Long-term protective effects of the combination of intermittent reperfusion and hypothermia on reperfusion injury in an experimental testicular torsion model.

INTRODUCTION: There are many significantfactors in testicular injury which determine the prognosis in testicular torsion. Reperfusion injury following detorsion also has a significant effect on testicular injury.This study was planned considering that with the implementation of intermittent reperfusion and hypothermia, reperfusion injury can be reduced, and such an application might have a positive effect on testicular tissue in the long term. MATERIALS AND METHODS: Forty adult male rats were divided into five groups as follows: Sham(Sh)(n = 8), Torsion(T)(n = 8), Intermittent reperfusion(IR)(n = 8), Hypothermia(H)(n = 8), and Intermittent reperfusion+hypothermia(IR+H)(n = 8). Except forGroup Sh, the left testicle was taken out of the scrotum in all groups, rotated three times counterclockwise, fixed back in the scrotum, and left for four hours.After four hours, and just before reperfusion, the testicle's detorsion was performed while holding the vascular structures in the proximal part of the torsed segment with an atraumatic vessel clamp, and thus, not allowing reperfusion in Groups T, IR, H, and IR+H. In Group T, the clamp was released immediately. In Group H, an ice-bag cooling was performed around the testis, and the clamp was released when the tissue temperature was reached and kept constant at 4 °C. In Group IR, the clamp was released, allowing reperfusion of five seconds, followed by reclamping, providing an ischemic status for ten seconds; this procedure was repeated ten times. In Group H+IR,an ice-bag cooling was performed around the testis, and the clamp was released when the tissue temperature was reached and kept constant at 4 °C. Then, reperfusion was applied for 5 s, followed by 10 s ischemia with reclamping. This procedure was repeated ten times.Tissue blood flow was provided for60 days of reperfusion in all groups. After 60 days, both testicles were excised under anesthesia in all living rats, and samples ofthe left testicle werereserved for biochemical and pathological examinations. At the end of the procedure, all animals were sacrificed by a high dose of anesthesia. RESULTS: It was biochemically and histopathologically determined that the tissues were preserved in the experimental groups compared to Group T, which was statistically significant (p < 0.05).However, no experimental group's superiority over each other was determined both biochemically and histopathologically (p > 0.05). CONCLUSION: Our long-term experimental study revealed that all methods were protective in testicular torsion. The authors believe that these methods can be applied in clinical practice because of their ease of application and no additional cost. On the other hand, the results of our study should further be supported by other experimental studies.

-Effects of Local Anesthetics on Smooth Muscle Tissue in Rat Trachea: An In Vitro Study.

OBJECTIVES: We evaluated the muscle responses of rat trachea to LA drugs, such as lidocaine and prilocaine, in terms of airway spasms. MATERIALS AND METHODS: A total of 16 male rats were used. After ketamine anesthesia, the tracheal ring of each rat was removed and placed in the organ bath in the Krebs solution. The rat tracheal veins were randomly divided into two groups based on the LA applied at the basal tonus level: group 1 (n=8), lidocaine; group 2 (n=8), prilocaine. Second, the baths were washed. Supramaximal contraction was obtained by applying acetylcholine to the tracheal rings (n=16) at a basal tonus level. The rat tracheas with supramaximal contraction were randomly divided into two groups: group 3 (n=8), lidocaine; group 4 (n=8), prilocaine. The contraction responses of each group were recorded and statistically compared. RESULTS: Lidocaine constituted a significant relaxation response in the tracheal tissue in both basal tonus and supramaximal tonus levels. Moreover, it was observed that the relaxation of lidocaine was higher in the supramaximal contraction than in the basal tonus tension level. However, for prilocaine, no significant change was observed in both tonus levels. CONCLUSION: This study suggests that lidocaine as a LA drug should be preferred as the first choice in patients with respiratory risk, and that its use over prilocaine should be preferred, if supported by advanced clinical studies.

The long-term protective effect of hypothermia and gradual detorsion on ovarian tissue in adnexal torsion/detorsion model in rats.

INTRODUCTION: Ischemia in ovarian torsion and subsequent reperfusion has significant effects on fertility in the long term. The most important reason for these changes is thought to be a reperfusion injury rather than ischemia. We aimed to evaluate whether the reperfusion injury following ovarian detorsion could be reduced by hypothermia and intermittent reperfusion. MATERIALS AND METHODS: Forty adult female rats were divided into five groups as follows: Sham (Sh) (n = 8), torsion detorsion (control TD) (n = 8), progressive reperfusion "gradual detorsion" (GD) (n = 8), hypothermia (H) (n = 8) and the progressive reperfusion + hypothermia (GD + H) (n = 8). In all rats, except for the Sh group, the left ovary was rotated counter clockwise 1080° and fixed to the abdominal wall by three 5-0 non-absorbable sutures followed by the closure of the laparotomy. After 30 h, reperfusion was achieved following the detorsion of the ovaries. In both the control TD and H groups, the torsed ovaries were detorsed. H group, however, was subjected to hypothermia with ice packs 30 min before and during the detorsion. Tissue temperature was kept constant at 4 °C, controlled by a digital thermometer. In the GD group, the torsed ovary and pedicle were detorsed by 360°, followed by a 5 min pause. This procedure was repeated twice until a complete detorsion was achieved. GD + H group underwent hypothermia with ice packs 30 min before the procedure and the torsed ovary and pedicle were detorsed by 360°. After a 5 min pause, we repeated this process twice to provide full detorsion. The tissue temperature was constantly held at 4 °C. In the hypothermia groups, we applied hypothermia for an additional 30 min after detorsion and then left the rats at normal body temperature during reperfusion. We followed the rats in all groups for 60 days. Then we excised the left ovaries of all rats through laparotomy and spared some of the ovaries for biochemical and pathological examination. Intracardiac blood was taken at the end of the procedure and it was sent to the biochemical laboratory to assess oxidative stress markers. Finally, all the animals were sacrificed with high-dose of anesthesia. RESULTS: Evaluation of the results revealed that oxidative stress markers were significantly lower, and antioxidant parameters were higher in the experimental groups compared with the control TD group (p < 0.05). Histopathologically, we found that tissues were preserved in GD, H, GD + H groups (p < 0.05). When we compared the groups among each other, both biochemical and histopathological values in GD + H group showed that the tissue was preserved from oxidative damage, albeit the difference did not reach a level of significance. DISCUSSION: Several studies have shown that both hypothermia and intermittent reperfusion protect tissue from IR damage in the early period. However, as far as we know there is no study on long-term outcomes of both practices. Our study showed that both hypothermia and intermittent reperfusion alone protect tissue from IR damage in the long term. However, it did not show the superiority of the combination of both methods compared to that of individual application. The advantages of these methods lie in their easy application and cost-effectiveness. We believe that our study will serve as a base for future studies on the subject.

Comparison of the effects of intermittent reperfusion and hypothermia in preventing testicular ischemia-reperfusion injury in the testicular torsion model in rats.

INTRODUCTION: Reperfusion injury after detorsion in testicular torsion is a clinical problem. This study was planned to investigate the protective effect of intermittent reperfusion in hypothermia-applied testicles. MATERIALS AND METHODS: A total of 40 adult male rats were used, and 5 groups were created: sham (Sh; n = 8), torsion (T; torsion-detorsion) (n = 8), intermittent reperfusion (IR; n = 8), hypothermia (H; n = 8), and intermittent reperfusion+hypothermia (H+IR; n = 8). The left testicle was removed in all groups except in the Sh group, and it was rotated 3 times counterclockwise, fixed in the scrotum, and left for 4 h. After 4 h, the testicle was detorsioned in the groups T, IR, H, and H+IR. During detorsion, an atraumatic vessel clamp was applied in the proximal part of the vascular structures to prevent any reperfusion of the testicle. The clamp was opened immediately in the group T. In the group IR, the clamp was opened, a reperfusion of 5 s was applied; then, the clamp was closed again, and ischemia was created for 10 s; this procedure was repeated 10 times. In the group H, an ice bag cooling was performed around the testis. The tissue temperature was kept constant at 4 °C using a digital thermometer control. The testicle was cooled using an ice bag in the group H+IR; the same procedure was applied to the IR group. In all groups, reperfusion was performed for 1 h at the end of these procedures. The left testicle was removed from all rats; a portion of each testicle was separated for biochemistry testing, and some was separated for histopathological evaluation. At the end of the procedure, intracardiac blood was taken to examine oxidative stress parameters. At the end of the procedure, all animals were sacrificed after administration of a high dose of anesthesia. RESULTS: The authors observed that the tissue was preserved in the experimental groups and this was statistically significant (p<0.05). It was detected that the tissues were also histopathologically and significantly preserved in the groups IR, H, and H+IR. However, both biochemically and histopathologically, there was no superiority of hypothermia, intermittent reperfusion, or combined application (p>0.05). DISCUSSION: Both hypothermia and intermittent reperfusion alone protect tissue from IR damage. But no studies have been found in which these applications were used together. And as a result of this work, the combination of both methods did not show superiority over the effect they showed when they were used separately. The authors think that these methods can be applied clinically because of their ease of application and no additional costs; however, it should be supported by other studies.

Short-interval postconditioning protects the bowel against ischaemia-reperfusion injury in rats.

Objective Acute mesenteric ischaemia leads to intestinal damage. Restoration of blood flow results in further damage to tissue, which is called reperfusion injury. This study aimed to investigate the protective effects of short-interval postconditioning and to determine the optimal interval for reperfusion in an experimental rat model of intestinal ischaemia. Methods Forty adult male Wistar rats were grouped as follows: sham (Sh), ischaemia + reperfusion (IR), ischaemia + postconditioning for 5 seconds (PC5), ischaemia + postconditioning for 10 seconds (PC10), and ischaemia + postconditioning for 20 seconds (PC20). For postconditioning, 10 cycles of reperfusion (5, 10, or 20 seconds) interspersed by 10 cycles of 10 seconds of ischaemia were performed. Blood glutathione reductase (GR) and glutathione peroxidase (GPx) levels were measured. Intestinal tissue damage was assessed histopathologically. Results GR levels were significantly higher in the PC5 group than in the IR group (37.7 ± 9.0 vs. 18.5 ± 2.0 min/g Hb). GPx levels were significantly higher in the PC10 group than in the IR group (43.2 ± 9.2 vs. 15.9 ± 4.6 U/g Hb). The histopathological score was significantly lower in the PC5 group (1.1 ± 0.1) than in the IR group (2.1 ± 0.2). Conclusion Short-interval postconditioning reduces reperfusion injury in the ischaemic bowel and the optimal interval for reperfusion is 5 seconds. The long-term effects of short-interval postconditioning and the optimal reperfusion interval in intestinal ischaemia-reperfusion in rats need to be investigated.

Does gradual detorsion protect the ovary against ischemia-reperfusion injury in rats?

AIM: Adnexal torsion is an infrequent and serious gynecologic surgical emergency. Adnexal torsion may result from pre-existing tubal or ovarian pathology or hyperstimulation of the ovary during ovulation. Early diagnosis and emergency surgical treatment (detorsion) are important to preserve fertility and to prevent peritonitis or loss of the adnexa. However, during reperfusion, tissue damage is more severe than during ischemia because of oxygen-derived radicals. The present study aimed to investigate the protective effect of gradual detorsion on adnexal torsion. MATERIALS AND METHODS: Twenty-one adult female rats were divided into three groups as sham-operated (Sh group, n = 7); torsion + detorsion (TD group, n = 7); and torsion + gradual detorsion (TGD group, n = 7). A midline laparotomy was performed under anesthesia. In the TD and TGD groups, the left adnexa along with tubal and ovarian vessels were twisted three times in a clockwise direction and fixed to the abdominal wall. After 30 h, detorsion was performed on the mesenteries of both TD and TGD groups. In the TGD group, however, detorsion was performed gradually: the ovarian mesentery was detorsioned 360°, followed by a 5-min pause, then a repeat of the cycle until full detorsion was achieved. Rats were killed 1 week later. Left ovaries were removed and evaluated histopathologically. RESULTS: The histopathological mean grade was significantly higher in the TD than in the TGD group (p < 0.05). CONCLUSION: Gradual detorsion can reduce reperfusion injury in a rat model of ovarian torsion. This method is easily applicable and may be a useful method for human patients with ovarian torsion.

The long-term protective effects of short-interval postconditioning in testicular ischemia-reperfusion injury in rats.

AIM: Even with prompt diagnosis and treatment, testicular torsion may lead to infertility and atrophy after testicular salvage. The aims of this study were to investigate the long-term protective effects of short-interval postconditioning on testicular atrophy and to optimize the reperfusion period. MATERIALS AND METHODS: Forty adult male rats were divided into 5 subgroups: sham operated; torsion + detorsion; torsion + postconditioning, 5 seconds (PC5); torsion + postconditioning, 10 seconds; and torsion + postconditioning, 20 seconds. Torsion was created by rotating the left testis 1080° counterclockwise and then fixing the testis to the scrotum with 3 sutures. Torsion was maintained for 4 hours. The testicular artery was visualized, and an atraumatic vascular clamp was applied to prevent reperfusion in all study groups. Detorsion of the testis was then performed. In the torsion + detorsion group, the clamp was released just after detorsion. In all the other intervention groups, the subsequent procedures were repeated 10 times. In the PC5 group, the clamp was released for 5 seconds and applied for 10 seconds; in the torsion + postconditioning, 10 seconds group, the clamp was released for 10 seconds and applied for 10 seconds; and in the torsion + postconditioning, 20 seconds group, the clamp was released for 20 seconds and applied for 10 seconds. Then, reperfusion was allowed. After 60 days, rats in all study groups were killed, both testes were removed, and the histopathology was evaluated. The χ(2) test was used for statistical analysis. RESULTS: Compared with the other groups, the extent of tissue injury determined by histopathologic grades according to Cosentino et al (J Androl. 1986;7:23-31) was significantly less in group PC5 (P < .05). CONCLUSION: We conclude that short-interval postconditioning can protect against long-term testicular reperfusion injury. Furthermore, the optimal time for reperfusion during postconditioning was 5 seconds in our rat model of testicular torsion. This technique seems easily applicable, and evidence suggests that similar techniques may be useful during testicular surgery.

The effects of short-interval postconditioning in preventing testicular ischemia-reperfusion injury in rats.

AIM: Testicular torsion can lead to testicular damage. During reperfusion, tissue damage is more severe. The aim of this study was to investigate the protective effect of short-interval postconditioning and determine the optimal time of reperfusion for postconditioning. MATERIALS AND METHODS: Thirty-five adult male rats were divided into 5 subgroups: Sh (sham operated), TD (torsion + detorsion), PC5 (torsion + postconditioning 5 seconds), PC10 (torsion + postconditioning-10 seconds), PC20 (torsion + postconditioning 20 seconds). Torsion was created by rotating the left testis counterclockwise 1080° and the testis fixed to the scrotum with 3 sutures. Torsion was maintained for 4 hours. The testicular artery was visualized, and before detorsion of the testis, an atraumatic vessel clamp was applied to prevent reperfusion in all study groups. Then, detorsion of the testis was performed. In the TD group, the clamp was released just after detorsion; in the PC5 group, the clamp was released for 5 seconds and closed for 10 seconds (10 times); in the PC10 group, the clamp was released for 10 seconds and closed for 10 seconds (10 times); and in the PC20 group, the clamp was released for 20 seconds and closed for 10 seconds (10 times). Then, all testes were reperfused for a 1-hour period in all study groups. After this period, the rats were sacrificed, and the left testes were removed and evaluated histopathologically and biochemically. The Mann-Whitney U test was used for statistical analyses. RESULTS: Tissue malondialdehyde levels were 79.3 ± 10.6, 231.7 ± 102.3, 71.3 ± 12.6, 73.8 ± 13.7, and 124.3 ± 48.0 nmol/g tissue in the Sh, TD, PC5, PC10, and PC20 groups, respectively. Tissue malondialdehyde levels were significantly lower in the PC5 and PC10 groups (P < .05) compared to the other groups. However, mean histopathologic grade was lower in all postconditioning groups compared to the control group, but the difference was significant only in the PC5 group (P < .05). CONCLUSION: We conclude that short-interval postconditioning can reduce reperfusion injury in ischemic tissue and the optimal mode of short-interval postconditioning is 5 seconds × 10 times. This technique seems easily applicable, and a similar technique may be used during testicular surgery.

Neutrophil/lymphocyte ratio in the diagnosis of childhood appendicitis.

Total leukocyte count (TLC) and neutrophil count are not reliable parameters in the diagnosis of appendicitis in children, necessitating a search for more sensitive criteria. This study's goal was to investigate the diagnostic value of neutrophil/lymphocyte (N/L) ratio in childhood appendicitis. The patients admitted for acute abdominal symptoms were reviewed retrospectively. Data collected included initial preoperative TLC, together with neutrophil and lymphocyte values. N/L ratio was calculated by dividing the values obtained. One hundred eighty-three of 240 patients were treated operatively and were proven as appendicitis histopathologically. The other observed 57 cases were accepted as non-specific abdominal pain (NAP). 90.2% of the appendicitis group and 12.3% of the NAP group had N/L ratio higher than 3.5. The results indicate that N/L ratio seems to be a more sensitive parameter than TLC when evaluated retrospectively. N/L ratio of 3.5 can be used in the prediction of appendicitis in children.

The protective effect of dexpanthenol on testicular atrophy at 60th day following experimental testicular torsion.

Despite the prompt diagnosis and treatment of testicular torsion (TT), there are problems with fertility and atrophy after testicular salvage. Dexpanthenol (Dxp) is the biologically active alcohol of pantothenic acid (PA). Dxp is converted to PA in tissues. PA increases the content of reduced glutathione (GSH), Coenzyme A and ATP synthesis in cells. GSH and glutathione-dependent peroxidases (GPX) are the major defense systems against oxidative stress. GPX-4 is the major antioxidant in testicular tissue. However, the activity of GPX-4 appeared and increased only after puberty. We investigated the effect of Dxp on testicular atrophy after TT at the 60th day. Rats were separated randomly into four groups. Group C: control group, group Td: torsion + detorsion, group Sal: torsion + saline + detorsion, group Dxp: torsion + Dxp + detorsion. The left testis was rotated 720 degrees for 2 h. In group Sal, normal saline and in group Dxp, Dexpanthenol were injected intraperitonally, 30 min before detorsion. After 60 days, the testicular weights and volumes were measured. Histopathology of the left testis was evaluated with mean seminiferous tubular diameter (MSTD) and mean testicular biopsy score (MTBS). The left (torsed) testicular weight and volume of groups Td and Sal were significantly lower compared to group Dxp. The MSTD and MTBS of group Td and Sal were significantly lower than group Dxp. Contralateral testicular weight and volume of groups Td, Sal and Dxp had no significant difference compared to the control group. Dxp significantly prevented testicular atrophy after 60 days of TT. Dxp has FDA approval, is safe, cost effective and readily available. Its relevance for clinical trials may especially be for the problem of testicular atrophy catastrophe, seen very frequently following testicular salvage.

Dexpanthenol attenuates lipid peroxidation and testicular damage at experimental ischemia and reperfusion injury.

Prevention of tissue damage after testicular torsion caused by I/R injury is still a clinical and experimental problem. There are many experimental studies made with several chemicals in the literature for decreasing the effect of reactive oxygen species after ischemia and reperfusion. Dexpanthenol (Dxp) is the biologically active alcohol of pantothenic acid. Pantothenic acid increases the content of reduced glutathione, Coenzyme A and ATP in cell. We studied the effect of Dxp on lipid peroxidation and testicular damage. Forty adult rats were separated randomly into five groups: group Sh, Sham-operation; group TD, torsion-detorsion; group NS, torsion-normal saline-detorsion; group D, torsion-Dxp 250 mg/kg detorsion; group D2, torsion-Dxp 500 mg/kg detorsion group. Serum MDA levels were taken before detorsion, after torsion at the first and fifth minute and at the first hour. Tissue sample was taken at the first hour. The alterations of I/R injury on testis were histological graded. Serum MDA levels were significantly lower in group D2 compared to all groups. The histopathology score of group D2 was significantly lower than groups TD, NS and D. Histopathological score and serum MDA levels are strikingly compatible. Dxp attenuated lipid peroxidation and tissue damage at I/R injury. This effect depends on its antioxidant effect with increasingly reduced glutathione, Coenzyme A and ATP. The effect of Dxp on I/R injury has been shown for the first time in the experimental testicular torsion.

Anomalous congenital band: a rare cause of intestinal obstruction and failure to thrive.

Intestinal obstruction caused by an anomalous congenital band is very rare in adults and children. A 7-year-old boy was admitted with acute intestinal obstruction. His parents mentioned that the child always had mild abdominal distention and failure to thrive from his infancy. On his medical history, there were not any attacks of abdominal pain, fever and hospitalization. Laparotomy showed an ileal loop compressed by an anomalous band, which extended from the ileum to the sigmoid mesentery resembling a mesenteric remnant. The band was resected. Histologically, it was composed of loose connective tissue containing mature vessels.

Tubularized incised plate urethroplasty for abortive hypospadiac urethral duplication.

Urethral duplication is among the rarest congenital anomalies and is characterized by two urethral canals. The urethral canals are most commonly located in the sagittal plane. We present a case of abortive hypospadiac urethral duplication and its surgical management with tubularized incised plate urethroplasty.

The study of expanded tri-lobed flap in a rabbit model: possible flap model in ear reconstruction?

BACKGROUND: Local flaps are widely used in reconstructive surgery. Tri-lobed skin flap is a relatively new flap and there has been no experimental model of this flap. This flap can be used for repair of full thickness defects in the face, ears and alar region. Based on the size of ears in a rabbit, we designed a model of ear reconstruction using expanded tri-lobed flap. Local flaps are more advantageous in that they provide excellent color and texture matching up with those of the face, adequately restore ear contour, place scars in a favorable location and ideally accomplish these goals in a single stage with minimal donor site morbidity. METHODS: Eight adult New Zealand rabbits were divided into two groups. 50 ml round tissue expander were implanted to four rabbits. After completion of the expansion, a superiorly based tri-lobed flap was elevated and a new ear was created from the superior dorsal skin of each rabbit. Scintigraphy with Technetium-99m pertecnetate was performed to evaluate flap viability. RESULTS: Subtotal flap necrosis was seen in all animals in non-expanded group. New ear in dimensions of the original ear was created in expanded group without complication. Perfusion and viability of the flaps were proved by Technetium-99m pertecnetate scintigraphy. CONCLUSION: According to our knowledge this study is the first to demonstrate animal model in tri-lobed flap. Also, our technique is the first application of the trilobed flap to the possible ear reconstruction. We speculated that this flap may be used mastoid based without hair, in human. Also, tri-lobed flap may be an alternative in reconstruction of cylindrical organs such as penis or finger.

Comparison of double vertical incision with various tubularization techniques and its clinical application.

INTRODUCTION: Tubularization is one of the indispensable practices of reconstructive surgery, especially in the repair of hypospadias. In all procedures of forming a tube, the desired diameter should be reached without any complication. MATERIALS AND METHODS: We used as a new technique, 'double vertical incision', in 8 rabbits and compared it with free skin graft, local flap and single vertical incision. We formed 32 tubes randomly around an 8-french catheter using 7/0 PDS suture. Twenty-one days after the operation, the tubes were taken, randomized to staining with hematoxylin and eosin and with Masson's trichrome and then subjected to histopathological examination. Inflammation, fibrosis and lumen diameter were statistically evaluated. RESULTS: Widest lumen diameters were found in the double incision group and this result was statistically different when compared with the results of the other groups (p < 0.001). CONCLUSIONS: Double vertical incision is promising in that it is easier to perform, provides a desired amount of tissue in cases in which the urethral bed is narrow, and causes no scar. Based on the results we obtained, we applied double vertical incision, a modification of tubularized incised plate urethroplasty popularized by Snodgrass, in 4 patients. The tubes were not distended, their long-term follow-up showed no complication and a urethra of the desired diameter was obtained.

A very late onset urethral fistula coexisting with skin bridge after neonatal circumcision: a case report.

Complications of neonatal circumcision are generally minor and occur early; a few reports exist on the late or serious kind. The authors describe a case of urethrocutaneous fistula occurring 13 years postcircumcision. The patient also had a skin bridge, another late complication of circumcision. The authors suggest erections in puberty as the triggering factor for onset of fistula. To our knowledge, neither such a late occurrence of fistula nor coexistence of these complications have been reported.

Nontraumatic myositis ossificans with an unusual location: case report.

Myositis ossificans is a pathologic entity rarely met, but still it must be kept in mind in differential diagnosis of a tender soft tissue swelling. The authors present an 8-year old boy with nontraumatic myositis ossificans circumscripta in the left paravertebral muscle. In diagnostic workup, ultrasonography and computed tomography (CT)-scan showed a well marginated, regular, ossified mass in the paravertebral muscle, but we were not able to exclude malignancy on the clinical grounds. The mass was excised totally, and the histopathologic examination found myositis ossificans. The authors suggest that surgical intervention may be an option for diagnosis and treatment in unusual cases when diagnosis is not certain.