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Heterotopic ossification: radiological and pathological review

Bilal Mujtaba
Bilal Mujtaba
, 
Ahmed Taher
Ahmed Taher
, 
Matthew J. Fiala
Matthew J. Fiala
, 
Sameh Nassar
Sameh Nassar
, 
John E. Madewell
John E. Madewell
, 
Abdelrahman K. Hanafy
Abdelrahman K. Hanafy
 and 
Rizwan Aslam
Rizwan Aslam
   | Sep 24, 2019
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Article Category: Review
Published Online: Sep 24, 2019
Page range: 275 - 284
Received: Feb 20, 2019
Accepted: Jul 11, 2019
DOI: https://doi.org/10.2478/raon-2019-0039
© 2019 Bilal Mujtaba, Ahmed Taher, Matthew J. Fiala, Sameh Nassar, John E. Madewell, Abdelrahman K. Hanafy, Rizwan Aslam, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Figure 1

Progression of Heterotopic Ossification from presentation (left), 4 months (middle), and 8 months (right). Axial CT with contrast depicts initial hyperemia with increasing calcification at the site of injury with eventual outer cortical and inner cancellous bone formation.
Progression of Heterotopic Ossification from presentation (left), 4 months (middle), and 8 months (right). Axial CT with contrast depicts initial hyperemia with increasing calcification at the site of injury with eventual outer cortical and inner cancellous bone formation.

Figure 2

AP X-rays show previous vascular calcifications (Left-blue arrow) with no apparent masses at the site of injury at presentation. At 4 months follow up, there is increased calcifications noted (blue arrow) with expansion to the adjacent soft tissue area (red arrow) both are consistent with Heterotopic Ossification.
AP X-rays show previous vascular calcifications (Left-blue arrow) with no apparent masses at the site of injury at presentation. At 4 months follow up, there is increased calcifications noted (blue arrow) with expansion to the adjacent soft tissue area (red arrow) both are consistent with Heterotopic Ossification.

Figure 3

Heterotopic Ossification shown with initial hyperemia without calcification at presentation (left- red arrow) with increasing organized calcification seen after 4 months on Non-contrast CT (Right-red arrow).
Heterotopic Ossification shown with initial hyperemia without calcification at presentation (left- red arrow) with increasing organized calcification seen after 4 months on Non-contrast CT (Right-red arrow).

Figure 4

Severe gout presenting on the first metatarsophalangeal joint. AP X-ray of the right foot shows a medial pararticular calcified soft tissue mass at the level of the first metatarsophalangeal joint (red arrow), resulting in adjacent intraosseous erosions with sclerotic borders.
Severe gout presenting on the first metatarsophalangeal joint. AP X-ray of the right foot shows a medial pararticular calcified soft tissue mass at the level of the first metatarsophalangeal joint (red arrow), resulting in adjacent intraosseous erosions with sclerotic borders.

Figure 5

Dystrophic calcifications secondary to dermatomyositis are seen in the peripheral soft tissue (2 red arrows). They appear as hazy ill-defined opacities on plain film.
Dystrophic calcifications secondary to dermatomyositis are seen in the peripheral soft tissue (2 red arrows). They appear as hazy ill-defined opacities on plain film.

Figure 6

T1 weighted non-contrast MRI (left-red arrow) of dystrophic calcifications show hypointense signal in patchy patterns. These appear as calicified hazy patches on CT (right-red arrow).
T1 weighted non-contrast MRI (left-red arrow) of dystrophic calcifications show hypointense signal in patchy patterns. These appear as calicified hazy patches on CT (right-red arrow).

Figure 7

Calcium Pyrophosphate Deposition disease can lead to calcification of intra-articular cartilage. There is opacification of the lateral joint space on plain film (left-red arrow) and a more clearly defined mineralization seen near the lateral condyle on CT (right-red arrow).
Calcium Pyrophosphate Deposition disease can lead to calcification of intra-articular cartilage. There is opacification of the lateral joint space on plain film (left-red arrow) and a more clearly defined mineralization seen near the lateral condyle on CT (right-red arrow).

Figure 8

X-ray of the (left- 2 red arrows) shoulder show opacified cystic, lobulated peri-articular lesions in Tumoral Calcinosis. Coronal MRI T2 sequencing (right-red arrow) reveals hypointense lesions with septal enhancement, hyperintense fluid filled cavities and fluid –fluid levels consistent with sedimentation.
X-ray of the (left- 2 red arrows) shoulder show opacified cystic, lobulated peri-articular lesions in Tumoral Calcinosis. Coronal MRI T2 sequencing (right-red arrow) reveals hypointense lesions with septal enhancement, hyperintense fluid filled cavities and fluid –fluid levels consistent with sedimentation.

Figure 9

An avulsed piece of bone is seen on the posterior aspect of the calcaneus secondary to trauma (red arrow).
An avulsed piece of bone is seen on the posterior aspect of the calcaneus secondary to trauma (red arrow).

Figure 10

The “sunburst” appearance with cloudlike density of untreated Osteosarcoma is observed in the distal femur (left-red arrow). After chemotherapy, the lesion ossifies and becomes increasingly opaque on plain film (right-red arrow), consistent with positive therapeutic response).
The “sunburst” appearance with cloudlike density of untreated Osteosarcoma is observed in the distal femur (left-red arrow). After chemotherapy, the lesion ossifies and becomes increasingly opaque on plain film (right-red arrow), consistent with positive therapeutic response).

Figure 11

Opaque linear coarse calcification along the expected location of the supraspinatus tendon insertion onto the greater tubercle of the humerus (red arrow), consistent with Calcific Tendonitis.
Opaque linear coarse calcification along the expected location of the supraspinatus tendon insertion onto the greater tubercle of the humerus (red arrow), consistent with Calcific Tendonitis.

Brooker classification of heterotopic ossification9

Class 1 Islands of bone within the soft tissues over the hip
Class2 Bone spurs from the pelvis or proximal end of the femur, leaving at least one centimeter between opposing bone surfaces.
Bone spurs from the pelvis or proximal end of the femur, reducing
Class 3 the space between opposing bone surfaces to less than one centimeter.
Class 4 Apparent bone ankylosis of the hip

Della Valle classification of heterotopic ossification49

Class 1 Absence of HO or islands measuring <1 cm in length
Class 2 Islands >1 cm or spurs leaving at least 1 cm between femur and pelvis
Class 3 Spurs leaving <1 cm between opposing surfaces or bony ankylosis

Schmidt and Hackenbroch classification of heterotopic ossification50

Region 1 Heterotopic ossifications strictly below tip of greater trochanter
Region 2 Heterotopic ossifications below and above tip of greater trochanter
Region 3 Heterotopic ossifications strictly above tip of greater trochanter
Grade A Single or multiple heterotopic ossifications < 10 mm in maximal extent without contact with pelvis or femur
Grade B Heterotopic ossifications > 10 mm without contact with pelvis but with possible contact with femur; no bridging from femur to proximal part of greater trochanter, with no evidence of ankylosis
Grade C Ankylosis by means of firm bridging from femur to pelvis
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