Avascular Necrosis of the Calcaneus 17 Years After Kidney Transplant: A Case Report

Olivia Stransky, DPM – Third Year Podiatric Resident, Highlands-Presbyterian St. Luke’s Podiatric Medicine and Surgery Residency Program, Denver, CO Cindy Oberholtzer-Classen, DPM – Castle Pines, CO Dustin Kruse, DPM, FACFAS – Director of Research at Highlands-Presbyterian St. Luke’s Podiatric Medicine and Surgery Residency Program, Denver, CO Paul Stone, DPM, FACFAS – Residency Director of Highlands-Presbyterian St. Luke’s Podiatric Medicine and Surgery Residency Program, Denver, CO

Introduction Case Report Literature Review Continued Figure 3: Left foot MRI, sagittal view (AVN) is a known complication of high dose, long term steroid use, however, it rarely occurs in the A 48 year old male presented to the office complaining of Similar to our patient, Huwez and colleagues reported a case

calcaneus. AVN can be caused by numerous etiologies such left heel pain. The pain was described as an ache that of calcaneal AVN approximately three years after a heart as steroid use, infection, trauma and sickle cell anemia to worsened with weight bearing. Stretching and rest transplant. The patient was a 38 year old female, who name a few. A helpful pneumonic is ASEPTIC: anemia, alleviated the pain, but were less effective as time went on. underwent two courses of methylprednisolone 1 gram daily

pancreatitis, steroid, trauma, infection, and caisson disease The patient had the pain for several months prior to seeking for three days because of transplant rejection. The patient (1). 3-9% of post-transplant patients develop AVN and most medical attention. There was no history of trauma or was also taking cyclosporine A, azathioprine, and often it is in the femur or other long (2, 3). This is a changes in activities. His past medical history was prednisolone as part of her immunosuppression regiment. Note the homogenous fluid in the calcaneus on the T2 case report of a 48 year old male who developed calcaneal significant for renal failure in 1997 requiring a kidney The authors hypothesized that the methylprednisolone image AVN with a pathologic 17 years after kidney transplant. Tacrolimus one milligram daily and prednisone increased her risk for developing AVN. The patient’s heel transplant. five milligrams daily were is immunosuppression regiment. pain resolved with conservative treatment. (2) He reported no history of graft rejection requiring

methylprednisolone. It is reported that 3% of transplant patients will develop AVN, most often it occurs in the femoral head and condyles Physical exam revealed loss of protective sensation and (2). Guichelaar and colleagues analyzed the incident of vibratory sensation to both feet, tenderness to palpation at AVN in post-transplant patients based on mineral the plantar central aspect of the left heel and bilateral density (BMD) and medication regimen. The incidence was gastroc-soleus equinus with ankle joint dorsiflexion less than 8.9% of AVN, one of which occurred in the foot in the Note the geographic cyst with sclerotic center on T1 image Figure 1: Left foot lateral weight bearing five degrees. Radiographic examination at the first visit metatarsal bones. AVN occurred at a mean of 2.4 years after radiograph demonstrated an infra-calcaneal exostosis and a geographic transplant They found that high 4-month steroid doses, sclerotic lesion in the posterior calcaneus with satellite cyclosporine therapy, low BMD, and elevated cholesterol sclerosis descending to the plantar aspect of the body (Fig. are all risk factors for developing AVN. Steroid treatment 1). increases the risk of AVN because it decrease bone Literature cited formation, causes apoptosis of osteocytes, and increases fat

emboli in the microvasculature of bone. (3) The patient underwent eight weeks of physical therapy with 1. Bui-Mansfield LT and Clayton TL. Isolated bone infarct

instructions for at home Achilles tendon stretches and of the calcaneus after fracture. Journal of Computer Assisted received a pair of custom orthotics. He reported 100% relief Andermahr and colleagues performed a cadaver study that Tomography 34(6):958-960, 2010. of symptoms. Radiographs were obtained at the eight week evaluated the lateral calcaneal artery. The study revealed the

visit which demonstrated increased sclerosis of the lateral calcaneal artery (anterior tibial artery) is joined by the calcaneus and a possible fracture through the bone island lateral tarsal artery (dorsalis pedis artery) and supplies the 2. Huwez FU, Belcher PR, Pathi VL, Naik SK, Wheatley Note the geographic sclerosis in the posterior aspect of the (Fig. 2). An MRI was obtained that confirmed a stress lateral aspect of the calcaneus. The medial side is supplied DJ. Osteonecrosis of the calcaneum in a heart transplant calcaneus with descending dot-dash sclerotic pattern. reaction of the calcaneus involving the site of avascular by the lateral plantar artery. Given the location of the lateral recipient. The Thoracic and Cardiovascular Surgeon 45(4): 204-205, 1997. necrosis (Fig. 3). The patient was placed in an air cast for calcaneal artery it is susceptible to injury during fractures eight weeks after which time the pain and swelling had and standard surgical approach on the lateral side. It is resolved. possible that damage to this artery could increase the risk for 3. Guichelaar MM, Schmoll J, Malinchoc M, and Hay JE. Figure 2: Left foot lateral weight bearing calcaneal AVN (6). A second theory, is a watershed zone in Fractures and avascular necrosis before and after orthotopic the posterior calcaneus where the recurrent vessels liver transplantation: long-term follow-up and predictive radiograph At twelve month follow-up the patient continued to been seen for verruca plantaris, however, reported no recurrence anastomose with the trans epiphyseal arteries,. The manner factors. Hepatology 46(4):1198-1207, 2007. in which the vessels converge with in the calcaneus creates a of heel pain and had resumed all physical activities. pseudo-single dominant vessel pattern as seen at the femoral 4. Abrahim-zadeh R, Klein RM, Leslie D, Norman A. neck (4). Literature Review Characteristics of calcaneal bone infarction: an MR imaging investigation. Skeletal Radiology 27: 321-324, 1998. Conclusions

There are nine case reports describing calcaneal AVN. The This is the second case report of calcaneal AVN after a 5. Symour MW, Mitchell WM, Mackworth-Young CG. most common etiology was prolonged, daily steroid use for transplant. The location of calcaneal AVN is in the posterior Bilateral calcaneal osteonecrosis in a patient with systemic disease control. Abrahim-zadeh and colleagues reported on half of the bone, which likely represents a watershed zone, lups erythematosus. 44(5):586, 2005. the largest case series that included MRI investigation of six despite the abundant vascularity. Conservative treatment has Note the lucency extending from the anterior and posterior patients with calcaneal AVN. All patients were taking daily thus far been a reliable treatment choice for symptomatic aspect of the large sclerotic lesion, a possible sign of stress prednisolone for systemic disease control. These patients calcaneal AVN. As demonstrated above prolonged steroid 6. Andermahr J, Helling HJ, Landwehr P, Fischbach R, reaction or fracture. had either bilateral or unilateral calcaneal AVN in the use can cause AVN of any bone, including the calcaneus. Koebke J, Rehm KE. The lateral calcaneal artery. Surgical posterior half of the bone. (4, 5) This is yet another diagnosis to keep in mind when dealing Radiology Anatomy 20: 419-423, 1998. with heel pain in immunosuppressed patients.