Myositis Ossificans in the Thigh of a Lacrosse Player

Multifocal Post-Traumatic Myositis Ossificans Circumscripta in a Young Male Following a Motor Vehicle Accident: A Review of Imaging and Clinical Presentation

Traumatic myositis ossificans (MO) circumscripta is an uncommon nonhereditary pathophysiological result of muscular trauma that is detected by radiographic imaging three to four weeks following initial trauma. It is responsible for great global morbidity, with symptoms of prolonged pain, diminished flexibility, and stiffness. There is frequently a delay in diagnosis due to the generalized symptoms and varying radiographic presentation. The goal of therapy is to rule out serious complications (such as soft tissue sarcoma) and to restore strength and range of motion (ROM) as soon as possible. Here we detail the case of a 32-year-old male with a delayed diagnosis of MO who presented to the hospital with left lower extremity pain and swelling following a motor vehicle accident (MVA) that occurred one month prior.

The Surgical Management of the Rare Neurogenic Myositis Ossificans of the Hip: A Report of 3 Cases

Introduction:

Myositis ossificans (MO) is a benign non-neoplastic condition in which heterotopic bone formation occurs in soft tissues. Neurogenic MO is one variant of MO where the lesion is a result of neurological disorders, including brain and spinal cord injuries, especially when followed by immobility and spasticity. MO can also be a result of direct trauma or even genetic mutations.

Case Report:

We present three cases of young men (16, 37, and 22-year-old) who developed MO of the hip joint following brain or spinal cord injuries. One of them had also sustained a direct trauma to the affected hip joint at the time of the accident. All three patients presented with inability to walk independently due to diminished range of motion at the affected joint. X-rays and computerized tomography (CT) scans with 3-dimentional (3D) reconstruction suggested the diagnosis of MO, but the serum alkaline phosphatase was within normal limits at the time of presentation. The first case had bilateral involvement with unmistakable separation between the heterotopic bone formation and the frank hip joints on CT. This patient underwent successful staged excision of the ossifications. The second patient had unilateral hip joint involvement with the absence of clear separation between the heterotopic bone formation and the hip joint, thus, underwent total hip replacement for the affected side as excision was not possible. The third patienthad unilateral hip joint involvement and underwent excision of the ossification with dynamic hip screw insertion after sustaining a stable intertrochanteric fracture intraoperatively. Postoperatively, all three patients received physiotherapy and oral indomethacin. Upon recovery, they were able to walk independently with a near-normal range of motion at the hip joint. There was no evidence of recurrence upon follow-up visits, and CT scans in patients I and II. Follow-ups for patient III were not possible as the patient died 1 month after surgery due to pulmonary embolism.

Conclusion:

The surgical management of MO is indicated when non-operative methods fail to provide an adequate range of motion around the hip joint. Pre-operative assessment utilizing 3D-CT scans proved to be essential in dictating the appropriate surgical approach. During post-operative follow-ups, the physiotherapy and oral indomethacin provided additional improvement in outcome and patients’ satisfaction.

Identifying small pelvic inclusions through SEM technology

Tiny calcified structures may be occasionally recovered during excavation of human skeletal remains. Since taphonomic processes may displace these structures from their topographical relation with neighbouring organs or bones, differential diagnoses may pose a major challenge to the archeologist and/or anthropologist. Enteroliths, kidney stones or gallstones, phleboliths, calcified ganglia, or sesamoid bones account for most of such calcified tiny structures. In addition to their pure medical/paleopathological interest, some remains may be related to diet, to chronic haemolytic conditions, and/or to infections or chronic intestinal diseases. We here describe the technical procedures carried out to confirm or refute the identification of a sesamoid bone. The object in question was a small (5 × 3 × 2 mm) calcified structure that appeared over the right coxal bone of an 18^th century individual buried in the church Nuestra Señora de La Concepción, in Santa Cruz de Tenerife (Canary Islands). For comparative purposes we also analyzed kidney stones and gallstones from modern individuals. As shown in this study, scanning electron microscope (SEM) analysis is the preferred method to establish a precise differential diagnosis in these cases.

MRI Findings of Early Myositis Ossificans without Calcification or Ossification

PURPOSE

To characterize and evaluate the MR imaging features of early myositis ossificans (MO) without calcification or ossification.

METHODS

The MRI manifestations of seven patients with pathologically proven early MO were retrospectively analyzed with regard to tumor location, size, margins, signal intensity, and enhancement appearance in MR images. Additionally, the surrounding soft-tissue edema and adjacent bone change were assessed.

RESULTS

All cases (n=7) had intramuscular tumor-like masses without calcifications. The lesions appeared as isointense in T1-weighted images (T1-WI) and inhomogeneous hyperintense in T2-weighted MR images (T2-WI). On T2-WI and postcontrast T1-WI, the heterogeneously high signal intensity in the expanded muscle interspersed with a few hypointense linear structures consistent with intact muscle fibers showed "striate pattern" in the plane parallel with muscle fibers. The relatively hypointense areas with geometrical pattern consistent with the bundles of intact muscle fibers are found within the lesion with diffuse high signal intensity, displaying the "checkerboard-like pattern" in the plane vertical to muscle fibers. A "striate pattern" (n = 7) and "checkerboard-like pattern" (n = 3) in the lesion appeared in T2-WI. In contrast-enhanced MRI images, all cases showed diffuse "striate pattern" enhancement. Among them, one case demonstrated "checkerboard-like pattern" enhancement. All cases had diffuse and prominent muscle edema that preserved the muscle fascicles. For two lesions located in the deep muscle group, the adjacent bone showed bone marrow edema.

CONCLUSION

MR imaging has unique advantages for diagnosis of early MO without calcification or ossification: the "striate pattern" and "checkerboard-like pattern" appearance shown in T2-WI and contrast-enhanced MRI images can be helpful for differential diagnosis. MRI can delineate the extent of the tumor and provides accurate anatomical information, which is important in diagnosis, treatment, and follow-up.

Surgical excision of symptomatic mature posttraumatic myositis ossificans: characteristics and outcomes in 32 athletes

PURPOSE

The purpose of this study was to report characteristics and outcomes of surgical excision of symptomatic mature posttraumatic myositis ossificans in adult athletes. The hypothesis was that surgical excision of the ossified mass in these circumstances can effectively relief symptoms and result in return to high-level sports with minimal postoperative complications.

METHODS

All operations involving excision of posttraumatic heterotopic ossifications performed between 1987 and 2015 were reviewed. Included cases had isolated excision of posttraumatic myositis ossificans, whereas excluded cases had: (1) concomitant reattachment of tendon to bone; (2) chronic overuse injuries which preceded the development of the heterotopic mass or large calcifications which were excised from tendon-to-bone insertions; and (3) excision of heterotopic ossification from a ligament, capsule, or tendon insertion following avulsion injury without tendon-to-bone repair. After surgery, return to sports was allowed at 4-6 weeks.

RESULTS

Of 57 athletes undergoing excision of heterotopic ossifications, 32 were eligible as isolated excision of posttraumatic myositis ossificans. Twenty-four (75%) were ice hockey or soccer players. Median age was 23 years. Prior to surgery, patients were unable to continue their sports. At surgery, the ossification was excised from a thigh muscle in 27 (84%) cases. Median follow-up was 2 years (range 1-20 years). Outcome was Good/Excellent in 26 (81%) patients, corresponding to return to preinjury sports with minimal symptoms at sports activities. Preinjury Tegner activity level was resumed after surgery in 30 of 32 (94%) athletes, of whom 28 (94%) were involved in high-level sports corresponding to Tegner levels 8-10. No postoperative complications were recorded other than minimal insensitive areas at the periphery of skin incisions.

CONCLUSION

In high-level athletes who present chronic disabling mature posttraumatic myositis ossificans that interferes with their sports career, surgical excision of the heterotopic mass results in effective clinical improvement with return to sports and minimal postoperative risks.

LEVEL OF EVIDENCE

Case series, Level IV.