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Lesions of the Heel CHAPTER 34 LESIONS OF THE HEEL Michael C. McGlamryt D.P.M. Malignant and benign tumors of bone in the foot Imaging of the calcaneus can easily be have traditionally been characterized as rare, or at accomplished in the office with plain film least unusual. \7hen these lesions do appeat, radiographs. Views which may be helpful in however, they are frequently localized to the heel. evaluating lesions of the heel include the lateral, They may be discovered on a routine radiographic axial, medial, lateral oblique, and occasionally evaluation for an unrelated condition. Only careful sunrise and Broden's views. More extensive evaluation of good quality radiographs and a evaluation may be obtained with special studies correlation with a thorough history will lead to an such as bone scans, magnetic resonance imaging accurate diagnosis and appropriate treatment. (MRI), and computed tomography (CT). These A review of a variety of lesions which may be studies may aid in ful1y evaluating the volume, seen in and around the calcaneus will be density, and metabolic activity of the lesions. The presented. Additionally, the typical patient higher sensitivity of these modalities may assist in population for each pathologic process will be detecting pathology such as coltical breaks not outlined to help correlate the information gained apparent on plain films. Despite the value of these from the history and physical with radiographic studies, they should still be considered ancillary, and imaging study information. For the purpose of and should be ordered under the appropriate discussion, the lesions of the heel have been circumstances. divided into categories of benign and malignant Initial evaluation of any lesion on plain film tumors. Although this is somewhat artificial and not radiographs should be fully characterized in a completely technically correct, it does correlate systematic fashion. This description should include well with plain film radiographic findings. the site (although this article is primarily concerned Overall, the incidence of bone tumors in the with the calcaneus), size, density compared with foot accounts for only 70/o to 20/o of bone tumors in surrounding bone, margin characteristics, and the body. Of these lesions, the benign lesions out- effect on the natural cortical barrier of the bone. A number malignant lesions 4 to 1. The most system of description using five levels of evaluation common sites of occurrence are the calcaneus and has been described by Zulli, and has appeared on metatarsals. The great majority of the lesions several occasions in recent literature. discussed have been seen by the author in the last several years. Case presentations will attempt to BENIGN LESIONS show the "real life" nature of these problems. In addition to traditional neoplasms which Unicameral Bone Cyst may be seen in the heel, other non-neoplastic Unicameral or solitary bone cysts are the most processes may include sequestered infection in the common bone lesion in the foot. They are found form Brodie's abscess, sclerotic changes of a most frequently in the calcaneus C75o/o to 850/o of all and from previous stress, or acute fracture cases in the foot), but may also be seen in the talus enthesiopathies which may be biomechanical or and metatarsal. Unicameral bone cysts begin in metabolic in origin. children and teenagers, and generally do not The value of the history and physical enlarge once the patient has reached skeletal examination cannot be overemphasized in maturity. Often, these lesions are asymptomatic, evaluation of these lesions. Important information and may be discovered on radiographs for an which may be gained is the quality, duration, unrelated condition. If symptomatic, the possibility course, and onset of pain as well as the response of pathologic fracture should be suspected. to daily activities and home therapies. Other key Plain film radiographs show a radiolucent or information, such as history of previous lesions at cystic area 2 cm to 3 cm in size in the bone, other sites in the body, may help discern primary surrounded by a sclerotic margin. These lesions and metastatic lesions. 214 CHAPTER 34 generally do not expand or violate natural cortical centrally. Early in the development of these lesions margins. They are generally found eccentrically they may not be apparent on radiographs despite located in the calcaneus, and in the shaft in long significant clinical symptoms. Fortunately, the bones. increased availability of CT and MRI have made Treatment is indicated when there is the risk detection of these and other lesions easier. of pathologic fracture. Treatment most often Treatment of these lesions is en bloc resection includes curettage, irrigation, and packing of the where possible, however, curettage has also been lesions with autogenous or allogeneic bone. The described. author also routinely obtains cultures and biopsies for definitive diagnosis. For lesions of the Chondroblastoma calcaneus, the author recommends a lateral Chondroblastomas are rare, accounting for only 7o/o curuilinear incision, which avoids and protects the of primary bone tumors. Interestingly, however peroneal tendons and sural nerye. 700/0, of these lesions in one study were found in the foot, and most commonly in the calcaneus or Aneurysmal Bone Cyst talus according to \7a11ing. Kricun went on to Aneurysmal bone cysts are less common than evaluate the position of occurrence within the heel unicameral bone cysts. When occurring in the foot, in 74 cases. This lesion typically arises from an they are found in the tarsals and metatarsals. These active epiphyseal plate in a patient between 10 and lesions are usually found in patients in their 2nd or 20 years of age. Patients present with pain and 3rd decade of life, and may present as a palpable swelling due to the subchondral location. tender mass. Radiographically, these lesions appear radiolucent Radiographically, these lesions are fairly with a sclerotic margin. distinct on plain fi1ms, showing bulging of the Treatment usually consists of curettage and coltex, and trabeculation or "honeycombing" inside grafting. How-ever, in more aggressive lesions or in the lesion. The author finds it helpful to look for a cases of recurrence, removal of the articular bubbly-appearance inside the overall lesion. cartilage and primary arthrodesis may yield good Aspiration or opening of the aneurysmal bone results with decreased risk of recurrence and need cyst produces a hemorrhagic fluid. Treatment is for additional potentially debilitating procedures. debridement, irrigation, and packing with bone chips. There is limited case experience of a Giant Cell Tumor of Bone technique under evaluation where demineralized Giant Cell Tumors are rare in the foot, and account bone paste is introduced under CT or fluoroscopic for 5o/o of all biopsied primary bone tumors. In a guidance through biopsy needle, following a review of 7782 lesions, less than 2o/o occtrred in the aspiration and irrigation. Early reports are foot. Vhen these lesions do arise in the foot, promising, although there is some concern of the however, they are most often noted in the possible increased recurrence risk of calcaneus and metatarsals. Patients who present with giant cell tumors Osteoid Osteoma/Osteoblastoma are usually in their third decade of life. Vhen the Osteoid osteoma and osteoblastoma are essentially malignant variety is encountered, men are affected histologically identical, but differ in size. three times as often as women. Radiographically, Convention dictates that lesions less than 2 cm are these lesions are radiolucent with a small zone of osteoid osteoma while lesions greater than 2 cm peripheral sclerosis. are osteoblastomas. The most common location in Giant CeIl Tumors are treated with curettage. the foot is the tarsal bones. Typically the patients However, due to their more aggressive nature, are 10- to 25-years-old and present with gradually adjuvant treatments are also recommended worsening symptoms which are more pronounced including the use of intra-lesional cryotherapy, in the evening. The pain is not improved with Phenol, polymethylmethacrylate, or cauterization. immobllization, but shows good, transient relief of The recurrence rate of these lesions is between symptoms with aspirin. 70o/o and 30%. Higher stage lesions, and recurrent Radiographically, there is radiolucency in the lesions may require wide excision and reconstruc- periphery with radiolucency or calcification tive arthrodesis, or even amputation. CHAPTER 34 215 Intraosseous Lipoma the patient seeks care. Radiographically, the Intraosseous lipomas are rare, accounting for only enchondroma radiates from the medullary area, expansion and 0.1o/o of all bone tumors. \7hen present, they are with varying degrees of cortical usually located in the metaphyseal area of the host thinning. bone. This lesion occurs equally in males and Treatment includes curettage and packing females, and has no particular age predilection. with bone graft. Smaller digital lesions may also be Intraosseous lipomas are frequently asymptomatic, effectively treated with phalangectomy. Care but risk of fracture is of specific concern. should be taken to completely remove all suspect potential for The radiographic appearance is usually of a areas, as the enchondroma does have well-defined, but expansile lesion. The lesion may recurrence as a benign or malignant lesion. result in thinning of the cortex and also may not show any significant sclerosis of the margin. The Brodie's Abscess treatment for the symptomatic lipoma or one at risk Although the Brodie's abscess is not a tumor, it is of pathologic fracture includes curettage and included for completeness sake. The chronic packing with bone chips. abscess of bone may also have a radiographic appearance of radiolucency with marginal Ganglion of Bone sclerosis. The patient history and a careful clinical Repofis of intraosseous ganglions in the calcaneus examination are paramount in obtaining an and cuboid have appeared several times in the accurate clinical diagnosis and effective treatment. recent literature. Despite these reports, the History of puncture wounds or pediatric hematoge- interest.
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