Delayed Reconstruction by Total Calcaneal Allograft following Calcanectomy: Is It an Option?
Delayed reconstruction is needed in rare cases, especially following calcanectomy. For example, conservative surgery can be considered in cases of low-grade tumors. The aim of this report was to make a functional assessment of delayed reconstruction of the calcaneus by total allograft and to discuss alternative treatments.
2. Clinical Case
A 58-year-old patient was referred to our University Hospital in June 2014 for a chronic wound of the left heel. Review of the patient's clinical history revealed total calcanectomy in 2007 with a cement spacer fixed by pins after bone cancer. Pathological examination showed a well-differentiated cartilaginous tumor with bone resorption and hyaline tumor matrix without myxoid reshuffle. Investigations were compatible with a low grade of calcaneal chondrosarcoma with involvement of the Achilles tendon (Figure 1).
In January 2015, delayed allograft bone reconstruction was performed using total calcaneus with the distal extremity of the Achilles tendon (Figure 2) retrieved during multiorgan removal and processed in the standard manner. Surgeon performed lateral approach of the calcaneus, avoiding the sural nerve and fibular tendons. After the spacer was extracted by fragmentation, bone scissors were used for joint cartilage removal. The calcaneus allograft was then calibrated with an oscillating saw to obtain a size appropriate for the morphology of the hindfoot. The graft was temporarily fixed by pins under scopic guidance. Double arthrodesis was then performed after spongy bone grafting from the iliac bone: subtalar arthrodesis with two screws of 6.5 mm diameter and calcaneocuboid arthrodesis with a Blount's staple (Figure 3). The plantar fascia and the extremities of the Achilles tendon were sutured at their respective insertion sites on the allograft with a Krackow-type suture using nonabsorbable suture PremiCron[R] USP 5 after removal. The Achilles peritendon was then sutured to itself to promote its vascularization. Postoperative recommendations were total rest for 3 months followed by gradual resumption of foot contact with the ground in a shoe with heel support. The patient started to walk on the full sole of the foot as from the 4th month, with the aid of two crutches.
At 12-month follow-up there were no signs of tumor relapse. The patient was pain-free and had returned to work (Figure 4), with an MSTS 93 score of 67% and an AOFAS score of 72 points. Dorsiflexion and plantar flexion were 15 and 30 degrees, respectively. Achilles tendon action was normal with muscle strength of 5/5, corresponding to similar contraction of the active plantar flexion compared to the contralateral side and a rise heel position allowed in single leg stance. Testing of subtalar and Chopart joints was painless. Podoscopic examination showed a hindfoot varus and defective medial support. The patient was able to walk barefoot without pain. He was prescribed pronation insoles for daily use over a walking distance of 500 m. X-rays showed a calcaneal varus of few degrees from Meary's method in weight-bearing and CT-scan highlighted a subtalar nonunion (Figure 4). The calcaneocuboid arthrodesis was healed. There was no evidence of secondary displacement, fracture, or graft necrosis.
Chondrosarcomas develop very slowly in the young adult with no overt symptoms. A study by the Mayo Clinic reported a survival rate of 89% at 10-year follow-up  despite metastatic evolution in a quarter of the cases. The reference treatment is a surgical resection with satisfactory results. However, treatment by conservative surgery is not restricted to removal of the tumor in free margins , and the final aim is to restore normal gait. This involves several factors including bearing of weight without deformation of the hindfoot and normal movement of the Achilles tendon and plantar fascia to allow plantigrade locomotion. Our patient underwent delayed reconstruction 6 years after calcanectomy. There are few documented reports of the surgical procedure and approaches differ between authors (Table 1).
(i) Ottolenghi and Petracchi  and Muscolo et al.  were the first to study the possibility of a total calcaneal allograft. In both reports, osteointegration was successful with satisfactory functional results. However, the authors reported secondary osteonecrosis of the hindfoot at 4-year follow-up in both studies.
(ii) Li et al. [2, 5, 6] recommended the use of composite fibular flaps with or without allograft and achieved satisfactory functional and oncologic results. No information was given on postoperative foot statics.
(iii) Scoccianti et al.  and Kurvin et al.  used vascularized iliac crest bone graft. Owing to its greater volume and according to the size of the resection, the iliac bone graft allowed full weight-bearing and goodquality tissue for arthrodesis. However, the use of free flaps required microsurgical anastomosis including its complications. One case of bone graft fracture was observed in follow-up but without long-term functional consequences.
(iv) Imanishi and Choong  and Chou and Malawer  used a titan prosthesis after scan planning. Postoperative progress was similar to that following allograft, with successful functional recovery.
Each technique had its specific problems with regard to fixation, soft tissue coverage, donor site morbidity, and functional recovery (Table 2). The use of Chopart's fixation was debatable. To our knowledge, there have been no biomechanical studies of the mode of fixation in calcaneal allografts. We attached the calcaneal allograft by double arthrodesis avoiding the talonavicular joint and using spongy autograft from the iliac bone . The authors dealt with different fixation regarding the type of reconstruction: subtalar fixation [2, 5, 6] or double arthrodesis [4, 8]. Calcaneal prostheses [9, 10] were stable after ligament fixation and without bone fixation.
Soft tissue coverage is not always necessary and the decision to use flaps depends on tumor invasion. Several authors recommend the use of mixed flaps (pediculated fibular [2, 5, 6] or free iliac [7, 8]) for coverage. However, in more than a third of cases repeat surgery was required for local complications. Despite a reported success rate of 96%, microvascular anastomoses of the free flaps lead to further complications . The use of flaps may be restricted by problems of tissue autonomization following calcaneal prosthesis. In calcaneal allografts, it is possible to include a sural pediculated flap and maintain epicritic plantar sensitivity.
Total calcaneal allograft is an alternative treatment of lowgrade calcaneal tumors. We describe its use in delayed construction by allograft following calcanectomy. At 12-month follow-up, our patient had satisfactory clinical and functional scores. However, long-term monitoring is required to assess allograft survival in this indication.
The patient's consent was obtained before publication.
Level of evidence is level IV. Competing Interests
The authors declare no conflict of interests.
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Benjamin Degeorge, Louis Dagneaux, David Forget, Florent Gaillard, and Francois Canovas
Department of Orthopedic Surgery, Division of Lower Limb Surgery, Lapeyronie University Hospital, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
Correspondence should be addressed to Louis Dagneaux; email@example.com
Received 12 June 2016; Revised 8 October 2016; Accepted 23 October 2016
Academic Editor: Kaan Erler
Caption: FIGURE 1: Clinical history: X-ray (a) and CT-scan (b and c) images of calcaneal chondrosarcoma showing a heterogeneous, lytic picture with intracystic calcifications. Visualization of a cortical rupture of the greater tuberosity with involvement of the Achilles tendon. Lateral X-ray (d) showing the spacer following calcanectomy with talocalcaneal and calcaneocuboid fixation.
Caption: FIGURE 2: Photograph of the total calcaneal allograft with the distal extremity of the Achilles tendon.
Caption: FIGURE 3: Intraoperative lateral view of the calcaneal allograft arthrodesis (a) and postoperative X-ray examination (b and c) of the calcaneal allograft and double arthrodesis.
Caption: FIGURE 4: Latest follow-up assessment: Photograph shows a slight varus of the hindfoot (a). X-ray (b) and scan (c) assessment at 12-month follow-up with Meary incidence showing the residual varus of the hindfoot.
TABLE 1: Review of the literature of the different options of reconstruction following calcanectomy. Authors Date NC Surgery Imanishi and Choong  2015 1 Calcaneal prosthesis Li and Wang  2014 Allograft + pediculated 5-4 composite fibular flap versus amputation Li et al.  2012 4 Allograft + pediculated composite fibular flap Li et al.  2010 5 Pediculated composite fibular flap Scoccianti et al.  2009 2 Free composite iliac flap Kurvin et al.  2008 1 Free composite iliac flap Chou and Malawer  2007 1 Calcaneal prosthesis Muscolo et al.  2000 2 Calcaneal autograft Ottolenghi and + iliac autograft Petracchi  Authors Characteristics MSTS (%) Imanishi and Choong  No tumor recurrence / Li and Wang  No local tumor recurrence 74-83 Li et al.  2 local repeated surgeries 93 No tumor recurrence Li et al.  2 local repeated surgeries 93 No tumor recurrence Scoccianti et al.  1 fracture No tumor recurrence / Kurvin et al.  / / Chou and Malawer  No tumor recurrence / Muscolo et al.  1 osteonecrosis / Ottolenghi and Petracchi  Authors AOFAS FU (y) Imanishi and Choong  82 0.4 Li and Wang  / 3.5 Li et al.  80-95 2 Li et al.  80-95 4.2 Scoccianti et al.  / 7.1 Kurvin et al.  / 2.6 Chou and Malawer  67 12 Muscolo et al.  / 9-32 Ottolenghi and Petracchi  NC: number of cases; MSTS: Musculoskeletal Tumor Society; AOFAS: American Orthopedic Foot and Ankle Society; FU: follow-up; y: years. TABLE 2: Comparison of different reconstruction techniques following calcanectomy. Fixation Calcaneal allograft [3,4] Double arthrodesis Composite fibular flap  Arthrodesis ST Allograft + pediculated Arthrodesis AT composite fibular suture flap [2, 5] Free composite Double arthrodesis iliac flap [7, 8] (ST, CC, and TN) Calcaneal prosthesis [9, 10] ST and CC avivement AT suture Calcaneal allograft [3,4] Yes Composite fibular flap  No Allograft + pediculated Yes composite fibular flap [2, 5] Free composite Yes iliac flap [7, 8] Calcaneal prosthesis [9, 10] Yes Yes + plantar fascia and spring ligament Donor site morbidity Calcaneal allograft [3,4] / Composite fibular flap  None in the study Risk of lesions common PN, pain Allograft + pediculated None in the study composite fibular Risk of lesions flap [2, 5] common PN, pain Free composite Pain iliac flap [7, 8] Scar Calcaneal prosthesis [9, 10] / Foot statics Calcaneal allograft [3,4] Restored Composite fibular flap  Restored but strait calcaneal support Allograft + pediculated Restored composite fibular flap [2, 5] Free composite Restored Heel iliac flap [7, 8] numbness Calcaneal prosthesis [9, 10] Restored Complication at last follow-up (years) Calcaneal allograft [3,4] Osteonecrosis of the graft (32 and 9) Composite fibular flap  3 repeat flaps (4,2) Allograft + pediculated 2 repeat flaps composite fibular (2 and 3,5) flap [2, 5] Free composite Graft fracture (7,1 iliac flap [7, 8] and 2,6) Calcaneal prosthesis [9, 10] None (0,4 and 12) Possibility of soft tissue coverage Calcaneal allograft [3,4] Yes * Composite fibular flap  Yes Allograft + pediculated Yes composite fibular flap [2, 5] Free composite Yes iliac flap [7, 8] Calcaneal prosthesis [9, 10] To be assessed ST: subtalar; CC: calcaneocuboid; AT: Achilles tendon; TN: talonavicular; PN: peroneal nerve; * associated or secondary sural flap.
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|Title Annotation:||Case Report|
|Author:||Degeorge, Benjamin; Dagneaux, Louis; Forget, David; Gaillard, Florent; Canovas, Francois|
|Publication:||Case Reports in Orthopedics|
|Article Type:||Case study|
|Date:||Jan 1, 2016|
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