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Myositis ossificans progressiva (MOP) is a rare hereditary connective tissue disorder. Skeletal abnormalities and progressive ectopic ossifications are features of this condition. Diagnosis is often delayed because of heterogenous picture of MOP. Treatment is unknown, so MOP leads to prolonged disability.
A heterotopic ossification is a non-neoplastic bone formation located in the soft tissues (so-called myositis ossificans). Important aspects of this condition, which is not uncommon after trauma or surgical procedures, are discussed from the trauma surgeon's viewpoint. The results of treatment of heterotopic ossifications are frequently unsatisfactory. Therefore, the importance of preventive measures is emphasized.
Benign fibrous lesions of the digits can present a considerable diagnostic challenge. Some lesions may resemble sarcomas, resulting in needless amputation. One such benign entity resembles myositis ossificans histologically but presents as an aggressive hand lesions. Unfortunately, this lesion has been given multiple names. It is most appropriately termed florid reactive periostitis. This paper reports a case of florid reactive periostitis in a 12-year-old girl.
The MR appearance of soft-tissue masses that simulate neoplasms has been described. In some cases, radiographs may demonstrate characteristic findings in association with MR imaging that may be diagnostic, such as an ossific rim seen in myositis ossificans, periosteal reaction seen in fibro-osseous pseudotumor, and retained foreign bodies present in a foreign body reaction or abscess. In other cases, the characteristic lesion location, age of the patient, and clinical presentation may be suggestive of the diagnosis, as in elastofibroma and nodular fasciitis.
The presence of bone and cartilage in some cases of malignant fibrous histiocytoma of the soft tissue as a microscopic finding has been reported previously but little note has been taken of the radiologic manifestations of these tumor elements. A series of five such cases with sufficient metaplastic osseous and cartilaginous elements to produce roentgenographic evidence of their presence is reported here. An additional two cases showed only histologic evidence of bone or cartilage formation. The reactive ossification tends to be peripheral in location, involving the pseudocapsule of the sarcoma or its fibrous septa. In three there was a zoning pattern with peripheral or polar orientation, strongly suggesting the diagnosis of myositis ossificans. The latter was the diagnosis considered radiologically in four of the five cases. Malignant fibrous histiocytoma with reactive bone and cartilage must be considered in the differential diagnosis of soft tissue masses with calcific densities, particularly when these occur in tumors of the extremities.
A 3 year study of 117 quadriceps contusions in West Point cadets was undertaken to document the effectiveness of a three-phased therapy program to return these young athletes to full activity with a normal knee range of motion and without recurrence of injury. The treatment protocol of this study was modeled after the 1973 West Point study of Jackson and Feagin with two major changes: 1) resting the injured leg in flexion (versus extension) and 2) emphasizing early flexion exercises (versus extension). Classification of contusions was based on knee range of motion at 12 to 24 hours after the injury (mild, greater than 90 degrees; moderate, 45 degrees to 90 degrees; severe, less than 45 degrees). The average disability time was 13 days for mild, 19 days for moderate, and 21 days for severe contusions. Myositis ossificans developed in 9% of cadets and was associated with five risk factors (knee motion less than 120 degrees, injury occurring during football, previous quadriceps injury, delay in treatment greater than 3 days, and ipsilateral knee effusion.
Authors report 2 cases of pseudoankylosis of the mandible secondary to myositis ossificans of the temporal muscle. Diagnostic workup is based on a clear history of trauma and clinic and X ray examinations. In the treatment of such a lesion the calcified part of the temporal muscle must be excised and an intraoral coronoidectomy performed to prevent further recurrence. Selected jaw exercises are useful too.
Recent views concerning the physiopathological aspects of restrictions on opening of the mouth attributable to extra-articular inflammation are examined. Stress is laid on the importance of psychological factors related to joint function and various organs and apparatuses that interferere with such function by reflex action via the brain. Instances of extra-articular inflammation limiting opening of the mouth are listed, with particular reference to primary and secondary myositis and myositis ossificans. Inflammation may also supervene in osteodysplasia, granuloxanthomatous hyperdysplasia of the maxillary bones, while opening of the mouth may be restricted by fibrosis of the muscles used in mastication due to protracted immobilisation, as in ankylosis of the T.M.A. Lastly, the way in which inflammation accompanying diseases of the salivary glands, dysembryoplasia, and jaw and mouth cavity neoplasia may prevent proper opening of the mouth is explained.
The development of a large circumscribed area of myositis ossificans at the junction of the aponeurosis of the tendo Achilles and the calf muscles may cause compression of the lateral saphenous nerve beneath the tight aponeurotic arch. The condition is usually encountered in athletes. Plantar flexion of the ankle will produce pain and diminution of sensation in the area served by the nerve. Treatment is by section of the tight band.
A rare case of spheno-mandibular ankylosis is reported in a 12 year-old child. The patient only complained of a restricted mouth opening; no particular etiologic factors were found to explain what was perhaps a myositis ossificans of the pterygoid muscles. However, neither the anatomic presentation at surgery, nor the histologic findings could confirm this diagnosis. An intra-oral route was chosen for the ankylosis resection, and the reconstruction of the resected upper part of the ramus was performed by a costo-chondral graft. The patient was free of recurrence 3 years after follow up.
This article discusses three selected areas of sports medicine in which MRI is useful. The first is muscle injuries and includes the MRI findings in muscle tears, contusions, and myositis ossificans. The second section discusses the usefulness of MRI in imaging the athlete with groin pain, which is a difficult clinical problem for the orthopedist. The ability of MRI to differentiate between such causes of groin pain as osteitis pubis, bursitis, and stress fractures is shown. The final section covers plain radiographic and MRI findings in osteochondritis dissecans. Also discussed is the MRI staging of osteochondritis dissecans, which is important in treatment decisions and surgical planning.
The pessimism associated with the treatment of pancreatic cancer may result in inappropriate management in certain patients thought to have that disease. We analyzed the recent UCLA experience with a variety of periampullary tumors in which various issues concerning management were unusual. The records of nine patients (age 15-75 years) with pancreatic or periampullary tumors were reviewed retrospectively. The tumor was evident on CT scan in all patients. The diameter of the mass was greater than 5 cm in five cases. Eight of the tumors appeared to arise from the pancreas, but at exploration, two were found to originate from other structures (duodenum and retroperitoneum). One patient with an apparent gastric lesion on CT scan was found to have a mass of pancreatic origin at operation. Operative procedures included: pancreaticoduodenectomy (four), distal pancreatectomy (three), total pancreatectomy (one), and retroperitoneal tumor resection (one). Pathological diagnoses included: solid and papillary epithelial neoplasm (two), mucinous cystic neoplasm (two), serous microcystic adenoma (two), myositis ossificans (one), degenerative neurilemoma (one), spindle cell tumor (one), and intraductal papillary carcinoma (one). We conclude that patients with large or unusual-appearing pancreatic or periampullary tumors should be managed aggressively. Major resections can be done safely with the achievement of an excellent quality of life in individuals at the extremes of age. Unlike the usual pancreatic ductal adenocarcinoma, the prognosis for many of these neoplasms is excellent.
Pseudosarcomatous lesions are benign neoplasms of the musculoskeletal system that are likely to be misdiagnosed as malignant, based on clinical and histologic features. These include soft-tissue "tumors" considered reactive or reparative lesions such as nodular fasciitis and myositis ossificans. Also included in the "pseudosarcoma" category are benign neoplasms which show "pseudoanaplastic" cytologic atypia. The latter include lipoma, leiomyoma, angiomyolipoma, and benign peripheral nerve-sheath tumors. These neoplasms, particularly the reparative processes and the nerve sheath tumors, are increasingly being subjected to initial diagnosis by fine-needle aspiration cytology. Even by conventional cytology this group of lesions represents a well-known pitfall for the diagnostic pathologist. We review some cytologic features: repair-like change, cohesion of cellular fragments, and presence of "normal" elements in the aspirate, which may help the cytopathologist avoid misdiagnosis of these notoriously difficult entities.
A review has been made of 30 cases of tumours arising in skeletal muscle seen over a 21-yr period (1954-74) in the Department of Pathology, Western General Hospital, Edinburgh. There were 17 females and 13 males in the series. The age range was 15 to 88 yr. The commonest site was thigh muscles (18 cases). Seven of the 14 benign tumours were myxomas: the other benign tumours included two solitary myositis ossificans, two haemangiomas and three lipomas. The three tumours which might be considered as being of borderline malignancy were two haemangiopericytomas and one desmoid tumour. There were 13 malignant tumours in the series: five fibrosarcomas, five liposarcomas, two rhabdomyosarcomas and one undifferentiated (pleomorphic) sarcoma. The average length of survival of the nine patients with malignant tumours who have died was only 15 mth. The fibrosarcomas in particular behaved in a highly malignant fashion. These 13 intramuscular sarcomas accounted for approximately 11 per cent, of all mesenchymal (non-lymphoid) sarcomas seen during the period of study.
1 case of circumscribed myositis ossificans of the temporal muscle is reported in a 21 years-old man. The initial complaint was a sudden non traumatic swelling. Roentgenography showed a characteristic feature: peripheral radio-opacity around a non-opacified area. Under microscope, we could find 3 zones: a central fibroblastic area, an intermediate zone with immature osteoid bone, a peripheral zone with mature lamellar bone. In addition, we used histoenzymological and electron microscopical methods. The difficulties of diagnosis, the pathogenesis and the prognosis of this disease were also discussed.
Noninfectious, nonneoplastic reactive processes of the hand, such as myositis ossificans circumscripta, pseudomalignant osseous tumor of soft tissue, and florid reactive periostitis, appear similar radiologically and histologically and are often difficult to differentiate. Magnetic resonance (MR) findings in two such lesions are reported. The extensive reactive change in the extraosseous soft tissue and the bone marrow and the relatively small extent of ossification may be characteristic. Although low-grade infection and small osseous neoplasms with reactive changes, such as osteoid osteoma, may still remain possible causes, MR imaging provides essential evidence for including noninfective, nonneoplastic reactive processes of uncertain cause in the list of differential diagnoses.
Myositis ossificans (MO) refers to non-neoplastic heterotopic soft tissue ossification that can have several aetiologies. Broadly it can be classified into three categories based on aetiology [1]. MO traumatica, the most common form occurs secondary to acute or chronic trauma. MO can also be associated with neurological disorders and in rare cases is congenital. The latter (progressive MO) is a genetic disorder in which congenital osseous abnormalities are associated with progressive soft tissue calcification. Despite an increased tendency to soft tissue bleeds, MO has been rarely reported in haemophilia. We treated three adolescents with haemophilia and MO of varying degrees of severity and outcome.
Eighty patients with soft tissue calcification were treated: 24 suffered from myositis ossificans traumatica, 23 from calcific bursitis (Duplay's disease), six from osteoarthropathy of elbow joint after severe craniocerebral trauma, nine from calcification around the elbow joint after local trauma, 13 from calcification around the hip joint, and five from calcification in ligaments and tendons. Using a new method of treatment about 75% of patients were cured. Calcifications disappeared or diminished substantially. Very good functional improvement followed in affected joints. The treatment involved local application of MgSO4 under local anaesthesia into calcified areas for 2-20 weeks, together with peroral administration of Mg lactate for 4-6 months. There were no complications or side effects of this treatment.