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The Journal of Bone & Joint Surgery, Volume 82, Issue 1
Articles   |   January 01, 2000 
Long-Term Results of Allograft Replacement After Total Calcanectomy. A Report of Two Cases*
D. LUIS MUSCOLO, M.D.†; MIGUEL A. AYERZA, M.D.†; LUIS A. APONTE-TINAO, M.D.†, BUENOS AIRES, ARGENTINA
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Investigation performed at the Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Buenos Aires
The Journal of Bone & Joint Surgery.  2000; 82:109-12 
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Total calcanectomy for the treatment of a primary tumor of the calcaneus is rarely indicated, and options for reconstruction after this procedure are limited. However, replacement of the entire calcaneus with a massive allograft is one option. We report the cases of two patients who had a reconstruction with a total calcaneal allograft and were followed for thirty-two and nine years. The case of the first patient was reported previously in The Journal of Bone and Joint Surgery, in 1953, after a short duration of follow-up8. We are not aware of any previous reports on the long-term results of this procedure.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was the Ottolenghi Foundation.

†Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Potosí 4215, 1199 Buenos Aires, Argentina. E-mail address for all authors: cineot@hitalba.edu.ar.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was the Ottolenghi Foundation.
†Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Potosí 4215, 1199 Buenos Aires, Argentina. E-mail address for all authors: cineot@hitalba.edu.ar.
 
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+FIG1-A:: Figs. 1-A, 1-B, and 1-C: Case 1. Fig. 1-A: Preoperative lateral radiograph showing an osteolytic lesion involving most of the calcaneus. An aspiration biopsy and a subsequent open biopsy confirmed the diagnosis of chondrosarcoma.
 
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+FIG1-B:: Fig. 1-B: Immediate postoperative lateral radiograph, made in 1948, showing the allogenic fresh-frozen calcaneus in place. The allograft was drilled in several directions in an attempt to enhance revascularization.
 
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+FIG1-C:: Fig. 1-C: Lateral radiograph, made thirty-two years postoperatively, showing partial collapse of the central portion of the calcaneus, subtalar fusion, and degenerative changes of the ankle joint.
 
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+FIG2-A:: Figs. 2-A through 2-E: Case 2. Fig. 2-A: Preoperative lateral radiograph showing an extensive osteolytic lesion. A needle biopsy showed the lesion to be a giant-cell tumor.
 
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+FIG2-B:: Fig. 2-B: Preoperative magnetic resonance images, made in the sagittal plane, showing massive involvement of the calcaneus by the tumor.
 
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+FIG2-C:: Fig. 2-C: Immediate postoperative lateral radiograph showing the allogenic fresh-frozen calcaneus, which was fixed with screws. The allografting procedure was performed in conjunction with a subtalar and calcaneocuboid arthrodesis.
 
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+FIG2-D:: Fig. 2-D: Lateral radiograph, made nine years postoperatively, showing an apparently well incorporated allograft with osseous union at the subtalar and calcaneocuboid joints. Some degenerative changes are evident in the ankle and talonavicular joints.
 
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+FIG2-E:: Fig. 2-E: Photograph, made nine years postoperatively, showing the clinical appearance with correct alignment and slight enlargement of the heel.
CASE 1. A fourteen-year-old boy was admitted to our hospital in July 1948 with a swollen, painful left ankle. Routine laboratory data (including the erythrocyte sedimentation rate, the leukocyte count, and the serum levels of alkaline phosphatase, calcium, and phosphorus) were within normal limits, and radiographs of the lungs revealed normal findings. Radiographs of the left foot and ankle showed an osteolytic lesion involving most of the calcaneus (Fig. 1-A).
An aspiration biopsy and a subsequent open biopsy established the diagnosis of chondrosarcoma, which was confirmed by Dr. Fritz Schajowicz. The patient was operated on by Dr. Carlos Ottolenghi in August 1948. The entire calcaneus was removed, and an allogenic fresh-frozen calcaneus was inserted (Fig. 1-B). There was a problem with the size of the allograft because the only calcaneus that was available at the time of the operation was smaller than the calcaneus that had been removed from the patient. The allograft was drilled in several directions in an attempt to enhance revascularization, and a subtalar and calcaneocuboid arthrodesis was performed. A plaster cast was worn for seven months, after which time the patient was allowed to walk without support.
Radiographs made four years later showed partial collapse of the central portion of the bone but healing between the autologous and the allogenic bone.
The patient was interviewed by telephone in 1980, thirty-two years after the operation, and radiographs were mailed to our hospital. The patient reported some limitation of the range of motion of the ankle, but he had no pain and was able to walk without support. At the time of the interview, he was working as a truck driver. The radiographs showed good trabeculation of bone but demonstrated partial collapse of the central part of the calcaneus, similar to that found in 1952 (Fig. 1-C).
CASE 2. A forty-one-year-old man was evaluated in January 1989 because of progressive pain in the left heel. Radiographs made at that time showed an extensive osteolytic lesion with several septa (Fig. 2-A).
Magnetic resonance images demonstrated that the lesion involved the calcaneus and extended into the subtalar and calcaneocuboid joints (Fig. 2-B). A needle biopsy showed the lesion to be a giant-cell tumor, and resection of the entire calcaneus was believed to be indicated. The operation was performed in January 1989 through an extensive posterolateral approach. The entire calcaneus was excised, and the subtalar articular cartilage and areas of subjacent bone were resected from the talus and cuboid in order to eradicate the invasive tumor and to allow a subtalar and calcaneocuboid arthrodesis to be performed with use of donor bone. The heel was reconstructed with an allogenic fresh-frozen calcaneus. Because an arthrodesis of the subtalar and calcaneocuboid joints had been done, the calcaneus was fixed in place with compression screws after the joint surfaces were resected, as needed, to obtain a proper fit (Fig. 2-C). The Achilles tendon was reinserted into the allograft along with a thin layer of autologous bone and was fixed with a screw. The postoperative period was uneventful. The patient wore a non-weight-bearing cast and walked with crutches for four months. At six months, he was fully weight-bearing without support, reported no pain, and had returned to his previous job as a salesman.
The patient was last evaluated in February 1998, nine years after the operation, at which time he reported no major clinical problems (Figs. 2-D and 2-E). Radiographs showed an apparently well incorporated allograft, with osseous union at the subtalar and calcaneocuboid joints and a well aligned heel (Fig. 2-D). Clinical examination revealed some enlargement, but proper alignment, of the heel (Fig. 2-E). The patient had minor pain after strenuous walking, and dorsiflexion and plantar flexion were both limited by 20 degrees compared with those on the contralateral side. These clinical limitations were related to the fused joints.
Giant-cell tumor is rarely seen in the tarsal bones, and it is exceptional for this lesion to arise in the calcaneus4. Two recent reports1,7 from referral institutions for musculoskeletal tumors support this statement. In one of those studies7, which was based on a review of the cases of 308 patients who had giant-cell tumor of bone, the lesion was located in the foot and ankle region of twelve patients and in the calcaneus of only one. In the other report1, which was based on an extensive registry of 13,000 tumors of the locomotor system, there were 260 bone tumors of the foot and only four giant-cell tumors of the calcaneus. None of the calcaneal tumors were reported to have been treated with full resection and reconstruction with an allograft. Treatment options for giant-cell tumor include intralesional curettage with or without the use of phenol or cryotherapy, marginal resection, and even total excision. The choice of treatment depends on the location of the lesion, whether the lesion has recurred, and whether the lesion has extended into surrounding areas.
Primary chondrosarcoma of the calcaneus is also rare. In one of the reports mentioned previously1, only four of fifty-eight primary malignant bone tumors of the foot were calcaneal chondrosarcomas. Treatment of a calcaneal chondrosarcoma may necessitate a calcanectomy. Satisfactory function has been reported after the treatment of a bone tumor with calcanectomy without reconstruction2. However, cosmetic deformity, ulceration of the skin, and additional deformities that develop later frequently occur after such a procedure9. Moreover, a filler inside the shoe or some form of orthosis is needed for independent function.
The first procedure in the present report was performed in 1948 and the second was performed in 1989, more than forty years later. Although a number of biological and biomechanical factors related to the reconstruction of bone defects with use of a massive allograft remain obscure, other factors are now better understood3,5,6,10. Drilling of bone in an attempt to enhance revascularization, as was performed for one of our patients (Case 1), causes stress-risers and fractures. Also, malalignment of the graft, which was seen on the postoperative radiographs of this patient as vertical positioning of the calcaneal allograft with an associated subluxation of the calcaneocuboid joint, may have predisposed the graft to fracture and partial collapse (Fig. 1-C). However, both of our patients remained asymptomatic, were able to bear full weight without support, and had no cosmetic deficit at the time of the most recent follow-up.
Reconstruction of the calcaneus with a massive allograft is rarely performed, and there was no mention of this procedure in the most extensive series of bone allografts that we found in the literature3. The long-term results for our two patients suggest that this procedure may be a durable reconstructive option after total calcanectomy.
1
Casadei, R.; Ferraro, A.; Ferruzzi, A.; Biagini, R.; and Ruggieri, P.: Bone tumors of the foot: epidemiology and diagnosis. Chir. org. mov.,76: 47-62, 1991.7647  1991 
 
2
Dhillon, M. S.; Singh, B.; Gill, S. S.; Walker, R.; and Nagi, O. N.: Management of giant cell tumor of the tarsal bones: a report of nine cases and a review of the literature. Foot and Ankle,14: 265-272, 1993.14265  1993  [PubMed]
 
3
Mankin, H. J.; Gebhardt, M. C.; Jennings, L. C.; Springfield, D. S.; and Tomford, W. W.: Long-term results of allograft replacement in the management of bone tumors. Clin. Orthop.,324: 86-97, 1996.32486  1996  [PubMed]
 
4
Mechlin, M. B.; Kricun, M. E.; Stead, J.; and Schwamm, H. A.: Giant cell tumor of tarsal bones. Report of three cases and review of the literature. Skel. Radiol.,11: 266-270, 1984.11266  1984 
 
5
Muscolo, D. L.; Ayerza, M. A.; Calabrese, M. E.; Redal, M. A.; and Santini Araujo, E.: Human leukocyte antigen matching, radiographic score, and histologic findings in massive frozen bone allografts. Clin. Orthop.,326: 115-126, 1996.326115  1996  [PubMed]
 
6
Muscolo, D. L., and Ayerza, M. A.: Allografts. In The Adult Hip, edited by J. J. Callaghan, A. G. Rosenberg, and H. E. Rubash. Vol. 1, pp. 297-312. Philadelphia, Lippincott-Raven, 1998. 
 
7
O'Keefe, R. J.; O'Donnell, R. J.; Temple, H. T.; Scully, S. P.; and Mankin, H. J.: Giant cell tumor of bone in the foot and ankle. Foot and Ankle Internat.,16: 617-623, 1995.16617  1995 
 
8
Ottolenghi, C. E., and Petracchi, L. J.: Chondromyxosarcoma of the calcaneus. Report of a case of total replacement of involved bone with a homogenous refrigerated calcaneus. J. Bone and Joint Surg.,35-A: 211-214, Jan. 1953.35-A211  1953 
 
9
Smith, D. G.; Stuck, R. M.; Ketner, L.; Sage, R. M.; and Pinzur, M. S.: Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. An amputation of the back of the foot. J. Bone and Joint Surg.,74-A: 571-576, April 1992.74-A571  1992 
 
10
Stevenson, S., and Horowitz, M.: Current concepts review. The response to bone allografts. J. Bone and Joint Surg.,74-A: 939-950, July 1992.74-A939  1992 
 

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+FIG2-E:: Fig. 2-E: Photograph, made nine years postoperatively, showing the clinical appearance with correct alignment and slight enlargement of the heel.
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+FIG2-D:: Fig. 2-D: Lateral radiograph, made nine years postoperatively, showing an apparently well incorporated allograft with osseous union at the subtalar and calcaneocuboid joints. Some degenerative changes are evident in the ankle and talonavicular joints.
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+FIG2-C:: Fig. 2-C: Immediate postoperative lateral radiograph showing the allogenic fresh-frozen calcaneus, which was fixed with screws. The allografting procedure was performed in conjunction with a subtalar and calcaneocuboid arthrodesis.
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+FIG2-B:: Fig. 2-B: Preoperative magnetic resonance images, made in the sagittal plane, showing massive involvement of the calcaneus by the tumor.
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+FIG2-A:: Figs. 2-A through 2-E: Case 2. Fig. 2-A: Preoperative lateral radiograph showing an extensive osteolytic lesion. A needle biopsy showed the lesion to be a giant-cell tumor.
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+FIG1-C:: Fig. 1-C: Lateral radiograph, made thirty-two years postoperatively, showing partial collapse of the central portion of the calcaneus, subtalar fusion, and degenerative changes of the ankle joint.
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+FIG1-B:: Fig. 1-B: Immediate postoperative lateral radiograph, made in 1948, showing the allogenic fresh-frozen calcaneus in place. The allograft was drilled in several directions in an attempt to enhance revascularization.
Anchor for JumpAnchor for Jump
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+FIG1-A:: Figs. 1-A, 1-B, and 1-C: Case 1. Fig. 1-A: Preoperative lateral radiograph showing an osteolytic lesion involving most of the calcaneus. An aspiration biopsy and a subsequent open biopsy confirmed the diagnosis of chondrosarcoma.
1
Casadei, R.; Ferraro, A.; Ferruzzi, A.; Biagini, R.; and Ruggieri, P.: Bone tumors of the foot: epidemiology and diagnosis. Chir. org. mov.,76: 47-62, 1991.7647  1991 
 
2
Dhillon, M. S.; Singh, B.; Gill, S. S.; Walker, R.; and Nagi, O. N.: Management of giant cell tumor of the tarsal bones: a report of nine cases and a review of the literature. Foot and Ankle,14: 265-272, 1993.14265  1993  [PubMed]
 
3
Mankin, H. J.; Gebhardt, M. C.; Jennings, L. C.; Springfield, D. S.; and Tomford, W. W.: Long-term results of allograft replacement in the management of bone tumors. Clin. Orthop.,324: 86-97, 1996.32486  1996  [PubMed]
 
4
Mechlin, M. B.; Kricun, M. E.; Stead, J.; and Schwamm, H. A.: Giant cell tumor of tarsal bones. Report of three cases and review of the literature. Skel. Radiol.,11: 266-270, 1984.11266  1984 
 
5
Muscolo, D. L.; Ayerza, M. A.; Calabrese, M. E.; Redal, M. A.; and Santini Araujo, E.: Human leukocyte antigen matching, radiographic score, and histologic findings in massive frozen bone allografts. Clin. Orthop.,326: 115-126, 1996.326115  1996  [PubMed]
 
6
Muscolo, D. L., and Ayerza, M. A.: Allografts. In The Adult Hip, edited by J. J. Callaghan, A. G. Rosenberg, and H. E. Rubash. Vol. 1, pp. 297-312. Philadelphia, Lippincott-Raven, 1998. 
 
7
O'Keefe, R. J.; O'Donnell, R. J.; Temple, H. T.; Scully, S. P.; and Mankin, H. J.: Giant cell tumor of bone in the foot and ankle. Foot and Ankle Internat.,16: 617-623, 1995.16617  1995 
 
8
Ottolenghi, C. E., and Petracchi, L. J.: Chondromyxosarcoma of the calcaneus. Report of a case of total replacement of involved bone with a homogenous refrigerated calcaneus. J. Bone and Joint Surg.,35-A: 211-214, Jan. 1953.35-A211  1953 
 
9
Smith, D. G.; Stuck, R. M.; Ketner, L.; Sage, R. M.; and Pinzur, M. S.: Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. An amputation of the back of the foot. J. Bone and Joint Surg.,74-A: 571-576, April 1992.74-A571  1992 
 
10
Stevenson, S., and Horowitz, M.: Current concepts review. The response to bone allografts. J. Bone and Joint Surg.,74-A: 939-950, July 1992.74-A939  1992 
 
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