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REVIEW ARTICLE

MYOSITIS
OSSIFICANS
B R I A N E . WA L C Z A K , D O
C H R I S TO P H E R N . J O H N S O N , D O
B . M AT T H E W H O W E , M D
INTRODUCTION

Kransdorf et al defined MO as a benign, solitary, self-limiting, ossifying soft-tissue


mass typically occurring within skeletal muscle
Variability in terminology, clinical presentation, imaging characteristics, and
histopathology at times continues to make the diagnosis of MO challenging
A multidisciplinary team approach is helpful because MO may share similarities with
malignancy, and the imaging characteristics, histopathology, and subsequent treatment
vary depending on its stage of evolution.
PATOFISIOLOGI
CLINICAL PRESENTATION
a specific injury or repetitive minor trauma
pain and joint stiffness
flexor muscles of the arm and extensor muscles of the thigh are the most commonly affected
locations
paresthesia, weakness, lymphedema, and venous thromboembolic disease have been reported
when MO compresses nearby neurovascular structures
patients who present late may not have significant symptomatology
limited range of motion of an adjacent joint,
edema
atypical clinical presentation combined with nonspecific often raises concern for malignancy
Pseudomalignant MO
LABORATORY TESTING

The serum alkaline phosphatase (SAP) level initially remains normal but after 3 weeks,
in parallel with bone formation, becomes acutely elevated. Levels peak (1.3 to 13.4 times normal) at
approximately 10 weeks and return to normal by 18 weeks. The SAP level cannot be used to
determine the maturity or activity of a lesion and can remain normal even in active lesions.
Acute phase reactants, including the C-reactive protein level, erythrocyte sedimentation rate, and
prostagandin-E2 serum level, are elevated during the initial stages of MO.
Calcium level typically decreases for a short period and then returns to normal before the rise in
SAP.
Creatine phosphokinase level is generally elevated if there is involvement of muscle and, unlike SAP,
may be predictive for the subsequent development and severity of MO
IMAGING
Ultrasonography(USG) as an initial diagnostic test. Thomas et al demonstrated the
role of ultrasonography in the early diagnosis of heterotopic bone formation. They described
three concentric zones: an outer hypoechoic zone that surrounds the lesion, a middle
hyperechoic zone that corresponds to the calcifying rim, and a central hypoechoic zone that
corresponds to the central fibroblastic stroma
Confirmation is recommended with CT or correlation with serial radiographs to confirm the
classic zone of peripheral mature calcification.
Radiographs for MO mature phase when the patients clinical presentation correlates.
Initial plain radiographs of MO in the first 2 weeks are typically normal but occasionally
demonstrate periosteal reaction, possibly because of associated subperiosteal hematoma, and
can be associated with adherence to the periosteum.
A soft-tissue mass may be noticed in the radiographs of acute MO. Soft-tissue calcifications
begin to become apparent radiographically at approximately 3 to 4 weeks.
The calcifications may first appear as amorphous and flocculent. The calcifications typically
become more peripherally oriented and coarse in appearance. These calcifications mature
during the next several weeks to produce a densely calcified peripheral rim with a lucent
center, typically around 6 to 8 weeks.
A follow-up AP radiograph of the shoulder
confirms the diagnosis. Note the
characteristic mature peripheral
calcifications.

Potential mimickers of
myositis ossificans.
illustrating a parosteal
osteosarcoma of the femur

Lateral radiograph of the mid and distal


femur demonstrates an undulating mass
with mature calcification consistent with
chronic myositis ossificans
Bone scintigraphy is of little diagnostic value in the imaging workup of trauma-induced
MO, especially when presenting as an isolated soft- tissue mass. However, a bone scan may be
ordered when other inflammatory conditions, such as cellulitis, osteomyelitis, or
thrombophlebitis, are considered.
A bone scan will demonstrate increased uptake in injured muscle because of the presence of
calcium salts and is the most sensitive imaging modality for detecting heterotopic bone
formation in the very early stages.

Lateral view of the femur on a


delayed-phase technetium-99m-
methylene diphosphonate bone scan.
The mass demonstrates increased
uptake
CT is the best modality for delineating the zonal pattern of calcification and can be diagnostic
before the characteristic calcification pattern becomes radiographically detectable.
In the initial stages, CT demonstrates soft-tissue swelling or a low-attenuation soft-tissue mass
without associated calcifications..

Coronal CT scan demonstrates


the developing mature peripheral
calcification (arrow)
MRI is the best single modality for imaging soft-tissue masses. An MRI for the evaluation of a
soft-tissue mass should be interpreted in conjunction with recent radiographs because
calcifications may not be well demonstrated on MRI.
Papp et al classified lesions as determinate or indeterminate based on imaging characteristics
and clinical presentation.
A determinate lesion can be definitively diagnosed by means of history and physical examination
combined with appropriate imaging modalities such as MRI.
Indeterminate lesions (eg, type of sarcoma) require biopsy for an accurate diagnosis.
In the acute phase, when hematoma is often present, MO typically demonstrates a
heterogeneous signal intensity on T1-weighted areas of high signal intensity that are
representative of blood products.
T2-weighted hyperintensity suggests regions of granulation tissue, blood products, and edema.
T2-weighted hypointensity may correspond to hemosiderin deposition or calcifications.
As lesions progress, a pattern of mature, lamellar bone becomes better defined and
demonstrates low signal intensity on all sequences, and the surrounding edema has resolved.
Mature lesions may have areas of internal fat,
Coronal fat-saturated T2-weighted
magnetic resonance image
demonstrates marked inflammatory
edema about the mass.
DIFFERENTIAL DIAGNOSIS
BIOPSY
In early lesions, radiographs may be nondiagnostic, and subsequent MRI findings are often
nonspecific. For patients with an indeterminate lesion, a tissue sample is necessary before
forming a treatment plan. A biopsy can be performed.
Fine-needle aspiration for cytology has been reported to be nondiagnostic and was unable
to rule out sarcoma in some patients with MO; it is generally not recommended when core
tissue samples can be obtained for pathologic analysis.
Image-guided core biopsy is the authors preferred technique. Moreover, CT guidance is
ideal for sampling representative tissue from both the central and peripheral aspects of the
lesion.
Incisional biopsy allows direct visualization of the lesion, but it is also the more invasive
compared to closed needle biopsies. Incisional biopsies may be used when image-guided biopsy
is unavailable, after a core-needle biopsy when the diagnosis is uncertain
Excisional biopsies are reserved for small, easily accessible lesions when imaging is
consistent with a benign etiology.
HISTOPATOLOGY
Early lesions demonstrate mesenchymal metaplasia, intermediate lesions display mixed
chondro-osseous differentiation
Mature lesions demonstrate mature bone as a thin shell of bone covering a soft red-gray
central area and is typically 3 to 6 cm in size.
Microscopically, MO is characterized by a distinct zonal pattern that correlates to its stage of
maturity.
Centrally, proliferating fibroblastic tissue and interstitial microhemorrhages are seen. Mild
cellular pleomorphism and mitotic activity may be present.
An intermediate zone has areas of immature woven bone mixed with fibroblastic tissue.
At the periphery of the lesion, mature lamellar bone is seen
TREATMENT: NONSURGICAL
GOAL: minimize symptoms and maximize function.
Initial treatment of muscle injury with the purpose of controlling the development of
hematoma and maintaining function is a reasonable approach.
Jar vinen et al recommend a brief period of relative immobilization for 3 to 7 days
combined with rest, ice, compression, and elevation.
Crutches may assist with resting the affected area and minimizing hematoma formation.
Cryotherapy 15 to 20 minutes of ice every 30 to 60 minutescan decrease intramuscular
blood flow by 50%.
Aggressive physical therapy should be avoided. Assisted range-of-motion exercises, within a
pain-free arc of motion, may begin as early as 48 to 72 hours and then gradual progressive
exercise program
The use of drugs in the prophylaxis of MO after injury is limited. In one case two doses of
pamidronate were associated with improvement in both the clinical and radiographic finding
TREATMENT: SURGICAL
GOAL : improve function and limit pain.
Surgical indications include intractable pain resulting from mechanical irritation of nearby
tendons, bursa, or joints; lesions that are causing compression of important neurovascular
structures; and decreased range of motion that compromises activities of daily living.
Marginal excision is adequate, but recurrence has been reported.
The decision to proceed with surgery is optimized in a multidisciplinary setting, accounting for
the etiology, radiographic findings, laboratory values, and patient symptoms.
SUMMARY
MO is a self-limiting, reactive, boneforming process of soft tissues that occurs following injury. It may
mimic malignancy early in its development, especially when it is not associated with a characteristic
presentation and imaging findings.
The pathophysiology is incompletely understood; however, it likely involves the inappropriate
differentiation of mesenchymal stems cells into chondrocytes and osteoblasts in an inflammatory-
rich environment.
Diagnosis is often made with a thorough history, physical examination, and orthogonal radiographs.
However, a variety of advanced imaging modalities may be useful depending on the stage of
evolution. A biopsy is necessary to confirm the diagnosis for indeterminate lesions.
Nonsurgical treatment focuses on reducing symptoms and maximizing function.
Surgical excision is reserved for lesions that have failed nonsurgical treatment. The optimal timing
of surgical excision is undetermined but has traditionally been felt to be best performed once a
lesion has reached maturity.
A multidisciplinary approach is helpful to accurately diagnose and optimize treatment.
THANK YOU

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