A calcaneal cyst

The first cyst of the calcaneus was described by the German physician Virchow at the end of the 19th century. Previously, the cyst was defined by multiple concepts - sinus calcaneus, intraosseous lipoma, chondroma, osteodystrophy of the calcaneus. There are still frequent cases when even experienced doctors diagnose a heel cyst as bursitis, although this is incorrect in the clinical and pathogenetic sense.

The heel bone is considered the main support of the foot, as the calcaneus is the largest bone in the overall structure of the lower leg. It connects to the talus and cuboid bones and bears the main support load when the body is upright, as well as when walking.

The calcaneus consists of a body and a tuberosity; a cystic tumor is most often localized in the body of the os calcis, which is due to the structural features of bone tissue and its ability to grow intensively at certain age periods.

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Symptoms of a heel cyst

The main clinical signs of a benign tumor-like formation in the calcaneus:

• The destructive focus has a round shape.
• Bone tissue destruction is clearly limited and separated from healthy tissue.
• The cyst tends to develop slowly in an inactive form.
• The cortical layer is expanded and its thinning is noticeable.
• There is no periosteal reaction.
• The tumor is defined as non-aggressive, less than 5-6 centimeters.

The inactive form of the calcaneal cyst is asymptomatic and often disappears spontaneously as the skeleton is completed. More aggressive are active cysts, which manifest themselves as pain when walking and running, obvious swelling of the heel in the area of tumor development, transient lameness and discomfort when wearing shoes. Microfractures are also quite common, which are inevitable with a long course of the disease and constant load on the foot.

Symptoms of a pathological fracture may also remain unnoticed for quite a long time, especially if the patient is bothered by other bone pains - in the knee, in the hip joint. A pathological bone fracture may be accompanied by swelling of the foot, heel, limitations of motor activity with full preservation of the range of motion in the ankle.

Bone cyst of the calcaneus

Osteodystrophic processes in the calcaneus are mainly found in childhood, much less often a bone cyst of the heel is diagnosed at a young age, this is possible in the presence of a constant traumatic factor, for example, during professional sports. According to statistics, ACC or SCC in the bones of the heel is determined in only 1-1.5% of the total number of detected bone cysts.

Bone cyst of the calcaneus, symptoms:

• Asymptomatic development of a cyst.
• The onset of clinical manifestations occurs in adolescence.
• Heel pain when walking, running.
• Heel bone pain during sports.
• There may be unilateral swelling of the foot at the site of cyst development.
• A pathological fracture that often recurs and limits movement.

In addition to external examination and palpation of the foot, axial imaging, X-ray, ultrasound examination of the joint, and preferably a tomogram to differentiate osteodystrophic pathologies are indicated as diagnostics.

A bone cyst of the heel is rarely subject to puncturing; more often it is removed surgically, while simultaneously filling the scraped cavity with a special biomaterial, allograft composites.

In case of pathological fractures, a calcaneal cyst requires the surgeon to make an important decision on the choice of the method, technique and timing of the operation:

1. Urgent, emergency surgery may be required if the patient is diagnosed with the following condition:
   • Open fracture.
   • In the case of a fracture, nerve endings and blood vessels are damaged, and there are clear symptoms of an internal hematoma – compartment syndrome.
   • Comminuted fracture and risk of pressure on tissue from fragments.
2. Planned operation.

Refusal of surgical treatment and choice of conservative methods:

• The patient's age is less than 2-3 years and older than 60 years.
• The fracture does not cause displacement of the joint.
• Medical contraindications to surgery (acute and severe chronic pathologies of the cardiovascular system and others).

A calcaneal cyst complicated by a fracture can be treated conservatively in the following manner:

• The first day – cold compresses.
• Elevated leg position for a week.
• Prescribing decongestants and painkillers.
• Application of a posterior splint for 5-7 days.
• Limitation of physical activity for a month.
• Use of crutches and walking sticks to reduce the axial load on the heel.
• Dynamic monitoring of the condition of the heel bone over one and a half to two months using X-rays.

If the heel bone cyst is treated surgically, the recovery period can last from a year to a year and a half. This is due to the complex structure of the foot, the abundance of blood vessels in this area, the risk of thrombosis and various osteopathies. Also, the process of implantation of the material used as a filling for the resection defect can become a complication. The only way to prevent multiple risks of surgical intervention is timely diagnosis; a small bone cyst is much easier to cure with the help of puncture and restore the supporting function of the heel and foot in 4-6 months.

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Solitary cyst of the calcaneus

The foot is considered a rather complex anatomical part of the human musculoskeletal system, as it consists of 26 bones, of which the calcaneus is the largest. It is the calcaneus that provides rigid support during movement and helps to support the weight of the human body. Statistics claim that the load on the heels increases by 1.5 times during simple walking, and by almost 3 times during running. This makes the calcaneus vulnerable in principle, despite its strength, with congenital anomalies of bone tissue formation, it can be subject to slow destruction and deformation.

A solitary cyst can develop in the heel bone from an early age, and this process sometimes lasts until the child reaches puberty, when significant changes occur throughout the body, including in the hormonal sphere and in the musculoskeletal system. Also, a solitary cyst in the calcaneus is diagnosed in children aged 5-7 years, more often in boys due to the rapid growth of the skeletal system. The factors that provoke the development of a heel cyst have not yet been clarified, it is obvious that the process is based on degenerative-dystrophic changes of a benign nature, which do not have signs of inflammation or blastomatous pathological changes. The musculoskeletal system is able to gradually recover, after lacunar resorption, bone tissue is rebuilt over time due to metaplasia and new formation of bone substance. Tumor-like growths in the calcaneus are diagnosed relatively rarely, since the calcaneus is a short spongy bone, while solitary bone cysts are typically localized in long tubular bones. SCC of the calcaneus is asymptomatic, often only its fracture can become a manifest clinical manifestation and a reason to consult a doctor. Due to the fact that this type of cyst, despite many published works, is still poorly studied, the diagnosis of a solitary heel cyst is often erroneous. SCC is often defined as bursitis, chondroma or osteoblastoclastoma. The difficulty in diagnosis is also due to the rather rare cases of SCC in the heel, the lack of clear criteria that help to determine a bone cyst in this localization.

A simple solitary cyst of the calcaneus, uncomplicated by fractures, can pass on its own. Periodic pain can be caused by physical activity, such as running or sports. Sluggish symptoms persist for a long period, until the foot finishes the process of formation and growth. Complex situations, when the SCC is in the active phase and is accompanied by a fracture, require surgical treatment and a fairly long recovery period. The cyst is removed, and the area where the resection was performed is filled with bone grafts. In most cases, a solitary cyst localized in the calcaneus is treated successfully and is not prone to recurrence, unlike the aneurysmal type of neoplasm, which can be multi-chambered and quite difficult to treat.

Cyst of the left calcaneus

The tarsal calcaneus (Os calcis, calcaneus) is the largest part of the foot, which is part of the tarsal bones. Calcaneus is responsible for the formation of the foot and performs supporting and spring functions. Periodic pain in the heel area is associated not only by patients themselves, but also, unfortunately, by doctors with heel spurs, bursitis. This is due to the complex structure of the foot, as well as the fact that bone cysts in this area are quite rare and poorly studied.

The left calcaneal cyst is no different in pathogenesis from cystic neoplasms in the right heel. Most often, the calcaneus bone cyst is asymptomatic until it manifests itself as a pathological fracture. Common fractures of the calcaneus are an injury that in 90% of cases occurs as a result of falling from a very great height. In contrast, stress fractures are rare; according to statistics, they do not exceed 10% of all tarsal injuries. It is no coincidence that a pathological fracture of the calcaneus foot is called a "march fracture", since it most often occurs in athletes or people doing military service. A gradually developing cyst, localized mainly in the area between the process of the talus and the triangular bone, as well as in the Sesamum zone - sesamoid small bones, causes pain during prolonged walking, and then a violation of the integrity of the calcaneus.

Only a thorough and comprehensive diagnosis can help to determine whether there is a cyst of the left calcaneus, since in the topographic-anatomical sense the heel and foot as a whole are not separated from the ankle joint, it also needs to be examined. Diagnostic methods that help to clarify the presence or absence of a bone cyst:

• X-ray of the talus, calcaneus and ankle joint.
• X-ray of the calcaneus in different projections, despite the pain symptom - necessarily in the axial projection.
• X-ray of the anterior and middle zones of the foot in oblique, lateral and plantar projections – with direct magnification of the image.
• Computed tomography of the foot, including the ankle joint.

Treatment of a bone cyst complicated by a fracture of the calcaneus is always very difficult. The surgeon has to choose between numerous methods and determine the degree of risk of complications. If a CT scan shows a fracture of the upper part of the calcaneal tuberosity running along the line of the upper wall of the cyst, excochleation of the tumor and parallel filling of the cavity with osteomaterial are performed. Osteosynthesis with a special calcaneal plate, closed reposition with fixation of the calcaneal tuberosity can also be used.

The duration of treatment and recovery period depends on the size, type of cyst and severity of the fracture, and takes from three months to one year.

Diagnosis of heel bone cyst

Practicing surgeons note that in 75% of cases, an active calcaneal cyst is diagnosed in children under 10 years of age, then the intensity of resorption decreases, the cyst often collapses, closes, which chronologically coincides with the end of the process of formation of the child's musculoskeletal system.

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Treatment of heel bone cyst

A bone cyst in this area most often develops without obvious clinical signs, so a person simply does not feel it, and therefore does not treat it. Treatment of a heel bone cyst begins when periodic pain appears when walking, pathological fractures mainly in the subtalar joint area.

The main method of treating a heel cyst is considered to be surgery, which involves curettage of the cavity and its subsequent filling with a special plastic material. Very rarely, a complicated cyst requires subtotal resection or perforation of the bone in the cyst area, followed by washing the cavity and filling it with allograft material.

Indications for surgical intervention when diagnosed with a calcaneal cyst:

• Steady progression of symptoms and growth of the cyst.
• Obvious radiographic signs indicating an aggressive course of the disease.
• X-ray confirmed risk of pathological fracture.
• Large heel cyst that limits mobility.

Modern biocomposite materials allow not only to relieve pain symptoms, but also to almost completely restore osteogenesis and musculoskeletal function of the entire lower limb.

Uncomplicated heel cysts in children are treated with conservative methods when the child is prescribed leg immobilization and bed rest. The cyst is punctured if it continues to grow after a month of treatment, the tumor is removed surgically. Excochleation of the tumor cavity is performed with parallel filling of the defect with a bone transplant (allostraw)

A simple fracture is also treated conservatively, the foot is immobilized with a plaster cast, the cast is applied from the knee to the tips of the toes. The leg is in a cast for at least 4 weeks, sometimes longer. After a certain period, the cast is removed, a control X-ray of the foot is performed. Usually, a fracture helps to reduce the cyst cavity, it disappears, and the bone tissue is gradually restored. Exercise therapy, massage and physiotherapy procedures help to completely restore the normal supporting function of the foot, recovery takes up to six months. If the fracture is accompanied by displacement, which is quite often diagnosed with injuries in this area, even with a decrease in the size of the cyst, an operation is performed to restore osteosynthesis using the Ilizarov apparatus and other intraosseous structures. Such methods are quite traumatic and carry a risk of complications, but they are considered the most effective in the treatment of complex comminuted fractures. It should be noted that fractures with displacement are not typical for cystic bone dystrophy, but they are often diagnosed in the foot area, this is explained by its complex structure, the presence of many small, vulnerable bones and the aggressive development of the cyst, which provokes tissue destruction.

Unfortunately, treatment of calcaneal cysts in adult patients in most cases cannot be done without surgery, which is fraught with complications in the form of flat feet, bone deformation (protrusions) of a post-traumatic nature. Long-term and adequate therapy, including surgery, helps to restore the supporting function of the heel and foot as a whole, provided that a doctor is consulted in a timely manner when the first painful symptoms appear in the lower limb.

Surgery for heel bone cyst

Surgery for a heel bone cyst is indicated in most cases, since the tumor in this area is characterized by an aggressive course, disrupting the normal blood supply to the foot, causing destruction of bone tissue and often immobilizing a person. The method of surgical treatment is determined by the possibility of access to the damaged area; surgery for a heel bone cyst is performed both under local anesthesia and under general anesthesia if a pathological fracture has occurred or if the cyst is giant in size. Before performing the surgery, the surgeon must carefully study and take into account the following clinical symptoms:

• The period of time in which the manifestation of symptoms occurred is childhood up to 10 years of age, puberty, age over 45 or 55 years.
• Duration of the disease.
• The nature of conservative treatment preceding the operation, if any.
• The volume of adjacent soft tissues (in the area of the proposed resection).
• Severity of motor impairment and risks of postoperative immobilization.
• Condition of the skin of the foot, condition of the vascular system.
• Blood clotting level, risk of thrombosis.

Indications for surgery of the heel bone cyst:

• Lack of positive dynamics with conservative therapy for one and a half months.
• Progressive development, enlargement of the cyst.
• Pathological fracture of the calcaneus with displacement.
• A fracture causing joint incongruence.
• The cyst is large – more than 4-5 centimeters.

The criteria for choosing a surgical treatment method are not standardized; the surgeon must make a decision based on the examination results and his own practical experience. The following types of treatment are most often used:

• Excochleation, curettage followed by filling the defect with a filling alloplastic material that promotes bone tissue restoration. Subtotal resection of the cyst without filling the defect is accompanied by frequent relapses, according to statistics they make up about 45-50%.
• A small cyst cannot be treated surgically; it is subject to dynamic observation, possibly with repeated aspiration.
• The most common method of treating fractures is closed bone repositioning using a device that fixes the bones of the foot (in case of a pathological fracture with displacement).

The choice of surgical access method is also a difficult task for the surgeon, since the operation itself is complex and can cause serious complications. Accesses can be as follows:

• External approach, in which tissues are dissected down to the periosteum. This option requires virtuoso skill from the doctor, as there is a risk of damaging the perforating arteries, surral nerve and peroneal tendons.
• Internal access is rarely used in the diagnosis of comminuted pathological fracture.

Surgeries for calcaneal cysts are considered complex, each type of surgery has its pros and cons. Segmental or marginal resection, excochleation - these are all radical treatment methods that are impossible without the use of transplants. Osteoplasty, replacing the bone defect, in turn carries the risk of tissue rejection or suppuration. Therefore, after surgery, it is very important to strictly adhere to the immobilization regime of the foot. The following postoperative plan is recommended:

• The foot remains in an elevated position for 3-5 days.
• Joints should be developed as early as possible, on the 3rd day after surgery.
• The stitches are removed after 10-14 days.
• For one and a half months, the patient is recommended to walk with the help of crutches.
• Dynamic monitoring of the bone and cyst condition using X-rays is required for 2-3 months.
• Weight bearing can only be permitted 2 months after surgery.