Aneurysmal bone cyst of the calcaneus: A rare case report and review of the literature

INTRODUCTION AND IMPORTANCE

Aneurysmal bone cyst (ABC) is a benign lytic bone tumor of the skeletal system but locally destructive lesion of unknown origin. It often occurs in childhood and usually involves the metaphyseal region of long bones; thus, its localisation in the calcaneum remains rare; its atypical presentation in our case makes it remarkable.

CASE PRESENTATION

We describe a case of a young patient who suffered from chronic heel pain, in whom the clinical examination finds swelling and pain on palpation. A complete radiological assessment was carried out, which revealed a solitary and expansive osteolytic lesion within the calcaneus. Treatment included tumor curettage and reconstruction with allograft and cement. The biopsy report was consistent with an ABC. The postoperative follow-up at 18 months was marked by a good radio-clinical evolution and no recurrence.

CLINICAL DISCUSSION

ABCs are benign cystic expansive tumors that are reactive, locally destructive and blood-filled, their occurrence in the calcaneus has been reported in only 1.6 % of total reported cases. Talalgia is the most frequent sign associated with swelling. Liquid-liquid level images on MRI is a pathognomonic sign of these lesions but the gold standard diagnosis remains histology. Their treatment is based on curettage - filling by grafting.

CONCLUSION

Curettage combined graft makes results butter and improves the quality of life.

Primary mycetoma of the calcaneum: Case report on an unusual hazard of barefoot walking

INTRODUCTION

Mycetoma is a rare tropical fungal infection characterized by a clinical triad of subcutaneous swelling, multiple discharging sinuses, and a purulent discharge containing granules. If left untreated, the disease can progress from cutaneous to intraosseous and can cause osteomyelitis. In very rare instances labeled "primary mycetoma", the fungus is insidiously inoculated directly into the bone and causes osteomyelitis without any preceding cutaneous involvement. This can make the diagnosis very difficult.

PRESENTATION OF CASE

A twelve-year-old girl with a history of walking barefoot, presented with pain and inability to bear weight on her left foot. There was no overlying cutaneous involvement. X-ray showed an osteolytic lesion in the calcaneum. After the failure of antibiotic treatment, the diseased bone was excised. Black granules were discovered inside the lesion and their histopathology confirmed a diagnosis of primary eumycetoma. After some time, the disease relapsed, necessitating another debridement. This occurred many times with worsened severity in each successive episode. Because of worsening disease and failure of both antifungal and surgical treatment, foot amputation was done.

DISCUSSION

Primary mycetoma is an insidious fungal infection that causes osteomyelitis without any cutaneous findings. Timely diagnosis and treatment provide the best chance of preventing an amputation.

CONCLUSION

A high index of suspicion must be maintained for patients presenting with symptoms of osteomyelitis without any skin involvement so that timely diagnosis and treatment can prevent the progression of the disease and the need for amputation.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study

BACKGROUND

Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures.

METHODS

Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5 cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4 mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7 mm cannulated partially threaded Charlotte^TM (Wright Medical Technology, Memphis, USA) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5 N, 10 N and 20 N force was measured in millimetres (mm).

RESULTS

2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88 ± 0.390 at 5 N and 1.7 ± 1.251 at 20 N) and the most stable construct (p < 0.05) when compared to other configurations. A single medial screw into the sustentaculum tali (conf. 3) resulted in the least stable construct and most displacement (4.04 ± 0.971 at 5 N and 11.24 ± 7.590 at 20 N) (p < 0.05).

CONCLUSION

This study demonstrates the optimal screw configuration to resist varus in calcaneal fractures using minimally invasive techniques. Optimal stability is achieved using 2 screws; one located along the long axis of the calcaneus (varus control) and the other placed in the short axis directed towards the posterior facet of the calcaneus (control varus and subsidence). Further cadaver research would help evaluate optimal screw placement in simulated fractures to further assess reproducibility.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study

BACKGROUND

Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures.

METHODS

Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7mm cannulated partially threaded Charlotte™ (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5N, 10N and 20N force was measured in millimetres (mm).

RESULTS

2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88±0.390 at 5N and 1.7±1.251 at 20N) and the most stable construct (p<0.05) when compared to other configurations. A single medial screw into the sustentaculum tali (conf. 3) resulted in the least stable construct and most displacement (4.04±0.971 at 5N and 11.24±7.590 at 20N) (p<0.05).

CONCLUSION

This study demonstrates the optimal screw configuration to resist varus in calcaneal fractures using minimally invasive techniques. Optimal stability is achieved using 2 screws; one located along the long axis of the calcaneus (varus control) and the other placed in the short axis directed towards the posterior facet of the calcaneus (control varus and subsidence). Further cadaver research would help evaluate optimal screw placement in simulated fractures to further assess reproducibility.

Angle of BRINK - a new way to measure Haglund's deformity

INTRODUCTION

Haglund's deformity, an abnormality of the postero-superior corner of the calcaneum, is a common, critically debated cause of posterior heel pain. Several radiological indices such as Fowler-Philip angle, Ruch pitch, Chauveaux-Liet angle, calcaneal pitch angle, parallel pitch lines, and X-Y ratio have been described to measure this deformity. However, most of these lack specificity and have variable intra- and inter-observer reliability.

PURPOSE

The study aims to describe a new radiological "angle of BRINK" (Botchu-Reilly-Iyengar-Nischal-Kakarala) to measure Haglund's deformity.

PATIENT AND METHODS

We performed a retrospective cohort analysis, assessing 20 weight-bearing lateral ankle radiographs of patients with Haglund's deformity (Haglund's cohort) and 100 radiographs without the deformity (normal cohort). Demographic details and angle of BRINK to measure Haglund's deformity were measured for each patient. Statistical analysis was performed using t-test and inter-observer reliability was calculated using kappa coefficient.

RESULTS

The mean angle of BRINK to measure Haglund's deformity in the normal cohort was 20.04° (SD 4.88), and in the Haglund's cohort was 25.1° (SD 3.3). This was statistically significant with a p-value of less than 0.0001. There was excellent intra- and inter-observer reliability with kappa value of 0.8.

CONCLUSION

Our proposed radiological angle of BRINK to measure Haglund's deformity is simple and easy to calculate on standard weight-bearing radiographs. Contrary to the traditional measurements used to estimate the deformity, it has shown a good intra- and inter-observer reliability and can support surgical decision-making process for management of patients with symptomatic Haglund's deformity.

An evaluation of the efficacy of percutaneous reduction and screw fixation without bone grafting in Sanders Type-II and Type-III displaced intra-articular calcaneal fractures

BACKGROUND

The aim of this retrospective monocentric study was to investigate the clinical efficacy of percutaneous reduction and screw fixation without bone grafting in Sanders Type-II and Type-III displaced intra-articular calcaneal fractures (DIACFs).

METHODS

The medical records of calcaneal fractures patients who were admitted to our department from January 2018 to January 2020 were retrospectively reviewed, and those meeting the inclusion criteria were fnally included for analysis. All patients were treated with percutaneous reduction and screw fixation, and no patients received bone grafting. The radiologic parameters evaluated included the BÖhler angle and the calcaneal height. In addition, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, Maryland Foot Score (MFS), and visual analog scale (VAS) score were determined.

RESULTS

Thirty-eight patients with Sanders Type-II and Type-III DIACFs were finally included, including 30 males and 8 females aged 21 to 61 years [(42.6 ± 9.6) years]. According to the Essex-Lopresti classification, 27 of the fractures were the tongue type, and 11 were the joint compression type. According to the Sanders classification, 27 of the fractures were type II, and 11 were type III. Immediately postoperatively, the calcaneal height had recovered to 39.8 ± 2.1 mm, the BÖhler angle had recovered from 4.2° ± 13.6° preoperatively to 27.2° ± 3.4° (P = 0.000). All patients were followed up for 18-42 months [(25.2 ± 9.5) months]. All fractures healed. No differences were found in the outcome measures six-months postoperatively (BÖhler angle, p = 0.24; calcaneal height, p = 0.82) or at final follow-up (BÖhler angle, p = 0.33; calcaneal height, p = 0.28) compared to the immediately postoperative values. At the final follow-up, the AOFAS score was 91.7 ± 7.4 points, with an excellent and good rate of 92.1%; the MFS was 90.3 ± 7.8 points, with an excellent and good rate of 92.1%; and the VAS score was 2.2 ± 1.5 points. None of the patients had incision complications, and one patient developed traumatic arthritis.

CONCLUSION

Percutaneous reduction and screw fixation without bone grafting in Sanders Type-II and Type-III DIACFs can achieve good recovery and maintenance of the BÖhler angle and calcaneal height. Moreover, it has the advantage of a low complication rate.

Management of displaced intra-articular calcaneal fractures; current concept review and treatment algorithm

Calcaneum fractures are debilitating injuries with high complication rates and poor functional outcomes after both operative and non-operative management. The optimal management of such fractures is still highly debated in the literature with conflicting evidence on the preferred management of displaced intra-articular calcaneum fractures (DICAF). This article reviews the current concepts in the management of DIACF.

Clear cell variant of chondrosarcoma of calcaneum: A case report with review of the literature

Clear cell chondrosarcoma (CCC) is an uncommon variant constituting less than 2% of all chondrosarcomas. CCC arises most commonly in the proximal end of the femur, followed by the humerus, and other small bones. CCC involving the tarsal bone is very rare, and to the best of our knowledge, only one case has been described involving the calcaneum in the English literature to date. In this article, we discuss a case of CCC involving the right calcaneum with complete clinico-immuno-histomorphological features, which is successfully managed by below-knee amputation. We also reviewed the reported cases of chondrosarcomas involving the calcaneum with special reference to clinical features, therapy, morphology, and follow-up data.

Calcaneal osteotomy for hindfoot deformity

Calcaneal osteotomy is an extra-articular procedure used for conservative surgical treatment of hindfoot deformity. It has static, architectural and dynamic effects, reorienting the tuberosity action point of the digastric muscle formation of the sural triceps and plantar aponeurosis. Calcaneal osteotomies vary in location, form and displacement, but can be categorized as tuberosity osteotomy, acting on talar position, and cervical osteotomy, acting on Chopart joint-line orientation. We here describe the 3 main calcaneal osteotomies we use for hindfoot deformity: talar varus/valgus, valgus flatfoot, and midfoot abductus/adductus. In each case, we describe our technique, resulting from our responses to the difficulties we have had to deal with: medializing osteotomy: performed percutaneously to limit skin complications, and easily associated to cervical calcaneal osteotomy to manage valgus flatfoot; Hintermann cervical adduction osteotomy: providing excellent angular correction, while conserving a medial cortical hinge; lateralizingosteotomy: performed on a medial approach, to enhance translation capacity and prevent the acute tarsal tunnel syndrome with which we have been otherwise confronted. Correcting foot deformities involves complex, multi-dimensional, multi-tissue surgery that is risky as it concerns a segment with terminal vascularization. The present three techniques need to be mastered, as they are usually associated to other tendon and/or ligament reconstruction procedures, and tourniquet time is limited. LEVEL OF EVIDENCE: V; expert opinion.

A primary solitary vascular tumor of calcaneum: case report and review of literature

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor with metastatic potential and estimated prevalence of less than one case per million. Among the musculoskeletal system, the long bones are commonly involved with approximately half patients experiencing multicentric involvement. Clinical course of EHE is often variable and nonspecific. Poorly demarcated osteolytic lesions are most commonly seen radiologically. Diagnostic confirmation is usually obtained by biopsy and histopathological exam, including immunostaining for endothelial markers. We present a rare case of unicentric EHE involving the calcaneum. Our patient had an indolent course of disease after surgical resection and no recurrence in seven years on clinical and radiological surveillance.

Calcaneal osteomyelitis caused by Acremonium sp in an immunocompetent adult - A case report

Fungal osteomyelitis of calcaneus is rare in immunocompetent adults. A case of fungal osteomyelitis of calcaneus in a 19 year old immunocompetent female without any history of trauma caused by Acremonium sp is presented. The patient was treated with surgical debridement, autogenous iliac crest bone grafting and antifungal chemotherapy for 6 months. At latest follow up after 2 years, patient is asymptomatic and the osteolytic lesion is healed with no signs of recurrence. This case report highlights a rare presentation of chronic painful calcaneal osteomyelitis with an osteolytic lesion.

Primary aneurysmal bone cyst of the calcaneum: A report of three cases and review of literature

CASE DESCRIPTION

Aneurysmal bone cysts (ABCs) are locally aggressive, cystic lesions of the skeletal system, most commonly seen in the metaphyseal region of long bones. On the other hand, an ABC of the foot (especially the calcaneum) is a rare entity, with very few cases reported in the literature. In this study, we present three such cases who presented to us with the chief complaint of chronic heel pain. All three patients were clinically reviewed following which a comprehensive radiological workup was performed. The latter revealed a solitary, expansile lesion within the calcaneum in all them. Treatment included extended curettage and reconstruction using autologous iliac crest bone grafts. Histopathological analysis of the curetted sample was consistent with features of primary ABC. There were no complications and all lesions had re-ossified at the latest follow up.

CONCLUSION

Calcaneal ABCs are rare, atypical lesions warranting a high index of suspicion and correlation of the patient's clinical, radiological and histopathological features to make a correct diagnosis.

Morphometric variations of the lateral surface of calcaneus: Can standard plate sizes fit all?

PURPOSE

Displaced intraarticular fractures of the calcaneum often require plate fixation. The complex fractures are usually fixed with standard lateral plates and are approached via the extensile lateral approach which is fraught with the risk of wound complications. Oversized calcaneal plates produce tension on the wound closure site and can, thus result in wound healing problems. The current study analyses the morphometry of the lateral surface of the calcaneus for the ideal configuration of the calcaneal plates for Indian patients using a CT based analysis of intact calcanei.

METHODS

Fifty CT based studies of normal calcanei were retrospectively analyzed using Horos® software version 3.3.5. The cross-section of the lateral third of calcaneum was assessed for the morphometric measurements relevant to the dimensions of the standard plating devices for calcaneum. We measured the overall plating length of calcaneum, the vertical heights at the anterior process and calcaneal tuberosity, the height of the posterior facet, the lengths of the anterior process, and the posterior facet. The inclination angles of the posterior facet, cuboid facet were also measured. The findings were compared between male and female cases.

RESULTS

The mean plating length of the calcaneus was 60.06 ± 4.05 mm. The mean vertical height of the anterior process and the calcaneal tuberosity were 24.3 ± 2.71 mm and 39.48 ± 4.73, respectively. The length of the anterior process and the posterior facet were 21.36 ± 1.72 and 25.02 ± 4.17, respectively. The mean Gissane angle and the angle of inclination of posterior facet in relation to the plating length were 118.04 ± 5.99° and 47.3 ± 5.20°. The mean anterior slant angle of the cuboid facet was 96.64 ± 4.39°. Significant differences were observed in the measurements among male and female groups except for the angular parameters.

CONCLUSION

The current analysis suggests the individual morphometric variations of the lateral plating surface of the calcaneus. Although female calcanei have smaller dimensions compared to male calcanei, the angular parameters are comparable among the two groups. Considering the wide variations in the majority of the morphometric parameters, it is difficult to standardize the plate dimensions. However, a few serial increments in the plate dimensions can help in providing the best fit rather than an ideal fit. Also, the plates should be available with multiple inclination angles of the facet limbs according to the local population variations.

The use of free fibula-flexor hallucis longus osteomuscular flap for calcaneal reconstruction after partial calcanectomy for the chronic osteomyelitis: A case report

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Calcaneal osteomyelitis is difficult to eradicate.

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Calcaneal debridement and infection control are critical.

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Osteomuscular flaps offer a stable and effective reconstruction.

Introduction

Calcaneal osteomyelitis poses a tough challenge for any reconstructive surgeon. The eradication of the infection and the reconstruction of the defect are the main goals of treatment.

Presentation of case

We present the case of a 53-year-old male with chronic calcaneal osteomyelitis. The patient was submitted to several bone and soft tissue debridements and twice the application of gentamicin/sulfate implants at the wound bed with no success. He was then submitted to a partial calcanectomy followed by obliteration of the bone defect (4.5 × 2 × 1.5 cm) with a free vascularized fibula-flexor hallucis longus osteomuscular flap (bone dimension:4.5 × 1.5 × 1.2 cm; muscle size: 4 × 1.5 × 0.5 cm). The flap remained viable, and the post-operative period was uneventful. Bone incorporation was evident nine months after the surgery with no signs of recurrent infection or avascular necrosis. Final follow up, at one year, showed an excellent functional result. The patient was able to ambulate without assistance and referred occasional minimal foot pain. Donor site morbidity was minimal.

Conclusion

The authors believe that this osteomuscular flap may be a valuable option to reconstruct calcaneal defects after chronic osteomyelitis.

Osteoid osteoma of the calcaneus misdiagnosed as subtalar sprain

Osteoid osteoma of foot and ankle account for ten percent of benign bone tumors and commonly involve the talus and metatarsals. Its occurrence in calcaneus is extremely rare and can mimic ankle instability, subtalar arthritis, osteochondritis or plantar fasciitis leading to delay in diagnosis. We present the case of a 17 year old boy with periarticular osteoid osteoma in the calcaneum, who presented following an ankle sprain. He was successfully treated with CT guided percutaneous radiofrequency ablation and we feel that it is a safe, precise and effective treatment option for even periarticular osteoid osteoma in the foot and ankle region.

Fractures of the anterior process of the calcaneum; a review and proposed treatment algorithm

BACKGROUND

There remains a lack of recognition of these fractures, which leads to a delay in diagnosis and appropriate management.

METHODS

A comprehensive literature search was performed. Following inclusion and exclusion criteria, 23 studies were available for analysis.

RESULTS

Delay in diagnosis is common and has a negative impact on outcome. If an APC fracture is suspected; anteroposterior, lateral and oblique plain radiographs should be requested. Further investigation with computed tomography or magnetic resonance imaging is indicated if plain radiographs are inconclusive and patient remains symptomatic. Non-operative measures are usually adequate for most undisplaced fractures, however surgical intervention maybe required for large, intra-articular fractures in the acute setting and for non-union.

CONCLUSIONS

A treatment algorithm is suggested that may help with the diagnosis and management of these injuries.

LEVEL OF EVIDENCE

Level IV.

Association of pre-treatment radiographic characteristics of calcaneal fractures on patient-reported outcomes

PURPOSES

Calcaneal fractures are known to influence patients' quality of life negatively. The type of calcaneal fracture might have a relation with the patient outcome. To inform patients in an early stage on how their calcaneal fracture may affect their lives, knowledge of the fracture characteristics is necessary. This study evaluates the association of type of calcaneal fracture, measurement of conventional radiograph angles, and the Sanders classification with patient-reported outcomes.

MATERIAL AND METHODS

This is a retrospective study based on a prospective trauma database including all patients aged 16 years or older with a calcaneal fracture admitted in one of the participating trauma level I or II hospitals. Patients, trauma, and fracture characteristics were collected. The conventional radiographs were evaluated in which type of fracture, and Böhler's, Gissane's, and calcaneal compression angles were determined. Also, the CT images were classified according to Sanders. In addition, displaced intra-articular calcaneal fractures were separately analyzed. A questionnaire was sent to the included patients that consisted of the EQ-6D, patient-specific characteristics, satisfaction with foot appearance and wearable shoe range, complications, and capability to work.

RESULTS

A total of 396 patients with 442 calcaneal fractures were eligible for follow-up. Two hundred fifteen patients with 246 calcaneal fractures participated. Patients with a calcaneal fracture into the talar surface reported a worse quality of life (p = 0.010), were less satisfied with their feet (p < 0.001), and had more complications (p = 0.001-0.006); extra-articular fractures had significantly opposite result. A negative Böhler's or calcaneal compression angle was related with unfavourable outcomes. Sanders classification was not related with any patient-reported outcome.

CONCLUSION

Our study implies that patients with an intra-articular calcaneal fracture into the talar surface have a lower health-related quality of life, will be less satisfied with the outcome of their feet, and have more complications compared to patients with other type of calcaneal fractures. Furthermore, the Sanders classification was not associated with the patient-reported outcomes.

New Treatment Strategy for a Delayed Skin Necrosis Related to a Calcaneal Fracture

In calcaneal avulsion fractures, skin necrosis as a result of pressure from the underlying fragment is a fairly common and serious complication. In spite of proper treatment, skin healing complication may occur. We report a calcaneal fracture case complicated by skin necrosis and managed with a novel treatment strategy including application of Platelet Rich Plasma (PRP) and Vacuum Assisted Closure (VAC). This is the first application of combined PRP and VAC treatment in a calcaneal fracture complicated by skin necrosis and was accompanied with very favorable outcomes while avoiding other more complex treatment modalities.

Ewing's Sarcoma of the Calcaneum

Ewing's sarcoma of the calcaneum is rare. Radiological features of this tumor can be misinterpreted as other benign bone tumors due to its rarity. The overall prognosis of Ewing's sarcoma of calcaneum is inferior compared to other sites of this tumor. Hence, these tumors should have extensive radiological evaluation and histological confirmation as misdiagnosis and treatment delays will have detrimental outcomes.

Chronic heel pain: It could be tuberculosis

INTRODUCTION

Heel pain is a common presentation at a primary care setting. The majority of these cases are benign and self limiting in nature. Common differential diagnoses include plantar fasciitis and peroneal muscle sprains. However, certain conditions-if undetected early-may cause significant morbidity to the patient. A high index of suspicion and early referral for further investigations are needed to prevent long-term morbidities.

METHODS

A clinical review of a patient with chronic left heel pain was performed. Blood parameters and imaging investigations indicated chronic infection of the calcaneum. Histopathological examination was highly suggestive of tuberculosis.

RESULT

The patient responded well to antituberculous therapy. She was pain free and showed no signs of recurrence at final follow-up.

CONCLUSION

Here, we report a case of chronic heel pain, which was later diagnosed as tuberculosis of the calcaneum and successfully treated with antituberculous therapy.

Tuberculosis of Calcaneum - A Rare presentation

Introduction:

Tuberculosis of calcaneum is a rare entity. Osteoarticular tuberculosis of foot is uncommon and that of calcaneum is very rare. In children, diagnosis is often delayed as clinical presentation is non-specific and awareness is low due to its rare presentation. Also pediatric tuberculosis has traditionally received a lower priority than adult TB in National TB programmes.

Case presentation:

8 yr old girl presented to OPD with swelling and dull aching pain over left heel. Radiograph of calcaneum showed small lytic puctate lesions in the calcaneum. Further investigations showed presence of multiple tuberculous bacilli. Anti-Kochs treatment was started immediately and patient was treated conservatively. Four drugs (HRZE) were prescribed for a period of 12 months. Radiographs at 2 years follow-up showed a healed lesion.

Conclusion:

Rare and unusual locations of osteoarticular TB often pose a problem of differential diagnosis. Meticulous history and clinical examination helps in reaching the diagnosis. Start of AKT drugs as soon as reports show presence of tubercular bacilli plays a vital role in treatment as well as functional outcome of the patient.

Aneurysmal Bone Cyst: An Uncommon Secondary Event in Calcaneal Chondroblastoma

Chondroblastoma is an uncommon benign bone tumour, involvement of epiphysis of long bones is typical. Chondroblastoma of the calcaneum is uncommon and its association with secondary aneurysmal bone cyst is even rarer. Only two cases of calcaneal chondroblastoma associated with secondary aneurysmal bone cyst have been reported till date. A 22-year-old male presented to the department of orthopaedics with complains of pain and swelling in the left heel since the last 10 months. On clinico-radiological grounds differentials considered were giant cell tumour of bone and aneurysmal bone cyst. In view of the histopathological findings of bone curettage and results of special stain and immunohistochemical marker, final diagnosis of chondroblastoma with secondary aneurysmal bone cyst, left calcaneum was rendered. Although rare, chondroblastoma should always be considered in osteolytic lesions of calcaneum. The identification of secondary aneurysmal bone cyst component is important as it has higher chances of recurrence than usual chondroblastoma.

A Prospective Study on Radiological and Functional Outcome of Displaced Tongue Type Intra-Articular Calcaneal Fractures Treated by Percutaneous Screw Fixation

INTRODUCTION

Calcaneal fractures have posed a challenge to orthopaedic surgeon for many years. The major problem is to reconstruct the fracture and improve healing of the fracture and also the surrounding tissues. Anatomic restoration of the three-dimensional anatomy of the calcaneum is the goal of surgical management of calcaneal fractures. Over the years, various techniques have been developed to accomplish this goal.

AIM

To determine the functional outcome in displaced tongue-type calcaneal fracture treated by percutaneous screw fixation.

MATERIALS AND METHODS

A prospective study was conducted from October 2012 and September 2014. A total of 23 patients with intra-articular 'tongue type' calcaneal fractures were included in the study. Complete clinical and radiological evaluation was done. The surgical procedure encompassed closed reduction and fixation with two criss-cross 6.5 mm cannulated cancellous across the fracture site under fluoroscopic guidance. Postoperatively, on day three ankle and toe mobilization was begun. Non-weight bearing crutch mobilization was begun on postoperative day three. Reviews were done at 6 weeks, 12 weeks and 24 weeks postoperatively. At 6 weeks partial weight bearing mobilization was started. Full weight bearing was begun at 12 weeks. The patient was finally reviewed at 24 weeks and assessment of ankle function was done as per the Maryland foot scoring system. Radiographs were compared and preoperative and postoperative Gissane's and Bohler's angles were also compared. The results were analysed as per descriptive statistics (frequency, percentage). The complications noted were documented.

RESULTS

Of the 23 patients under the study, three had excellent results with mean score of 90, 17 had good results with mean score of 82.94 and three had fair results with mean score of 74. Only one patient had subtalar arthritis as a complication. No other complications were seen.

CONCLUSION

Percutaneous screw fixation of tongue type calcaneal fractures is a very effective surgical technique.

Intraosseous leiomyoma of the calcaneum: An unusual bone tumor of foot and review of literature

Leiomyoma is a benign tumor of smooth muscle origin and commonly diagnosed in the uterus, gastrointestinal tract, skin, and mucous membranes. To the best of our knowledge, the only reported intraosseous leiomyomas in extremities occurred in the proximal aspect and distal aspect of the femur, in the tibia, and in the ulna. We are not aware of any previous reports of intraosseous leiomyomas in the foot. The radiograph of the intraosseous leiomyoma shows unilocular or multilocular lytic lesion with sclerotic rim. Due to lack of definitive radiological features on magnetic resonance imaging and computed tomography diagnosis of this rare tumor is established with histopathological study and immuno-histochemistry markers. Smooth muscle spindle cells and positive immunohistochemistry markers for muscle cells is hall mark for the diagnosis. The treatment of intraosseous leiomyoma is surgical intervention by excision with wide margin and curettage followed by filling the cavity. The diagnosis of this tumor is challenging due to its extraordinarily rare incidence. Intraosseous leiomyoma should be included in the differential diagnosis of intraosseous lesion with benign radiographic feature. We report of the first published case of primary intraosseous leiomyoma of calcaneum in a 22-year-old male patient.

Patient satisfaction after open reduction and internal fixation through lateral extensile approach in displaced intraarticular calcaneal fractures (Sander's type II and III)

AIM

To determine patient satisfaction in the patients of displaced intraarticular calcaneal fractures treated with standard lateral approach.

METHOD

The patients of displaced calcaneal fractures (Sander's type II and III) treated between March 2009 and March 2012 were included in the retrospective review and functional outcome was evaluated using American Orthopaedic Foot and Ankle Society (AOFAS) hind foot score, Creighton Nebraska Health Foundation Assessment (CNHFA) scale and foot function index (FFI).

RESULT

The cohort included 26 patients (19 males: seven were females) with a mean age of 38.16 ± 13.53 years (range 18-64 years). The mean period of follow-up was 24.42 ± 6.68 months. The patients achieved good functional scores after anatomical reduction of the fracture. The complication rate was low following strict inclusion criteria.

CONCLUSION

Careful patient selection in displaced intraarticular calcaneal fractures treated through lateral extensile approach achieves good patient satisfaction.

[Surgical treatment of articular fractures of the calcaneus by bone plate]

Les fractures du calcanéum sont peu fréquentes mais le plus souvent graves. Le traitement chirurgical par plaque vissée est ardemment défendu. L'objectif de notre travail rétrospectif est d’évaluer les résultats du traitement chirurgical des fractures articulaires du calcanéum à travers une série de 12 patients opérée aux service d'orthopédie du CHU Hassan II de Fès sur une durée de 3 ans, et les comparer aux données de la littérature. L’âge moyen dans notre série était de 34 ans, le geste opératoire était réalisé au 7^ème jour. Tous nos patient ont bénéficie d'une réduction à foyer ouvert avec une ostéosynthèse par plaques vissées. Le recul moyen était de 12 mois et les résultats fonctionnels ont été évaluer selon le score de Kitaoka.

Clear cell chondrosarcoma calcaneum - a case report and review of literature

Chondrosarcoma is the second most common primary bone malignancy accounting for 20-25% of all bone sarcomas. However chondrosarcoma of the foot is rare with just a handful of cases being described. Among the subtypes clear cell variant is the rarest and has never been documented in the foot. We present a rare case of clear cell chondrosarcoma of the calcaneum with multiple metastases that was treated at our institute. The patient was a 62-year old male who presented to us with pain and mass in the left hindfoot with difficulty in walking for 2 years and a discharging ulcer over the lateral aspect for 4 months. Radiography showed aggressive, destructive, lytic lesion in the calcaneum with cortical breach and soft tissue invasion. Bone scan and PET-CT revealed multiple bony metastases and lung metastasis. After initial biopsy, patient underwent below knee amputation and has been in remission since the last 18 months. Given the rarity of this tumor in the calcaneum, this report highlights the importance to consider the possibility of this tumor in the calcaneum as an early diagnosis; complete metastatic workup and expeditious management can thus significantly improve prognosis.

Calcaneal chondrosarcoma: a case report

Chondrosarcoma is a rare malignant cartilaginous tumour of the bone. It commonly occurs in the pelvis, scapula proximal femur, and shoulder girdle .We present a case of a woman in her 56 years of age with chondrosarcoma of the calcaneum-a rare lesion that accounts for 0.5-2.97% of all chondrosarcomas of other sites. Treatment for chondrosarcoma is generally wide surgical excision. Chemotherapy or radiation is not effective for most of these lesions.

Osteochondroma of the OsCalcaneum- A Case Report

Osteochondromas are common benign bone tumours. They usually occur in the patients who are below thirty years of age. They probably are developmental malformations rather than true neoplasms. They are believed to originate within the periosteum as small cartilaginous nodules. The foot is rarely a common site of presentation for these tumours. The calcaneum is one of the most unusual regions for the occurrence of osteochondromas 1. The osteochondromas which arise from the calcaneum, especially those which project onto the plantar surface, pose considerable problem to the ambulation. Malignant transformations are seen in less than 1% to 2% of the patients with solitary osteochondromas 2. We herewith present a case of osteochondroma which arose from the calcaneum, which was surgically excised to improve the patient's daily functioning. The patient was followed up for a period of one year. She is now able to walk comfortably.