Heterotopic Ossification in Post-COVID-19 Patient on Anticoagulation with Limited Treatment Options

RESEARCH OBJECTIVES: To investigate treatment options for heterotopic ossification in the setting of COVID-19 and anticoagulation use. DESIGN: Case report. Patient followed through the entirety of inpatient acute rehabilitation. Used chart review to examine events during his intubation before coming to rehab. SETTING: University affiliated Acute Rehabilitation Unit. PARTICIPANTS: Case report: 59-year-old male with a past medical history of diabetes, hypertension, and pulmonary embolism on anticoagulation who developed heterotopic ossification (HO) after a prolonged hospitalization secondary to COVID-19. He presented to the ED with dyspnea and was noted to have bilateral pleural effusion and +SARS-CoV-2. He was admitted for COVID-19 treatment and was subsequently intubated. While intubated, he received Physical Therapy (PT) and was noted to have progressive hip pain by day 23 that interfered with PT. A CT of his abdomen and pelvis was done on day 30 of his intubation without any significant bony abnormalities. He was subsequently extubated after 43 days, stabilized, and admitted to acute rehabilitation for ICU associated weakness 15 days later. He continued to have worsening hip pain. Bilateral hip radiographs and follow up CT hips were obtained on rehabilitation day 35 (day 103 of overall hospitalization), which demonstrated Booker Grade 3 HO on the right and Booker Grade 2 on the left. INTERVENTIONS: A multidisciplinary approach to treatment was sought using consultants from Orthopedics, Endocrinology, Radiation Oncology, Pharmacy, and PT. Due to his anticoagulation and high risk factors, nonsteroidal anti-inflammatory drugs were not recommended. Radiation therapy and bisphosphonates were also not recommended. His pain was controlled with acetaminophen as needed and tizanidine which allowed him to participate in therapies during his rehabilitation admission. MAIN OUTCOME MEASURES: Radiologic images and clinical description or pain/pain control. RESULTS: Utilized a multidisciplinary approach. Care included NSAID avoidance, acetaminophen as needed, tizanidine, and PT which provided pain control without compromising coagulation status in the setting of COVID-19. CONCLUSIONS: HO is a known complication in COVID-19 patients requiring extended intubation which presents unique treatment challenges related to this diagnosis. AUTHOR(S) DISCLOSURES: No disclosures.