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Atraumatic myositis ossificans of iliopsoas excised through an ASIS osteotomy: case report and description of a novel technique.

Ossification occurring in muscles and soft tissues is referred to as myositis ossificans. (1) Such ectopic bone formation occurring following injury has been known by various names such as heterotopic ossification, (2) hyperostosis, (3) para-articular ossification, (4) and myositis ossificans traumatica. (5) Myositis ossificans following head or spinal injury is often referred to as neurogenic myositis ossificans and occurs within the first month following injury. (6) Such a condition could also complicate patients with other disease processes involving the central nervous system. (6) Neurogenic myositis ossificans has also been described in comatose patients as well as in patients following tetanus. (3) Although the occurrence of myositis ossificans following spinal injury is well established between 15% to 20%, that following head injury is not. (7) Repeated microtrauma by forceful passive mobilization during rehabilitation is the most widely accepted theory supporting occurrence of myositis ossificans following head trauma. Myositis ossificans often leads to significant functional disability by causing limitation of joint mobility. In order to regain functional range of motion, surgical excision is required. (8) The present case report describes a case of extensive myositis ossificans of the iliopsoas in a middle aged man secondary to head injury and its successful extraction through iliofemoral approach and anterior superior iliac spine (ASIS) osteotomy.

Case Report

A 41-year-old male presented to our tertiary care institute with complaints of stiffness in right hip for 9 months and difficulty in walking. The patient had sustained a road traffic accident 1 year back following which he had a severe head injury for which the patient was managed by neurosurgeons and was bed ridden for 6 months. The patient also gave history of tying a warm bandage around the right hip region following massage due to pain in that region. There was no injury to hip during accident. There was no history of previous trauma to hip.

On examination, the patient's limb was in an attitude of external rotation. Palpation revealed a hard swelling along the medial aspect of upper thigh and hip region. This swelling was non-tender, and the local temperature was normal. It appeared to move with the femur. The hip was fixed in external rotation of 20[degrees], flexion of 20[degrees], and 10[degrees] adduction. No further movements in any plane were possible (Fig. 1).

On plain roentgenogram a radio-opaque mass extending from the iliac fossa to the lesser trochanter was seen. It appeared as a bony mass resembling a bar. The x-ray showed no evidence of periosteal reaction or soft tissue swelling (Fig. 2A). The patient's biochemical markers were unremarkable. Serum alkaline phosphatase was within normal range. Other hematological investigations were also normal.

A computed tomography with 3D reconstruction revealed the complete extent of the mass. Margins of the mass, as they appeared on the CT, were well defined and were smooth and regular (Fig. 2B).

Excision of the mass was planned, and the patient was taken up under spinal anesthesia. The ilio-femoral approach was used. The ASIS was osteotomized, the sartorius along with ASIS was reflected, and the iliac fossa along with the mass was brought into view. Using an osteotome, the mass was detached from the iliac fossa and exposed down to the lesser trochanter. Preserving the femoral nerve, the mass was osteotomized into two halves. The upper portion was excised and the lower portion was delivered using a 4.5 mm tap as lever arm. The part lying over the anterior capsule was also excised. Wound was closed in layers over drain (Fig. 3). Patient was given perioperative prophylaxis with oral indomethacin. Intraoperative a flexion of 110[degrees] was achieved. The mass was sent for histopathological analysis, which confirmed our provisional diagnosis of myositis ossificans.

Postoperatively the patient was put on antibiotics and was given indomethacin. Roentgenograms performed postoperatively confirmed the complete excision of the mass. At 1-year follow-up, the patient is leading an active life, with active range of flexion in the involved hip to the range of 70[degrees] (Fig. 4).

Discussion

Dejerine and Ceillier were the first to describe periarticular ossification in patients with severe head injury. (9) They also called this periarticular ossification occurring following a significant neurological injury as neurogenic myositis ossificans.

Shoulders and elbows are the most common site of posttraumatic myositis ossificans following head injury. Hip, as well as the knee, are seen to be involved more in patients with spinal injury as compared to those with head injury. (10) The cause of myositis ossificans is, however, poorly understood, (11) and head injury is believed to provide a suitable environment. It allows inducing agents, such as BMP 4, to act on the osteogenic precursors released as a result of muscle trauma. (12) Various vasomotor, metabolic, and trophic changes induced by prolonged immobilization as a result of head injury provide a setting apt for heterptopic ossification. (4) Trauma leading to muscle damage and periosteal injury seem to initiate osteogenic progenitor cells which differentiate into osteoblasts and mature bone. Such ectopic ossification occurs between the muscle planes and not within the muscle fibers themselves. (13)

Bagaria and coworkers (12) in 2011 described a case of ankylosis of the hip joint due to extensive myositis ossificans. They reported a post-traumatic myositis ossificans of the iliopsoas of the left side measuring up to almost 25 cm. Such extensive involvement leads to significant functional impairment. However, surgical excision leads to improvement of the range of motion. The patient had gained 90[degrees] flexion, 30[degrees] of coronal plane movement, and 20[degrees] of external and internal rotation.

Nielsen (14) reported a case of myositis ossificans around the hip in a 21 year old who developed mental retardation and left sided spastic hemiplegia following severe traumatic head injury. This patient was made further prone to myositis ossificans due to the repeated corrective surgeries around hip due to impaired mobility as a result of hemiplegia.

Myositis ossificans of the hip is common following spine injury; however, its occurrence following head injury is infrequent. (8) Further, it is rare to find an extensive myositis ossificans of the hip following head injury leading to extra-articular ankylosis. The Smith-Peterson approach to hip was found to be the most commonly used approach, allowing easy access to the mass.

Carlier and colleagues (7) in an enhanced volumetric CT study concluded that surgical delay was associated with significant joint space reduction and bone demineralization. Volumetric CT was found to be a very good method of preoperative assessment, and its results correlated well with the intraoperative findings.

The patient of myositis ossificans in hip often complains of pain as the initial symptom and presents with local rise of temperature, tenderness, swelling, and restriction of movements. They can be, however, asymptomatic in a few cases. Functionally significant restriction of movement is seen in almost 10% to 20% of patients. (12) Absence of any associated bone destruction, massive periosteal reaction, no other soft tissue mass, and an intact underlying cortex on a plain roentgenogram are used to differentiate it from any other neoplastic osseous lesion.

The 3D reconstructed CT images of our patient showed the true extent of the lesion and were used to plan the excision of the mass. The iliofemoral approach with osteotomy of the ASIS allowed us to have an adequate exposure of the lesion and complete excision. This approach exposed the entire span of the mass extending from the iliac blade to the lesser trochanter. The extensive excision of the mass helped the patient regain a good range of motion in the involved hip. Postoperatively, the patient had regained active flexion to the range of 70[degrees] with passive range of 90[degrees] and coronal plane motion to the range of 20[degrees].

Conclusion

Although the occurrence of an ankylosing myositis of the hip is common following spinal injury, very few cases have been reported following head trauma. (8) We report one such case with extensive myositis ossificans of the iliopsoas along with the description of a novel technique through ASIS osteotomy for excision of the mass. The innovative technique and good soft tissue handling helped the patient regain good range of motion in the involved joint, allowing the patient a good socio-economic re-establishment.

Caption: Figure 1 Preoperative images of the patient showing a fixed flexion deformity of 20[degrees].

Caption: Figure 2 A, Preoperative plain radiographs AP view showing the joint space well preserved. B, CT image of patient 9 months after head injury showing the mass extending from the iliac fossa to the lesser trochanter. There is continuity of bone from the lesser trochanter to the iliac fossa.

Caption: Figure 3 On table photographs showing: A, mass separated from underlying structures using an osteotome and B, intraoperative image after the entire mass was excised showing the femoral head. To view these images in color, see www.nyuhjdbulletin.org.

Caption: Figure 4 Patient showing a good range of motion at 1-year follow-up.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References

(1.) Hendifar AE, Johnson D, Arkfeld GA. Myositis ossificans: a case report. Arthritis Care Res. 2005 Oct;53:793-5.

(2.) Naraghi FF, Decoster TA, Moneim MS, et al. Heterotopic ossification. Orthop Inter ED. 1996;4(2):131-8.

(3.) Luisto M, Zitting A, Tallorth K. Hyperostosis and osteoarthritis in patients surviving after tetanus. Skeletal Radiol. 1994 Jan;23(1):31-5.

(4.) Mielants H, Vanhove E, De Neels J, Veys E. Clinical survey of and pathogenic approach to para-articular ossifications in long-term coma. Acta Orthop Scand. 1975 May;46(2):190-8.

(5.) Resnick D, Niwayama G. Soft tissues. In: Resnick D (ed): Diagnosis of Bone and Joint Disorders (3rd ed). Philadelphia: W.B. Saunders Co., 1995, pp. 4491-4622.

(6.) Della Santa DR, Reust P. [Heterotopic ossification and ulnar nerve compression syndrome of the elbow: a report of two cases]. Ann Chir Main Memb Super. 1990;9(1):38-41.

(7.) Carlier RY, Safa DM, Parva P, et al. Ankylosing neurogenic myositis ossificans of the hip. An enhanced volumetric CT study. J Bone Joint Surg Br. 2005 Mar;87(3):301-5.

(8.) Cassar-Pullicino VN, McClelland M, Badwan DAH, et al. Sonographic diagnosis of heterotopic bone formation in spinal injury patients. Paraplegia. 1993 Jan;31(1):40-50.

(9.) Dejerine M, Ceillier A. Trois cas d'osteomes: ossifications periostees juxta-musculaires et interfasciculaires chez les: paraplegiques par lesion traumatique de la moelle epiniere. Rev Neurol. 1918;25:159-72.

(10.) Bravo-Peyna P, Esclarin A, Arzoz T, et al. Incidence and risk factors in the appearance of heterotopic ossification in spinal cord injury. Paraplegia. 1992 Oct;30(10):740-5.

(11.) Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusions: West Point update. Am J Sports Med. 1991 May-Jun;19(3):299-304.

(12.) Rothwell AG. Quadriceps hematoma. A prospective clinical study. Clin Orthop Relat Res. 1982 Nov-Dec;(171):97-103.

(13.) Bagaria V, Rasalkar DD, Paunipagar BK. Extensive myositis ossificans with extra-articular ankylosis of the hip joint. Hong Kong J Radiol. 2011;14:35-8.

(14.) Nielsen BF. Myositis ossificans articulating with the pelvis: A case report. Acta Orthop Scand. 1985 Feb;56(1):86.

Narender Kumar Magu, M.D., Reetadyuti Mukhopadhyay, M.D., Paritosh Gogna, M.D., Amanpreet Singh, M.D., Rohit Singla, M.D., and Rajesh Rohilla, M.D.

Narender Kumar Magu, M.D., Reetadyuti Mukhopadhyay, M.D., Paritosh Gogna, M.D., Amanpreet Singh, M.D., Rohit Singla, M.D., and Rajesh Rohilla, M.D., Department of Orthopaedics, Pt. B.D. Sharma PGIMS, Haryana, India.

Correspondence: Reetadyuti Mukhopadhyay, M.D., Department of Orthopaedics, Pt. B.D. Sharma PGIMS, Rohtak 124001, Haryana, India; reetya_m@hotmail.com.

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Article Details
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Author:Magu, Narender Kumar; Mukhopadhyay, Reetadyuti; Gogna, Paritosh; Singh, Amanpreet; Singla, Rohit; Ro
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Clinical report
Geographic Code:1USA
Date:Jan 1, 2015
Words:1949
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