Case Study: Myositis Ossificans of the left leg
presented by |
Jay Lieberman, DPM, FACFAS,
Director of
Podiatric
Medical Education,
Northwest Medical Center |
Steven Weiss, MD
Director of Pathology Services,
Northwest Medical Center
|
Caroline Smith, DPM
First Year Resident Medical Education,
Northwest Medical Center
|
An 86 year old male survivor of the Holocaust, whom was imprisoned in the Buchenwald Nazi concentration camp, presents to the office with a chief complaint of an abscess and cellulitis along the anteromedial aspect of the left leg. The patient states that 64 years ago, while imprisoned in Buchenwald, he developed a deep seated abscess in the left leg. This problem went untreated for some time and the patient developed sepsis. A physician from Czechoslovakia was brought in to treat some of the prisoners; due to conditions inside the concentration camp, medical equipment was limited. The patient states that without the benefit of anesthesia, a large railroad spike was driven into his leg to drain the abscess. A hose was then placed into the entry wound created by the railroad spike, to flush the infection out through the exit wound. The patient went on to heal with a hypertrophic scar on the medial side of the left leg. He has recently developed an abscess in the area of the exit wound.
Past Medical history: Osteoarthritis
Medications: None
Social History: Married holocaust survivor. He does not smoke or drink alcohol, but he does drink coffee.
Allergies: No known drug allergies
Lower Extremity exam:
The dorsalis pedis is a +1/4 bilaterally, the posterior tibial is a +2/4 bilaterally. Epicritic sensation is grossly intact bilaterally. There is a hypertrophic scar along the medial aspect of the left leg. There is an abscess overlying the exit site. Positive pain upon palpation of this area is noted, as is mild erythema and edema. Examination of the right lower extremity is unremarkable.
Radiographic Findings:
AP and mortise plain film x-rays of the left leg were taken. Both views demonstrate soft tissue ossifications, which show the same radiopacity as the tibia and fibula. These ossifications may be related to breakdown of muscle in the leg. There were no other remarkable findings on the x-rays.
Treatment:
The wound was debrided in the office. A small amount of purulence was noted and a sliver of bone was removed. Cultures of the drainage were obtained. However, no growth was noted on the preliminary results. The patient was to keep the area covered with Bactraban cream and a dry sterile dressing. For many months the wound would heal and reopen occasionally extruding bone Treatment options were discussed and excision of the ossifications was decided upon. All risks, benefits, complications and alternatives were discussed in detail with the patient. The patient consented to the procedure and all necessary preoperative lab work and data were obtained.
Procedure: Excision of bone from left leg
The patient was brought into the operating room under mild sedation,. After the induction of general anesthesia, a well padded pneumatic tourniquet was placed about the left thigh and set to 350mmHg but was not inflated at this time. The patient was then placed on the OR table in the prone position.
The left leg was then scrubbed, prepped and draped in the normal sterile fashion. A time out was conducted to confirm the correct patient, procedure, site of procedure and surgeon to perform procedure. The left lower extremity was then exsanguinated using a sterile esmarch and the pneumatic tourniquet was inflated to 350mmHg. At this time, using a #15 blade scalpel, a 3:1 ellipitcal incision was made overlying the area of the distal cicatrix. This area measured approximately 6cm long X 2cm wide.
The ellipse was then resected, allowing visualization of the subcutaneous scar tissue and superficial bone fragments. All bleeders were cauterized as necessary. At this time, all osseous fragments were removed and placed on the back table for specimen. Next, intraoperative fluoroscopy was used to insure that all fragments had been resected. The surgical area was then flushed with copious amounts of normal sterile saline. 4-0 Nylon was then used to reapproximate the wound edges. The area was then dressed with adaptic, 4x4’s, Kerlix and then a Jones compression dressing was applied. The left thigh tourniquet was deflated and a prompt hyperemic response was noted to the left lower extremity.
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Pathology report: Extensive fibrosis with sclerosis, Dystrophic Calcifications, and Foci of ossification. “No atypical tissues or malignancy seen.” Dr. Weiss further notes, "Myositis ossificans is a reactive non-neoplastic response of muscle tissue to hemorrhagic traumatic injury. Organizing reactive fibroblasts undergo a metaplastic transformation which can form cartilage, calcification, and ossification with the production of grossly appreciable bone. Its major medical significance is that it may be clinically or histologically mistaken for a tumor of bone."
Discussion: Myositis Ossificans is a condition that causes abnormal bone formation in an area of soft tissue trauma that causes deep tissue bleeding. This is new ectopic bone formation that is not related to the underlying bony structure. This most commonly occurs in athletes who have sustained some form of blunt trauma. This condition does not usually require surgical excision, unless it becomes bothersome to the patient, as was the case with this patient. After the procedure, the patient was placed in Jones compression dressing and the sutures were removed in twelve days. The patient tolerated the procedure well and has gone on to heal without complication.
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