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Porrino J, Liu X, Kani K, Lee H. Spectrum of imaging findings in soft-tissue necrosis. Emerg Radiol 2023; 30:217-223. [PMID: 36626029 DOI: 10.1007/s10140-023-02113-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Soft tissue necrosis can occur at different tissue levels, with numerous underlying causes. In this pictorial review, we highlight myonecrosis, and its accompanying stages, fat necrosis, devitalized soft tissue seen with infection, and necrotizing soft tissue infections. Imaging examples are provided with each entity.
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Affiliation(s)
- Jack Porrino
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520, USA.
| | - Xiaozhou Liu
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520, USA
| | - Kimia Kani
- Department of Radiology, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, 21201, USA
| | - Hyojeong Lee
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520, USA
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2
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Expansile calcific myonecrosis arising in the lower leg: A case report and recommendation for treatment. J Orthop Sci 2022; 27:1149-1153. [PMID: 31870641 DOI: 10.1016/j.jos.2019.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/23/2019] [Accepted: 11/28/2019] [Indexed: 11/23/2022]
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3
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Higuchi T, Yamamoto N, Nishida H, Hayashi K, Takeuchi A, Tsuchiya H. Treatment of infected calcific myonecrosis with chronically discharging sinus caused by iatrogenic aspiration: A case report. Int J Surg Case Rep 2022; 95:107145. [PMID: 35561467 PMCID: PMC9108875 DOI: 10.1016/j.ijscr.2022.107145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/26/2022] [Accepted: 04/30/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance Calcific myonecrosis (CM) is a rare, benign post-traumatic sequela which is often challenging to differentiate from soft tissue tumors. Infected CM is recalcitrant and sometimes requires invasive treatment despite its benign nature. We present a case of infected CM in which MRI and 201Tl scintigraphy proved useful for diagnosis and intralesional debridement with prolonged placement of a suction tube allowed for successful treatment. Case presentation A 71-year-old man had undergone repeated aspiration for swelling of the lower leg and presented with a sustained pyogenic discharging wound. He underwent intralesional debridement of purulent necrotic tissue followed by prolonged suction tube placement. Enterobacter cloacae was detected in the discharge, and specific antibiotics were administered. Once the wound closed, a new sinus recurred four months after surgery, warranting reoperation with debridement of the remnant fascia and necrotic tissue with suction tube replacement. The wound healed eight months after the first surgery with no signs of recurrence. Clinical discussion CM can be diagnosed based on its unique imaging features and a history of compartment syndrome. To avoid infection, CM must be treated conservatively without surgical invasions, such as biopsy or aspiration. Extensive debridement with a myocutaneous flap is nevertheless recommended for infected CM treatment, despite significant invasion including intraoperative bleeding being problematic. Conclusion MRI and 201Tl scintigraphy can help diagnose CM and avoid biopsy to exclude malignancy. Intralesional debridement of necrotic tissue with prolonged suction tube placement could be a valid treatment alternative to reduce the invasiveness of infected CM. Calcific myonecrosis is a rare, benign posttraumatic sequela. Biopsy to differentiate malignancy can cause calcific myonecrosis. Absence of accumulation on enhanced MRI or 201Tl scintigraphy helped diagnosis. Extensive debridement and flaps are reliable but invasive in case of infection. Intralesional debridement with prolonged tube placement may be less invasive.
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Affiliation(s)
- Takashi Higuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan.
| | - Hideji Nishida
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan
| | - Akihiko Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan
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Xia AN, Wang JS. Giant nontraumatic myositis ossificans in a child: A case report. World J Clin Cases 2022; 10:2901-2907. [PMID: 35434084 PMCID: PMC8968807 DOI: 10.12998/wjcc.v10.i9.2901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/02/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nontraumatic myositis ossificans is a rare disease whose specific pathogenesis is unclear. Early diagnosis of this disease is very difficult in children because of difficulties in determining medical history and nonspecific early clinical manifestations, which may lead to the failure of timely and effective diagnosis and treatment in some patients. We report the diagnosis and treatment of a child with nontraumatic myositis ossificans and summarize the clinical characteristics and diagnosis and treatment of the disease.
CASE SUMMARY An 8-year-old girl first came to our hospital for more than a week with pain in the right lower limb. There was no history of trauma or strenuous activities. On physical examination, no mass on the right thigh was found, and the movement of the right lower extremity was limited. Ultrasonography showed synovitis of the hip, and bed rest was recommended. Three days later, the child’s pain persisted and worsened, accompanied by fever and other discomforts. She came to our hospital again and a mass was found on the right thigh with redness and swelling on the surface. The images showed a soft tissue tumor on the right thigh with calcification. Routine blood tests revealed that the inflammation index was significantly increased. In case of infection, the patient was given antibiotics, and the pain was relieved soon after, without fever. However, the right thigh mass persisted and hardened. The patient underwent incision biopsy more than 1 mo later, and the postoperative pathology showed nontraumatic myositis ossificans. After approximately 9 mo of observation, the tumor still persisted, which affected the life of the child, and then resection was performed. Since follow-up, there has been no recurrence.
CONCLUSION Due to the difficulty in discerning a child's medical history and the diverse early manifestations, it is difficult to diagnose nonossifying muscle disease in children in its early stage. Measures such as timely follow-up and periodic image monitoring are conducive to early diagnosis of the disease. The disease has a certain degree of self-limitation, and it can be observed and treated first. If the tumor persists in the later stage or affects functioning, then surgery is considered.
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Affiliation(s)
- An-Ning Xia
- Department of Orthopedic, Shenzhen Children’s Hospital, Shenzhen 518000, Guangdong Province, China
| | - Jiang-Sheng Wang
- Department of Orthopedic, Shenzhen Children’s Hospital, Shenzhen 518000, Guangdong Province, China
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5
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Xia AN, Wang JS. Giant nontraumatic myositis ossificans in a child: A case report. World J Clin Cases 2022; 10:2899-2905. [DOI: 10.12998/wjcc.v10.i9.2899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nontraumatic myositis ossificans is a rare disease whose specific pathogenesis is unclear. Early diagnosis of this disease is very difficult in children because of difficulties in determining medical history and nonspecific early clinical manifestations, which may lead to the failure of timely and effective diagnosis and treatment in some patients. We report the diagnosis and treatment of a child with nontraumatic myositis ossificans and summarize the clinical characteristics and diagnosis and treatment of the disease.
CASE SUMMARY An 8-year-old girl first came to our hospital for more than a week with pain in the right lower limb. There was no history of trauma or strenuous activities. On physical examination, no mass on the right thigh was found, and the movement of the right lower extremity was limited. Ultrasonography showed synovitis of the hip, and bed rest was recommended. Three days later, the child’s pain persisted and worsened, accompanied by fever and other discomforts. She came to our hospital again and a mass was found on the right thigh with redness and swelling on the surface. The images showed a soft tissue tumor on the right thigh with calcification. Routine blood tests revealed that the inflammation index was significantly increased. In case of infection, the patient was given antibiotics, and the pain was relieved soon after, without fever. However, the right thigh mass persisted and hardened. The patient underwent incision biopsy more than 1 mo later, and the postoperative pathology showed nontraumatic myositis ossificans. After approximately 9 mo of observation, the tumor still persisted, which affected the life of the child, and then resection was performed. Since follow-up, there has been no recurrence.
CONCLUSION Due to the difficulty in discerning a child's medical history and the diverse early manifestations, it is difficult to diagnose nonossifying muscle disease in children in its early stage. Measures such as timely follow-up and periodic image monitoring are conducive to early diagnosis of the disease. The disease has a certain degree of self-limitation, and it can be observed and treated first. If the tumor persists in the later stage or affects functioning, then surgery is considered.
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Affiliation(s)
- An-Ning Xia
- Department of Orthopedic, Shenzhen Children’s Hospital, Shenzhen 518000, Guangdong Province, China
| | - Jiang-Sheng Wang
- Department of Orthopedic, Shenzhen Children’s Hospital, Shenzhen 518000, Guangdong Province, China
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6
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Richter RH, Byerly D, Schultz D, Mansfield LT. Challenges in the Interpretation of MRI Examinations Without Radiographic Correlation: Pearls and Pitfalls to Avoid. Cureus 2021; 13:e16419. [PMID: 34414045 PMCID: PMC8364739 DOI: 10.7759/cureus.16419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 11/16/2022] Open
Abstract
As physics introduces more complex and seemingly thorough techniques to evaluate patient symptoms, cross-sectional imaging, especially magnetic resonance imaging (MRI), seems like the modality of choice to best help patients. However, musculoskeletal radiology (MSK) requires not just the excellent soft-tissue contrast provided by MRI but also an evaluation of the aggressiveness of a lesion, a detailed evaluation of osseous anatomy or distribution of disease, and a way to easily identify calcifications and gas in soft tissue in order to make the correct diagnosis. This article will demonstrate, through numerous cases, the importance of radiographs in the full characterization of MSK-related pathology. It will focus on imaging pearls and pitfalls to avoid when radiographs are not available and discuss the findings that can be expected if comparison radiographs were available.
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Affiliation(s)
- Ryan H Richter
- Department of Radiology, Brooke Army Medical Center, San Antonio, USA
| | - Douglas Byerly
- Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, USA
- Department of Radiology, Wilford Hall Ambulatory Surgical Center, San Antonio, USA
| | - Donald Schultz
- Department of Radiology, Brooke Army Medical Center, San Antonio, USA
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7
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Extensive calcific myonecrosis of the lower leg treated with free tissue transfer. Arch Plast Surg 2021; 48:329-332. [PMID: 33657779 PMCID: PMC8143952 DOI: 10.5999/aps.2020.01200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/23/2020] [Indexed: 01/28/2023] Open
Abstract
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.
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8
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Management of Infected Calcific Myonecrosis: A Report of 2 Cases. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2817. [PMID: 33133893 PMCID: PMC7572218 DOI: 10.1097/gox.0000000000002817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/17/2020] [Indexed: 11/26/2022]
Abstract
Calcific myonecrosis (CM) is a rare condition in which a large calcified mass develops after trauma. Generally, CM occurs in a lower extremity, and there have been no reports of its occurrence in the upper arm. We report 2 cases of infected CM, including a rare case of CM occurrence in the arm and a typical case in the leg. Case 1: An 84-year-old woman presented with a draining sinus and a large calcified mass in the arm and axillary region. The mass involved the neurovascular bundle; thus, complete resection was impossible. We performed surgical debridement and postoperative negative-pressure wound therapy with instillation and dwell. Case 2: A 43-year-old man presented with a large calcified mass in the right leg and 2 draining sinuses. After surgical debridement, negative-pressure wound therapy was initiated. However, the wound became infected, and we performed additional debridement, followed by a split thickness skin grafting. The infection was controlled in both patients, although complete resection was not feasible. Complete resection is generally considered the optimum treatment for infected CM, but it is difficult to achieve in some patients. Negative-pressure wound therapy with instillation and dwell appears as a good option for postoperative management if complete resection of infected CM cannot be achieved.
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9
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Angelini A, Mavrogenis AF, Pagliarini E, Trovarelli G, Fanelli GN, Cappellesso R, Ruggieri P. Calcific Myonecrosis of the Leg: A Rare Entity. ACTA ACUST UNITED AC 2019; 55:medicina55090542. [PMID: 31466356 PMCID: PMC6780786 DOI: 10.3390/medicina55090542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/20/2019] [Accepted: 08/23/2019] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Andrea Angelini
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, 35128 Padova, Italy
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 115 27 Athens, Greece
| | - Elisa Pagliarini
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, 35128 Padova, Italy
| | - Giulia Trovarelli
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, 35128 Padova, Italy
| | - Giuseppe Nicolò Fanelli
- Department of Medicine, Surgical Pathology & Cytopathology Unit, University of Padova, 35128 Padova, Italy
| | - Rocco Cappellesso
- Department of Medicine, Surgical Pathology & Cytopathology Unit, University of Padova, 35128 Padova, Italy
| | - Pietro Ruggieri
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, 35128 Padova, Italy.
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10
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Puvanesarajah V, Fayad LM, Rao SS, McCarthy EF, Morris CD. Extremity gossypiboma mimicking sarcoma: case report and review. Skeletal Radiol 2019; 48:629-635. [PMID: 30203183 DOI: 10.1007/s00256-018-3059-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 02/02/2023]
Abstract
A 70-year-old man with a history of bladder and colon cancer presented with an enlarging mass in his right lower extremity. Forty years before presentation, he had injured his right lower extremity in a motor vehicle accident. Imaging findings indicated suspected sarcoma, which led to biopsy. Biopsy and further surgical exploration revealed the presence of a surgical sponge and surrounding local inflammatory reaction. No neoplasm was found, and the sponge and involved tissues were removed. Gossypiboma is exceedingly rare in the extremities. Imaging of retained foreign material can appear suggestive of sarcoma because of strong inflammatory responses and local tissue mass-like derangement resulting in heterogeneous signal changes. Ultimately, biopsy must be performed to ensure that no oncological pathological condition is present.
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Affiliation(s)
- Varun Puvanesarajah
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21287, USA
| | - Laura M Fayad
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21287, USA.,Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21287, USA.,Department of Oncology, The Johns Hopkins University, 401 North Broadway, Baltimore, MD, 21287, USA
| | - Sandesh S Rao
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21287, USA
| | - Edward F McCarthy
- Department of Pathology, The Johns Hopkins University, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Carol D Morris
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21287, USA. .,Department of Oncology, The Johns Hopkins University, 401 North Broadway, Baltimore, MD, 21287, USA.
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11
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Kwee RM, Kwee TC. Calcified or ossified benign soft tissue lesions that may simulate malignancy. Skeletal Radiol 2019; 48:1875-1890. [PMID: 31297550 PMCID: PMC6813287 DOI: 10.1007/s00256-019-03272-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 02/02/2023]
Abstract
The purpose of this article is to review calcified or ossified benign soft tissue lesions that may simulate malignancy. We review the clinical presentations, locations, imaging characteristics, and differential diagnostic considerations of myositis ossificans, tophaceous gout, benign vascular lesions, calcific tendinopathy with osseous involvement, periosteal chondroma, primary synovial chondromatosis, Hoffa's disease, tumoral calcinosis, lipoma with metaplasia, calcifying aponeurotic fibroma, calcific myonecrosis, ancient schwannoma, and Castleman disease.
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Affiliation(s)
- Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, The Netherlands
| | - Thomas C Kwee
- Department of Radiology, Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700, RB, Groningen, The Netherlands.
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12
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Barron SL, McGrory BJ. Total knee arthroplasty in a patient with ipsilateral calcific myonecrosis. Arthroplast Today 2018; 4:421-425. [PMID: 30560169 PMCID: PMC6287287 DOI: 10.1016/j.artd.2018.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 11/17/2022] Open
Abstract
Calcific myonecrosis (CM) is a rare soft tissue condition associated with previous trauma that presents with a large lower extremity mass and can be misdiagnosed as a malignancy. Biopsy, accidental entry, or disturbance to the lesion can be accompanied by a high risk of complications. We present the case of a 72-year-old man with severe post-traumatic knee arthritis, as well as a large pretibial mass consistent with CM, who successfully underwent total knee arthroplasty. To our knowledge, this is the first report focusing on total knee arthroplasty in a patient with CM and we discuss considerations for evaluation, tourniquet usage, component positioning and placement, postoperative care, and range-of-motion expectations.
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Affiliation(s)
| | - Brian J. McGrory
- Tufts University School of Medicine, Boston, MA, USA
- Maine Joint Replacement Institute, Portland, ME, USA
- Corresponding author. 5 Bucknam Road, Suite 1D, Falmouth, ME 04105, USA. Tel.: +1 207 781 1551.
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13
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Matar HE, Stritch P, Emms N. Calcific myonecrosis: imaging and radiographic findings. Br J Hosp Med (Lond) 2018; 79:654. [PMID: 30418826 DOI: 10.12968/hmed.2018.79.11.654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hosam E Matar
- Specialty Registrar, Department of Trauma and Orthopaedics, Whiston Hospital, Prescot L35 5DR
| | - Paula Stritch
- Advanced Surgical Practitioner, Department of Trauma and Orthopaedics, Whiston Hospital, Prescot
| | - Nick Emms
- Consultant Trauma and Orthopaedic Surgeon, Department of Trauma and Orthopaedics, Whiston Hospital, Prescot
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14
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Leyva A, Cibulas A, Boron A, Dennison J, LiMarzi G, Porrino J, Wasyliw C, Bancroft L, Scherer K. Musculoskeletal Faces of Death: A Diagnostic Imaging Review. Semin Roentgenol 2018; 54:190-202. [PMID: 31128741 DOI: 10.1053/j.ro.2018.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | | | - Agnieszka Boron
- Department of Radiology, Florida Hospital, Orlando, FL; University of Central Florida College of Medicine, Orlando, FL
| | - John Dennison
- Department of Radiology, Florida Hospital, Orlando, FL
| | - Gary LiMarzi
- Department of Radiology, Florida Hospital, Orlando, FL
| | | | | | | | - Kurt Scherer
- Department of Radiology, Florida Hospital, Orlando, FL.
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15
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Abstract
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.
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16
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Ukon Y, Tanaka T, Nagata S, Hagizawa H, Imura Y, Tamiya H, Oshima K, Naka N, Aoki Y, Kuratsu S. Calcific myonecrosis mimicking soft tissue sarcoma: A case report. Oncol Lett 2018; 15:7909-7913. [PMID: 29731908 PMCID: PMC5920900 DOI: 10.3892/ol.2018.8320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/28/2018] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Yuichiro Ukon
- Department of Orthopaedic Surgery, Belland General Hospital, Sakai, Osaka 599-8247, Japan.,Department of Orthopaedic Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Takaaki Tanaka
- Department of Orthopaedic Surgery, Belland General Hospital, Sakai, Osaka 599-8247, Japan.,Department of Orthopaedic Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Shigenori Nagata
- Department of Pathology and Cytology, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Hiroki Hagizawa
- Department of Orthopaedic Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Yoshinori Imura
- Department of Orthopaedic Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Hironari Tamiya
- Department of Orthopaedic Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Kazuya Oshima
- Department of Orthopaedic Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Norifumi Naka
- Department of Orthopaedic Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Yasuaki Aoki
- Department of Orthopaedic Surgery, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo 670-8540, Japan
| | - Shigeyuki Kuratsu
- Department of Orthopaedic Surgery, Belland General Hospital, Sakai, Osaka 599-8247, Japan
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Smitaman E, Flores DV, Mejía Gómez C, Pathria MN. MR Imaging of Atraumatic Muscle Disorders. Radiographics 2018; 38:500-522. [PMID: 29451848 DOI: 10.1148/rg.2017170112] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Atraumatic disorders of skeletal muscles include congenital variants; inherited myopathies; acquired inflammatory, infectious, or ischemic disorders; neoplastic diseases; and conditions leading to muscle atrophy. These have overlapping appearances at magnetic resonance (MR) imaging and are challenging for the radiologist to differentiate. The authors organize muscle disorders into four MR imaging patterns: (a) abnormal anatomy with normal signal intensity, (b) edema/inflammation, (c) mass, and (d) atrophy, highlighting each of their key clinical and imaging findings. Anatomic muscle variants, while common, do not produce signal intensity alterations and therefore are easily overlooked. Muscle edema is the most common pattern but is nonspecific, with a broad differential diagnosis. Autoimmune, paraneoplastic, and drug-induced myositis tend to be symmetric, whereas infection, radiation-induced injury, and myonecrosis are focal asymmetric processes. Architectural distortion in the setting of muscle edema suggests one of these latter processes. Intramuscular masses include primary neoplasms, metastases, and several benign masslike lesions that simulate malignancy. Some lesions, such as lipomas, low-flow vascular malformations, fibromatoses, and subacute hematomas, are distinctive, but many intramuscular masses ultimately require a biopsy for definitive diagnosis. Atrophy is the irreversible end result of any muscle disease of sufficient severity and is the dominant finding in disorders such as the muscular dystrophies, denervation myopathy, and sarcopenia. This imaging-based classification, in correlation with clinical and laboratory data, will aid the radiologist in interpreting MR imaging findings in patients with atraumatic muscle disorders. ©RSNA, 2018.
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Affiliation(s)
- Edward Smitaman
- From the Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.); Department of Radiology, Philippine Orthopedic Center, Quezon City, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); and Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.)
| | - Dyan V Flores
- From the Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.); Department of Radiology, Philippine Orthopedic Center, Quezon City, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); and Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.)
| | - Catalina Mejía Gómez
- From the Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.); Department of Radiology, Philippine Orthopedic Center, Quezon City, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); and Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.)
| | - Mini N Pathria
- From the Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.); Department of Radiology, Philippine Orthopedic Center, Quezon City, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); and Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.)
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Flores DV, Mejía Gómez C, Estrada-Castrillón M, Smitaman E, Pathria MN. MR Imaging of Muscle Trauma: Anatomy, Biomechanics, Pathophysiology, and Imaging Appearance. Radiographics 2017; 38:124-148. [PMID: 29220207 DOI: 10.1148/rg.2018170072] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Muscle is an important component of the muscle-tendon-bone unit, driving skeletal motion through contractions that alter the length of the muscle. The muscle and myotendinous junction (MTJ) are most commonly injured in the young adult, as a result of indirect mechanisms such as overuse or stretching, direct impact (penetrating or nonpenetrating), or dysfunction of the supporting connective tissues. Magnetic resonance (MR) imaging is widely used for assessment of muscle injuries. This review illustrates the MR imaging appearance of a broad spectrum of acute, subacute, and chronic traumatic lesions of muscle, highlighting the pathophysiology, biomechanics, and anatomic considerations underlying these lesions. Concentric (shortening) contractions are more powerful, but it is eccentric (lengthening) contractions that produce the greatest muscle tension, leading to indirect injuries such as delayed-onset muscle soreness (DOMS) and muscle strain. Strain is the most commonly encountered muscle injury and is characteristically located at the MTJ, where maximal stress accumulates during eccentric exercise. The risk of strain varies among muscles based on their fiber composition, size, length, and architecture, with pennate muscles being at highest risk. Direct impact to muscle results in laceration or contusion, often accompanied by intramuscular interstitial hemorrhage and hematoma. Disorders related to the muscle's collagen framework include compartment syndrome, which is related to acute or episodic increases in pressure, and muscle herniation through anatomic defects in the overlying fascia. The healing response after muscle trauma can result in regeneration, degeneration with fibrosis and fatty replacement, or disordered tissue proliferation as seen in myositis ossificans. In athletes, accurate grading of the severity and precise location of injury is necessary to guide rehabilitation planning to prevent reinjury and ensure adequate healing. In elite athletes, MR imaging grading of muscle trauma plays an increasingly important role in recently developed comprehensive grading systems that are replacing the imprecise three-grade injury classification system currently used. ©RSNA, 2017.
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Affiliation(s)
- Dyan V Flores
- From the Department of Radiology, Philippine Orthopedic Center, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G., M.E.C.); and Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.)
| | - Catalina Mejía Gómez
- From the Department of Radiology, Philippine Orthopedic Center, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G., M.E.C.); and Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.)
| | - Mauricio Estrada-Castrillón
- From the Department of Radiology, Philippine Orthopedic Center, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G., M.E.C.); and Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.)
| | - Edward Smitaman
- From the Department of Radiology, Philippine Orthopedic Center, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G., M.E.C.); and Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.)
| | - Mini N Pathria
- From the Department of Radiology, Philippine Orthopedic Center, Maria Clara Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G., M.E.C.); and Department of Radiology, UCSD Medical Center, San Diego, Calif (E.S., M.N.P.)
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Tan AM, Loh CYY, Nizamoglu M, Tare M. A challenging case of calcific myonecrosis of tibialis anterior and hallucis longus muscles with a chronic discharging wound. Int Wound J 2017; 15:170-173. [PMID: 29076298 DOI: 10.1111/iwj.12833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/08/2017] [Indexed: 11/30/2022] Open
Abstract
The occurrence of calcific myonecrosis of the anterior compartment of the leg is rare. Common risk factors include a history of trauma, although little is known about the exact pathophysiology, latency period or triggering factors resulting in disease progression. Macroscopically, it begins with a single muscle being replaced by a fusiform calcified mass, which progresses peripherally. We present a rare case of a 7-year history of chronic discharging sinus overlying the site with protruding calcified muscle and discuss the senior author's wound management strategy and surgical considerations. The initial approach used dressing applications to reduce wound exudate while obtaining repeated imaging for disease progression comparison. Repeated CT scans showed significant disease progression from a single solitary amorphous soft tissue calcification to disseminated scattered calcified myonecrosis. In planning such surgeries, extensive debridement and temporary wound coverage is the first stage. Subsequent definitive coverage includes skin grafting of the remaining defect.
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Affiliation(s)
- Alethea My Tan
- St Andrew Centre for Burns and Plastics, Chelmsford, UK.,Plastic Surgery Unit, St Andrew Centre for Burns and Plastics, Chelmsford, UK
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Nagamoto H, Hosaka M, Watanuki M, Shiota Y, Hatori M, Watanabe M, Hitachi S, Itoi E. Calcific myonecrosis arising in the bilateral deltoid muscles: A case report. J Orthop Sci 2017; 22:790-794. [PMID: 26806333 DOI: 10.1016/j.jos.2015.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 11/10/2015] [Accepted: 12/09/2015] [Indexed: 02/09/2023]
Affiliation(s)
- Hideaki Nagamoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masami Hosaka
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Munenori Watanuki
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuki Shiota
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masahito Hatori
- Department of Orthopaedic Surgery, Tohoku Kosai Hospital, Sendai, Japan
| | - Mika Watanabe
- Department of Pathology, Tohoku University Hospital, Sendai, Japan
| | - Shin Hitachi
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Cunningham J, Sharma R, Kirzner A, Hwang S, Lefkowitz R, Greenspan D, Shapoval A, Panicek DM. Acute myonecrosis on MRI: etiologies in an oncological cohort and assessment of interobserver variability. Skeletal Radiol 2016; 45:1069-78. [PMID: 27105618 PMCID: PMC4912434 DOI: 10.1007/s00256-016-2389-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/27/2016] [Accepted: 04/06/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the etiologies of myonecrosis in oncology patients and to assess interobserver variability in interpreting its MRI features. MATERIALS AND METHODS Pathology records in our tertiary cancer hospital were searched for proven myonecrosis, and MRIs of affected regions in those patients were identified. MRI reports that suggested myonecrosis were also identified. Each MRI was reviewed independently by 2 out of 6 readers to assess anatomical site, size, and signal intensities of muscle changes, and the presence of the previously reported stipple sign (enhancing foci within a region defined by rim enhancement). The stipple sign was assessed again, weeks after a training session. Cohen kappa and percentage agreement were calculated. Medical records were reviewed for contemporaneous causes of myonecrosis. RESULTS MRI reports in 73 patients suggested the diagnosis of myonecrosis; pathological proof was available in another 2. Myonecrosis was frequently associated with radiotherapy (n = 34 patients, 45 %); less frequent causes included intraoperative immobilization, trauma, therapeutic embolization, ablation therapy, exercise, and diabetes. Myonecrosis usually involved the lower extremity, the pelvis, and the upper extremity; mean size was 13.0 cm. The stipple sign was observed in 55-100 % of patients at first assessment (κ = 0.09-0.42; 60-80 % agreement) and 55-100 % at second (κ = 0.0-0.58; 72-90 % agreement). Enhancement surrounded myonecrosis in 55-100 % patients (κ = 0.03-0.32; 58-70 % agreement). CONCLUSION Myonecrosis in oncology patients usually occurred after radiotherapy, and less commonly after intraoperative immobilization, trauma, therapeutic embolization, ablation therapy, exercise, or diabetes. Although interobserver variability for MRI features of myonecrosis exists (even after focused training), a combination of findings facilitates diagnosis and conservative management.
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Affiliation(s)
- Jane Cunningham
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY 10065
| | - Richa Sharma
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY 10065
| | - Anna Kirzner
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY 10065
| | - Sinchun Hwang
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY 10065,Weill Medical College of Cornell University, New York, NY 10065
| | - Robert Lefkowitz
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY 10065,Weill Medical College of Cornell University, New York, NY 10065
| | - Daniel Greenspan
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY 10065
| | - Anton Shapoval
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY 10065
| | - David M. Panicek
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY 10065,Weill Medical College of Cornell University, New York, NY 10065
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Pesquer L, Poussange N, Sonnery-Cottet B, Graveleau N, Meyer P, Dallaudiere B, Feldis M. Imaging of rectus femoris proximal tendinopathies. Skeletal Radiol 2016; 45:889-97. [PMID: 26956398 DOI: 10.1007/s00256-016-2345-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 02/02/2023]
Abstract
The rectus femoris is the most commonly injured muscle of the anterior thigh among athletes, especially soccer players. Although the injury pattern of the muscle belly is well documented, less is known about the anatomy and specific lesions of the proximal tendons. For each head, three distinctive patterns may be encountered according to the location of the injury, which can be at the enthesis, within the tendon, or at the musculotendinous junction. In children, injuries correspond most commonly to avulsion of the anteroinferior iliac spine from the direct head and can lead to subspine impingement. Calcific tendinitis and traumatic tears may be encountered in adults. Recent studies have shown that traumatic injuries of the indirect head may be underdiagnosed and that injuries of both heads may have a surgical issue. Finally, in the case of tears, functional outcome and treatment may vary if the rupture involves one or both tendons and if the tear is partial or complete. Thus, it is mandatory for the radiologist to know the different ultrasound and magnetic resonance imaging (MRI) patterns of these lesions in order to provide accurate diagnosis and treatment. The purpose of this article is to recall the anatomy of the two heads of rectus femoris, describe a reliable method of assessment with ultrasound and MRI and know the main injury patterns, through our own experience and literature review.
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Affiliation(s)
- Lionel Pesquer
- Centre d'Imagerie Ostéo-articulaire, Clinique du Sport de Bordeaux, 2, rue Georges Negrevergne, 33700, Mérignac, France.
| | - Nicolas Poussange
- Centre d'Imagerie Ostéo-articulaire, Clinique du Sport de Bordeaux, 2, rue Georges Negrevergne, 33700, Mérignac, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopedique Santy, Groupe Ramsay Generale de Santé - Hôpital Privé Jean Mermoz, 24 avenue Paul Santy, Lyon, France
| | - Nicolas Graveleau
- Centre de Chirurgie Orthopédique et Sportive, Clinique du Sport de Bordeaux, 2, rue Georges Negrevergne, 33700, Mérignac, France
| | - Philippe Meyer
- Centre d'Imagerie Ostéo-articulaire, Clinique du Sport de Bordeaux, 2, rue Georges Negrevergne, 33700, Mérignac, France
| | - Benjamin Dallaudiere
- Centre d'Imagerie Ostéo-articulaire, Clinique du Sport de Bordeaux, 2, rue Georges Negrevergne, 33700, Mérignac, France
| | - Matthieu Feldis
- Centre d'Imagerie Ostéo-articulaire, Clinique du Sport de Bordeaux, 2, rue Georges Negrevergne, 33700, Mérignac, France
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Yuenyongviwat V, Laohawiriyakamol T, Suwanno P, Kanjanapradit K, Tanutit P. Calcific myonecrosis following snake bite: a case report and review of the literature. J Med Case Rep 2014; 8:193. [PMID: 24934373 PMCID: PMC4086687 DOI: 10.1186/1752-1947-8-193] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 04/01/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction Calcific myonecrosis is a rare condition in which muscle in a limb compartment undergoes necrosis and becomes peripherally calcified with central liquefaction. The patient usually presents with a slowly progressive enlarged mass that sometimes can be misdiagnosed as soft tissue sarcoma. Most of the reported cases showed that the disease occurs often after trauma or compartment syndrome. However, the case of calcific myonecrosis following snake bite is rarely reported. Case presentation A 66-year-old Thai woman presented with a gradually progressive enlarged mass over a period of 10 years in her left leg. She had a history of untreated compartment syndrome after she was bitten by a snake (Malayan pit viper) in her left leg when she was 14-years old. At presentation, a plain X-ray showed a large soft tissue mass at the anterior compartment of her left leg. A sheet-like mass with an enlarged central cavity combined with peripheral calcification and cortical erosion of her tibia were observed. A biopsy was performed and the result was negative for neoplastic cells. During a 5-year follow-up, the mass progressively enlarged and then became infected and finally broke through the skin. She was treated by excision of the mass and administration of antibiotics. The wound completed healed at 1 month postsurgery. There was no wound complication or disease recurrence at 1 year postoperation. Conclusions The diagnosis of calcific myonecrosis was done by history taking and radiographic interpretation. In an asymptomatic patient the management should be observation and clinical follow-up. A biopsy should be avoided due to the high rate of postoperative infection. Treatment of choice in a symptomatic condition is mass excision.
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Affiliation(s)
- Varah Yuenyongviwat
- Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand.
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24
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Ultrasound of tibialis anterior muscle and tendon: anatomy, technique of examination, normal and pathologic appearance. J Ultrasound 2013; 17:113-23. [PMID: 24883132 PMCID: PMC4033720 DOI: 10.1007/s40477-013-0060-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/12/2013] [Indexed: 11/04/2022] Open
Abstract
Lesions of the tibialis anterior muscle and tendon are not frequently reported in international literature although pathology is not rare. Pathology can be spontaneous, associated with arthropathy or more generalized conditions. Clinical assessment may not be sufficient for distinguishing conditions like tendinopathy, tears, bursitis, etc. Therefore, imaging studies are necessary to plan appropriate therapy. US has a number of advantages, including widespread availability, absence of contraindications and low cost. It can also be used for dynamic studies of the muscle during contraction and relaxation. This article reviews the anatomy of the tibialis anterior, normal variants, the technique used for standard US examination of this muscle and tendon, its normal appearance on US and the sonographic characteristics of the most common lesions that affect it including tips on US-guided injections used for treatment.
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25
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Karkhanis S, Botchu R, James S, Evans N. Bilateral calcific myonecrosis associated with epilepsy. Clin Radiol 2013; 68:e349-52. [DOI: 10.1016/j.crad.2012.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 11/30/2012] [Accepted: 11/30/2012] [Indexed: 11/26/2022]
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Abstract
Muscle injuries can be classified into strain injuries and contusions. Depending on the type of injury, different complications may occur, which in turn can be divided into early, intermediate and delayed complications. A prompt diagnosis of complications allows early treatment and permits to avoid harmful sequelae. Imaging studies, ultrasonography in particular, allow (recognizing) the assessment of complications whenever clinically suspected. In this article the most frequent complications of muscle injuries are presented.
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Sreenivas T, Nandish Kumar KC, Menon J, Nataraj AR. Calcific myonecrosis of the leg treated by debridement and limited access dressing. INT J LOW EXTR WOUND 2013; 12:44-9. [PMID: 23446369 DOI: 10.1177/1534734613479382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Calcific myonecrosis is a rare late complication of limb trauma characterized by liquefaction and dystrophic calcification of muscles in the single compartment, usually in the leg. This occurs many years after the trauma and is probably due to chronic compartment syndrome. We report 2 cases of calcific myonecrosis involving the anterior compartment of the leg that presented to us in an advanced stage of multiple sinuses discharging calcific material. Incision and drainage had been attempted at a local hospital prior to presentation at our hospital resulting in a non healing wound. Both patients had a history of antecedent trauma to the leg a few years ago. Patients were treated by thorough debridement of the involved muscles in the anterior compartment. Limited access dressing (LAD) was used to manage the dead space left after debridement. After application of the LAD, the wound was covered with split skin grafting. In both patients, healing of the cavity following debridement was facilitated by application of limited access dressing. While the wound completely healed, the disability due to extensive debridement of anterior compartment of the leg persisted. At the latest follow-up, the patients were asymptomatic without any recurrence. Thorough debridement of the compartment involved and application of LAD may be another option of treating calcific myonecrosis of the leg, which was initially considered a "do not touch" lesion. Morbidity due to surgery and need of repeated surgeries for recurrences should be kept in mind and regular follow-up should be considered.
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Affiliation(s)
- T Sreenivas
- Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India.
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Portabella F, Nárvaez JA, Llatjos R, Cabo J, Maireles M, Serrano C, Pedrero S, Romero E, Pablos O, Saborido A. [Calcific myonecrosis of the leg]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012. [PMID: 23177942 DOI: 10.1016/j.recot.2011.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
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.
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Affiliation(s)
- F Portabella
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, España.
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29
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De Carvalho BR. Calcific myonecrosis: a two-patient case series. Jpn J Radiol 2012; 30:517-21. [PMID: 22454093 DOI: 10.1007/s11604-012-0077-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 03/13/2012] [Indexed: 11/30/2022]
Abstract
Calcific myonecrosis is a rare entity with only 57 cases reported in the English literature to date. It is a late complication of compartment syndrome of the limb and results in characteristic muscle necrosis with central liquefaction and peripheral calcification. This series presents a further two cases and consolidates the diagnostic features and treatment modalities described in the literature.
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Affiliation(s)
- Bruno R De Carvalho
- Tauranga Hospital, C/O RMO Office (2nd Floor), Cameron Road, Tauranga 3110, New Zealand.
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30
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Portabella F, Nárvaez J, Llatjos R, Cabo J, Maireles M, Serrano C, Pedrero S, Romero E, Pablos O, Saborido A. Calcific myonecrosis of the leg. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012. [DOI: 10.1016/j.recote.2011.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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31
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Rynders SD, Boachie-Adjei YD, Gaskin CM, Chhabra AB. Calcific myonecrosis of the upper extremity: case report. J Hand Surg Am 2012; 37:130-3. [PMID: 22119606 DOI: 10.1016/j.jhsa.2011.09.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 09/26/2011] [Accepted: 09/27/2011] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Sara D Rynders
- Department of Radiology, University of Virginia, Charlottesville, VA 22908-0876, USA
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32
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Calcific Myonecrosis of the Leg: Report of Three Patients Presenting with Infection. Surg Infect (Larchmt) 2011; 12:247-50. [DOI: 10.1089/sur.2010.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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34
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Affiliation(s)
- Y Tang
- Lister Hospital, Coreys Mill Lane, Stevenage SG1 4AB, UK
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Okada A, Hatori M, Hosaka M, Watanuki M, Itoi E. Calcific myonecrosis and the role of imaging in the diagnosis: a case report. Ups J Med Sci 2009; 114:178-83. [PMID: 19736609 PMCID: PMC2852764 DOI: 10.1080/03009730903016050] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
| | - Masahito Hatori
- 1Department of Orthopaedic Surgery, Tohoku University School of Medicine
| | - Masami Hosaka
- 1Department of Orthopaedic Surgery, Tohoku University School of Medicine
| | - Munenori Watanuki
- 1Department of Orthopaedic Surgery, Tohoku University School of Medicine
| | - Eiji Itoi
- 1Department of Orthopaedic Surgery, Tohoku University School of Medicine
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