Microstructural analysis and biomechanical impact of myositis ossificans: A cadaveric case report

Jay J. Byrd; Ethan L. Snow; Travis L. McCumber

doi:10.1016/j.jorep.2023.100173

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Case Report

2023

:2;

100173

doi:

10.1016/j.jorep.2023.100173

Microstructural analysis and biomechanical impact of myositis ossificans: A cadaveric case report

Jay J. Byrd^a, Ethan L. Snow^a,b, Travis L. McCumber^a,b,

a College of Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA

b Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE, 68198, USA

∗Corresponding author: Travis L. McCumber. travis.mccumber@unmc.edu

Received: 2023-4-10, Accepted: 2023-5-2, Published: 2023-5-6

The Author(s)

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Myositis ossificans (MO) is a benign, ossifying, self-limited lesion that most commonly occurs in limb musculature secondary to trauma and may cause pain, stiffness, pressure sores, or decreased range of motion. The purpose of this study is to perform microstructural analysis of myositis ossificans and determine the biomechanical impact on the adductor longus (AL) muscle.

In situ radiographic imaging was performed prior to additional dissection, visualization, measurement, and photography of the AL and MO. Subsequently, the MO was removed for micro-computed tomography and histological analysis. Tissue parameters were used to calculate physiological cross-sectional area (PCSA) and maximal isometric force (Fmax) of the AL and determine the functional impact of the MO on the AL.

On in situ imaging, the MO appeared radio-dense along its perimeter and lucent at its core. AL morphology and attachments were typical. MO microarchitecture parameters and histology revealed low bone volume; decreased structural integrity; and lamellar bone formation with mature osteocytes, lacunae, and functional osteons. The MO occupied approximately 25.79% of the AL and decreased AL's Fmax from 112.726 N to 83.654 N and torque on the femur from 972.221 N·cm to 721.486 N cm.

The combination of gross, radiographic, histomorphometric, histological, and biomechanical findings suggest a mature MO traumatica resulting in a functional deficit of the AL. This report may benefit healthcare providers evaluating soft tissue masses as well as bone and mineral scientists and medical educators when presented with similar research or educational cases.

Keywords

Myositis ossificans

Heterotopic ossification

Micro-CT

Biomechanics

Adductor longus

Bone histopathology

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1 Introduction

1.1

1.1 History and classification

Myositis ossificans (MO) is a classification of heterotopic ossification (HO), an umbrella term for a diverse pathologic process which results in the formation of extraskeletal bone in muscle and other soft tissues. Nongenetic forms of HO are most common, and genetic forms exist but are rare. HOs are classified by their pathology, with MO implying origination of extraskeletal bone within skeletal muscle. MO was first described in 1692 by Guy Patin¹, better characterized in the 1900s², and classified into forms in the 1920s³. It is currently most accurately defined as a ‘benign, solitary, self-limiting, ossifying soft tissue mass’⁴. The Noble classification in 1924 is widely used and has three forms: MO traumatica, MO without a history of trauma, and MO progressiva^5–8.

1.2

1.2 Etiology

Cases of nongenetic MO classically present in individuals in their twenties or thirties with a history of surgery or trauma, though there is a broad age distribution ranging from early infancy to older adults with a higher incidence in males^9–16. Traumatic etiology is assumed to account for most cases with repetitive mechanical stress or minor trauma accounting for most of the rest⁹^,¹²^,¹⁴. Hip arthroplasty^17–20, bone fracture or dislocation^21–23, high-energy extremity trauma^24–26, traumatic central nervous system injury²⁷, and severe thermal injury²⁸ are well documented predispositions with ossification most commonly occurring in the musculature of the elbow, shoulder, pelvis, and thigh¹⁵^,²⁹^,³⁰.

1.3

1.3 Presentation, differential diagnosis, and management

Symptomatic MO may present as pain, joint stiffness, decreased range of motion, or pressure sores. Diagnosis may be more straightforward in a patient with a characteristic history and imaging findings; however, multiple pathologies mimic the symptoms and presentation of MO and could misguide diagnosis if they are not considered. For example, benign lesions that mimic MOs include abscess, periosteal reaction, parosteal osteochrondromatous proliferation, melorheostosis, and recurrent giant cell tumor³¹^,³². In addition, malignant lesions include parosteal osteosarcoma, extraskeletal osteosarcoma, and soft-tissue sarcoma^32–36. Patient presentation, imaging, laboratory results, and a high level of clinical scrutiny are therefore necessary for accurate MO diagnosis and treatment. Nonsurgical interventions are often successful and consist of immobilization with rest, ice, compression, and elevation to minimize hematoma formation³⁷. Surgical removal may be indicated in cases of failed nonoperative management, declined ability for activities of daily living, or recalcitrant pain, but recurrence is common³⁸.

1.4

1.4 Radiography, histology, and pathology

Radiographic characteristics of MO reflect its histologic characteristics as it matures. Early MO formations are highly cellular with immature mesenchymal cells that are negative for calcifications radiographically. Over time, an intermediate MO lesion develops cartilage and immature bone, which shows a calcified perimeter with a lucent core on imaging. Mature MO lesions show lamellar bone on histology which is densely calcified¹⁵^,³⁹. Clinicians may therefore need to use multiple imaging modalities such as conventional radiography, computed tomography, magnetic resonance imaging, ultrasound, or bone scintigraphy to aid in diagnosis³². No single laboratory test is currently sufficient for diagnosis of all MO stages, but changes in serum alkaline phosphatase⁴⁰, C-reactive protein³⁰, calcium⁴¹, and creatine phosphokinase⁴² levels have been correlated with clinical MO. Peripheral calcification on x-ray and laboratory findings combined with an identified etiology may be sufficient to classify the soft tissue mass, but early intermediate lesions require image-guided core biopsy for diagnosis and a multidisciplinary approach for treatment³².

1.5

1.5 Animal models and micro-computed tomography

Due to lack of effective early diagnostic techniques, curative interventions, and understanding of pathophysiology, many have developed and utilized animal models to study genetic and nongenetic etiologies of HO. The genetic models mainly simulate fibrodysplasia ossificans progressive, whereas nongenetic models are induced via trauma, bone morphogenetic protein, or nervous system injury⁴³. Investigations are typically conducted in mice⁴⁴ and rabbits⁴⁵, though some progress has been made towards the development of large animal models⁴⁶. Small animal models allow feasible micro-computed tomography (micro-CT) analysis, which has higher sensitivity than standard computed tomography in detecting early lesions⁴⁷. Despite the early diagnostic advantage, micro-CT has rarely been utilized in human research and clinical applications.

1.6

1.6 Analysis

Gross implications of MO are well documented; however, microstructural analysis of the ossification and its effect on human skeletal muscle contraction are less represented in the literature. Force-generating capabilities of cadaveric skeletal muscle can be quantified using structural measurements to calculate physiological cross-sectional area (PCSA), which approximates the total cross-sectional area of muscle fibers. PSCA is proportional to the maximal isometric force of contraction (Fmax) with a conversion factor for specific tension⁴⁸^,⁴⁹. This methodology has been demonstrated to estimate increased mechanical ability of accessory muscles in the neck⁵⁰, and the same methodology could be applied to a muscle with an MO to estimate the anomaly's impact on muscle function. Considering the risk of human MO biopsy and excision in vivo, combined with limited information about microarchitecture and functional impact of MO in general, the purpose of this study was to perform microstructural analysis of MO and determine its biomechanical impact on the adductor longus (AL) muscle.

2 Materials and methods

2.1

2.1 Initial discovery and radiology

An anatomically embalmed, cadaveric, human body donor was obtained for anatomy education. During routine dissection of the lower limb, the authors discovered a non-typical, unilateral, irregularly shaped mass encased within the left AL muscle near its distal attachment. Upon completion of the regional dissections, the anomaly and contiguous anatomy were placed in situ and a diagnostic, anterior to posterior, plain film x-ray was obtained of the left pelvis, hip, and thigh with the following scanning parameters: voltage: 75 kV, current: 800 mA, exposure: 9 msec.

2.2

2.2 Specimen collection and gross parameters

Further systematic dissection of the anteromedial thigh was completed to fully expose the AL and its proximal and distal points of attachment (Fig. 1A). AL parameters measured included: AL muscle length including and excluding tendonous dense connective tissue attachments, length of the AL proximal attachment along the inferior pubic crest, length of the distal AL attachment along the middle third of the linea aspera, and pennation angle of muscle fibers. Muscle length was calculated as the average length of the muscle along its superior border, mid-belly, and inferior border. The medial border of the femur was measured from the lesser trochanter to the superior most point of the distal attachment of the AL. AL and bone parameters were measured in triplicate with a digital caliper (8-inch Adoric Digital Caliper, Model DWQ) and averaged. Dissections were photographed (iPad Pro, Apple Inc.) in situ prior to the removal of the AL from its proximal and distal attachments to fully expose and release the MO from its muscular encasement. The AL and MO were weighed (Ohaus Micro Balance, Model AR3130), and MO parameters were measured. Considering the irregular morphometry of the MO, multiple measurements about the MO long axis, short axis, and thickness were made with digital caliper to record its morphological characteristics (Fig. 1B). The MO was photographed (iPad Pro, Apple Inc.) and was modeled using Blender three-dimensional computer graphics software (V3.1.2) (Fig. 1C).

Gross dissection and specimen collection. A) AL muscle and surrounding musculoskeletal structures with sartorius and vastus medialis muscles removed. AL proximal attachment along the inferior pubic crest and distal AL attachment along the middle third of the linea aspera. Dashed lines marking AL boarders. Oval highlighting the general location of non-typical, unilateral, irregularly shaped mass encased within the left AL near its distal attachment. ASIS: anterior superior iliac spine. B) MO fully exposed and released from its muscular encasement within the AL muscle (scale: 100mm × 100mm). C) MO modeled using Blender (V3.1.2) three-dimensional (3D) computer graphics software.

2.3

2.3 Micro-computed tomography

Four 5mm wide bone bore samples (S1–S4) were collected every 20 mm along the long axis of the MO for micro-CT analysis. Each sample was scanned using a high-resolution micro-CT (Bruker SkyScan 1172, Kontich, Belgium) with the following scanning parameters: voltage: 80 kV, current: 120 μA current, filter: 0.5 mm aluminum, exposure: 817 msec, intervals: 0.4°, frames per rotation: 4. Reconstructions were performed to establish 3D structures using NRecon software. Sample analysis of histomorphometric parameters was focused on a 5 mm region of trabecular bone at the midpoint of the long axis of the MO. Subsequently, custom analysis in CTan software was used to calculate MO parameters [percent bone volume (BV/TV), trabecular pattern factor (Tb.Pf), structure model index (SMI), trabecular thickness (Tb.Th), trabecular number (Tb.N), and trabecular separation (Tb.Sp)] for each of the four samples. MO parameters were compared to previously established, typical, healthy bone parameters [Hahn 1992,⁵¹].

2.4

2.4 Histology

The four bone samples (S1–S4) were subsequently prepared for histological analysis. Samples were subjected to decalcification in 100 ml of Leica Surgipath Decalcifier I solution. Samples remained in solution for 72 h and were subsequently washed in running water⁵². Decalcified samples were processed, embedded, sectioned, and stained with Hematoxylin and Eosin (H&E). Light microscopy (Nikon Optiphot Series) was used for cell and tissue analysis.

2.5

2.5 Impact analysis⁵³

Since AL fibers attached to and encapsulated the MO, the AL's function would certainly be impacted. The extent of dysfunction, however, can only be estimated with conservative assumptions in a post-mortem specimen. Therefore, the detached AL with MO was photographed, and the faced areas of AL and MO were measured (ImageJ software, 1.52q). A 0.5 cm border around the MO was included to account for a reasonable amount of surrounding muscle tissue that would likely be impacted by the MO. The amount of AL dysfunction according to these parameters was proportionally applied to AL isometric force and torque calculations to determine the MO's estimated functional impact on AL.

2.5.1

2.5.1 PCSA and Fmax calculations

To accurately estimate the effects on AL force-generating capacity, physiological cross-sectional area was calculated using previously measured muscle parameters and the equation⁴⁹^,⁵⁴: PCSA = [(m)(cos(θ))]/[(ρ)(FL)]; where m is muscle mass (g), θ is muscle fiber pennation angle (degrees), ρ is skeletal muscle density (g/cm³), and FL is fascicle length (cm). An experimentally determined and accepted density of fixed human muscle of 1.055 g/cm³ was utilized for calculations⁵⁴. The calculated PSCA (cm²) of AL was then used to determine its maximal isometric force of contraction (Fmax, in N) using the following equation⁴⁹^,⁵⁵: Fmax = (PCSA)(σ); where σ is the specific tension of contraction. The experimentally determined and accepted specific tension value of 22.5 N/cm² for fast-acting skeletal muscle was utilized for calculations⁴⁹^,⁵⁵. Fmax was calculated for the AL and proportionally adjusted for the muscle mass impacted by the MO.

2.5.2

2.5.2 Modeling and torque calculations

In situ radiographic imaging was utilized to visualize spatial relationships of the pathology and lever system created between the femur and acetabulum. Soft tissue measurements of the gross specimen were applied precisely to scale in the radiograph for recreation in a two-dimensional model. The angles of AL attachment to the femur and its Fmax were used to calculate its perpendicular force vector (V), and the distance from AL distal attachment (midpoint) to the articulation of the hip joint (midpoint) was measured (ImageJ). AL torque with and without MO impact were calculated using: τ = (d)(Fmax)(sin(θ)); where d is the distance from AL distal attachment to the fulcrum (cm).

3 Results

3.1

3.1 In situ imaging

Diagnostic, anterior to posterior plain film x-ray of the pelvis, hip, and thigh visualized a non-typical, unilateral, radiodensity within the left anteromedial thigh. The radiodensity appears calcified along the length of the perimeter, to have a lucent core, and measures approximately 100 mm in length along its long axis. In addition, a potential oblique fracture line was noted along the middle third of the femoral shaft extending through both cortices (Fig. 2).

In situ x-ray imaging. Diagnostic, anterior to posterior plain film x-ray with dashed line highlighting the location of a non-typical, unilateral radiodensity within the left anteromedial thigh. Radiodensity appears calcified along the length of the perimeter, to have a lucent core, and measures approximately 100 mm in length along its long axis. Arrows noting a potential oblique fracture line along the middle third of the femoral shaft extending through both cortices.

3.2

3.2 Gross specimen morphometry

The AL measured an average total muscle length of 246.19 mm from proximal to distal attachment, and 165.72 mm in length upon exclusion of tendonous dense connective tissue attachments. The length of the AL proximal attachment along the inferior pubic crest measured 15.89 mm, while the length of the distal attachment along the middle third of the linea aspera measured 106.85 mm. The AL muscle fibers were oriented at a pennation angle of 6.32° with respect to the force-transmitting axis. The femur measured 127.13 mm from the lesser trochanter to the superior most point of the distal attachment of the AL. The masses of AL and MO were 88.128 g and 9.698 g, respectively. The MO measured 102.19 mm in length along its long axis, averaged 6.47 mm in thickness, and was tapered to a sharp end along the entire length of the perimeter. Considering the irregular morphometry of the MO, additional measurements about the MO long and short axis (Fig. 3A) and thickness (Fig. 3B) were made with digital caliper to record morphological characteristics.

Myositis ossificans morphometry and sectioning. MO measured 102.19 mm in length along its long axis, averaged 6.47 mm in thickness, and was tapered to a sharp end along the entire length of the perimeter. Considering the irregular morphometry of the MO, additional measurements about the MO long and short axis (A) and thickness (B) were made with digital caliper to record morphological characteristics (scale: 100mm × 100mm). C) Dashed lines defining the location of MO sample collection (S1–S4) for micro-computed tomography and histological analysis.

3.3

3.3 Micro-computed tomography

A calcified perimeter was consistently found along the entire parameter of the MO which based on the micro-CT sample imaging averaged 0.14 ± 0.06 mm in thickness, ranging from 0.04 mm to 0.28 mm. MO trabecular parameters were calculated for each of the four samples (S1–S4) (Fig. 3C). Parameters for each sample were averaged to calculate global MO microarchitecture (MO Average): BV/TV = 6.29 ± 1.19%, Tb.Pf = 12.72 ± 72/mm, SMI = 2.12 ± 0.20∗∗∗, Tb.N = 0.60 ± 0.10/mm, Tb.Th = 0.11 ± 0.01 mm, Tb.Sp = 0.79 ± 0.05 mm (Table 1).

Table 1 MO trabecular parameters. Parameters calculated for each of the four samples (S1–S4) and averaged to calculate global MO microarchitecture (MO Average). Previously established, typical, healthy bone parameters⁵¹^,⁵³. ∗∗∗ SMI = 0–3, plates = 0 and rods = 3.

Parameter	S1	S2	S3	S4	MO Average	Hahn∗, Recker∗∗	Unit
Percent bone volume (BV/TV)	6.33	7.47	4.65	6.72	6.29 ± 1.19	19.50 ± 6.79∗∗	%
Trabecular pattern factor (Tb.Pf)	12.81	10.31	15.52	12.24	12.72 ± 2.15	0.89 ± 0.15∗	1/mm
Structure model index (SMI	2.21	1.87	2.34	2.08	2.12 ± 0.20	0.91 ± 0.63∗∗	∗∗∗
Trabecular number (Tb.N)	0.57	0.69	0.47	0.66	0.60 ± 0.10	1.33 ± 0.16∗∗	1/mm
Trabecular thickness (Tb.Th)	0.11	0.11	0.10	0.10	0.11 ± 0.01	0.17 ± 0.05∗∗	mm
Trabecular separation (Tb.Sp)	0.87	0.76	0.78	0.75	0.79 ± 0.05	0.71 ± 0.10∗∗	mm

3.4

3.4 Histology

Examination of the MO perimeter (S1–S4) revealed lamellar bone formation. Fibrous periosteal and cellular endosteal layers were noted along with mature osteocytes, lacunar spaces, and functional osteon units with central canals. The lucent MO core consisted of trabecular spindles of bone, with notable osteocytes and lacunae, and highly vascularized adipose tissue (Fig. 4).

Myositis ossificans histology. A) MO perimeter with fibrous periosteal (Ps) and cellular endosteal (Es) layers, and mature osteocytes (Ot) within lacunar spaces. MO core consisting of trabecular (Tb) spindles of bone, mature osteocytes within lacunae, and highly vascular (BV) adipose (Ad) tissue. Dashed line highlighting the location of magnification (4x, H&E, scale: 60μm). B) Lamellar bone formation, mature osteocytes within lacunae, and functional osteon unit with Haversian (H) canal (10x, H&E, scale: 60μm).

3.5

3.5 Impact analysis

Two-dimensional surface area measurements of the faced AL and MO were 123.550 cm² and 31.862 cm², respectively. The MO grossly, with AL fibers in 0.5 cm proximity, decreased AL grossly surface area functional muscle tissue by 25.79%. The PCSA of the AL was 5.010 cm² resulting in a Fmax of 112.726 N. With the decrease in muscle tissue available for functional contraction, the MO impacted Fmax by 29.07 N, leaving the AL capable of producing 83.654 N.

3.5.1

3.5.1 Torque calculations

Radiographic imaging allowed two-dimensional visualization of the AL-femur-acetabulum leaver system and measurements to complete biomechanical analysis. Adduction of the hip act occurs in a class 3 lever system with the hip joint acting as the fulcrum, AL acting as the effort in this isolated analysis, and distal bones and soft tissue acting as the load. The AL's insertion onto the middle third of the linea aspera of the femur was 25.649 cm from the fulcrum and generated 37.905 N of force at a 19.469° angle to the lever in a static AP view. After accounting for the impact from the MO, the AL perpendicular force vector decreases to 28.129 N (33.63% of Fmax). The MO impact decreases AL torque from 972.221 N⋅cm to 721.486 N cm. The magnitude of perpendicular force change is relatively small (less than 10 N) compared to the torque impact due to the distance of AL's distal attachment to the femur from the hip joint (Fig. 5).

Diagramming and torque calculations. The angle of pull (19.649°) and AL Fmax with (ALMO) and without (AL) MO are shown on the plane film anterior to posterior x-ray. Perpendicular vertical vectors (V & VMO) are noted, and the distance of distal attachment from the hip joint (d) determine torque (τ) on the femur for AL and ALMO.

4 Discussion

This study presents a microstructural analysis and biomechanical impact of MO formation within the AL of a cadaveric donor. The most plausible etiology for this ossification is secondary to fracture of the distal femoral shaft. Though nutrient vessels may present similarly on radiographs, presence of consistent oblique lines through both cortices suggests fracture and trauma had likely ensued. Histological examination of the MO perimeter and core revealed lamellar bone formation and trabecular spindles of bone, respectively. Mature osteocytes and lacunae were noted throughout the lesion. While post-mortem analysis of MO does not allow for history taking, symptomology detection, laboratory investigation, or additional in vivo diagnostic procedures and that might be used in clinical setting, the combination of gross, radiographic, and histopathologic findings suggests a mature myositis ossificans traumatica lesion.

To our knowledge, the analysis of a presumed myositis ossificans traumatica via micro-CT by Bacci et al. is the only other micro-level imaging performed on a human cadaveric specimen. This study reported a 52.7 mm length and 12.1 mm diameter cylindrical ossification attached to the anterior sacrum within the piriformis muscle. Imaging showed an ossification circumscribed by compact bone with an internal trabecular core; however, the study did not include histomorphometry⁵⁶. In the present study, micro-CT analysis of trabecular histomorphometry at the midpoint of the long axis of the MO revealed calcified bone tissue of low bone volume and decreased structural integrity compared to previously established healthy bone parameters. The stability of trabecular bone depends not only on bone volume but also trabecular orientation and connectedness. This can be summarized via trabecular bone pattern factor (Tb.Pf) and the relation of convex (isolated/disconnected) to concave (well connected) surfaces⁵³. The relatively large Tb.Pf value determined in this study suggests that the trabecular organization of the MO consists of isolated trabeculae and lacks connectedness. Structure model index (SMI) is used throughout the bone research community as a parameter for determining plate (0) or rod (3) -like trabecular geometry. The deterioration of cancellous bone structure has previously been characterized by the conversion from plate to rod-like geometry⁵⁷^,⁵⁸. The relatively large SMI value (2.12 ± 0.20 on a scale from 0 to 3) suggests deteriorated rod-like trabecular geometry within the MO. In addition, the total trabecular number was less than half the number found per millimeter within healthy bone; and MO trabecular thickness and separation were decreased and increased, respectively.

While reports of MO within the AL are available, only one investigated the mechanics of the adductor muscles post-surgical excision of the MO. The study utilized dynamometry to quantify force generation to compare adductors and abductors on left and right sides at follow-up intervals of 3, 5, and 7 months postoperatively. Capabilities of the antagonistic muscle groups were comparable five months after surgery⁵⁹. This technique may be useful in clinical scenarios but requires active contraction, thus is not feasible in the analysis of cadaveric skeletal muscle. Further, the impact on force-generating capacity was not evaluated prior to surgical excision. The present study applied previously validated biomechanical calculations to estimate the mechanical impact this pathology had on the AL.

The MO impacted AL's force generating ability by 25.79%, decreasing Fmax by 29.07 N and torque by 250.736 N cm. Considering the position of the AL, ectopic bone formation may decrease functional adduction, lateral rotation, and adduction of the thigh at the hip joint and lead to imbalance when standing and during ambulation. AL strain is the most common cause of chronic groin pain in athletes, accounting for up to 62% of cases⁶⁰^,⁶¹. Chronic refractory groin pain due to strain injury of the AL is effectively treated with tenotomy.⁶² Depending on the location and extent of ossification, MO within the AL may also exacerbate the severity of groin pain or complicate tenotomy procedures. This report may benefit healthcare providers, bone and mineral scientists, and medical educators when considering soft-tissue masses of the thigh.

While incredibly valuable, analysis of cadaveric human body donors is not without limitations. Ethically approved state and/or institutional anatomical donor programs are tasked with the responsibility of acquiring donors for basic and clinical science curricula and research. These programs develop and implement policies that address requirements and limitations for the protection of donors. While necessary, this does create barriers associated with the potential for pre-mortem correlations based on donor medical history and physical exam. Additionally, a thorough and accurate medical history for donors is often limited, and donor lifestyle (e.g., diet, drug consumption, hormonal or metabolic state) may be self-reported or unavailable. Lastly and specific to this report, no pre-mortem biomechanical analysis was possible for the validation of the MO impact reported via post-mortem analysis.

5 Conclusions

This study presents the microstructural analysis of a MO within the AL while quantifying the MO impact on AL function. Ectopic ossification is a common phenomenon for which the pathophysiology has not been completely elucidated. Human cadaveric histologic and histomorphometric analysis is a critical supplement to ongoing investigations in patients and animal models. Persistent MO lesions may manifest serious symptoms, demand medical or surgical intervention, or impact joint mechanics and patient outcomes. These effects may be debilitating to patients, and therefore, expedited and accurate diagnosis is imperative in the management of MO masses.

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical statement

All human body donors are obtained from an ethically approved Anatomical Donor Program. All donors provide personal, conscious and cognizant, premortem informed consent to anatomy education and research. The study of cadaveric donors at the University of Nebraska Medical Center (UNMC) is classified IRB exempt, UNMC Policy 8007.

Authorship contributions

Each author has made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

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Forsberg J.A., Pepek J.M., Wagner S., et al . Heterotopic ossification in high-energy wartime extremity injuries: prevalence and risk factors. J Bone Joint Surg. 2009;91(5):1084-1091.
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Newaz F., Parvez M.F., Rahman M.S., et al . Rehabilitation approach of a patient with myositis ossificans: non-surgical management, hazard of being unguided over exercised. Mymensingh Med J. 2021 Jan;30(1):228-232.
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Teasell R.W., Mehta S., Aubut J.L., et al . A systematic review of the therapeutic interventions for heterotopic ossification after spinal cord injury. Spinal Cord. 2010;48(7):512-521.
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Engber W.D., Reynen P., . Post-burn heterotopic ossification at the elbow. Iowa Orthop J. 1994;14:38-41.
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Hoch B., Montag A., . Reactive bone lesions mimicking neoplasms. Semin Diagn Pathol. 2011;28(1):102-112.
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Mavrogenis A.F., Soucacos P.N., Papagelopoulos P.J., . Heterotopic ossification revisited. Orthopedics. 2011;34(3)
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Turecki M.B., Taljanovic M.S., Stubbs A.Y., et al . Imaging of musculoskeletal soft tissue infections. Skeletal Radiol. 2010;39(10):957-971.
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Walczak B.E., Johnson C.N., Howe B.M., . Myositis ossificans. J Am Acad Orthop Surg (10):612-622.
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Cortellazzo Wiel L., Trevisan M., Murru F.M., Rabusin M., Barbi E., . Myositis ossificans mimicking sarcoma: a not so rare bioptic diagnostic pitfall. Ital J Pediatr. 2020 Jul 31;46(1):110.
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Kransdorf M.J., Murphey M.D., . Centennial dissertation. Radiologic evaluation of soft-tissue masses: a current perspective. Am J Roentgenol. 2000;175(3):575-587.
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Wilkerson B.W., Crim J.R., Hung M., Layfield L.J., . Characterization of synovial sarcoma calcification. Am J Roentgenol. 2012;199(6):730-734.
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Järvinen T.A.H., Järvinen T.L.N., Kääriäinen M., Kalimo H., Järvinen M., . Muscle injuries: biology and treatment. Am J Sports Med. 2005;33(5):745-764.
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Ellerin B.E., Helfet D., Parikh S., et al . Current therapy in the management of heterotopic ossification of the elbow: a review with case studies. Am J Phys Med Rehabil. 1999;78(3):259-271.
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Kaplan F.S., Glaser D.L., Hebela N., Shore E.M., . Heterotopic ossification. J Am Acad Orthop Surg. 2004;12(2):116-125.
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Garland D.E., . A clinical perspective on common forms of acquired heterotopic ossification. Clin Orthop Relat Res. 1991;263:13-29.
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Orzel J.A., Rudd T.G., . Heterotopic bone formation: clinical, laboratory, and imaging correlation. J Nucl Med. 1985;26(2):125-132.
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Singh R.S., Craig M.C., Katholi C.R., Jackson A.B., Mountz J.M., . The predictive value of creatine phosphokinase and alkaline phosphatase in identification of heterotopic ossification in patients after spinal cord injury. Arch Phys Med Rehabil. 2003;84(11):1584-1588.
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Meyers C., Lisiecki J., Miller S., et al . Heterotopic ossification: a comprehensive review. JBMR Plus. 2019;3(4):1-19.
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Pavey G.J., Qureshi A.T., Hope D.N., et al . Bioburden increases heterotopic ossification formation in an established rat model. Clin Orthop Relat Res. 2015;473(9):2840-2847.
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Schneider D.J., Moulton M.J., Singapuri K., et al . Inhibition of heterotopic ossification with radiation therapy in an animal model. Clin Orthop Relat Res. 1998;355:35-46.
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Epperson R.T., Isaacson B.M., Rothberg D.L., et al . Developing a combat-relevant translatable large animal model of heterotopic ossification. BoneKEy Rep. 2021;15(September):1-10.
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Brownley R.C., Agarwal S., Loder S., et al . Characterization of heterotopic ossification using radiographic imaging: evidence for a paradigm shift. PLoS One. 2015;10(11):1-15.
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Lieber R.L., Ward S.R., . Skeletal Muscle Design to Meet Functional demands.Philosophical Transactions of the Royal Society B: Biological Sciences. 2011;vol. 366:1466-1476.
[Google Scholar]
Powell P.L., Roy R.R., Kanim P., Bello M.A., Edgerton V.R., . Predictability of skeletal muscle tension from architectural determinations in Guinea pig hindlimbs. J Appl Physiol Respir Environ Exerc Physiol. 1984;57(6):1715-1721.
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Byrd J.J., Mccumber T.L., Snow E.L., . Cadaveric case report and biomechanical analysis of an accessory clavicular head to the sternocleidomastoid. Translational Research in Anatomy. 2022;28
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Recker R.R., Akhter M.K., Lappe J.M., Watson P., . Bone histomorphometry in transiliac biopsies from 48 normal, healthy men. Bone. 2018;111:109-115.
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Gül M., Bayat N., Gül S., Hüz M., Yıldız A., Otlu A., . A comparison of three different agents of decalcification for a histological examination of bone tissues. Journal of Turgut Ozal Medical Center. 2014;21(4):274-279.
[Google Scholar]
Hahn M., Vogel M., Pompesius-Kempa M., Delling G., . Trabecular bone pattern factor-a new parameter for simple quantification of bone microarchitecture. Bone. 1992;13(4):327-330.
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Ward S.R., Lieber R.L., . Density and hydration of fresh and fixed human skeletal muscle. J Biomech. 2005;38(11):2317-2320.
[Google Scholar]
Sacks R.D., Roy R.R., . Architecture of the hind limb muscles of cats: functional significance. J Morphol. 1982;173(2):185-195.
[Google Scholar]
Bacci N., Mazengenya P., Billings B.K., . Myositis ossificans traumatica of the piriformis muscle: a rare mature case in an adult African male. Surg Radiol Anat. 2019;41(12):1513-1517.
[Google Scholar]
Hildebrand T., Rüegsegger P., . Quantification of bone microarchitecture with the structure model index. Comput Methods Biomech Biomed Eng. 1997;1(1):15-23.
[Google Scholar]
Salmon P.L., Ohlsson C., Shefelbine S.J., Doube M., . Structure model index does not measure rods and plates in trabecular bone. Front Endocrinol. 2015;6(162):1-10.
[Google Scholar]
De Smet G.H.J., Buijk S.E., Weir A., . Surgical excision of post-traumatic myositis ossificans of the adductor longus in a football player. BMJ Case Rep. 2020;13(3):1-4.
[Google Scholar]
Iorio R., Massafra C., Viglietta E., Mazza D., Ferretti A., . Bilateral post traumatic myositis ossificans of adductor longus in a young soccer player: a case report and literature review. Curr Sports Med Rep. 2021 Nov 1;20(11):584-587.
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Renström P.A., . Tendon and muscle injuries in the groin area. Clin Sports Med. 1992;11(4):815-831.
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Åkermark C., Johansson C., . Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med. 1992;20(6):640-643.
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Show Sections

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[22] Laasri K., Haddad S.E., Marrakchi S., Halfi I.M., Allali N., Chat L., . Pediatric myositis ossificans circumscripta following traumatic hip dislocation: a case report. Radiol Case Rep. 2023 Jan 31;18(4):1406-1410.
[Google Scholar]

[23] Sandeep K.N., Suresh G., Gopisankar B., Abhishek N., Sujiv A., . Does excision of heterotopic ossification of the elbow result in satisfactory patient-rated outcomes? Malaysian Orthopaedic Journal. 2017;11(1):35-40.
[Google Scholar]

[24] Forsberg J.A., Pepek J.M., Wagner S., et al . Heterotopic ossification in high-energy wartime extremity injuries: prevalence and risk factors. J Bone Joint Surg. 2009;91(5):1084-1091.
[Google Scholar]

[25] Newaz F., Parvez M.F., Rahman M.S., et al . Rehabilitation approach of a patient with myositis ossificans: non-surgical management, hazard of being unguided over exercised. Mymensingh Med J. 2021 Jan;30(1):228-232.
[Google Scholar]

[26] Nieuwenhuizen C.J., van Veldhoven P.L.J., van Oosterom R.F., . Rare case of a traumatic myositis ossificans in the tibialis anterior muscle. BMJ Case Rep. 2020 Aug 17;13(8)
[Google Scholar]

[27] Teasell R.W., Mehta S., Aubut J.L., et al . A systematic review of the therapeutic interventions for heterotopic ossification after spinal cord injury. Spinal Cord. 2010;48(7):512-521.
[Google Scholar]

[28] Engber W.D., Reynen P., . Post-burn heterotopic ossification at the elbow. Iowa Orthop J. 1994;14:38-41.
[Google Scholar]

[29] Hoch B., Montag A., . Reactive bone lesions mimicking neoplasms. Semin Diagn Pathol. 2011;28(1):102-112.
[Google Scholar]

[30] Mavrogenis A.F., Soucacos P.N., Papagelopoulos P.J., . Heterotopic ossification revisited. Orthopedics. 2011;34(3)
[Google Scholar]

[31] Turecki M.B., Taljanovic M.S., Stubbs A.Y., et al . Imaging of musculoskeletal soft tissue infections. Skeletal Radiol. 2010;39(10):957-971.
[Google Scholar]

[32] Walczak B.E., Johnson C.N., Howe B.M., . Myositis ossificans. J Am Acad Orthop Surg (10):612-622.
[Google Scholar]

[33] Cortellazzo Wiel L., Trevisan M., Murru F.M., Rabusin M., Barbi E., . Myositis ossificans mimicking sarcoma: a not so rare bioptic diagnostic pitfall. Ital J Pediatr. 2020 Jul 31;46(1):110.
[Google Scholar]

[34] Kransdorf M.J., Murphey M.D., . Centennial dissertation. Radiologic evaluation of soft-tissue masses: a current perspective. Am J Roentgenol. 2000;175(3):575-587.
[Google Scholar]

[35] Chen C.K., Wu H.T., Chiou H.J., et al . Differentiating benign and malignant soft tissue masses by magnetic resonance imaging: role of tissue component analysis. J Chin Med Assoc. 2009;72(4):194-201.
[Google Scholar]

[36] Wilkerson B.W., Crim J.R., Hung M., Layfield L.J., . Characterization of synovial sarcoma calcification. Am J Roentgenol. 2012;199(6):730-734.
[Google Scholar]

[37] Järvinen T.A.H., Järvinen T.L.N., Kääriäinen M., Kalimo H., Järvinen M., . Muscle injuries: biology and treatment. Am J Sports Med. 2005;33(5):745-764.
[Google Scholar]

[38] Ellerin B.E., Helfet D., Parikh S., et al . Current therapy in the management of heterotopic ossification of the elbow: a review with case studies. Am J Phys Med Rehabil. 1999;78(3):259-271.
[Google Scholar]

[39] Kaplan F.S., Glaser D.L., Hebela N., Shore E.M., . Heterotopic ossification. J Am Acad Orthop Surg. 2004;12(2):116-125.
[Google Scholar]

[40] Garland D.E., . A clinical perspective on common forms of acquired heterotopic ossification. Clin Orthop Relat Res. 1991;263:13-29.
[Google Scholar]

[41] Orzel J.A., Rudd T.G., . Heterotopic bone formation: clinical, laboratory, and imaging correlation. J Nucl Med. 1985;26(2):125-132.
[Google Scholar]

[42] Singh R.S., Craig M.C., Katholi C.R., Jackson A.B., Mountz J.M., . The predictive value of creatine phosphokinase and alkaline phosphatase in identification of heterotopic ossification in patients after spinal cord injury. Arch Phys Med Rehabil. 2003;84(11):1584-1588.
[Google Scholar]

[43] Meyers C., Lisiecki J., Miller S., et al . Heterotopic ossification: a comprehensive review. JBMR Plus. 2019;3(4):1-19.
[Google Scholar]

[44] Pavey G.J., Qureshi A.T., Hope D.N., et al . Bioburden increases heterotopic ossification formation in an established rat model. Clin Orthop Relat Res. 2015;473(9):2840-2847.
[Google Scholar]

[45] Schneider D.J., Moulton M.J., Singapuri K., et al . Inhibition of heterotopic ossification with radiation therapy in an animal model. Clin Orthop Relat Res. 1998;355:35-46.
[Google Scholar]

[46] Epperson R.T., Isaacson B.M., Rothberg D.L., et al . Developing a combat-relevant translatable large animal model of heterotopic ossification. BoneKEy Rep. 2021;15(September):1-10.
[Google Scholar]

[47] Brownley R.C., Agarwal S., Loder S., et al . Characterization of heterotopic ossification using radiographic imaging: evidence for a paradigm shift. PLoS One. 2015;10(11):1-15.
[Google Scholar]

[48] Lieber R.L., Ward S.R., . Skeletal Muscle Design to Meet Functional demands.Philosophical Transactions of the Royal Society B: Biological Sciences. 2011;vol. 366:1466-1476.
[Google Scholar]

[49] Powell P.L., Roy R.R., Kanim P., Bello M.A., Edgerton V.R., . Predictability of skeletal muscle tension from architectural determinations in Guinea pig hindlimbs. J Appl Physiol Respir Environ Exerc Physiol. 1984;57(6):1715-1721.
[Google Scholar]

[50] Byrd J.J., Mccumber T.L., Snow E.L., . Cadaveric case report and biomechanical analysis of an accessory clavicular head to the sternocleidomastoid. Translational Research in Anatomy. 2022;28
[Google Scholar]

[51] Recker R.R., Akhter M.K., Lappe J.M., Watson P., . Bone histomorphometry in transiliac biopsies from 48 normal, healthy men. Bone. 2018;111:109-115.
[Google Scholar]

[52] Gül M., Bayat N., Gül S., Hüz M., Yıldız A., Otlu A., . A comparison of three different agents of decalcification for a histological examination of bone tissues. Journal of Turgut Ozal Medical Center. 2014;21(4):274-279.
[Google Scholar]

[53] Hahn M., Vogel M., Pompesius-Kempa M., Delling G., . Trabecular bone pattern factor-a new parameter for simple quantification of bone microarchitecture. Bone. 1992;13(4):327-330.
[Google Scholar]

[54] Ward S.R., Lieber R.L., . Density and hydration of fresh and fixed human skeletal muscle. J Biomech. 2005;38(11):2317-2320.
[Google Scholar]

[55] Sacks R.D., Roy R.R., . Architecture of the hind limb muscles of cats: functional significance. J Morphol. 1982;173(2):185-195.
[Google Scholar]

[56] Bacci N., Mazengenya P., Billings B.K., . Myositis ossificans traumatica of the piriformis muscle: a rare mature case in an adult African male. Surg Radiol Anat. 2019;41(12):1513-1517.
[Google Scholar]

[57] Hildebrand T., Rüegsegger P., . Quantification of bone microarchitecture with the structure model index. Comput Methods Biomech Biomed Eng. 1997;1(1):15-23.
[Google Scholar]

[58] Salmon P.L., Ohlsson C., Shefelbine S.J., Doube M., . Structure model index does not measure rods and plates in trabecular bone. Front Endocrinol. 2015;6(162):1-10.
[Google Scholar]

[59] De Smet G.H.J., Buijk S.E., Weir A., . Surgical excision of post-traumatic myositis ossificans of the adductor longus in a football player. BMJ Case Rep. 2020;13(3):1-4.
[Google Scholar]

[60] Iorio R., Massafra C., Viglietta E., Mazza D., Ferretti A., . Bilateral post traumatic myositis ossificans of adductor longus in a young soccer player: a case report and literature review. Curr Sports Med Rep. 2021 Nov 1;20(11):584-587.
[Google Scholar]

[61] Renström P.A., . Tendon and muscle injuries in the groin area. Clin Sports Med. 1992;11(4):815-831.
[Google Scholar]

[62] Åkermark C., Johansson C., . Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med. 1992;20(6):640-643.
[Google Scholar]

Microstructural analysis and biomechanical impact of myositis ossificans: A cadaveric case report

Abstract