|Year : 2016 | Volume
| Issue : 1 | Page : 59-62
Hydroxyapatite granules for the surgical treatment of calcaneal intraosseous lipomas: A case report
Amit Chandrakant Supe, Chandrashekhar Martand Badole, Kiran Narayanrao Wandile
Department of Orthopedics, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Web Publication||4-Mar-2016|
Amit Chandrakant Supe
Department of Orthopedics, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Intraosseous lipoma of calcaneus is a rare occurrence. It is a benign tumor and frequently associated with pain in heel. Diagnosis can be done by a biopsy of the lesion. This tumor can be treated with curettage and filling cavity with hydroxyapatite granules. We present a case of intraosseous lipoma treated with curettage and hydroxyapatite granules.
Keywords: Curettage, hydroxyapatite granules, intraosseous lipoma
|How to cite this article:|
Supe AC, Badole CM, Wandile KN. Hydroxyapatite granules for the surgical treatment of calcaneal intraosseous lipomas: A case report. J Mahatma Gandhi Inst Med Sci 2016;21:59-62
|How to cite this URL:|
Supe AC, Badole CM, Wandile KN. Hydroxyapatite granules for the surgical treatment of calcaneal intraosseous lipomas: A case report. J Mahatma Gandhi Inst Med Sci [serial online] 2016 [cited 2020 Jul 11];21:59-62. Available from: http://www.jmgims.co.in/text.asp?2016/21/1/59/178109
| Introduction|| |
Intraosseous lipoma is a benign tumor originating from proliferating mature lipocytes. Frequently it involutes spontaneously through a process of infarction, calcification, and cyst formation.  Intraosseous lipoma has incidence rates of approximately 0.1%. The calcaneus is the second most common location after the proximal femur.  About 15% of these intraosseous lipoma are localized within the calcaneus, mostly at the Wards triangle.  This condition is frequently asymptomatic. However, surgery is required when the tumor causes pain or a lesion is large enough to lead to a pathological fracture.  Curettage followed by bone graft is the most common surgery. , We present a case with intraosseous lipoma of calcaneus.
| Case Report|| |
A 49-year-old male presented with dull aching pain in right heel since 1 year. Pain was insidious in onset and gradually progressive, relived with rest and increased with weight bearing. There was no history of trauma to foot in the past. There was associated swelling around right ankle which was diffuse. Initially the patient took treatment for pain relief in form of analgesics and non-weight bearing from private practitioner but was not relieved. When the patient presented to us, we performed the plain radiograph of the right ankle joint lateral view, which revealed osteolytic lesion with a sclerotic margin in ward's triangle [Figure 1]. Computed tomography of the calcaneus suggested a well-defined lytic lesion with fat densities of size 3.1 cm × 3 cm with sclerotic margins [Figure 2].
|Figure 1: Preoperative radiograph showing osteolytic lesion in calcaneus|
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After routine blood investigations like complete blood count, renal function test, random blood sugar and chest radiograph PA view, anesthetic fitness and consent for operation, the patient was treated with curettage. Curettage was performed with a lateral calcaneal incision. An incision was made on the lateral margin of the Achilles tendon near its insertion and passed it distally to a point 4 cm inferior to and 2.5 cm anterior to the lateral malleolus. After dividing superficial and deep fascia, peroneal tendons were retracted and calcaneus was exposed. Then under an image intensifier, the lesion was located and cavity was opened by making window from lateral cortex of calcaneus. Then lipoma was curetted out and cavity was filled with hydroxyapatite granules till a lateral wall was created by the granules [Figure 4]. Wound was sutured and the patient was given below knee slab for 8 weeks. The curetted material was sent for histopathology which reported it as mature fat cells with large areas of calcifications and fibrous tissue [Figure 3].
|Figure 4: Immediate postoperative radiograph of calcaneus showing defect filled with hydroxyapatite granules|
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Wound was checked by removing slab at time of dressing and after dressing slab was reapplied. We didn't notice infection or drainage from the operation site. After 8 weeks, slab was removed and physiotherapy was given for ankle range of motion, also weight bearing was allowed. We didn't notice recurrence of tumor after 3-month follow up [Figure 5].
| Discussion|| |
Intraosseous lipomas are rare bone tumors. The first case of intraosseous lipoma was described by Child in 1955, with Milgram having published the largest series of these lesions.  The most common location of an intraosseous lipoma is the metaphyseal ends of the long bones, especially the fibula (20%), the femur (15%), the tibia (13%) and the calcaneus (15%). In the calcaneus, these lesions are located between the anterior and the middle thirds of the calcaneus, just plantar to the angle of the fissure. 
Its etiology is unknown. But various hypotheses have been put forward. A post-traumatic secondary bone reaction, a healing bone infarct, and a true benign tumor are described as the possible occurrence of intraosseous lipoma.
The incidence of intraosseous lipoma is equal in males and females and it can present at any age.  In 40% of the cases, intraosseous lipomas are found incidentally. In the remaining cases, pain is the most common presenting symptom, occurring in up to 50% of the patients. In our case report the patient is a 49-year-old male, presented with pain in heel.
Milgram classified intraosseous lipoma into three histological groups, depending on their degree of involution; group I lesions are those with viable lipocytes; group II lesions are transitional, consisting of some viable lipocytes and some areas of fat necrosis and group III lesions are those which lack viable lipocytes. 
Radiographically, these lipomas typically appear as osteolytic lesions that are surrounded by a thin, well-demarcated sclerotic border. Lobulation or internal osseous ridges are present frequently and osseous expansion may be evident. 
Goto et al. suggested surgical indication of intraosseous lipoma as follows:
Bertram et al. reported 54 cases of intraosseous lipoma in calcaneus. They concluded that asymptomatic intraosseous lipoma of the calcaneus should not be operated on, since the tumor always occurred in the region of Ward's triangle, which is a non-weight-bearing area. They proposed curettage and bone grafting only for symptomatic patients. 
- Painful tumor,
- Occurrence of pathological fracture,
- Necessity for histological diagnosis, and
- Need to decrease the risk of malignant transformation.  In our case report, surgical indication for intraosseous lipoma was painful tumor and the need to decrease the risk of malignant transformation.
We treated patient with creating window in lateral cortex of calcaneus and curettage of lesion was done. Intraoperatively, the site of curettage was confirmed under c-arm. After completion of curettage, the cavity in calcaneus was filled with hydroxyapatite granules. The patient was kept non-weight bearing for 8 weeks postoperatively.
Goldenhar et al. reported a conventional procedure of curettage followed by bone graft using a 2 cm × 2 cm bone fenestration in the central lateral calcaneus. This procedure required non-weight bearing for 12 weeks to avoid pathological fracture postoperatively.  Futani et al. treated 30-year-old female with bilateral calcaneal lipoma using endoscope and curetted the lesion. They filled the void using beta-tricalcium phosphate (β-TCP) (OSferion Olympus, Tokyo, Japan). 
Several graft options, after the curettage of this condition, have been reported, such as autologous bone graft, autologous bone graft with hydroxyapatite, calcium sulfate, or curettage without graft. The advantage of using a bone substitute is to avoid the pain and morbidity of a donor site.  There are few disadvantages of hydryapatite. It is costly and takes more time for incorporation as compared to bone graft. But in spite of this, we have found that filling small defect in bone by hydroxyapatite granules is better than using bone graft to avoid pain and morbidity at donor site.
| Conclusion|| |
Intraosseous lipoma of calcaneus is a rare tumor which is most of the time an incidental finding. Treatment of this tumor with curettage and filling cavity with hydroxyapatite avoids donor site morbidity, decreases risk of pathological fracture and early postoperative recovery.
| References|| |
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Goto T, Kojima T, Iijima T, Yokokura S, Motoi T, Kawano H, et al. Intraosseous lipoma: A clinical study of 12 patients. J Orthop Sci 2002;7:274-80.
Goldenhar AS, Maloney JP, Helff JR. Negative bone scan in the diagnosis of calcaneal intraosseous lipoma. J Am Podiatr Med Assoc 1993;83:600-2.
Futani H, Fukunaga S, Nishio S, Yagi M, Yoshiya S. Successful treatment of bilateral calcaneal intraosseous lipomas using endoscopically assisted tumor resection. Anticancer Res 2007;27:4311-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]