lable at ScienceDirect

The Journal of Foot & Ankle Surgery 49 (2010) 93–97

Contents lists avai

The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

Tips, Quips, and Pearls

‘‘Tips, Quips, and Pearls’’ is a special section in The Journal of Foot & Ankle Surgery which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We inviteour readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little biteasier, or virtually any other ‘‘pearl’’ that the reader believes will assist the foot and ankle surgeon in providing better care. Please address your tips to: D. Scot Malay, DPM, MSCE, FACFAS,Editor, The Journal of Foot & Ankle Surgery, PO Box 590595, San Francisco, CA 94159-0595; E-mail: editorjfas@gmail.com

Treatment of a Unicameral Bone Cyst of Calcaneus with Endoscopic Curettageand Percutaneous Filling with Corticocancellous Allograft

Cengiz Yıldırım, MD 1, Mahir Mahirogulları, MD 2, Mesih Kuskucu, MD 3,_Ibrahim Akmaz, MD 4, Kenan Keklikci, MD 5

1 Orthopaedic Surgeon, Department of Orthopaedics and Traumatology, Mevki Military Hospital, Ankara, Turkey2 Associate Professor, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Department of Orthopaedics and Traumatology, Tıbbiye Caddesi, Uskudar, _Istanbul, Turkey3 Professor, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Department of Orthopaedics and Traumatology, Tıbbiye Caddesi, Uskudar, _Istanbul, Turkey4 Associate Professor, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Department of Orthopaedics and Traumatology, Tıbbiye Caddesi, Uskudar, _Istanbul, Turkey5 Assistant Professor, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Department of Orthopaedics and Traumatology, Tıbbiye Caddesi, Uskudar, _Istanbul, Turkey

a r t i c l e i n f o

Keywords:allograftbonecalcaneus

endoscopyminimal invasive

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Cengiz Yıldırım, MD, D

Traumatology, Mevki Military Hospital Ankara, TurkeE-mail address: drcengizyildirim@yahoo.com (C. Yı

1067-2516/$ – see front matter � 2010 by the Ameridoi:10.1053/j.jfas.2009.08.005

a b s t r a c t

The surgical procedures for unicameral solitary calcaneal bone cysts have ranged from simple curettage andgrafting to subperiosteal resection with internal fixation and grafting. In this article, an endoscopically assistedtechnique is proposed for the curettage of a simple calcaneal cyst that takes advantage of direct visualization ofthe cyst wall and contents and permits accurate assessment of the extent of the lesion. After curettage,percutaneous filling of the defect with corticocancellous allograft makes the technique a complete, minimallyinvasive surgical approach for this condition. The technique uses 2 lateral portals, one for viewing and theother for manipulation, both of which are created under fluoroscopic control. Once the cyst has been located,the 30� arthroscope is used to evacuate fluid, after which more solid cyst contents are fragmented andremoved. Thereafter, curettage of the inner surface of the cavernous cyst wall is performed. Finally, completepacking of the previously cystic cavity with crushed corticocancellous allograft is performed under endoscopicvisualization and confirmed radiographically.

� 2010 by the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Solitary bone cysts are benign, fluid-filled lesions (1) that usuallyoccur in the femur or humerus of children or adolescents. Solitarycysts of the calcaneus are much less common and, when present, aremost often seen in adults. This report describes a rather unique,minimally invasive approach to the treatment of a solitary calcanealcyst. This technique involves the use of arthroscopic inspection andcurettage of the solitary cyst, with the advantage of requiring smallincisions, minimal blood loss, and a limited dissection. The use ofcorticocancellous bone allograft, moreover, obviates the need forharvesting autogenous donor bone graft, and provides orthotopicgraft material to readily fill the cavitary defect that results fromevacuation of the cyst. In the patient described in this report, thecalcaneal lesion contained multiple, well-formed bony pillars within

epartment of Orthopaedics andy.ldırım).

can College of Foot and Ankle Surgeo

the cyst cavity that were visible on preoperative computerizedtomographic scans (Figure 1).

Surgical Technique

The patient is placed in the supine position on the operating table,and a sandbag is placed under the ipsilateral hip so that the leg can beinternally rotated in an effort to more readily expose the lateral side ofthe hindfoot (Figure 2). A tourniquet is properly applied to the ipsi-lateral upper thigh to aid hemostasis. Care is taken to topographicallyconsider the courses of the sural nerve and the peroneal tendons andto avoid and protect these structures during the subsequent, minimaldissection. A needle is placed on the lateral side of the hindfoot underfluoroscopic control to locate the cyst cavity exactly (Figures 3 and 4).The viewing portal incision is made with the ‘‘nick-and-spread’’technique at the lateral aspect of the calcaneus, centered directly overthe cystic lesion as determined by the position of the needle as viewedfluoroscopically (Figure 5). A blunt trocar is then directed toward thecyst, penetrating the lateral wall of the calcaneus (Figures 6 and 7),

ns. Published by Elsevier Inc. All rights reserved.

Fig. 1. In the patient depicted in this report, the calcaneal lesion contained multiple, well-formed bony pillars within the cyst cavity that were visible on preoperative computerizedtomographic scans.

Fig. 3. A needle is placed on the lateral side of the hindfoot in preparation for isolation ofthe cyst with the fluoroscope.

C. Yıldırım et al. / The Journal of Foot & Ankle Surgery 49 (2010) 93–9794

thus creating the first, or viewing portal. Then, a 4.0-mm, 30�

arthroscope is inserted into the cystic cavity through the lateral tovisualize the cyst contents (Figure 8). Next, the second, or workingportal is created approximately 2 cm anterior to the viewing portal by

Fig. 2. The patient is placed in the supine position on the operating table, and a sandbag isplaced under the ipsilateral hip so that the leg can be internally rotated in an effort tomore readily expose the lateral side of the hindfoot.

following the same steps described for creation of the first portal(Figures 9 and 10). Thereafter, through the working portal, the fluidcontents of the cyst are evacuated and tissue procured for biopsy, andany other laboratory testing that is desired, by means of sampleremoval under direct visualization. In the patient depicted in thisreport, the gross appearance of the evacuated fluid and biopsymaterial was consistent with a solitary calcaneal cyst, which was sentfor cytology, as well as bacterial and fungal microbiological cultures.Throughout the procedure, the arthroscope is used in a fashionconsistent with standard arthroscopy, with inflow and outflowcannulas and the use of normal saline solution. After drainage andirrigation, the 30� and 70� endoscopes are used to evaluate the cystic

Fig. 4. Under fluoroscopic control, the cyst cavity is precisely localized.

Fig. 5. The viewing portal incision is made at the lateral aspect of the calcaneus, centereddirectly over the cystic lesion as determined by measuring the distance identified with theneedle fluoroscopically.

Fig. 7. Fluoroscopic image showing placement of the viewing portal into the cyst throughthe lateral wall of the calcaneus.

C. Yıldırım et al. / The Journal of Foot & Ankle Surgery 49 (2010) 93–97 95

lining to complete a thorough examination of the confines of thelesion. A shaver is then introduced through the working portal andused to remodel the internal bony surfaces, after which, in sequentialorder and as deemed necessary by the operating surgeon, curettes,the rotary burr, and the radiofrequency ablation device are introducedto remove the cystic lining under endoscopic visualization. The scopeis then used to assess the adequacy of the curettage (Figure 11). Afterdetermining that a satisfactory evacuation and debridement of thecyst has taken place, percutaneous filling of the void through theworking portal is performed with the use of corticocancellous allo-graft chips and a 50-cc syringe, once again, under endoscopic visu-alization (Figure 12). Thorough filling of the defect in the calcaneus isconfirmed by fluoroscopy in the operating room (Figure 13).

We have performed this percutaneous endoscopic techniquewithout complications in 5 patients, and the operative time is similarto that for the standard open approach to this operation. Completepacking of the previously cystic cavity was observed endoscopicallyand, in the postoperative phase, standard radiographs confirmed

Fig. 6. A blunt trocar is then directed toward the cyst, penetrating the lateral wall of thecalcaneus, thus creating the first (viewing) portal.

thorough filling of the defect in the calcaneus of each of the patients.The patients were all symptom free from the third postoperative weekonward, and, after 12 months, no recurrence of the solitary cyst of thecalcaneus was noted in any of the patients, and bony integrationpersisted on the radiographs (Figure 14).

Discussion

Solitary cysts of the calcaneus are usually diagnosed as incidentalfindings that are observed when radiographs are used in the evalu-ation of other sources of pedal symptomatology (2). The generallyaccepted guidelines for treatment of solitary cysts of the calcaneus

Fig. 8. Placement of the 4.0-mm, 30� endoscope into the cystic cavity through the lateralwall to visualize the cyst contents.

Fig. 9. Placement of the second, or working portal is created approximately 2 cm anteriorto the viewing portal.

Fig. 11. Intraoperative appearance of the viewing (posterior) and working (anterior)portals at the lateral aspect of the calcaneus.

C. Yıldırım et al. / The Journal of Foot & Ankle Surgery 49 (2010) 93–9796

hinge on the presence or absence of symptoms and the threat ofcortical fracture and joint deformation (3). Asymptomatic lesions thatsatisfy the diagnostic imaging criteria for a solitary bone cyst can betreated by means of periodic clinical and radiographic inspection,whereas lesions that are persistently painful warrant surgical treat-ment involving evacuation, curettage, and packing (4). Curettage andautogenous bone grafting remain the standard surgical treatment forsymptomatic unicameral cysts of the calcaneus (5, 6). Open surgeryhas disadvantages associated with donor-site morbidity, longeroperative time, and increased intraoperative blood loss related toharvesting donor bone (7, 8). In an effort to avoid problems related toharvesting autogenous donor bone graft, a variety of other materials,including allogeneic cancellous bone chips and bioceramic osteo-conductive substitutes, have been used for packing cystic lesions inthe calcaneus (9).

Overall, we feel that endoscopically assisted curettage presentsseveral advantages over open curettage. First, direct visualization ofthe cyst wall and contents permits accurate assessment of the extentof the lesion. Second, the endoscope permits accurate assessment of

Fig. 10. Placement of the trocar for the working portal access to the cyst.

the adequacy of the curettage, thus avoiding the need to performmultiple, blind, and aggressive passes with a curette, which canincrease the risk of violation of the cortical shell and may prolong theprocedure. Third, the ability to completely evacuate the lesion shouldlogically reduce the rate of recurrence. In the patients depicted in thistechnique, the authors used endoscopic curettage because it providedoptimal visualization with the advantage of a small incision, minimalblood loss, and a limited dissection. Moreover, the authors chose touse corticocancellous allograft because of the advantages it offered inregard to percutaneous back-filling of the evacuated cyst, the use ofa minimally invasive surgical approach to the defect, and the fact thatit obviated the need for harvesting autogenous donor bone graft (2).Based on our experience with a small series of patients, we believethat endoscopically assisted curettage of a unicameral cyst of the

Fig. 12. The endoscope is used to assess the adequacy of the curettage and back-fillingoperation.

Fig. 13. Thorough filling of the defect in the calcaneus is confirmed by fluoroscopy in theoperating room.

Fig. 14. After 12 months, no recurrence of the solitary cyst of the calcaneus was noted onthe lateral heel radiograph.

C. Yıldırım et al. / The Journal of Foot & Ankle Surgery 49 (2010) 93–97 97

calcaneus is a useful modification that promises to save time, decreasemorbidity, and possibly improve long-term outcomes. Furthermore,this technique can be performed as an alternative procedure for othercystic lesions affecting other portions of the skeleton.

In conclusion, in this report we describe a rather unique approachto the treatment of a solitary calcaneal cyst by means of endoscopic-assisted percutaneous filling of corticocancellous allograft chips intothe cavitary defect created by evacuation of the cyst. We feel that thismethod represents a simple and innovative approach to the surgicaltreatment of this benign lesion of the calcaneus. The technique,moreover, provides adequate exposure to allow complete resectionand bone grafting of the lesion, while maintaining the soft tissuebenefits of a minimally invasive approach.

Acknowledgment

The writer wishes to express his gratitude to Dr _Ilkay Alp, IstanbulUniversity Faculty of Pharmacy, Istanbul, Turkey, for her suggestions

and assistance in preparing the manuscript, and Fatih Gungor for hiscontribution in the performance of the surgical procedures.

References

1. Altermatt S, Schwobel M, Pochon JP. Operative treatment of solitary bone cysts withtricalcium phosphate ceramic. A 1 to 7 year follow-up. Eur J Pediatr Surg 2:180–182,1992.

2. Csizy M, Buckley RE, Fennell C. Benign calcaneal bone cyst and pathologic fracturesurgical treatment with injectable calcium-phosphate bone cement (Norian): a casereport. Foot Ankle Int 22:507–510, 2001.

3. Pogoda P, Priemel M, Linhart W, Stork A, Adam G, Windolf J, Rueger JM, Amling M.Clinical relevance of calcaneal bone cysts: a study of 50 cysts in 47 patients. ClinOrthop Relat Res 424:202–210, 2004.

4. Sodergard J, Karaharju EO. Cystic lesions of the calcaneus. Some aspects on thediagnosis and treatment. Rev Chir Orthop 76:502–506, 1990.

5. Glaser DL, Dormans JP, Stanton RP, Davidson RS. Surgical management of calcanealunicameral bone cysts. Clin Orthop Relat Res 360:231–237, 1999.

6. Smith RW, Smith CF. Solitary unicameral bone cyst of the calcaneus. A review oftwenty cases. J Bone Joint Surg Am 56-A:49–56, 1974.

7. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bonegraft. Complications and functional assessment. Clin Orthop Relat Res 339:76–81,1997.

8. Dietz JF, Kachar SM, Nagle DJ. Endoscopically assisted excision of digital enchon-droma. Arthroscopy 23(6):678.e1–678.e4, 2007.

9. Mainard D, Galois L. Treatment of a solitary calcaneal cyst with endoscopic curet-tage and percutaneous injection of calcium phosphate cement. J Foot Ankle Surg45(6):436–440, 2006.