Case presentation: Minimally invasive treatment of calcaneal bone lesion

The patient is 16, and he had a spraining injury to the left ankle, whereupon an x-ray of the ankle was taken. This showed a lesion in the left calcaneus.

The patient is relatively healthy, with no significant past or present illness. He plays football and is looking forward to participating if possible this coming fall. The patient has been noticing some discomfort in the foot but he is walking normally wearing regular shoes and does not have an appreciable limp. He does not feel a mass or swelling in the area.

There is some tenderness on the left calcaneus which is not present on the right. No mass or expansion or swelling of the calcaneus is noted. The subtalar joint motion appears normal. Ankle motion is normal.

Plain radiographs show a lytic lesion that is sharply defined in the midportion of the calcaneus on the left. The lesion abuts but does not enter the middle facet of the subtalar joint. The CT scan shows that the lesion involves the entire midportion of the calcaneus and the thin shell of the calcaneus is all that remains.

Diagnosis and treatment options:

This lesion has clinical and radiographic features consistent with unicameral bone cyst. Please see the web page on this site devoted to unicameral bone cyst and the peculiar presentation of unicameral bone cyst in the calcaneus of older children and young adults. This patient has a real risk of pathological fracture especially during football. Treatment of the cyst appears to be necessary.

Treatment options were reviewed with the patient. Options include observation only, percutaneous injection of cortisone, minimally invasive curettage and biopsy of the lesion followed by injection on bone marrow and bone graft, conventional open biopsy, complete curettage, and bone grafting. Given the success with minimally invasive techniques, and the potential for complete resolution of the lesion without open surgery, minimally invasive treatment was recommended.

Description of the minimally invasive procedure:

The patient was taken to the operating room, and general anesthesia was given. Interoperative mini C-arm fluoroscopy was used to locate the lesion and to verify the placement of the instruments and the bone graft preparation.

A 6 mm incision was made over the lateral calcaneus, and the bone was entered. The portal was gradually enlarged to permit placement of curettes and pituitary forceps, as well as the bone graft preparation. Specimens were removed for pathologic examination and the pathologist confirmed that the lesion was benign, consistent with unicameral bone cyst. The interior of the lesion was completely curetted.

Bone marrow was aspirated from the distal medial tibia, and mixed with 10 cc of Grafton demineralized bone matrix (Osteotech, Inc.) and placed in a 60 CC catheter tip syringe. The catheter tip of the syringe was introduced into the bone lesion and the bone graft mixture was delivered into the cyst, with filling of the cyst monitored using the fluoroscope.

The incision was closed with a few small nylon sutures, and the patient was placed in a splint for one week.

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