Extensive Ossification Research Articles

Diffuse idiopathic skeletal hyperostosis (DISH): Detection on dental radiologic examinations in two older adults and overview of the literature.

Diffuse idiopathic skeletal hyperostosis (DISH) is a potentially serious osteopathic disorder associated with coalescing ossifications of the anterior vertebrae and may be concomitant with a constellation of symptomatology and systemic comorbidities. There is limited dental literature describing this finding on panoramic radiographs and cone beam computed tomography (CBCT) scans. Two case reports of DISH are provided. One patient manifested extensive ossifications along the cervical vertebrae and consequent episodes of dysphagia and hoarseness. The other affected patient's cervical ossification was found at an earlier stage of formation and without symptomatology. Panoramic radiography, cervical spine radiography, and CBCT examinations have been provided. Attending dental healthcare practitioners should carefully evaluate all areas of interest and surrounding fields of view when taking panoramic radiographs and CBCT scans for manifestations of DISH and other potential disorders of the cervical vertebrae. A suspected radiologic finding of DISH should prompt timely referral for comprehensive medical assessment to mitigate neurologic deficits and other comorbidities.

A rare case of extensive neurogenic heterotopic ossification: a case report

IntroductionNeurogenic Heterotopic ossification (NHO) is a potential sequalae and a detrimental complication following neurological insult. It is characterized by formation of localized gradually progressive, peri-articular lamellar bone formation in extra-skeletal tissues. We would like to report a rare case of heterotopic ossification involving all 4 limbs, in which we tried to restore joint mobility to improve his functional status so that he could perform his daily tasks.Case presentationWe present a case of a 33-year-old bed ridden male, diagnosed with NHO involving all 4 limbs (bilateral hip, right knee, right shoulder, left elbow). The patient had a crippled posture, significant pain and impaired range of motion hampering movement of all four limbs which prevented him from lying down supine, sitting, walking and performing activities of daily living. After three surgeries, the patient achieved wheelchair mobilization and upright posture with the assistance of calipers.ConclusionThe management of NHO requires a multidisciplinary approach involving orthopaedic surgeons, neurologists & rehabilitation specialists. Prognosis of NHO depends on factors such as extent of ossification, underlying neurological condition & patients overall health.

Complete Extensive Heterotopic Ossification of the Entire Free Fibula Flap Vascular Pedicle in Maxillary Reconstruction.

Heterotopic ossification is a pathologic extra-skeletal bone formation as a form of aberrant repair process with acquired or genetic etiologies. In plastic surgery, it has been well-described in the burn and trauma patients. Rarely, it can happen along the vascular pedicle of free tissue transfer, and when it happens, it is most commonly in head and neck reconstruction. Here we present a case of complete extensive heterotopic ossification of the entire vascular pedicle from the anastomosis to the bone in an osteocutaneous free fibula flap (FFF). The fibula was used as a 2-segment reconstruction for a maxillary defect resulting from a self-inflicted gunshot wound. The skin paddle was used to reconstruct the anterior palatal defect. Heterotopic ossification of the FFF vascular pedicle is most reported in the head and neck reconstruction cases. It is rare, but when it happens, it occurs earlier, more commonly, and more extensively in cases of maxillary reconstruction than in cases of mandibular reconstruction. Flap loss due to this sequela has not been reported, and surgical debridement is indicated only when symptomatic. Heterotopic ossification of an FFF vascular pedicle is a rare but well-described entity. The periosteal bone formation capacity preservation after revascularization of the flap is thought to be one of the major etiologies of this phenomenon. Hence, some have suggested a modification in the harvesting technique of the FFF that could mitigate return to the operating room, especially when it is for maxillary reconstruction in the trauma patient. Keywords: Keywords: free fibula flap, heterotopic ossification, maxillary reconstruction, mandibular reconstruction.

3D-Printed Model in Preoperative Planning of Sciatic Nerve Decompression Because of Heterotopic Ossification: A Case Report.

A 31-year-old patient presented with an encapsulated sciatic nerve secondary to extensive hip heterotopic ossification (HO), which prevented visualization of a safe osteotomy site to avoid nerve damage. The 3D-printed model demonstrated an easily identifiable osseous reference point along the inferior aspect of the heterotopic mass, allowing for a vertical osteotomy to be safely performed. HO is associated with loss of normal anatomic topography. The current case report illustrates the use of a 3D-printed model to identify pertinent anatomic landmarks required for safe decompression of an encapsulated sciatic nerve within the anatomic region of the hip.

An Extremely Rare Case of Extensive Myositis Ossification: Complete Extra-Articular Ankylosis of Hip Joint

Myositis ossificans, in its literal translation, is defined as an inflammatory ossification of muscle and the neighboring soft tissues. A rare case of post-brain injury ossification of the Gluteus maximus muscle extending from the greater trochanter of the femur to the right wing of the iliac bone, leading to extra-articular bony ankylosis of the hip is reported. A 40-year-old male presented to the Outpatient department with a stiff right hip and restriction of its movements. The patient had a history of cerebral hemorrhage 18 months back and subsequently developed stiffness in the right hip since the last 3 months. X-ray and CT scan revealed the extension of an ossified bar extending between the lateral aspect of the right iliac wing above the right acetabulum and upper 1/3 of the anterior lateral aspect of the femur near the greater trochanter, measuring 1003240 mm. The patient was then allowed to go for rehabilitation with appropriate physiotherapy and anti-inflammatory drugs. Extensive hypertrophic ossification can occur at a totally unrelated site as a consequence of cerebral insult/ head injury.

An interesting case of papillary thyroid carcinoma with heterotrophic ossification

Calcification in thyroid gland is associated with both benign and malignant lesion. However calcification is most frequently seen in malignant lesions. Calcification can give rise to metaplasia and bone containing marrow tissue. Papillary carcinoma with heterotrophic ossification has been associated with high incidence extrathyroidal invasion, multifocality, lymphnode metastsasis and older age group than in those without heterotrophic ossification. It has not been described as a specific entity in WHO classification because of its rarity. Expression of both basic fibroblast growth factor and bone morphogenetic protein was highest in papillary carcinoma with intratumoral heterotrophic ossification. In this case report we described a 71-year-old female patient who sought medical care for swelling in the neck for the past 4 years. The cervical ultrasound showed a 2 well defined nodules measuring 2x2 cms and 4mm in the right lobe with larger lesion showing peripheral rim of calcification and left lobe and isthumus shows well defined lesions measuring 5mm and 4 mm each. The clinical diagnosis was multinodular goitre. Patient subsequently underwent thyroidectomy. On histopathological investigation right lobe showed follicular adenoma and papillary carcinoma thyroid with extensive heterotrophic ossification and calcification within the tumor. The margins were free of neoplasia and there was no extrathyroidal extension. No preineural/ vascular invasion noted. One lymphnode was identified which was free of tumor. pTNM staging was pT1bNxMx.

Living with Fibrodysplasia Ossificans Progressiva: Radiological Images of a Patient with Extensive Heterotopic Ossification.

Fibrodysplasia ossificans progressiva (FOP) is an exceptionally rare genetic disorder characterized by the progressive formation of heterotopic bone in soft tissues. Here, we present the radiological findings of an 18-year-old female diagnosed with FOP who had severe spinal and right-upper-limb abnormalities. Her SF-36 scores suggested significant impairment in physical function, affecting work and other regular daily activities. Radiographic evaluation with X-rays and CT scans revealed scoliosis and total fusion of almost all levels of the spine, with only a few disc spaces spared. A large mass of heterotopic bone was observed, corresponding to the location of the paraspinal muscles in the lumbar region, branching upwards and fusing with the scapulae on both sides. On the right side, this exuberant heterotopic bone mass fused with the humerus, resulting in a fixed right shoulder, while the rest of the upper and lower limbs are spared and have a range of motion. Our report highlights the extensive ossification that can manifest in patients with FOP, resulting in restricted mobility and a poor quality of life. While there is no definite treatment that can reverse the effects of the disease, preventing injuries and minimizing iatrogenic harm is of critical importance in this patient as inflammation is known to play a key role in triggering heterotopic bone. Meanwhile, ongoing research into therapeutic strategies holds the key to unlocking a potential cure for FOP in the future.

A Novel De Novo Frameshift Pathogenic Variant in the FAM111B Resulting in Progressive Osseous Heteroplasia Phenotype.

Progressive osseous heteroplasia (POH) is a rare, debilitating disorder characterized by heterotopic ossification in the skin and muscles, resulting in contractures of the joints and progressive loss of function. While 60-70% of the POH patients have paternally inherited, inactivating pathogenic variants in GNAS, the remaining 30-40% have no known etiology. FAM111B pathogenic variants, located on chromosome 11q12.1, cause POIKTMP (hereditary fibrosing poikiloderma with tendon contractures, myopathy, and pulmonary fibrosis), a very rare, autosomal-dominant disorder with high frequency of de novo missense pathogenic variants, which affects multiple tissues and organs, causing extensive fibrosis and muscle adiposis, though the exact mechanism is unknown. To our knowledge, there are no reports of FAM111B associated with POH. We describe the first case of POH phenotype associated with a novel de novo frameshift pathogenic variant in the FAM111B and present an analysis of the protein structure and function caused by this genomic disruption. A 15-year-old African-American male presented with generalized calcific nodules, progressive contractures, and muscle weakness leading to immobility, beginning at 6years of age. Cutaneous examination showed generalized hard nodules varying from small to plaque-like ulcerated erupted skin lesions. Biochemical evaluation revealed 25(OH) vitamin D insufficiency (20ng/mL), and normal levels of parathyroid hormone, FGF-23, alkaline phosphatase, calcium, and phosphorus. Skeletal survey radiographs and computed tomography (CT) of the chest, abdomen, and pelvis showed extensive soft tissue and muscle heterotopic ossifications involving shoulders, axillae, trunk, abdomen, pelvis, upper and lower extremities, in a clumped, conglomerate distribution within muscle, subcutaneous fat, and in some areas extending to the skin. There was no pulmonary fibrosis on the chest CT. The clinical and radiographic findings were most consistent with POH. A trio-clinical exome sequencing revealed a de novo heterozygous likely pathogenic variant in the FAM111B (OMIM # 615584) (c.1462delT [p.Cys488Valfs*21]). The resulted frameshift change in exon 4 replaced C-terminal region with 21 alternative amino acids. Multiple, previously reported disease-associated variants appear to localize within the trypsin-like cysteine/serine peptidase domain in which this variant occurs, supporting the functional significance of this region, though none have been previously reported to be associated with POH phenotype. Our 3D protein modeling showed obliteration of predicted protein folding and structure, and elimination of the zinc-binding domain, likely severely affecting protein function. This is the first case of POH phenotype associated with a novel de novo pathogenic frameshift variant in FAM111B. Whether the frameshift change in FAM111B predicts POH remains unclear. Further evaluations are necessary to fully elucidate this finding and the potential role and mechanism by which the FAM111B variants contributes to POH phenotype.

A Case Report of an Extensively Ossified Left Atrial Myxoma

A cardiac myxoma, a rare but relatively common cardiac tumor, was surgically excised. Histopathological examination of the lesion revealed an extensive internal ossification. Ossification of the interior of myxomas is rarely reported, and most are large tumors; however, this is a rare case of a small tumor. The cause of ossification has not yet been clearly reported.

Long-standing Renal Hydatid Cyst Mimicking an Angiomyolipoma: A Rare Case Report

Primary hydatid cyst of the kidney is very rare and accounts for 1-4% of all hydatid disease. Authors hereby reports an unusual case of an isolated, long-standing renal hydatid cyst, mimicking an angiomyolipoma on imaging. A 72-year-old female, from a rural area, presented with pain in the right flank since two years. She also complained of mild fever off and on, since one year. A 10×10 cm, non tender lump was palpated in the right flank. Ultrasonography and computerised tomography showed a large rightsided renal mass measuring 10 cms and a diagnosis of angiomyolipoma was rendered. A right sided open/simple nephrectomy was done. The kidney was large, cystic, firm and was sent for histopathological examination. On gross examination, a large, unilocular, thick- walled, cystic lesion was seen. Cut-surface showed heterogeneous, creamy coloured necrotic contents, with few nodular gelatinous masses. On microscopy, characteristic acellular, laminated structure of the ectocyst of Echinococcus granulosus was seen. Extensive calcification and ossification of the cyst wall with bone marrow production was also seen. Contents of the cyst were necrotic and no daughter cysts were seen. Adipose tissue of the bone marrow was mistaken on imaging for the lipomatous component of an angiomyolipoma. Isolated renal hydatid cyst is very uncommon and though active hydatid cysts do have characteristic radiological findings, they can be misdiagnosed as a benign renal tumours. Renal cysts or abscesses. Old cases show degenerative changes as well as calcification and are difficult to diagnose preoperatively. Surgical treatment of renal hydatid cyst depends on the size, number of cysts, exact intrarenal location and residual renal function.

Value of a Multidisciplinary Approach in Sinonasal Inverted Papilloma with Extensive Ossification

Patient: Male, 51-year-old Final Diagnosis: Sinonasal inverted papilloma Symptoms: Nasal congestion • nasal mass Medication: — Clinical Procedure: — Specialty: Pathology Objective: Rare disease Background:Inverted papilloma is a benign epithelial lesion of the nasal cavities. Although commonly encountered in clinical practice, it rarely presents with extensive ossification and few cases have been described in the literature.Casa Report:Herein, we describe the case of a 51-year-old man who presented to clinical attention for persistent right nasal obstruction. Magnetic resonance imaging (MRI) and computed tomography (CT) scans of the facial bones showed a lobated lesion with ossification occupying most of the right nasal cavity. The lesion was removed by endoscopic sinus surgery, leaving the surrounding bone structures intact. On pathological examination, mature bone tissue was found within an inverted papilloma. The pathologist contacted the surgeon, who confirmed that no healthy bone tissue was removed during the procedure. Therefore, a diagnosis of inverted papilloma with ossification could be made without the use of ancillary techniques.Conclusions:Inverted papilloma with ossification is a common lesion with a rare feature. Our report investigates the diagnostic difficulties of a paradigmatic case, highlighting the importance of multidisciplinary teamwork in reaching the final diagnosis.

DISHphagia – A Riddle Unwrapped a Clinical Case with Literature Review

Abstract Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed systemic skeletal disease. It is characterized by calcifications affecting mainly the spinal anterior longitudinal ligament. In the majority of cases, the patients are asymptomatic, but cervical osteophytes can sometimes cause hoarseness, dysphagia (DISHphagia) and even dyspnea. Case description: A 61-year-old man was admitted to our department with complaints of difficulty in swallowing and weight loss. Dysphagia had been increasing gradually for nine months. Barium swallow esophagram revealed asymmetric swallowing with expansion above the upper esophageal sphincter without other abnormalities. The extension was confirmed by esophago-gastro-duodenoscopy (EGD). Furthermore, CT scan of the thorax clearly demonstrated degenerative changes of the cervical and thoracic region, extensive ossification of the anterior longitudinal ligament, and osteophytes from C2-C7 with a forward displacement of the esophagus by 14 mm. The so-called “wax dripping down the candle” phenomenon was as well observed. Conclusion: DISH is a systematic, musculo-skeletal disease of older adults with unknown etiology. Dysphagia is the most common symptom of the disease and might be caused by osteophytes of the cervical region. We presented a case of DISH with a rare localization of the osteophytes in the cervical region C2-C7. Due to the increasing incidence of the Forestier’s syndrome and its associated “DISHphagia”, the gastroenterologist should increase the awareness of this underestimated disease and improve the diagnostic approach.

Sacroiliac Joint Variation in Patients With Ossification of the Posterior Longitudinal Ligament.

Retrospective Cohort Study. Ossification of the posterior longitudinal ligament (OPLL) reveals heterotopic ossification in the spinal ligament. OPLL also tends to ossify ligaments and entheses throughout the body. However, hallmarks of sacroiliac (SI) joint ossification and its variation in OPLL have not been clarified. Here, we investigated the morphological changes in SI joints in individuals with and without OPLL. We included 240 age- and sex-matched patients (OPLL+, 120; OPLL-, 120) in the study. SI joint variations were classified into 4 types: Type 1, normal or small peripheral bone irregularity; Type 2, subchondral bone sclerosis and osteophyte formation; Type 3, vacuum phenomenon; and Type 4, bridging osteophyte and bony fusion. Type 4 was further divided into 3 subgroups as previously described. Interactions between the ossified spinal region in OPLL and morphological changes in the SI joint were evaluated. SI joint ankylosis occurs more frequently in patients with OPLL (51.7%) than in those without (non-OPLL) (33.3%). The SI joint vacuum phenomenon (49.2%) was the main finding in non-OPLL. SI joint ankylosis in OPLL was characterized by anterior bridging and intra-articular fusion. OPLL patients with multilevel ossification tend to develop degeneration and ankylosis of the SI joints. OPLL conferred a high risk of SI joint ossification compared with non-OPLL, and patients with extensive ossification had a higher rate of SI joint ankylosis. Understanding SI joint variation could help elucidate OPLL etiology and clarify the phenotypic differences in the SI joint between OPLL and other spinal disorders.

Ossification of the Anterior Longitudinal Ligament with Dysphagia as the First Symptom: Rehabilitation of Two Cases

Dysphagia is associated with poor quality of life, and pneumonia due to aspiration is life-threatening. Cervical ossification of the anterior longitudinal ligament (C-OALL) is one of the causes of dysphagia, and we report two cases in which dysphagia improved after surgery. Case 1: A 76-year-old man had C-OALL of greater than 16 mm and dysphagia and developed myelopathy. A fall resulted in upper and lower limb insufficiency paralysis, and posterior decompression fixation was performed. Pressure on the pharynx by C-OALL remained, but dysphagia improved. Improvement in this case was considered to be due to the loss of intervertebral mobility. Case 2: A 62-year-old man developed dysphagia 6 years ago. It gradually exacerbated, and the C-OALL increased. Laryngeal fiberscope and swallowing angiography revealed that the pharyngeal cavity was compressed and narrowed anteriorly due to ossification. Resection of the ossification was performed, and the patient’s symptoms improved. Direct decompression was successful in this case. Several evaluation methods for dysphagia have been reported, including screening tests, endoscopy, contrast studies, and radiological evaluation. In case 1, extensive ossification was improved by posterior fixation, albeit incidentally, whereas in case 2, a patient with extensive ossification exhibited symptoms. It is necessary to examine the cervical mobility, extent and morphology of ossification, and timing of surgery stenosis to determine the risk factors and treatment options, including rehabilitation.

Extensive Ossification of the Achilles Tendon with and without Acute Fracture: A Scoping Review

Extensive Ossification of the Achilles Tendon (EOAT) is an uncommon condition characterized by the presence of heterotopic ossification within the substance of the Achilles Tendon and is distinct from other tendinopathies associated with tendon mineralization. The purpose of this scoping review of the literature on EOAT is to describe the pathogenesis, patient population, presentation, management, and outcomes of this rare condition. Fifty-four articles were included in the scoping review after screening and selection. According to the literature, EOAT often presents with pain and swelling around the Achilles Tendon and is frequently associated with acute trauma. EOAT is more common in men, and although the exact mechanisms of the pathology are not fully understood, EOAT may demonstrate specific molecular signaling patterns. The lack of knowledge regarding the molecular mechanism may be a significant hindrance to the management of the condition. Even though a standard treatment regimen for EOAT does not exist, conservative management for six months in patients without complications is recommended. Those who have an acute fracture of the ossification should be managed more aggressively and will often require surgical repair with autograft, although there is no standardized procedure at this time. Clinicians should be aware of the typical presentation, risk factors, and management options of patients with EOAT. Additionally, they should be cautious when selecting treatment strategies and conduct a thorough evaluation of long-term outcomes with various treatment modalities, which this review provides. Most important, this review highlights the need for further research to determine the best course of clinical treatment of EOAT injuries, in order to establish a standard treatment regimen.

Association between the developing sphenoid and adult morphology: A study using sagittal sections of the skull base from human embryos and fetuses.

The developing sphenoid is regarded as a median cartilage mass (basisphenoid [BS]) with three cartilaginous processes (orbitosphenoid [OS], ala temporalis [AT], and alar process [AP]). The relationships of this initial configuration with the adult morphology are difficult to determine because of extensive membranous ossification along the cartilaginous elements. The purpose of this study was therefore to evaluate the anatomical connections between each element of the fetal sphenoid and adult morphology. Sagittal sections from 25 embryos and fetuses of gestational age 6-34weeks and crown-rump length 12-295mm were therefore examined and compared with horizontal and frontal sections from the other 25late-term fetuses (217-340mm). The OS was identified as a set of three mutually attached cartilage bars in early fetuses. At all stages, the OS-post was continuous with the anterolateral part of the BS. The BS included the notochord and Rathke's pouch remnant in embryos and early fetuses. The dorsum sellae was absent from embryos, but it protruded from the BS in early fetuses before a fossa for the hypophysis became evident. Although not higher than the hypophysis at midterm, the dorsum sellae elongated superiorly after gestational age 25weeks. In early fetuses, the AP was located on the side immediately anterior to the otic capsule. The AT developed on the side immediately posterior to the extraocular rectus muscles. At late term, the greater wing was formed by membranous bones from the AT and AP. The AT and AP formed a complex bridge between the BS and the greater wing. A small cartilage, future medial pterygoid process (PTmed) was located inferior to the AT in early fetuses. At midterm, one endochondral bone and multiple membranous bones formed the PTmed. The lateral pterygoid process (PTlat) was formed by a single membranous bone plate. Therefore, we connected fetal elements and the adult morphology as follows. (1) Derivative of the OS makes not only the lesser wing but also the anterior margin of the body of the sphenoid. (2) Derivatives of the BS are the body of the sphenoid including the sella turcica and the dorsum sellae. (3) Most of the greater wing including the foramen rotundum and the foramen oval originate from the AT and AP and multiple membranous bones. (4) The PTmed originate from endochondral bones and multiple membranous bones, while the PTlat derive from a single membranous bone.

Visceral Adipose Tissue and Different Measures of Adiposity in Different Severities of Diffuse Idiopathic Skeletal Hyperostosis.

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is associated with both obesity and type 2 diabetes. Our objective was to investigate the relation between DISH and visceral adipose tissue (VAT) in particular, as this would support a causal role of insulin resistance and low grade inflammation in the development of DISH. Methods: In 4334 patients with manifest vascular disease, the relation between different adiposity measures and the presence of DISH was compared using z-scores via standard deviation logistic regression analyses. Analyses were stratified by sex and adjusted for age, systolic blood pressure, diabetes, non-HDL cholesterol, smoking status, and renal function. Results: DISH was present in 391 (9%) subjects. The presence of DISH was associated with markers of adiposity and had a strong relation with VAT in males (OR: 1.35; 95%CI: 1.20–1.54) and females (OR: 1.43; 95%CI: 1.06–1.93). In males with the most severe DISH (extensive ossification of seven or more vertebral bodies) the association between DISH and VAT was stronger (OR: 1.61; 95%CI: 1.31–1.98), while increased subcutaneous fat was negatively associated with DISH (OR: 0.65; 95%CI: 0.49–0.95). In females, increased subcutaneous fat was associated with the presence of DISH (OR: 1.43; 95%CI: 1.14–1.80). Conclusion: Markers of adiposity, including VAT, are strongly associated with the presence of DISH. Subcutaneous adipose tissue thickness was negatively associated with more severe cases of DISH in males, while in females, increased subcutaneous adipose tissue was associated with the presence of DISH.

Braincase anatomy of extant Crocodylia, with new insights into the development and evolution of the neurocranium in crocodylomorphs.

Present-day crocodylians exhibit a remarkably akinetic skull with a highly modified braincase. We present a comprehensive description of the neurocranial osteology of extant crocodylians, with notes on the development of individual skeletal elements and a discussion of the terminology used for this project. The quadrate is rigidly fixed by multiple contacts with most braincase elements. The parabasisphenoid is sutured to the pterygoids (palate) and the quadrate (suspensorium); as a result, the basipterygoid joint is completely immobilized. The prootic is reduced and externally concealed by the quadrate. It has a verticalized buttress that participates in the canal for the temporal vasculature. The ventrolateral processes of the otoccipitals completely cover the posteroventral region of the braincase, enclose the occipital nerves and blood vessels in narrow bony canals and also provide additional sutural contacts between the braincase elements and further consolidate the posterior portion of the crocodylian skull. The otic capsule of crocodylians has a characteristic cochlear prominence that corresponds to the lateral route of the perilymphatic sac. Complex internal structures of the otoccipital (extracapsular buttress) additionally arrange the neurovascular structures of the periotic space of the cranium. Most of the braincase elements of crocodylians are excavated by the paratympanic pneumatic sinuses. The braincase in various extant crocodylians has an overall similar structure with some consistent variation between taxa. Several newly observed features of the braincase are present in Gavialis gangeticus and extant members of Crocodylidae to the exclusion of alligatorids: the reduced exposure of the prootic buttress on the floor of the temporal canal, the sagittal nuchal crest of the supraoccipital projecting posteriorly beyond the postoccipital processes and the reduced paratympanic pneumaticity. The most distinctive features of the crocodylian braincase (fixed quadrate and basipterygoid joint, consolidated occiput) evolved relatively rapidly at the base of Crocodylomorpha and accompanied the initial diversification of this clade during the Late Triassic and Early Jurassic. We hypothesize that profound rearrangements in the individual development of the braincases of basal crocodylomorphs underlie these rapid evolutionary modifications. These rearrangements are likely reflected in the embryonic development of extant crocodylians and include the involvement of neomorphic dermal anlagen in different portions of the developing chondrocranium, the extensive ossification of the palatoquadrate cartilage as a single expanded quadrate and the anteromedial inclination of the quadrate.

Accelerated Pulmonary Ossification as a Sequela of SARS-CoV-2 Pneumonia

HomeRadiology: Cardiothoracic ImagingVol. 3, No. 2 PreviousNext Images in Cardiothoracic ImagingFree AccessPulmonary ImagingAccelerated Pulmonary Ossification as a Sequela of SARS-CoV-2 PneumoniaBeatriz García Moreno , Guadalupe Buitrago Weiland, María Luisa Sánchez Alegre, Jhon Edilberto Vanegas RodríguezBeatriz García Moreno , Guadalupe Buitrago Weiland, María Luisa Sánchez Alegre, Jhon Edilberto Vanegas RodríguezAuthor AffiliationsFrom the Department of Radiology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.Address correspondence to B.G.M. (e-mail: [email protected]).Beatriz García Moreno Guadalupe Buitrago WeilandMaría Luisa Sánchez AlegreJhon Edilberto Vanegas RodríguezPublished Online:Apr 1 2021https://doi.org/10.1148/ryct.2021200598MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack Citations ShareShare onFacebookTwitterLinked In This case illustrates extensive dendriform lung ossification manifesting after SARS-CoV-2 pneumonia. Organizing pneumonia is an established CT finding in subacute SARS-CoV-2 infection (1,2), usually manifesting as bilateral consolidations (80%–95% of the cases) in a predominantly peripheral or peribronchial distribution, sometimes sparing the subpleural regions (3). Histologic analysis reveals plugs of fibroblastic tissue filling bronchioles and airspaces (3,4), which usually disappear after steroid treatment. However, fibromyxoid tissue may progress to fibrosis, a condition recently described as “cicatricial organizing pneumonia (4–6).” Some of these cases may evolve with pathologic osseous metaplasia, seen on imaging as nodular and branching calcifications, described as dendriform pulmonary ossification (5). This finding is usually seen in patients with underlying lung fibrosis, most commonly in usual interstitial pneumonia, and it is considered as a marker of chronicity and severity of lung fibrosis (7).Differential diagnoses include dystrophic calcifications, metastatic calcifications, and pulmonary alveolar microlithiasis. Dystrophic calcifications occur in diseased lung, in the settings of granulomatous infections, sarcoidosis, occupational lung diseases, and metabolic diseases (eg, as amyloidosis). Metastatic calcifications occur in normal lung due to hypercalcemia secondary to end-stage kidney disease. The differential diagnosis also includes nodular ossification seen in patients with chronic venous lung congestion (8). Normal renal function, phosphate calcium homeostasis, and the absence of any relevant past medical history or concomitant diseases excluded other causes of lung calcification/ossification in this case (Figs 1, 2).Figure 1: Images in a 49-year-old man who presented to the emergency department with SARS-CoV2 infection. A and B, Non–contrast-enhanced chest CT scans obtained 1 month after the onset of symptoms show multifocal peribronchovascular and peripheral consolidation, relatively sparing the subpleural region, consistent with organizing pneumonia. Follow-up chest CT was performed 6 months after steroid treatment. C, Axial and, D, coronal CT images show multiple micronodular calcifications within faint ground-glass opacities.Figure 1:Download as PowerPointOpen in Image Viewer Figure 2: Bone window images in same patient. Comparison between A, initial and, B, follow-up CT on axial maximum intensity projection images shows interval development of micronodular and branching calcifications, confirmed on C, coronal and, D, magnified axial views. Follow-up lung function testing revealed decreased diffusion capacity.Figure 2:Download as PowerPointOpen in Image Viewer Disclosures of Conflicts of Interest: B.G.M. disclosed no relevant relationships. G.B.W. disclosed no relevant relationships. M.L.S.A. disclosed no relevant relationships. J.E.V.R. disclosed no relevant relationships.Keywords: CT, Lung, Thorax Authors declared no funding for this work.

Extensive Heterotopic Ossification of Bilateral Hip and Knee Joints in a Patient with Recurrent Traumatic Injuries

Background: Heterotopic ossification (HO) refers to the growth of lamellar bone in soft tissues. Extensive heterotopic ossification is rarely seen. In this case, we illustrate a 35-year-old civilian patient with extensive HO due to recurrent traumatic injuries with no neurological deficit. Case Presentation: A 35-year-old man, with a history of recurrent trauma episodes in the past year, presented with pain and swellings in bilateral lower limbs. Physical examination showed stiffness and deformities of bilateral hip and knee joints. Plain x-ray showed patchy ossification extending from hip joints to knee joints bilaterally. 3-dimensional Computer Tomography (3D-CT) showed extensive heterotopic ossifications along gluteal muscles, quadratus muscles and the deep fascia beneath, confirming the diagnosis of extensive heterotopic ossifications of bilateral hip and knee joints. Excision of ossified tissues and re-mobilization of iliotibial bands were performed. Early recovery after surgery (ERAS) strategy was used to speed up recovery. Conclusion: i) Extensive heterotopic ossification in civilian patients is possible. Clinical history should be reviewed to rule out recurrent traumatic injury. Surgery should be considered. ii) Three-dimensional Computer Tomography (3D-CT) is a viable tool for surgical planning to show the extent, site, and anatomical relationship with adjacent tissues. iii) Post-op early recovery after surgery (ERAS) should be considered for better clinical outcomes.