Heterotopic Ossification after a Prolonged Course of COVID-19: A Case Report and Review of the Literature

Abstract

We report the case of a 20-year-old male who developed severe HO of the left hip secondary to a prolonged course of COVID-19 pneumonia. Upon extubation, he was found to have debilitating left hip pain and significant functional deficits with regard to his range of motion and functional status. There are numerous known causes of heterotopic ossification (HO), including trauma, surgery, and traumatic brain or spinal cord injuries. An increased incidence of HO has also been reported in patients who undergo prolonged intubation. While the COVID-19 virus has many known respiratory and medical complications, it has also resulted in unforeseen complications that present long-term challenges for patients. When treating patients with coronavirus, physicians should be aware of HO as a possible complication and consider it as a cause of musculoskeletal pain.

Heterotopic Ossification of Bilateral Hips Post–COVID-19 and Prolonged Immobilization

“…However, altered acid-base homeostasis, the systemic inflammatory condition, and local myositis, which may have been caused by COVID-19, might have also contributed to HO occurrence after COVID-19. Recently, 8 case series were published demonstrating HO around the hips, shoulders, elbows, knees, ankles, and ribs in 21 patients with COVID-19 requiring prolonged immobilization [2][3][4][5][6][7][8][9] , of whom were treated with surgery. Unfortunately, the long-term outcomes and HO severity of the conservatively treated patients were not reported, so we are unable to compare our surgical case report with the existing 21 conservative cases.…”

“…We identified 21 previously published reports describing 47 patients who developed HO after prolonged immobilization 2-9,15-27 . Twenty-one of those patients developed HO after prolonged immobilization due to COVID-19; none underwent surgery (Table I).…”

“…HO seems to be more prevalent in patients with coronavirus disease 2019 (COVID-19)-induced immobilization possibly due to local myositis, deranged calcium metabolism, and systemic inflammatory condition 2 . While many COVID-19-related HO cases are reported, none describe surgery [2][3][4][5][6][7][8][9] . Surgical resection is recommended only for severe joint limitation severely interfering with quality of life (QoL) and autonomy 1 .…”

“…immobilization[2][3][4][5][6][7][8][9][15][16][17][18][19][20][21][22][23][24][25][26][27] . Twenty-one of those patients developed HO after prolonged immobilization due to COVID-19; none underwent surgery (Table…”