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Early diagnosis of heterotopic ossification among patients admitted to a neurological post intensive care rehabilitation unit.

BACKGROUND
Heterotopic ossification (HO) is defined as the formation of endochondral bone within soft tissue. Non-genetic forms, mainly corresponding to a consequence of bone, brain or spinal cord injury, are the most common. HO leads to important functional limitations and alteration of quality of life. To our knowledge, the time between brain, bone, or spinal cord injury and clinical suspicion of HO has never been studied. By admitting patients with severe neurological disorders, we hypothesised that the prevalence of HO in neurological post intensive care rehabilitation units (PICRU) might be significant as these patients have recognised risk factors for HO.


AIM
This study investigates HO among patients admitted to a neurological PICRU with two objectives: 1) describe the prevalence of HO in PICRU; 2) assess the time between neurological disorder, clinical suspicion of HO and radiological diagnosis.


DESIGN
A monocentric retrospective cohort study.


SETTING
PICRU in our public university teaching hospital. This inpatient referral department is specifically dedicated to the early discharge from intensive care units (ICU) of patients with severe neurological impairment who need rehabilitation.


POPULATION
We study all patients admitted between April 2016 and January 2019. 125 subjects were admitted for a rehabilitation program after neuro-trauma or stroke. We included all first-time stays in PICRU lasting 7 days or longer.


METHODS
Retrospective data extraction using administrative data from an electronic patient management program was done to select eligible subjects. Included subjects were then identified by a retrospective review of electronic inpatient medical records after patient discharge. Data of interest were collected from these same medical records.


RESULTS
44 HO were diagnosed in 24 subjects (24 / 125; 19 %), with a median number of 2 [1; 2] HO per subject. Neurological trauma was the main reason for admission to ICU (89 / 125; 71 %) and half of patients had a traumatic brain injury (TBI) (67 / 125; 54 %). The diagnosis of HO was made in PICRU in 75 % of cases. Clinical suspicion of HO (autonomic dysfunction, local inflammatory signs, pain, or reduced joint range of motion) was made 6 [5; 7] weeks after admission to ICU. Radiological confirmation of clinical suspicion or fortuitous diagnosis by imaging (50 % of the cases) occurred 8 [7; 12] weeks after admission to ICU. The median time of clinical suspicion or radiological diagnosis was 1 week after admission to PICRU.


CONCLUSIONS
HO is a sub-acute complication which develops in patients admitted to ICU for severe central nervous system disorders as clinical suspicion or radiological confirmation of diagnosis was made within the first week after admission in neurological PICRU (i.e. 6 to 8 weeks after ICU admission).


CLINICAL REHABILITATION IMPACT
As treatment for HO may at least partially improves rehabilitation and quality of life, we recommend a systematic screening in PICRU patients for HO by clinical examination supplemented by imaging in case of suspicion.