Polytrauma patient with lateral thoracic spondyloptosis: case report and literature review

Background: Spondyloptosis is caused by high force trauma. The vast majority of cases occur in the sagittal plane and at transition points where ridged sections meet more flexible regions. Lateral thoracic spondyloptosis is extremely rare and there is no current consensus on the optimal treatment plan. Case Description: Here we present a case of a previously physically healthy 24-year-old polytrauma patient after he was struck as a pedestrian by a motor vehicle. Of note the patient was found to have lateral spondyloptosis between T9-10 with complete spinal cord transection. The patient also sustained multi-ligamentous left knee injury, pelvic fractures, open comminuted left tibia and fibular fracture, lacerated liver, bilateral renal lacerations, ischemic bowel, and an aortic arch pseudoaneurysm. Conclusion(s): Lateral thoracic spondyloptosis is a devastating injury with an extreme rate of persistent neurologic deficits. There is no unanimously accepted treatment because of the rarity if the injury and the poor outcomes that patients face. Additionally, patients who experience high level trauma often develop severe psychiatric illness, and the importance of identifying risk factors and implementing care early may improve patient outcomes.Copyright © AME Medical Journal.

Heterotopic ossification post COVID-19: Report of two cases.

Heterotopic ossification is often associated with trauma and surgery, and infrequently reported with immobilization due to critical illness. We present 2 patients who developed heterotopic ossification following severe COVID-19 infection. Both patients were middle-aged females who were hospitalized for one month or greater due to COVID-19 requiring mechanical ventilation. Both developed shoulder pain and/or stiffness a few months after discharge, with imaging studies clearly illustrating development of heterotopic ossification around the shoulders. The etiology is unclear, with immobilization and hypoxia being the primary considerations. Physical examination and radiography are essential to diagnosis. Awareness of this complication and early diagnosis may help minimize functional impairment.

A follow-up report on the published paper Social and clinical impact of COVID-19 on patients with fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder associated with increased immune activity and severe, progressive heterotopic ossification. We previously described a cohort of 32 patients with FOP who were either exposed to SARS-CoV-2 or received a COVID-19 vaccine1 and showed that these patients did not develop heterotopic ossification after COVID-19 vaccination. Here, we present additional clinical data from new subjects and additional long-term follow-up from the first cohort. We enrolled 15 new subjects between August 24th, 2021 and May 17th, 2022 and collected additional self-reported outcomes. The larger cohort with 47 individuals encompassing 49 events showed that patients with FOP exhibited no additional change in FOP disease activity or flare activity resulting from COVID-19 infection or after receipt of a SARS-CoV-2 vaccine. Thus, although any vaccination carries a risk of inducing heterotopic ossification in patients with FOP, our results show that patients with FOP who choose to receive a COVID-19 vaccination may be able to tolerate the procedure without a high risk of heterotopic ossification when following the published guidelines.

Long-term Orthopedic Manifestations of COVID-19: Heterotopic Ossification and Digital Necrosis.

Despite its classification as an atypical pneumonia, COVID-19 is a disease that is capable of inflicting damage beyond the respiratory system. The wide range of musculoskeletal complications secondary to acute COVID-19 are a significant source of morbidity in hospitalized patients. We present the case of a 23-year-old woman with severe COVID-19 who required intubation and had a prolonged hospital course that was complicated by partial-thickness necrosis of her fingers and heterotopic ossification of the distal thigh. We review current treatments for these orthopedic conditions in the setting of SARS-CoV-2 infection as well as highlight areas for future research. Additionally, we discuss the subacute musculoskeletal complications of COVID-19, which are among the most common long-term manifestations of the disease and are increasingly important for a growing number of COVID-19 survivors.

HETEROTOPIC OSSIFICATION AFTER COVID-19 INFECTION - CASE REPORT

Background/Aims Heterotopic ossification (HO) is the abnormal formation and deposition of mature lamellar bone within soft tissue, associated with trauma, surgery, neurologic injury and prolonged immobilisation. Several recent case reports have demonstrated this condition in COVID-19 patients requiring mechanical ventilation. Methods We present a case of heterotopic ossification in the shoulder after a long stay in intensive care unit (ICU) due to COVID-19 infection. Results A 55-year-old man with stable psoriatic arthritis on sulfasalazine was admitted to ICU for mechanical ventilation after contracting COVID-19 infection. After discharge from ICU, he began noticing increasing right shoulder pain with restricted movements of abduction, internal and external rotation. His serum alkaline phosphatase was moderately elevated. Despite physiotherapy and NSAIDs, there was slow improvement. Shoulder x-ray showed significant bony overgrowth around proximal humerus which was initially thought to be part of his psoriatic arthritis. It was confirmed at Rheumatology/Radiology MDT to be heterotopic ossification. A computed tomography of the right shoulder was requested to evaluate the extent of the condition and orthopaedic advice was sought. Conclusion There are many factors contributing to the development of heterotopic ossification including trauma, spinal cord injury, brain injury, hypoxia, prolonged immobilisation with limitation of joint movement and prolonged bed rest which cause alterations in calcium homeostasis, male sex and over 60 years of age. New onset joint pain and stiffness in patients who have recovered from COVID-19 especially those who had long ICU stay should be further investigated for this condition. Treatment includes analgesia and physiotherapy with potential surgical intervention.

Atraumatic heterotopic ossification after pulmonary failure and prolonged mechanical ventilation: case report

Heterotopic ossification is well-described, often complication after musculoskeletal trauma, surgery and neuro-trauma. We present a patient who developed heterotopic ossification of hip joints with bony ankylosis after prolonged artificial pulmonary ventilation because of pulmonary failure after H1N1 pneumonia. Atraumatic heterotopic ossification occurs in critically ill patients after mechanical ventilation, including patients with COVID-19 disease. We consider imobilization and artificial pulmonary ventilation as a possible causal factors of heterotopic ossification. Early diagnosis and implementation of potentional preventive and therapeutical tools, such as anti-inflammatory drugs and appropriate physiotherapy, are needed to decrease morbidity in patients with risk factors. The timing of surgical excision must be considered according to a risk of recurrence and irreversible joint damage.

Heterotopic ossification and COVID 19: Imaging analysis of ten consecutive cases.

PURPOSE: Heterotopic ossification (HO) is defined by the formation of mature lamellar bone in periarticular soft tissue due to prolonged immobility. This study aimed to explore the imaging features of HOs in immobilized COVID-19 patients compared to other causes previously described in the literature. METHOD: This retrospective single centre study included patients with severe COVID-19 hospitalized in intensive care unit (ICU) with mechanical ventilation and affected by HOs between March 2020 and December 2021. Two radiologists reviewed imaging features of biphasic CT-scans using a standardized template including morphological findings and anatomical relationship of the HO with the joint, vessels and nerves. RESULTS: 10 COVID-19 patients with 19 analyzed HOs following ICU hospitalization were including. Biphasic CT imaging characteristics were analyzed. The hips were the most commonly affected joint (n = 14/19; 74%). The distribution was mainly posterior (n = 7/19; 38%). HOs were located away from main arteries. No case of severe demineralization was observed. Capsular disruption was observed for three HOs (n = 3/19; 16%). One patient presented concomitant venous thrombosis ipsilateral to the HO. CT-scan demonstrated neural involvement of the sciatic nerve in 3 patients with HO (n = 3/19; 16%). CONCLUSION: Severe COVID-19 patients with a biphasic CT imaging presented HO mainly located around the hips, with rare vessel and nerve invasion and no severe demineralization. Some features such as a lower level of local invasion differ from HOs related to other disorders as described in the literature whereas morphological aspects are similar.

[Heterotopic ossification in SARS-CoV-2: Scintigraphic and radiological images]. / Osificación heterotópica en paciente con SARS-CoV-2: imágenes gammagráficas y radiológicas.

Patients with severe COVID-19 can develop painful range-of-motion restrictions of large joints due to heterotopic ossification. We present the case of a patient who developed hip pain after prolonged admission for severe COVID-19 pneumonia. Conventional radiography, computed tomography and bone scan showed extensive heterotopic ossification in the hips. It is probable that both local and systemic factors contribute to the development of heterotopic ossifications and it is necessary to rule out this entity when these patients reported joint pain. Early diagnosis is important to provide non-pharmacological interventions such as mild passive mobilization and anti-inflammatory medication and in refractory cases surgical resection of the ectopic bone is consider.

A case report of a patient with COVID-19 infection and widespread heterotopic ossification.

Since the beginning of the novel coronavirus disease-2019 (COVID-19) pandemic, physical medicine and rehabilitation specialists have played an important role in fighting this disease apart from the pulmonary rehabilitation. As a high number of patients have needed immobilization and intensive care unit (ICU) treatment, many complications have emerged inevitably. Heterotopic ossification (HO) is one of these complications. Herein, we present a case of young male patient who had widespread HO in his shoulders, elbows, and hips. Although he managed to survive, he still has difficulty in ambulation and daily living activities. Given the continuing high prevalence of COVID-19, many patients would need immobilization and ICU treatment. Therefore, causes of HO should be scrutinized, physicians and caregivers need to raise vigilance, and comprehensive protective measures should be put in place. On the other hand, as HO is used to be diagnosed quite frequently in the patients with neurological diseases, diagnosis of HO in the COVID-19 patients should not automatically be linked to the stay in the ICU. Yet, it is a fact that impaired immune response is prevalent both in COVID-19 and HO. The correlation between COVID-19 and HO is remarkable, but further research is needed to establish a causal relationship.

Plasmin Therapy to Prevent Post-Traumatic Heterotopic Ossification in the Upper Extremity After Severe Injury

The purpose of this prospective animal study is to investigate new treatments to improve upper extremity joint function and prevent heterotopic ossification (HO, pathologic bone formation in muscle) follow severe injury. Plasmin is a critical reparative protease, essential for tissue regeneration following injury. The work proposed in this application will delineate the ideal timing for prophylactic plasmin therapy needed for clinical trials in both military and civilian trauma patients at risk for developing HO and associated impaired joint function. If our overarching hypothesis is proven true, the clinical impact is of most importance in the upper extremity as even partial prevention of a shoulder or elbow joint contracture can provide a wounded soldier or civilian within dependence in activities of daily living. Importantly, as we have established that plasmin is essential both for preventing HO and promoting fracture repair/bone health, this would be the first therapy that does not compromise bone biology in order to prevent HO.

Social and clinical impact of COVID-19 on patients with fibrodysplasia ossificans progressiva.

BACKGROUND: COVID-19, caused by the SARS-CoV-2 virus, is a severe inflammatory condition. Patients with pre-existing conditions including diabetes, hypertension, and cardiovascular disease are at particularly high risk of complications. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare and debilitating genetic disorder that is characterized by a pro-inflammatory state, which leads to progressive heterotopic ossification and complications after trauma, including intramuscular vaccinations. To better understand the impact of COVID-19 on patients with FOP, we first examined the social impact of the pandemic using data from the FOP Registry managed by the International FOP Association. We also identified patients with FOP who were exposed to or contracted the SARS-CoV-2 virus, or who received a COVID-19 vaccine, to investigate if patients with FOP were at increased risks of complications from SARS-CoV2 exposure or vaccination. RESULTS: Data from 326 individuals in 69 countries in the International FOP Association FOP Connection Registry were examined using patient-reported outcomes measurement information system (PROMIS) global health scale scores. Twenty-six (28.9%) participants aged ≥ 15 years old rated their satisfaction with their social activities and relationships as poor in 2020, which was an increase from 18 (18.9%) in 2019, prior to the SARS-CoV-2 outbreak. Similar trends were noted for physical and mental health in the pediatric population. Frequency of physician visits was not changed, but a larger portion of patients reported missing dental visits in 2020 compared with 2019 (31.5% vs. 41.7%). A second cohort with 32 subjects was tracked after SARS-CoV-2 exposure or vaccination. Ten subjects were positively diagnosed with COVID-19, 15 received a COVID-19 vaccine, and seven had high-risk SARS-CoV-2 exposure but either did not have a confirmed clinical diagnosis or tested negative. Subjects who tested positive for the virus showed no major complications or increased FOP disease activity, though our sample size is very limited. Among the 15 subjects who received a COVID-19 vaccine, using the International Clinical Council on FOP guidelines for prophylaxis with ibuprofen or acetaminophen, only one person experienced flare-like activity at the injection site. CONCLUSIONS: Patients with FOP showed a significant decrease in social activities that was reflective of the isolation and mobility changes in this debilitated population. In our limited cohort, the majority of the patients with FOP who tested positive for COVID-19 showed no major complications. Also, although limited in sample size, the majority of patients who received a COVID-19 vaccination and followed guidelines from the FOP International Clinical Council tolerated vaccination well. Only one person experiencing flare activity following their injection. Thus, the risks and benefits of COVID-19 vaccination needs to be discussed carefully so as to support informed decisions.

Fracture in a Person with Spinal Cord Injury with Heterotopic Ossification due to Improper Exercise in Pandemic: A Case Report

Fractures following inappropriate exercises are rarely reported in Spinal Cord Injury (SCI) population. During pandemic physical inactivity and barriers to access to rehabilitation facility are conspicuous. Authors report a case of femur fracture following improper exercise and its interrelationship with Heterotopic Ossification (HO) and impact of pandemic. A 23-year-old male with American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade C tetraplegia presented with operated left femur shaft fracture following care-partner administered sudden improper exercise. X-ray of left hip and femur revealed HO around left hip joint and intramedullary nailing of shaft of femur. Routine rehabilitation protocol for SCI was followed especially focusing on safety home-exercise precaution program during pandemic time. To the best of our knowledge, this is the first case report of long bone fracture in a person with SCI following improper exercise which is influence by pandemic situation. Here, we described the causation of fracture in perspective of the vicious cycle of HO, improper exercise and pandemic impact. Further studies are required to find out appropriate precautionary guidelines regarding exercise during pandemic times for people with SCI.

Extensive progressive heterotopic ossification post-Covid-19 in a man.

Heterotopic ossification (HO) is the formation of extraskeletal bone in muscle and soft tissues and could be genetic or non-genetic. The classic presentation of non-genetic HO is in young adults with a clear history of local trauma, surgery or prolonged immobilization after spinal cord and traumatic brain injuries. Genetic HO has a significant clinical severity compared to non-genetic causes and includes fibrodysplasia ossificans progressiva (FOP). FOP is an extremely rare genetic skeletal disorder characterized by congenital malformations of the great toes and progressive heterotopic ossification that forms qualitatively normal bone in characteristic extraskeletal sites affecting skeletal muscles, fascia, tendons, and ligaments. Previously, it has been reported an association between SARS-CoV-2 infection (COVID-19) and HO or FOP exacerbation with unclear etiopathogenesis. The possible mechanisms could be prolonged immobilization and systemic inflammation. Here, we describe the case of a 55-year-old apparently healthy man who suffered from a severe SARS-CoV-2 infection after that he experienced an extensive and progressive heterotopic ossification around the shoulders, the elbows, the hip, the knees, and the ankles. Because of the clinical severity, the painful soft-tissue swelling, the progressive HO, and the bilateral congenital hallux valgus deformity, a late-onset atypical FOP was suspected. Nevertheless, no variant of clinical significance has been identified in the coding regions and splicing sites in the ACVR1 gene and no deletions and/or duplications have been identified in exonic regions.

Post-COVID-19 exacerbation of fibrodysplasia ossificans progressiva with multiple flare-ups and extensive heterotopic ossification in a 45-year-old female patient.

Fibrodyplasia ossificans progressiva (FOP) is a rare hereditary disease, which has a variable course characterized by occasional flare-ups of heterotopic ossification (HO) in soft tissues that are followed by swelling, stiffness, pain and warmth. Here, we report for the first time a case of a 45-year-old female patient with known FOP recovering from COVID-19 with disease progression potentially linked with the viral illness. In December 2020 the patient contracted a mild form of COVID-19 infection without need for hospital admission. Since January 2021, the patient felt unwell, with occasional abdominal pain which progressively intensified. In March 2021 she presented with new onset of HO, complaining of pain, swelling and thickening sensation in the lower abdomen and left part of the neck. Computerized tomography (CT) and cytokine analysis were performed. CT scan revealed new heterotopic bone formation in multiple soft tissue areas of the neck indicating clear radiological progression. Radiotherapy, which has proven to be an efficient tool to control HO in this patient, was not able to halt HO formation after COVID-19 infection. Cytokine analysis of a plasma sample obtained during a flare-up after COVID-19 infection showed a significantly elevated pro-inflammatory cytokines compared to a flare-up panel prior to infection. Of the 23 analyzed levels of cytokines, a staggering number of 21 were above normal levels. This case is the first confirmation of uncontrolled post-COVID-19 effects in a FOP patient, which manifested with flare-ups followed by progressive HO, possibly caused by a thus far, never described form of post-COVID syndrome.

Genetic and Acquired Heterotopic Ossification: A Translational Tale of Mice and Men.

Heterotopic ossification is defined as an aberrant formation of bone in extraskeletal soft tissue, for which both genetic and acquired conditions are known. This pathologic process may occur in many different sites such as the skin, subcutaneous tissue, skeletal muscle and fibrous tissue adjacent to joints, ligaments, walls of blood vessels, mesentery and other. The clinical spectrum of this disorder is wide: lesions may range from small foci of ossification to massive deposits of bone throughout the body, typical of the progressive genetically determined conditions such as fibrodysplasia ossificans progressiva, to mention one of the most severe and disabling forms. The ectopic bone formation may be regarded as a failed tissue repair process in response to a variety of triggers and evolving towards bone formation through a multistage differentiation program, with several steps common to different clinical presentations and distinctive features. In this review, we aim at providing a comprehensive view of the genetic and acquired heterotopic ossification disorders by detailing the clinical and molecular features underlying the different human conditions in comparison with the corresponding, currently available mouse models.