literature review and discussion on versatile nature of myositis ossificans and throwing light on diagnostic dilemma.

2. X-RAY

3. CT

4. MRI

5. SEP 2010

6. JUNE 2011

7. OCT 2010
JULY 2011

8. 5 JULY 2011

9. 19.10.2011

10. Myositis ossificans traumatica:
A benign lesion with a malignant
character
Dr.Abu Bakar Siddique
MS (Ortho) WOC-SICOT (Int.) Fellow
Spine microsurgery fellow (Ganga Hospital)
Observer ship on spine deformity correction
Associate prof. Ad-din medical college
Senior consultant ,Impulse Hospital.

11. My present working place

12. Repon -30

14. • 30 years old Ripon, a BDR constable
presented with right arm swelling for six
months with a scar mark on lateral
aspect. He had a history of acute trauma
sustained to right biceps region
following a heavy weight lifting
in a weight lifting competition. Following
trauma he developed a painful swelling
which is relieved by cold application ,
rest and analgesics

15. • By three to four weeks the patient
gradually developed mildly tender
warm swelling with mild restriction of
shoulder and elbow movement. He
didn't care .By 3 months local doctor
sent him Dhaka for evaluation and
management.

16. Sep.2010
• Orthopaedic surgeon
• Advice given for urgent surgery
• Elbow bag
• Patient became apprehended.
• Went back to Cancer Research Centre
Thakurpukur kolkata.

17. Biopsy done

18. Inconclusive Histopathology
• Fibro
cartilaginous
tissue with
bites of bone,
inflammatory
& few spindle
cells but no
features of
malignancy

19. Advice from Thakurpukur
Cancer Centre, Kolkata.
• REVIEW
• RE BIOPSY
- Return back home.
- BDR Hospital Dhaka
- Review Biopsy done.

20. OCT.2010

21. MAY 2011
• Cancer Research
centre Thakurpukur
• They review the
histopathology
slides from
Bangladesh

22. REVIEW BIOPSY

23. Review biopsy report
• Tissue
insufficient.
• Deeper biopsy
needed.
• Lamellar bony
bite,fibrocartill
agenous tissue
• Few spindle
cell having
nuclear
hypercromasia.

24. ????????
• Why so many confusion?
• Why repeated biopsy?

25. AJR Am J Roentgenol. 1976
Jan;126(1):32-40
• AJR Am J Roentgenol. 1976 Jan;126(1):32-40.
• Myositis ossificans circumscripta: a benign lesion with a
malignant differential diagnosis.
• Goldman AB.
• Abstract
• Localized areas of active myositis ossificans, occurring without a clear
history of antecedent trauma, have been referred to as a "pseudo-malignant
osseous tumor of soft tissue." This lesion may be mistaken
both roentgenographically and pathologically for
a malignancy. The roentgenographic signs which favor a diagnosis of
non-neoplastic heterotopic bone formation include a lucent zone between
the lesion and the adjacent bone, an intact underlying cortex, diaphyseal
location, dense calcification in the periphery, and loss of volume on serial
films.
•

26. Indian J Radiol Imaging
v.22(1); Jan-Mar 2012
PMID: 22623814
Myositis ossificans imaging: keys to successful
diagnosis
…On one hand, premature biopsy done at the
early stage of MO may lead to a wrong
diagnosis of sarcoma and, on the other hand, there is a
risk that if biopsy is delayed a true sarcoma may be missed and
result in tumor dissemination. It is therefore critical to identify the
zone phenomenon of MO as early as possible using imaging. Another
important feature that helps differentiate between MO and
osteosarcoma is the well-circumscribed appearance of the former on
histopathology.

27. Literatures
• Case report 488: post-traumatic myositis ossificans mimicking a soft tissue neoplasm
• L Ackerman, S Ramamurthy, V Jablokow… - Skeletal …, 1988 - inis.iaea.org
• [en] A case of post-traumatic myosotis ossificans (MO) in a young man with only a vague
history of preceding physical trauma to the area of the lesion was presented. Imaging
modalities, including plain film radiography, CT, contrast angiography and bone
scintigraphy, could not exclude a malignancy with a reliable degree of certainty. The biopsy
specimen was consistent with MO but
could easily be misinterpreted as a
sarcomatouslesion. A diagnosis of MO was only established by a scrupulous analysis of all clinical …
• Cited by 25 Related articles All 9 versions
•

28. J Clin Orthop Trauma. 2014 Dec;
5(4): 261–265.
• J Clin Orthop Trauma. 2014 Dec; 5(4): 261–265.
• Published online 2014 Oct 11. doi: 10.1016/j.jcot.2014.09.005
• PMCID: PMC4264036
• Abstract
• Myositis ossificans circumscripta (MOC) is a benign condition of non-
neoplastic heterotopic bone formation in the muscle or soft tissue.
Trauma plays a role in the development of MOC, thus, non-traumatic
MOC is very rare. Although MOC may occur anywhere in the body, the
lesions are localized predominantly in the high-risk sites of injury, such
as the thigh, buttock, and elbow. MOC can easily be mistaken for
osteomyelitis or a malignant tumor, specifically osteosarcoma or soft-
tissue sarcoma. We report a rare case of non-traumatic myositis
ossificans circumscripta of thigh which appear clinically and
radiologically as a malignant neoplasm. Despite its rarity, MOC
should be contemplated in the differential
diagnosis of malignant tumors.

29. Indian J Radiol Imaging. 2012
Jan-Mar; 22(1): 35–39.
• Indian J Radiol Imaging. 2012 Jan-Mar; 22(1): 35–39.
• Myositis ossificans imaging: keys to successful diagnosis
• Alexis Lacout, Mohamed Jarraya,1 Pierre-Yves Marcy,2 Juliette Thariat,3 and Robert Yves Carli
• Abstract
• Myositis ossificans (MO) is an inflammatory pseudotumor of the muscle that may be
mistaken clinically and even histologically for a malignant
soft tissue tumor. The aim of this article is to report the imaging characteristics of
MO, the emphasis being on the early diagnostic clues. USG can be used at an early stage to
reveal the ‘zone phenomenon,’ which is highly suggestive of MO. A short course
of nonsteroidal anti-inflammatory drug therapy may be an efficient treatment for early MO.
• Keywords: Myositis ossificans, ossification, tumor, ultrasonography, zone phenomenon
•

30. Zone Phenomenon

31. Ackerman’s Zone phenomenon
i
A. Centre: Proleferating fibroblast
haemorrhage and necrosis.
MO
is important criterion
for the diagnosis of
Myositis Ossificans,no
such divisions occur in
sarcomatous lesion
OS

32. Middle zone
-Mature and
immature
osteoblast
-Islands of
immature bone

33. Peripheral zone
-Mature trabecular bone
separated from
surrounding
connective tissue
-Maturation process is
centrifugal.
-Central area being the
last to ossify.

34. Literatures
• There are known publications showing that biopsy can erroneously
suggest the diagnosis of osteosarcoma, especially since biopsy taken
from central portion of the area affected by
myositis ossificans may yield immature,
undifferentiated tissue resembling a
sarcoma. Histopathological examination performed after tumor
excision confirmed MO.

35. Pathology and pathogenesis
-Inappropriate response of bone stem
cell causes inappropriate
differentiation of
-

36. Our judgment regarding this
lesion
• Huge swelling but
no tenderness
• Biopsy wounds are
properly healed in
time.
• No weakness, no
wasting, no
vascular signs or
signs of ischemia.

37. Bony cortex are intact &
intra soft tissue lesion
Timely healed biopsy
wounds CT & MRI

38. Finally we decided for Excision
Without
loosing much
blood
Vital structres

39. Per operative
signs
Capsulated/pseudocapsulated
Minimum bleeding
No soft tissue invation
Intact neurovascular stractures
Bony cortex intact
Intact neurovascular
stractures
Capsulated/pseudocapsulated

40. Post operative signs

43. • Myositis ossificans is an aggressive
benign condition characterized by the
aberrant formation of bone in
extraskeletal soft tissues.

44. • It is usually confined to a single
muscle or muscle group, most
commonly in quadriceps, gluteal and
brachial muscle in male of second to
third decade of life.

45. • Usually it occurs following muscle
injury (myositis ossificans traumatic )
but it can also occur without previous
trauma in patients with burn,
neuromuscular disorders, hemophilia,
tetanus and drug abuse

46. • Myositis ossification is essentially a
proliferative mesenchymal response
to an initiating injury to the soft tissue
and muscle leading to localized
ossification.

47. • The mechanism of myositis ossificans
suggested is the abnormal
differentiation of fibroblast to bone
forming cells under the influence of
bone morphogenic protein

48. • Myositis ossificans usually is a self
limiting condition. Some time it needs
to be differentiated from
osteosarcoma. In the acute phase
which lasts for about 3 to 6 weeks it
should be managed conservatively.

49. • The lesion shouldn't be removed
surgically until the lesions have
matured as there is high risk of
recurrence.

50. Take home messages
• All aggressive lesions are not
malignant
• History taking and close observation
regarding clinical course of the growth
is important.
• Should not be dogmatic on early
biopsy rather repeated radiological
examination and it’s analysis

53. THANKS

55. Before
Surgery
After
surgery