Heterotopic ossification following surgery: an unusual cause of resuscitation injury
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Heterotopic ossification following surgery: an unusual cause of resuscitation injury Kelly Olds • Roger W. Byard • Neil E. I. Langlois
Accepted: 17 February 2014 Ó Springer Science+Business Media New York 2014
Case report A 55-year-old male with a medical history of cerebrovascular accident, coronary artery bypass grafting, type II diabetes mellitus, and infection of the leg (following coronary bypass grafting), collapsed after sexual intercourse. Resuscitation was unsuccessful. At autopsy, a healed vertical thoracotomy scar extending to the xiphisternum, associated with underlying dense peri- and epicardial fibrous adhesions was found. Patent coronary artery bypass grafts were connected to the left anterior and posterior descending coronary arteries, with the distal native vessels demonstrating marked atherosclerosis with significant stenosis. Myocardial fibrosis with full thickness scarring of the left ventricular free wall was confirmed microscopically, with no evidence of acute ischemic myocardial damage. An area of previous ischemic injury was identified in the right basal ganglia of the brain. There were no injuries; toxicology and biochemistry tests were unremarkable. No other underlying organic illnesses were present which could have caused or contributed to death. Death was therefore attributed to ischemic heart disease. Also noted at autopsy were multiple rib fractures and a laceration of the liver, the results of attempts at resuscitation. Specifically, there were recent fractures (without intercostal muscle/soft tissue hemorrhage) of the second to K. Olds R. W. Byard (&) N. E. I. Langlois Discipline of Anatomy and Pathology, School of Medical Sciences, The University of Adelaide, Level 3 Medical School North Building, Frome Road, Adelaide, SA 5005, Australia e-mail: [email protected] R. W. Byard N. E. I. Langlois Forensic Science SA, Adelaide, SA 5005, Australia
seventh ribs on the left, and the second to ninth ribs on the right, in the mid-clavicular lines. Within the abdomen there was a 3 cm long vertical laceration of the anterior surface of the left lobe of the liver in the midline, which extended to a depth of approximately 1 cm (Fig. 1). There was subcapsular bruising surrounding the tear but no intraabdominal bleeding. Histological examination of samples from the region of the laceration revealed no inflammatory reaction. Of note, the liver laceration had been caused by a 3.5 cm bony spur that projected downwards from the xiphisternum (Fig. 2). The bony spicule measured approximately 0.3 cm in diameter and ended in a terminal nodule 0.5 cm in diameter (Fig. 3). The bone spur had arisen from heterotopic ossification within an area of dense fibrous scar tissue associated with the previous coronary artery bypass surgery. This calcified extension had caused the tear in the liver when resuscitation was performed. Radiography confirmed the bony nature of the tissue (Fig. 4) and that it was not an extension of the wire suture that had been used to close the sternum afte
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