconstruction is necessary.

Idiopathic Proximal Radioulnar Synostosis - A Rare Case Report and Review of Literature.

INTRODUCTION: Radioulnar synostosis is a bony connection between the radius and ulna, which causes restriction of the active and passive rotational movements of the forearm such as supination and pronation, which can lead to significant functional disability in the patients. CASE REPORT: A 35-year-old male carpenter presented with the complaint of right forearm supination and pronation restriction for the past 8 months with minimal pain at the elbow region with no previous history of trauma or surgery. On examination, forearm supination and pronation movements were completely restricted with normal elbow flexion and extension and with no neurovascular deficit. X-ray of the right radius ulna with elbow revealed synostosis between proximal radius and ulna at the level of the radial tuberosity. Synostosis was removed using both anterior and posterior approaches. Postoperatively patient is having good supination and pronation movements, no pain, and difficulty in his occupation. CONCLUSION: Idiopathic proximal radioulnar synostosis should be suspected in patients having restricted rotatory movements of forearm with no previous history of trauma or surgery and this is the first reported case of idiopathic proximal radioulnar synostosis. Complete resection of the synostosis with early initiation of aggressive physiotherapy helps in getting good functional outcomes.

Treatment of Massive Giant Cell Tumor of Bone of the Proximal Radius. Case Study.

This paper presents a case of a massive giant cell tumor of bone (GCTB), Campanacci and Enneking type III, in an atypical location at the proximal end of the radius. In type I and II cases, surgical treatment is the treat-ment of choice: curettage of the lesion, replacement of bone defects with bone grafts or cement. Advanced type III changes frequently require segmental resection and joint reconstruction. In our patient, a segmental resection of the proximal third of the radius and infiltrated surrounding soft tissues was performed without reconstruction of the radius. A good clinical outcome without a relapse has been noted at one year post surgery.

Safe zone for the posterior interosseous nerve with regard to the lateral and posterior approaches to the proximal radius.

PURPOSE: The posterior interosseous nerve (PIN) is at risk during the posterior and lateral approaches to the proximal radius. We aimed to define a safe zone for these approaches to avoid injury of the PIN and to evaluate their close and changing relationship to the nerve during forearm rotation. METHODS: The study collective consisted of 50 upper limbs. After performance of the lateral approach, the distance between the tip of the radial head and the PIN's exit point from the supinator (= distance 1) and the shortest interval between the nerve's exit to the radial margin of the ulna (= distance 2) were measured in maximum pronation and supination. Then, the dorsal approach was conducted and again distance 1 and the interval between the distal margin of the anconeus and the nerve's exit point (distance 2) were evaluated (pronation and supination). RESULTS: There were significantly shorter distances during supination in comparison to pronation. Regarding the lateral approach, distance 1 changed from a mean of 60.3 mm (supination) to 62.7 mm in pronation (p < 0.001). For the dorsal approach, distance 1 decreased significantly (p < 0.001) from 62.9 mm (pronation) to 60.2 mm (supination). CONCLUSION: Supination during the lateral and dorsal approaches to the proximal radius needs to be avoided to protect the PIN. Furthermore, the nerve appeared at an interval between 45 and 84.1 mm (lateral approach) and 47.5-93.8 mm (dorsal approach), respectively. Therefore, care must be taken at this height during extension of the approaches in a distal direction.

Avoiding radial nerve palsy in proximal radius shaft plating - a cadaver study.

BACKGROUND: Opinions vary concerning the position of forearm rotation during detachment of the supinator in radial nerve palsy Henry's and Thompson's approaches. PURPOSE: To define the optimal forearm position for a safe detachment of the supinator during these approaches and to clarify their close relationship to the posterior interosseous nerve (PIN). METHODS: The study sample comprised 90 upper extremities of 45 human adult cadavers, embalmed using Thiel's method. After detection of the radial nerve in the interval between the brachialis and brachioradialis, its pathway was traced to the Arcade of Frohse (AF). Measurements involved the distance between the AFand the radial border of the distal biceps tendon (DBT) in pronation and supination, the interval between the AF and the radiocapitellar joint space (RCJS) in supination and the radial length (RL). RESULTS: Distances between the DBT and the AF were significantly shorter during pronation (right side: 14.1 ± 3.4mm; left side: 13.5 ± 3.2mm) compared with supination (right side: 20.5 ± 3.6mm; left side: 19.8 ± 3.5mm) for both right and left extremities. The mean interval between the AF and the centre of the RCJS was 25.2 ± 5.9mm for the right side and 24.7 ± 5.6mm for the left side, which correlated positively with the RL. CONCLUSION: These results indicate a safe detachment of the supinator from the radius with the forearm placed in supination during both Henry's and Thompson's approaches.

Giant-cell tumour of proximal radius in a 50-year-old female with wrist drop: a rare case report.

Giant-cell tumour is a locally aggressive tumour of long bones of epiphyseal region commonly occurring in adults aged 20-40 years. Most common location is distal femur, proximal tibia, and distal radius. Different treatment options being used are curettage with bone graft or bone cement, resection with arthrodesis, reconstruction, radiation, and chemotherapy. We are reporting a case of giant-cell tumour of right proximal radius in a 50-year-old female with posterior interosseous nerve palsy. It is very rare, and only four cases have been reported in the literature. It was treated by wide margin resection with fibular grafting, titanium elastic nail system along with cancellous bone graft reconstruction.

Radial shortening osteotomy reduces radiocapitellar contact pressures while preserving valgus stability of the elbow.

PURPOSE: Shortening osteotomy of the proximal radius might represent a potential salvage procedure in symptomatic radiocapitellar osteoarthritis, which could decrease radiocapitellar load while preserving the native radial head. In an in-vitro biomechanical investigation, we sought to determine whether shortening osteotomy of the proximal radius (1) decreases the radiocapitellar joint pressure upon axial loading and (2) retains valgus stability of the elbow. In addition, the anatomic configuration of the lesser sigmoid notch was evaluated to assess possible contraindications. METHODS: Axial loading (0-400 N) and valgus torque (7.5 N m) over the full range of motion were applied to 14 fresh-frozen specimens before and after shortening osteotomy of the proximal radius by 2.5 mm. Radiocapitellar and ulnohumeral load distribution during axial compression was evaluated using a digital pressure mapping sensor. Valgus displacement was analyzed with a 3D camera system. The inclination angle (α) of the lesser sigmoid notch was assessed via 50 CT scans. RESULTS: Up to axial loading of 250 N, shortening osteotomy caused a significant decrease in radiocapitellar contact pressures (p < 0.041). Valgus stability of specimens did not differ before and after shortening osteotomy (n.s.). The mean inclination angle (α) of the lesser sigmoid notch was 11.3° ± 6.3°. 46% had an inclination angle of ≤ 10° (type I). 46% had an inclination angle of 11°-20° (type II). In 8%, the inclination angle was >20° (type III). CONCLUSION: Shortening osteotomy of the proximal radius can decrease radiocapitellar contact pressures during axial loading of up to 250 N. Primary valgus stability is not relevantly influenced by this procedure. In few patients, shortening osteotomy may cause radioulnar impingement of the radial head at the distal edge of the lesser sigmoid notch due to an inclination angle of >20°. Shortening osteotomy might be a promising treatment option to decrease pain levels in case of isolated radiocapitellar osteoarthritis.

The clinical implications of heterotopic ossification in patients treated with radial head replacement for trauma: A case series and review of the literature.

Radial head arthroplasty (RHA) is an acceptable treatment for comminuted radial head fractures (RHF). Fourteen patients with no postop HO prophylaxis were treated with RHA for comminuted RHF. A 50% incidence in HO was seen following RHA with a statistically increased risk (p ≤ 0.05) of reoperation compared to those without HO. Decreased ROM was seen on the affected side (p ≤ 0.05); patients without HO showed no statistical difference (p ≥ 0.05) in ROM or grip strength. HO following RHA increases patient risk for reoperation and decreases ROM. We recommend HO prophylaxis with NSAIDs and/or radiotherapy if no direct patient contraindications are found.