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| CASE REPORT |
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| Year : 2021 | Volume
: 29
| Issue : 1 | Page : 18-20 |
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Calcific myonecrosis of leg: A case report
Chaitanya Halder1, Sabyasachi Santra1, Sanjay Keshkar2
1 Department of Orthopaedics, College of Medicine & Sagore Dutta Hospital, Kamarhati, Kolkata, India
2 Department of Orthopaedics, ESIC Medical College & Hospital, Joka, Kolkata, India
| Date of Submission | 08-Jul-2021 |
| Date of Acceptance | 12-Jul-2021 |
| Date of Web Publication | 21-Aug-2021 |
Correspondence Address:
Chaitanya Halder
Department of Orthopaedics, College of Medicine & Sagore Dutta Hospital, Kamarhati, Kolkata.
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijors.ijors_18_21
Calcific myonecrosis is a rare entity characterised by a latent formation of dystrophic calcified mass occurring most commonly in the anterior compartment of the leg and is usually a posttraumatic condition. Diagnosis is based on the history of trauma and typical radiological features. Symptomatic patients require complete excision of the mass. We report such a case not only for its rarity but also for challenging diagnosis and treatment. Keywords: Calcific myonecrosis, compartment syndrome, soft-tissue calcified mass
How to cite this article:
Halder C, Santra S, Keshkar S. Calcific myonecrosis of leg: A case report. Int J Orthop Surg 2021;29:18-20 |
| Introduction | |  |
Calcific myonecrosis is a rare entity characterised by a latent formation of dystrophic calcified mass occurring most commonly in the anterior compartment of the leg and is usually a posttraumatic condition.[1] This was initially described by Gallie and Thompson in 1960.[2] Diagnosis is based on the history of trauma and typical radiological features. Asymptomatic patients can be treated nonoperatively, whereas symptomatic patients require complete excision of the mass. We report such a case not only for its rarity but also for challenging diagnosis and treatment.
| Case Report | | |
A 48-year-old man visited our hospital with a complaint of swelling in the left leg with intermittent pain for a long duration. He had a history of trauma on that limb about 10 years ago, leading to the formation of a small mass. Over a period of several years, the mass gradually increased in size with episodes of intermittent pain. No significant findings were detected in his past medical history.
Clinically, a large cystic longitudinal mass along the anterior tibial muscle was present [Figure 1]A. A range of motion at the ankle joint was reduced to some extent on plantar flexion. There was no distal neurovascular deficit. The complete blood test, blood biochemistry, and serum electrolyte levels were normal. The radiograph of the affected leg showed well-marginated radio-opaque density in the parosteal area of the midshaft of the tibia without any sign of tibial cortical erosion or thickening [Figure 1]B. Based on these findings, a clinic-radiological diagnosis of calcific myonecrosis was made, which was subsequently confirmed by FNAC, which showed white chalky material of calcium phosphate. Excision through debridement was planed under spinal anaesthesia. Preoperative findings revealed that the mass was located at the anterior tibial area and covered with fibrotic sheath [Figure 2]A. The inside of the capsule was filled with chalky white powder with a yellowish tint [Figure 2]B. After complete excision through debridement and saline wash, the wound was closed, and a compression bandage was recommended for two weeks. The histology of excised mass showed extensive amorphous white substance with calcific material caused by skeletal muscle and fibrin necrosis. The radiograph taken after six months of surgery showed no residual mass, and there was a complete resolution of symptoms. | Figure 1: A large longitudinal mass on the left leg along the anterior tibial muscle (A) and the radiograph showed well-marginated radio-opaque density in the parosteal area of the midshaft of tibia without any sign of tibial cortical erosion or thickening (B)
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 | Figure 2: Operative findings revealed—the mass located at the anterior tibial area and covered with fibrotic sheath (A), the inside of the capsule was filled with chalky white powder with a yellowish tint (B), and excised mass with inside chalky material in syringe (C)
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| Discussion | | |
Calcific myonecrosis is a very rare disease. Calcific myonecrosis was first reported by Gallie and Thompson in 1960.[2] It is primarily a sequel of compartment syndrome that develops after trauma and tends to progress slowly over a period of several years.[3] Recurrent haemorrhage within necrosed and fibrotic muscle tissue is another possibility for the occurrence of this problem, but the exact mechanism of its pathophysiology is still to be established.[1],[4] It is a benign entity, though often uncomfortable and disfiguring. Differential diagnosis includes calcified soft-tissue mass, haematoma, soft-tissue sarcoma, parosteal osteosarcoma, myositis ossificans, tumoral calcinosis, and diabetic myonecrosis.[4],[5] Though radiologically one can differentiate them, MRI is much helpful.[6] A failure to recognise this lesion at imaging and with traditional practice prompts a biopsy occasionally with a devastating result, such as chronic draining sinus, secondary infection. Nonoperative treatment is the preferred approach if the patient is asymptomatic, even with such a large calcification, although it is tempting for a young surgeon to opt for surgery irrespective of postoperative complications.[7] In asymptomatic patients, the management should be observation and clinical follow-up.[7],[8] Complete excisional biopsy is the treatment of choice for a symptomatic patient, but considering complications such as secondary infection, a few studies do not favour open excision.[3],[7] In our case, complete excision was done, as there were symptoms for a long duration. Perioperative period was uneventful, and at six-month follow-up, there was a complete resolution of mass and symptom.
| Conclusion | | |
Calcific myonecrosis can be confidently diagnosed when a mass is in a single muscle or muscle compartment with a history of previous trauma, supported by radiological feature of well-marginated radio-opaque density in the parosteal area without any sign of tibial cortical erosion or thickening. MRI and FNAC can be done for diagnosing calcific myonecrosis. Nonoperative treatment is the preferred approach if the patient is asymptomatic, but for symptomatic patient, excisional biopsy is the only choice.
Acknowledgment
During the study period, the sole author(s) of this article were attached to ESIC Medical College & Hospital, Kolkata and the article represents the honest work performed at this institute.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Authors’ contribution
Dr. Chainatya Halder contributed to study design, analysis of data, preparation of article, and review of the article; Dr. Sabyasachi Santra helped in study design and reviewed the article for final preparation; Dr. Sanjay Keshkar contributed to study design, analysis of data, surgical intervention, supervision of the study, and review of the article for final preparation. All the authors have approved this final article and agreed to submit it to the International Journal of Orthopaedic Surgery.
| References | | |
| 1. | Chun YS, Shim HS Calcific myonecrosis of the antetibial area. Clin Orthop Surg 2010;2:191-4.  |
| 2. | Gallie WE, Thomson S Volkmann’s ischaemic contracture: Two case reports with identical late sequelae. Can J Surg 1960;3:164-6. |
| 3. | Janzen DL, Connell DG, Vaisler BJ Calcific myonecrosis of the calf manifesting as an enlarging soft-tissue mass: Imaging features. AJR Am J Roentgenol 1993;160:1072-4. |
| 4. | Tang Y, Kaniyur S, Jain K A calcified conundrum. Br J Radiol 2010;83:535-7. |
| 5. | Tuncay IC, Demirörs H, Isiklar ZU, Agildere M, Demirhan B, Tandogan RN Calcific myonecrosis. Int Orthop 1999;23:68-70. |
| 6. | Okada A, Hatori M, Hosaka M, Watanuki M, Itoi E Calcific myonecrosis and the role of imaging in the diagnosis: A case report. Ups J Med Sci 2009;114:178-83. |
| 7. | Gangrade K, Yeotikar G, Wadhwani A, Naneria V Calcific myonecrosis of the leg: A case report. Case Rep Orthop Res 2019;2:47-53. |
| 8. | Jalil R, Roach J, Smith A, Mukundan C Calcific myonecrosis: A case report and review of the literature. BMJ Case Rep2012 Oct 10;2012. |
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