Calcific myonecrosis mimicking an invasive soft-tissue neoplasm. A case report and review of the literature

Extensive calcific myonecrosis of the lower leg treated with free tissue transfer

Calcific myonecrosis is a rare condition in which hypoperfusion due to compartment syndrome causes soft tissue and muscle to become calcified. As calcific myonecrosis gradually deteriorates, secretions steadily accumulate inside the affected area, forming a cavity that is vulnerable to infection. Most such cases progress to chronic wounds that are unlikely to heal spontaneously. After removing the calcified tissue, the wound can be treated by primary closure, flap coverage, or a skin graft. In this case, a 72-year-old man had extensive calcific myonecrosis on his left lower leg, and experienced swelling and increasing tenderness. After removing the muscle calcification, we combined two anterolateral thigh free flaps, which were harvested from the patient's right and left thigh, respectively, to reconstruct the wound with a dead-space filler and skin-defect cover at the same time. The patient recovered without revision surgery or major complications.

Calcific Myonecrosis of the Leg: A Rare Entity

Calcific myonecrosis is a rare disease that has been shown to be a late sequela of trauma. This article presents a 68-year-old man with calcific myonecrosis of the leg 40 years after a tibial fracture complicated with peroneal nerve palsy. The soft tissue mass increased in size after another injury to the leg that occurred two years before his presentation. Physical examination at presentation showed a palpable extra-osseous mass at the anterior aspect of the left leg; the mass was not adherent to adjacent soft-tissues and bone, and it was painless but tender to palpation. Radiographs of the left leg showed extensive calcification at the soft-tissue of the anterior and posterior leg. An ultrasonography-guided trocar biopsy was done; histological findings were indicative of calcific myonecrosis. Given the benign entity of the lesion and known high rate of complications, he was recommended for no further treatment except for clinical and imaging observation. Located at the site of the biopsy, he experienced infection with drainage that eventually healed after six months with antibiotics and wound dressing changes. During the last follow-up examination, two years after diagnosis, the patient was asymptomatic without progression of the mass.

Management of calcific myonecrosis with a sinus tract: A case report

RATIONALE

Calcific myonecrosis is a very rare late sequela that occurs in patients who have had trauma accompanied by vascular compromise, in which a single muscle or entire muscles in a compartment undergoes necrosis and form a calcified mass. It is mostly a benign entity, but some cases cause bone destruction and form non-healing chronic sinuses. In such cases, wound management becomes difficult and there is a potential risk of secondary infection.

PATIENT CONCERNS

A 60-year-old male was referred for evaluation of a pain, erythematous changes, and draining sinus of the anterolateral aspect of his left leg. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery owing to a distal femur fracture and femoral artery rupture.

DIAGNOSES

A thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The radiographs of the left leg showed a large, fusiform-shaped, radiopaque soft tissue mass in the space between the tibia and fibula. We performed an incisional biopsy to differentiated soft tissue sarcoma and malignant cells were found. Pathologic evaluation revealed acute and chronic inflammation with dystrophic calcification. These findings led to the diagnosis of calcific myonecrosis.

INTERVENTIONS

We performed an extensive debridement of the anterior and deep posterior compartments to ensure definitive treatment. Upon performing extensive debridement, we inserted a drain tube and performed primary closure.

OUTCOMES

The fluid continued to be discharged through the drain even after the surgery; delayed wound healing occurred 4 weeks following the surgery, and there was no recurrence at follow-up conducted 2 years later.

LESSONS

Calcific myonecrosis is mostly a benign entity, but some cases of calcific myonecrosis cause bone destruction and form non-healing chronic sinuses. In such cases, surgical treatment is required, during which the necrotic tissue and calcific material must be extensively debrided and drained.

Calcific myonecrosis mimicking soft tissue sarcoma: A case report

Calcific myonecrosis is a rare soft tissue condition. The first case was reported in 1960, however, the precise pathophysiology of calcific myonecrosis remains unclear. The disease was thought to arise from compartment syndrome within a confined space resulting in necrosis and fibrosis, subsequent repeated intralesional hemorrhage, mass enlargement and calcification. Several previous reports have described calcific myonecrosis, which include the formation of calcific myonecrosis after a prolonged period of post trauma. Notably, calcific myonecrosis has typically been described in the lower legs and characteristic imaging findings have been indicated. Furthermore, surgical intervention carries a high risk of complications. In the present case report 2 cases of calcific myonecrosis that occurred after a prolonged period of time following a traumatic event that impacted the lower leg were reported. CT images revealed disruption of calcified fascia and disease expansion into the outside of the fascia. Previous reports have implied that there is late focal enlargement of calcific myonecrosis following earlier enlargement, which may be caused by herniation through muscle fascia. However, no previous publications have focused on images for evidence of late local enlargement. To the best of our knowledge, this is the first report focusing on fascial herniation of calcific myonecrosis using images. Analysis of this feature using images may aid clinicians to differentiate calcific myonecrosis from malignancies.

Calcific myonecrosis: diagnostic dilemma

Calcific myonecrosis is a rare benign condition affecting mainly the muscles of a single leg compartment. It is thought to follow a history of trauma with a latent period of years. Patients present with a slowly growing mass. Differential diagnosis from a malignant tumour can be made from the history and the distinctive radiographical features of a fusiform lesion with predominantly peripheral calcifications. Magnetic resonance imaging may be necessary to confirm the diagnosis; treatment is largely symptomatic.

A case of dystrophic calcification in the masseter muscle

Background

Dystrophic calcification can occur in any soft tissue with the absence of a systemic mineral imbalance and is often associated with trauma, infection, or inflammation. It is easily found in the site of the heart and skeletal muscles and rarely appears in the head and neck area.

Case report

We present a rare case of multiple calcified masses in the left masseter muscle of a 26-year-old female with a history of trauma in the area. In computed tomography, multiple radiopaque masses were observed inside the left masseter muscle and blood test results were normal. The calcified masses were diagnosed as dystrophic calcification and removed by surgery without any complications.

Conclusion

Different types of calcifications may occur in the cheek area, and they need to be distinguished from dystrophic calcification. Thorough clinical examination and history taking is required together with blood testing and radiographic examinations.

Leiomyoma of deep soft tissue mimicking calcific myonecrosis

Leiomyoma of deep soft tissue is an unusual entity reported in less than 60 cases in the English literature. The lesion is now accepted as a rare neoplasm. Leiomyomata of deep soft tissue have been divided into 2 groups, those occurring primarily in women in the retroperitoneum, histologically similar to leiomyomata of the uterus, and those occurring equally in both sexes in the somatic deep soft tissues. Irrespective of location, these lesions can demonstrate calcification, and even less commonly ossification. We report a unique case of a leiomyoma of deep soft tissue that mimicked the clinical and radiographic features of calcific myonecrosis, also a rare mass forming soft-tissue lesion. Clinical and radiographic information are often critical in the diagnosis of soft-tissue lesions; however, this case demonstrates that a lesion can deviate from the standard clinical and radiographic interpretations most commonly attributed to it.

[Calcific myonecrosis of the leg]

Calcific myonecrosis is a rare post-traumatic sequela almost exclusively located in the lower extremity, which can be mistaken for an aggressive primary neoplasm. This lesion, initially described by Gallei and Thompson in 1960, is characterized by the formation of a calcified mass that appears decades after trauma. The pathophysiologic mechanism is not fully understood, although the lesion most likely results from post-traumatic ischemia and it may be associated with a common peroneal nerve injury. The typical radiographic image is a fusiform soft tissue mass with linear calcifications. The treatment of choice is conservative in asymptomatic patients because the surgical treatment has a high complication rate. We report four cases of calcific myonecrosis treated surgically in our hospital. Three of the cases had an infection as a complication that required subsequent debridement and special therapies to achieve the resolution of the cases.

Calcific myonecrosis: a case report and review of the literature

Calcific myonecrosis is a rare post-traumatic sequel of the lower limb, presenting in a delayed manner several years after the initial injury. We report a case of a 43-year-old gentleman who presented emergently with an enlarging painful mass in the lateral side of his left leg, that although present for several years had recently worsened with respect to the pain and erythema. Following laboratory and radiological investigations this was diagnosed to be calcific myonecrosis, which was then treated conservatively, and patient discharged when symptomatically improved.

Calcific myonecrosis of the upper extremity: case report

Calcific myonecrosis is an uncommon late sequela of limb trauma that results in calcification and necrosis of damaged muscle. It almost exclusively occurs in the lower extremity. We present a second case of calcific myonecrosis in the upper extremity.

Calcific myonecrosis of the antetibial area

Calcific myonecrosis is a rare late post-traumatic condition, in which a single muscle is replaced by a fusiform mass with central liquefaction and peripheral calcification. Compartment syndrome is suggested to be the underlying cause. The resulting mass may expand with time due to recurrent intralesional hemorrhage into the chronic calcified mass. A diagnosis may be difficult due to the long time between the original trauma and the symptoms of calcific myonecrosis. We encountered a 53-year-old male patient diagnosed with calcific myonecrosis in the lower leg. We report the case with a review of the relevant literature.

Calcific myonecrosis of the lower leg: diagnosis and options of treatment

INTRODUCTION

Calcific myonecrosis is a rare condition characterized by a calcified lesion. Because this lesion sometimes presents as a huge mass with unique radiographic characteristics, it can be confused with soft tissue sarcoma. The appropriate treatment is still controversial. We report here three cases diagnosed as calcific myonecrosis of the lower leg and discuss its clinical presentation, diagnosis and options for treatment.

PATIENTS AND METHODS

Three patients presented as expanding masses in the anterior or lateral compartment muscle and occurred more than 10 years after an initial injury. Plain radiographs showed a large soft tissue mass with extensive amorphous calcifications. Computed tomograms revealed a low-density tumor with scattered calcifications. Magnetic resonance imaging showed a bright, high-signal area on T2-weighted imaging consistent with fluid. Two patients underwent excisions for histopathological evaluation and one was treated conservatively because of the absence of disability.

RESULTS

Two operative patients had no complication and the returned to work without evidence of deterioration of the disease. In a patient treated conservatively, the mass was not enlarged and was still painless at 2-year follow-up.

CONCLUSION

The key points for diagnosis were (1) amorphous liner calcification, (2) anterior or lateral compartment, (3) previous injury (several decades) of the tibia or femur, and (4) compartment syndrome. Although calcific myonecrosis is not commonly encountered, it must be considered in the differential diagnosis of an expanding intramuscular mass. In asymptomatic masses where the diagnosis is recognized, observation may be possible and unnecessary aggressive surgical intervention should be avoided.

Calcific myonecrosis and the role of imaging in the diagnosis: a case report

Calcific myonecrosis is a rare posttraumatic complication characterized by the replacement of muscles of one or more compartments with central liquefaction and peripheral calcification. We report magnetic resonance imaging (MRI) and CT imaging features of calcific myonecrosis arising 43 years after trauma. A 62-year-old man presented with a slowly enlarging mass in the left lower leg. Plain radiographs revealed a soft tissue mass with extensive amorphous calcification. The middle third of the tibia and fibula were eroded. MRI demonstrated peripheral ring enhancement on postcontrast fat-suppressed T1-weighted images. Volume-rendered images extracting only the images of bone and vessels also showed many branches from the tibialis posterior and peroneal arteries around the bone defect. During the operation, bleeding continued heavily from the vessels penetrating the cortical bone of the tibia, from the posterior compartment, and from the branches of tibialis posterior artery. The total blood loss was approximately 2,400 milliliters. There may be a causal relationship between massive bleeding and the hypervascularity of this tumor as evidenced by MRI and volume-rendering CT studies.

Calcific myonecrosis: case report and radiopathological correlation

We present a patient with an enlarging calf mass 36 years after a tibia and fibula fracture. He developed a peroneal nerve palsy after the accident, which was probably due to a subclinical compartment syndrome. Imaging of the leg was consistent with calcific myonecrosis. The diagnosis was confirmed histologically. The radiopathological findings of calcific myonecrosis are discussed.

Calcific myonecrosis and tenosynovitis: sonographic findings with correlative imaging

We report the sonographic appearance of a case of calcific myonecrosis and tenosynovitis with correlative plain radiography and CT findings. Calcific myonecrosis is a rare complication of previous trauma that presents as a tumor-like calcified mass years after an initial injury, most commonly affecting the anterior compartment of the lower leg. Although the clinical, radiographic, and MRI features of calcific myonecrosis have been well described, to our knowledge the sonographic appearance has not been reported previously in the literature.

Calcific myonecrosis: keys to recognition and management

OBJECTIVE

Calcific myonecrosis masses can become quite large and worrisome for malignancy. The key to recognition is a combination of radiologic imaging features and remote clinical history of injury associated with compartment syndrome or vascular or neurologic compromise.

CONCLUSION

This article will highlight importance of correct diagnosis by identifying the severe and devastating complications following inappropriate management.

Calcific myonecrosis: a report of ten new cases with an emphasis on MR imaging

The aim of this study is to report the typical radiographic and MR imaging features of calcific myonecrosis, which help to distinguish this rare entity from other causes of a calcifying calf mass. Ten patients with a final diagnosis of calcific myonecrosis were referred to a specialist orthopaedic oncology service in a 5-year period with the presumptive diagnosis of malignancy based on recent clinical presentation and imaging findings. Radiographs were available for retrospective review in all ten cases and MR imaging in six. All patients presented with a slow-growing painless calf mass. All gave a history of major trauma to the lower leg many years before, but in only two cases did the referring clinician query whether trauma might be a contributory factor. Radiographs showed well-defined fusiform mineralised masses up to 25 cm in length arising within the calf. The calcification was consistently peripheral and plaque-like. Ossification was not present. MR imaging showed the anterior compartment to be involved in four cases and all compartments in two. T1- and T2-weighted images showed peripheral low signal intensity, more prominent on the T2-weighted images, because of the peripheral mineralization. The contents of the masses were variable on T1-weighted images depending on the differing amounts of blood breakdown products and were heterogeneous on T2-weighted images. The latter may be explained by a combination of the mineralisation and T2 shortening due to blood breakdown products. A gadolinium chelate, administered in two cases, failed to show any appreciable enhancement. Calcific myonecrosis has characteristic clinical, radiographic and MR features that should make the condition easy to recognise. Despite its rarity, it should be included in the differential diagnosis of focal mineralisation of the calf.

Calcific myonecrosis: a unique presentation in the upper extremity

Calcific myonecrosis is a rare and latent condition characterized by a dystrophic calcified lesion that can present 10-64 years following initial trauma. Of the 25 cases documented in English world literature, all have occurred in the lower extremity exclusively. We report a case of a 60-year-old man with a painless enlarging left forearm mass that was subsequently diagnosed as calcific myonecrosis. Awareness of this lesion arising outside of the lower extremity is important to avoid unnecessary surgical intervention and patient reassurance.

Calcific myonecrosis: case report and review

Although a rare diagnosis, with few reports in the literature, calcific myonecrosis is a diagnosis that must be entertained in individuals presenting with expanding masses in the muscle compartments occurring years after an initial injury. The authors report a previously healthy 66-year-old man with an expanding right lower extremity mass felt initially to be an abscess. Despite presumably appropriate antimicrobial therapy, the lesion continued to expand, causing pain and loss of function. The patient subsequently underwent extensive debridement and free muscle flap transfer with an excellent outcome. This patient serves to remind us that, although calcific myonecrosis is an uncommonly encountered condition, it must be maintained in the differential diagnosis of an expanding muscle compartment mass.