Executive Summary of the American Radium Society (ARS) Appropriate Use Criteria (AUC) for the Use of Radiation in the Prevention and Treatment of Heterotopic Ossification (HO).

Abstract

Objectives: To summarize the current evidence for radiation therapy (RT) in the prevention and treatment of heterotopic ossification (HO), including patient selection, optimal RT technique, and associated risks.

Methods: This multispecialty-led committee includes radiation oncologists, rheumatologists, orthopedic surgeons, and physical medicine/rehabilitation physicians. Using the population, intervention, comparator, outcome, timing and study design (PICOTS) framework, evidence regarding treatment outcomes was assessed using Cochrane and PRISMA methodology. Eligible studies included prospective and retrospective studies published between January 1, 1980, and November 1, 2025, from Embase, Medline, and PubMed databases. Of the 197 articles identified using the search strategy, 83 were selected for inclusion as evidence, including 27 well-designed studies (phase II randomized and phase III), 16 moderately well-designed studies that account for most common biases (matched cohort and phase II studies), 31 studies with design limitations (retrospective reviews), 2 supplemental studies (not useful as primary evidence), and 7 meta-analyses. Additional studies were included to provide context and were not used to guide recommendations. Well-established RAND-UCLA consensus methodology (modified Delphi) was used to rate the appropriateness of the treatment options.

Results: The results of this analysis demonstrate that in appropriately selected patients, RT is an effective and safe therapy for prophylaxis of HO formation.

Conclusions: This systematic review provides consensus guidelines for the use of RT as prophylaxis of HO based on current peer-reviewed evidence in the literature.