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Year : 2022  |  Volume : 37  |  Issue : 3  |  Page : 286-287  

Functional characterization of posttraumatic heterotopic ossification of tibiofibular syndesmosis with dynamic bone scan and single-photon emission computed tomography/computed tomography


1 Department of Radiology, Hull University Teachings Hospitals NHS Trust, Hull, HU3 2JZ, United Kingdom
2 Department of Nuclear Medicine, Kuwait Cancer Control Center, Kuwait City, Kuwait

Date of Submission10-Aug-2021
Date of Acceptance27-Sep-2021
Date of Web Publication02-Nov-2022

Correspondence Address:
Dr. Bhavana Shyamanur
Department of Radiology, Hull Royal Infirmary, Hull University Teachings Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.ijnm_124_21

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   Abstract 


A 53-year-old man was investigated for ongoing right ankle pain and lateral malleolus swelling following a traumatic inversion injury 12 weeks prior. The initial ankle radiograph was normal with no evidence of fracturing. The follow-up radiograph showed bridging ossification in the distal tibiofibular syndesmosis. As the pain did not subside, posttraumatic heterotopic ossification (HO) was suspected, and triple-phase dynamic bone imaging with technetium 99m-methylene diphosphonate was performed to guide further management. The bone scan revealed intense focal tracer activity centered on the HO of the tibiofibular syndesmosis, with no evidence of occult fracturing confirming HO as a pain generator.

Keywords: Dynamic bone imaging, heterotopic bone formation, heterotopic ossification, technetium 99m-methylene diphosphonate, tibiofibular syndesmosis


How to cite this article:
Shyamanur B, Ahmed N, Usmani S. Functional characterization of posttraumatic heterotopic ossification of tibiofibular syndesmosis with dynamic bone scan and single-photon emission computed tomography/computed tomography. Indian J Nucl Med 2022;37:286-7

How to cite this URL:
Shyamanur B, Ahmed N, Usmani S. Functional characterization of posttraumatic heterotopic ossification of tibiofibular syndesmosis with dynamic bone scan and single-photon emission computed tomography/computed tomography. Indian J Nucl Med [serial online] 2022 [cited 2022 Nov 29];37:286-7. Available from: https://www.ijnm.in/text.asp?2022/37/3/286/360254



Heterotopic ossification (HO) of the soft tissues is a well-recognized complication following trauma, resulting in nonneoplastic formation of bone in soft tissue. It has been documented to lead to tibiofibular synostosis, which may require surgical excision to relieve symptoms and facilitate return to normal activity.[1],[2] The initial plain radiograph is often negative as the lesion is composed of granulation tissue in the early stages of disease development, containing fibroblasts, and cellular tissue.[3],[4] Radiograph appearances [Figure 1]a and [Figure 1]b can also mimic periosteal or parosteal osteosarcoma, and further imaging is often needed to confirm the diagnosis.[5] The preexisting history of trauma in this case is a key discriminating factor in identifying the correct diagnosis. Magnetic resonance images are valuable in assessing ligamentous injury, especially of the anterior tibiofibular and posterior tibiofibular ligaments, but are of limited diagnostic utility in syndesmotic HO as appearances can show significant temporal change depending on the stage that the imaging is performed.[6]
Figure 1: A 53-year-old man presented with persistent right ankle pain and lateral malleolus swelling following traumatic inversion injury 12 weeks prior. (a) The anteroposterior right ankle X-ray was normal. (b) Follow-up X-ray 2 months later showed bridging ossification and synostosis between the distal tibia and fibula, leading to the diagnosis of posttraumatic heterotopic ossification

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Dynamic bone imaging [Figure 2]a, [Figure 2]b, [Figure 2]c is a useful diagnostic tool in investigating HO. The investigation has a high sensitivity allowing the evaluation of pathology such as trauma, infection, and malignant disease[7] but a low specificity, which in this case necessitates correlation with the history of trauma and other imaging findings. Flow studies and blood-pool imaging in dynamic bone imaging can positively identify tracer activity in HO around 2.5 weeks following trauma, earlier than radiography. Radiography remains less sensitive to findings for at least another 6 days after radionuclide diagnosis.[8],[9]
Figure 2: The patient continued to have persistent symptoms and triple-phase dynamic bone imaging with technetium 99m-methylene diphosphonate was performed to direct further management. (a-c) Both blood pool and bone phase imaging revealed intense focal tracer activity. The localization to heterotopic ossification centered on the heterotopic ossification of the tibiofibular syndesmosis was best seen with single-photon emission computed tomography/computed tomography indicating ongoing osteoblastic turnover in the region. There was no scintigraphic evidence of occult fracturing

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Surgical management should be considered where limb function is compromised by pain and decreased range of movement. Serial dynamic bone imaging can play a part in deciding on the correct time for surgical intervention. In the early stages of HO, the bone scan demonstrates increased uptake which progresses to a decreased or a lack of tracer activity as the lesion matures.[3] As postoperative recurrence rates are high, surgical excision should be planned once the bone scan indicates lesion maturation.[10] While surgery is the definitive method of removing established bone, it must be combined with indomethacin therapy and radiotherapy to further reduce the risk of recurrence.[11],[12]

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 initial s 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.



 
   References Top

1.
!Fu JH, Hwang CC, Chao TH. Tibiofibular synostosis in a military soldier. J Med Sci (Faisalabad, Pakistan) 2003;23:135-8.  Back to cited text no. 1
    
2.
Veltri DM, Pagnani MJ, O'Brien SJ, Warren RF, Ryan MD, Barnes RP. Symptomatic ossification of the tibiofibular syndesmosis in professional football players: A sequela of the syndesmotic ankle sprain. Foot Ankle Int 1995;16:285-90.  Back to cited text no. 2
    
3.
Tyler P, Saifuddin A. The imaging of myositis ossificans. Semin Musculoskelet Radiol 2010;14:201-16.  Back to cited text no. 3
    
4.
Hendifar AE, Johnson D, Arkfeld DG. Myositis ossificans: A case report. Arthritis Rheum 2005;53:793-5.  Back to cited text no. 4
    
5.
Botchu R, Douis H, Davies AM, James SL, Puls F, Grimer R. Post-traumatic heterotopic ossification of distal tibiofibular syndesmosis mimicking a surface osteosarcoma. Clin Radiol 2013;68:e676-9.  Back to cited text no. 5
    
6.
Kransdorf MJ, Meis JM, Jelinek JS. Myositis ossificans: MR appearance with radiologic-pathologic correlation. AJR Am J Roentgenol 1991;157:1243-8.  Back to cited text no. 6
    
7.
Love C, Din AS, Tomas MB, Kalapparambath TP, Palestro CJ. Radionuclide bone imaging: An illustrative review. Radiographics 2003;23:341-58.  Back to cited text no. 7
    
8.
Shehab D, Elgazzar AH, Collier BD. Heterotopic ossification. J Nucl Med 2002;43:346-53.  Back to cited text no. 8
    
9.
Orzel JA, Rudd TG. Heterotopic bone formation: Clinical, laboratory, and imaging correlation. J Nucl Med 1985;26:125-32.  Back to cited text no. 9
    
10.
Drane WE. Myositis ossificans and the three-phase bone scan. AJR Am J Roentgenol 1984;142:179-80.  Back to cited text no. 10
    
11.
Vanden Bossche L, Vanderstraeten G. Heterotopic ossification: A review. J Rehabil Med 2005;37:129-36.  Back to cited text no. 11
    
12.
Gurcan S, Ozyurek S, Kose O, Sehirlioglu A. Ankylosing pelvitrochanteric heterotopic ossification in a patient with spinal cord injury. BMJ Case Rep 2013;2013:bcr2013009983.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2]



 

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