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A lipoma within the Achilles tendon sheath
Foot and Ankle Surgery 18 (2012) e16–e17
Contents lists available at SciVerse ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
A lipoma within the Achilles tendon sheath Asif Z. Khan *, Masood Shafafy, Mark D. Latimer, John Crosby Peterborough and Stamford Hospitals NHS Foundation Trust, Department of Trauma & Orthopaedics, Peterborough City Hospital, Edith Cavell Campus, Bretton Gate, Bretton, Peterborough PE3 9GZ, United Kingdom
A R T I C L E I N F O
Article history: Received 14 February 2011 Received in revised form 17 September 2011 Accepted 6 October 2011 Keywords: Lipoma Achilles tendon
A B S T R A C T
We report a case demonstrating a rare finding associated with a relatively common injury. Lipomata are rarely found within tendon sheaths; but in the case of our patient, at the time of operative repair for a ruptured Achilles tendon, we found a fatty growth within the tendon sheath. The diagnosis of a lipoma was confirmed by histology. Although uncommon, it remains important to be aware of the existence of neoplastic growths within tendon sheaths and to establish the exact nature of these growths by histological analysis. Crown Copyright ß 2011 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
1. Introduction A lipoma is a benign tumour made up of fatty tissue and is the most commonly occurring soft tissue tumour. The World Health Organisation has classified soft tissue tumours in 2002 into 9 distinct subtypes ranging from lipoma to hibernoma as noted by Bancroft et al. [1]. Certain inherited conditions can involve the development of lipomata, e.g. familial multiple lipomatosis, but lipomata themselves are more often sporadic in nature as noted by Toy [2]. Lipomata usually require no treatment, unless they grow too large, cause pain or hinder mobility for which they can be surgically removed as described by Salam [3]. Lipomata do not usually undergo malignant transformation and liposarcomas are usually not derived from lipomata [4]. Lipomata are rarely found within tendon sheaths. However, there have been reports of these cases in the last 100 years – in their paper Sullivan et al. [5] gathered 43 cases from the literature and provided two of their own. Nine of these involved only the ankle or foot. Only two cases reported the presence of a lipoma in the Achilles tendon sheath. The other seven included tibialis anterior/posterior, extensor digitorum longus, flexor/extensor hallucis longus, peroneus longus and brevis tendons. 2. The case A 60-year-old man presented with a clinically ruptured Achilles tendon. He normally works as an engineer and is regularly active in terms of exercise. He was running when he heard a ‘snap’ from his left ankle and developed instant pain, swelling, bruising and an inability to weight bear. The diagnosis was made clinically with no
* Corresponding author. Tel.: +44 7990 525 709. E-mail address: [email protected] (A.Z. Khan).
plantar-flexion on the affected side on squeezing both calves (positive Simmonds test) and a 2 cm palpable gap, 1 cm proximal to the calcaneal insertion. After discussion with the operating surgeon the decision was made for operative management. It is important to note that clinically he did not have a soft palpable lump on either side indicating the possible presence of a lipoma. He was taken to theatre the same day for a repair of his Achilles tendon. A large fatty mass that appeared to be a lipoma was discovered to arise from within the paratenon at the level of the rupture (see Figs. 1 and 2). The fatty lump was removed in its entirety and was found to not involve the tendon itself. The tendon was therefore repaired using the surgeons default technique – 2 modified Kessler stitches orthogonal to each other (Ticron, Syneture), then a circumferential continuous stitch for reinforcement (Vicryl, Ethicon). Post-operatively the patient was placed into an equinas cast and the standard protocol for post-op management was followed. The fatty mass was sent for histological examination and the results were as follows: macroscopically fibrofatty tissue measuring 2.5 cm 1.4 cm 1.0 cm, nodular in slicing. Microscopically fibrofatty tissue present with haemorrhage, thick and thin-walled blood vessels at the edge; fibrin thrombi are present focally; fat necrosis present; consistent with lipoma – histological changes suggest trauma. No malignancy seen. Post operatively the patient was followed up in the fracture clinic at 2 weeks for a wound review and removal of sutures, and then at 6 weeks after completion of the casting/bracing stage, prior to commencement of physiotherapy. The patient subsequently returned to his normal place of work as an engineer and was able to undertake regular mild exercise, e.g. swimming, jogging. 3. Discussion The lipoma discovered in our patient did not involve the tendon itself. It was possible to remove it entirely and we feel it did not
1268-7731/$ – see front matter . Crown Copyright ß 2011 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2011.10.003
A.Z. Khan et al. / Foot and Ankle Surgery 18 (2012) e16–e17
Fig. 1. The lipoma intra-operatively prior to removal.
e17
Tendon sheath tumours can be of varied origin including benign and malignant. It is of course important to distinguish between the two. The significance of a ganglion cyst is very much different to say a giant cell tumour or fibroma, so histological examination is essential in every case. Establishing the exact diagnosis is important as tendon sheath masses can display bony involvement or require surgical excision, after which they may recur as mentioned by Schissel and Elston [6]. There is the issue of whether a mass within a tendon sheath structurally weakens it. This of course depends on exactly what structures are involved. With our case we do not believe there to have been any pre-morbid structural weakness as the lipoma did not involve the tendon itself, and the history was consistent with a traumatic rupture. It is a common occurrence for people playing sports to lunge or jump and land awkwardly on their ankle/foot and rupture their Achilles tendon, more so if they are unaccustomed to physical exercise. The presence of the lipoma may affect the structural integrity of the tendon although this has not been formally studied or assessed. If the lipoma had involved the tendon itself partially or even entirely, the repair may not have been as sound as was undertaken. This could ultimately lead to a reduced push-off strength and increased risk of re-rupture compared to a standard ruptured tendon without lipoma. In addition, removing the lipoma could leave a gap that the surgeon cannot approximate and therefore necessitate tendon lengthening or grafting. In conclusion, tendon sheath masses are common enough that medical professionals should remain aware of their existence as this may alter their choice of tendon repair technique, and also may alter the outcome for the patient subsequently. The mass should be sent for histological diagnosis to rule out malignancy. Conflict of interest
Fig. 2. The lipoma as it was discovered.
affect the structural integrity of the tendon, nor did it therefore predispose the patient to rupturing his tendon in the first place. The number of cases of lipomas found within tendon sheaths is low and the number of cases of lipomas found within the Achilles tendon sheath is very rare indeed. After extensive literature search only two such cases have been found to be recorded, both in 1928. Although it has been difficult to get hold of the original paper by Mannini, 1928 that documented these two cases, a literature review by Sullivan, 1956 as mentioned before [5], summarised the cases of lipomata in tendon sheaths and recorded the cases from the paper by Mannini. Sullivan et al. recorded 45 cases. Of these 30 involved only the hands or wrists, 9 in the ankle or foot, two cases had tumours of both upper and lower limbs and one had them in both hands and both ankles. In total 14 cases demonstrated lipomata bilaterally. Unfortunately two cases gathered gave no detail regarding anatomical site of the lipomata. Interestingly extensor tendons were more often involved than flexor tendons.
The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, centre, clinical practice, or other charitable or non-profit organization with which the authors, or a member of their immediate families, are affiliated or associated. References [1] Bancroft LW, KRansdorf MJ, Peterson JJ, O’Connor MI. Benign fatty tumours classification, clinical course, imaging appearance and treatment. Skeletal Radiol 2006;35(10):719–33. [2] Toy BR. Familial multiple lipomatosis. Dermatol Online J 2003;9(4):9. [3] Salam GA. Lipoma excision. Am Fam Physician 2002;65(5):901–4. [4] Dalal KM, Antonescu CR, Singer S. Diagnosis and management of lipomatous tumors. J Surg Oncol 2008;97(4):298–313. [5] Sullivan CR, Dahlin DC, Bryan RS. Lipoma of the tendon sheath. J Bone Joint Surg Am 1956;38:1275–80. [6] Schissel DJ, Elston DM. Achilles tendon nodule: inflammation, rupture, or tumor? Phys Sportsmed 1998;26(5):59–62.
Contents lists available at SciVerse ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
A lipoma within the Achilles tendon sheath Asif Z. Khan *, Masood Shafafy, Mark D. Latimer, John Crosby Peterborough and Stamford Hospitals NHS Foundation Trust, Department of Trauma & Orthopaedics, Peterborough City Hospital, Edith Cavell Campus, Bretton Gate, Bretton, Peterborough PE3 9GZ, United Kingdom
A R T I C L E I N F O
Article history: Received 14 February 2011 Received in revised form 17 September 2011 Accepted 6 October 2011 Keywords: Lipoma Achilles tendon
A B S T R A C T
We report a case demonstrating a rare finding associated with a relatively common injury. Lipomata are rarely found within tendon sheaths; but in the case of our patient, at the time of operative repair for a ruptured Achilles tendon, we found a fatty growth within the tendon sheath. The diagnosis of a lipoma was confirmed by histology. Although uncommon, it remains important to be aware of the existence of neoplastic growths within tendon sheaths and to establish the exact nature of these growths by histological analysis. Crown Copyright ß 2011 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
1. Introduction A lipoma is a benign tumour made up of fatty tissue and is the most commonly occurring soft tissue tumour. The World Health Organisation has classified soft tissue tumours in 2002 into 9 distinct subtypes ranging from lipoma to hibernoma as noted by Bancroft et al. [1]. Certain inherited conditions can involve the development of lipomata, e.g. familial multiple lipomatosis, but lipomata themselves are more often sporadic in nature as noted by Toy [2]. Lipomata usually require no treatment, unless they grow too large, cause pain or hinder mobility for which they can be surgically removed as described by Salam [3]. Lipomata do not usually undergo malignant transformation and liposarcomas are usually not derived from lipomata [4]. Lipomata are rarely found within tendon sheaths. However, there have been reports of these cases in the last 100 years – in their paper Sullivan et al. [5] gathered 43 cases from the literature and provided two of their own. Nine of these involved only the ankle or foot. Only two cases reported the presence of a lipoma in the Achilles tendon sheath. The other seven included tibialis anterior/posterior, extensor digitorum longus, flexor/extensor hallucis longus, peroneus longus and brevis tendons. 2. The case A 60-year-old man presented with a clinically ruptured Achilles tendon. He normally works as an engineer and is regularly active in terms of exercise. He was running when he heard a ‘snap’ from his left ankle and developed instant pain, swelling, bruising and an inability to weight bear. The diagnosis was made clinically with no
* Corresponding author. Tel.: +44 7990 525 709. E-mail address: [email protected] (A.Z. Khan).
plantar-flexion on the affected side on squeezing both calves (positive Simmonds test) and a 2 cm palpable gap, 1 cm proximal to the calcaneal insertion. After discussion with the operating surgeon the decision was made for operative management. It is important to note that clinically he did not have a soft palpable lump on either side indicating the possible presence of a lipoma. He was taken to theatre the same day for a repair of his Achilles tendon. A large fatty mass that appeared to be a lipoma was discovered to arise from within the paratenon at the level of the rupture (see Figs. 1 and 2). The fatty lump was removed in its entirety and was found to not involve the tendon itself. The tendon was therefore repaired using the surgeons default technique – 2 modified Kessler stitches orthogonal to each other (Ticron, Syneture), then a circumferential continuous stitch for reinforcement (Vicryl, Ethicon). Post-operatively the patient was placed into an equinas cast and the standard protocol for post-op management was followed. The fatty mass was sent for histological examination and the results were as follows: macroscopically fibrofatty tissue measuring 2.5 cm 1.4 cm 1.0 cm, nodular in slicing. Microscopically fibrofatty tissue present with haemorrhage, thick and thin-walled blood vessels at the edge; fibrin thrombi are present focally; fat necrosis present; consistent with lipoma – histological changes suggest trauma. No malignancy seen. Post operatively the patient was followed up in the fracture clinic at 2 weeks for a wound review and removal of sutures, and then at 6 weeks after completion of the casting/bracing stage, prior to commencement of physiotherapy. The patient subsequently returned to his normal place of work as an engineer and was able to undertake regular mild exercise, e.g. swimming, jogging. 3. Discussion The lipoma discovered in our patient did not involve the tendon itself. It was possible to remove it entirely and we feel it did not
1268-7731/$ – see front matter . Crown Copyright ß 2011 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2011.10.003
A.Z. Khan et al. / Foot and Ankle Surgery 18 (2012) e16–e17
Fig. 1. The lipoma intra-operatively prior to removal.
e17
Tendon sheath tumours can be of varied origin including benign and malignant. It is of course important to distinguish between the two. The significance of a ganglion cyst is very much different to say a giant cell tumour or fibroma, so histological examination is essential in every case. Establishing the exact diagnosis is important as tendon sheath masses can display bony involvement or require surgical excision, after which they may recur as mentioned by Schissel and Elston [6]. There is the issue of whether a mass within a tendon sheath structurally weakens it. This of course depends on exactly what structures are involved. With our case we do not believe there to have been any pre-morbid structural weakness as the lipoma did not involve the tendon itself, and the history was consistent with a traumatic rupture. It is a common occurrence for people playing sports to lunge or jump and land awkwardly on their ankle/foot and rupture their Achilles tendon, more so if they are unaccustomed to physical exercise. The presence of the lipoma may affect the structural integrity of the tendon although this has not been formally studied or assessed. If the lipoma had involved the tendon itself partially or even entirely, the repair may not have been as sound as was undertaken. This could ultimately lead to a reduced push-off strength and increased risk of re-rupture compared to a standard ruptured tendon without lipoma. In addition, removing the lipoma could leave a gap that the surgeon cannot approximate and therefore necessitate tendon lengthening or grafting. In conclusion, tendon sheath masses are common enough that medical professionals should remain aware of their existence as this may alter their choice of tendon repair technique, and also may alter the outcome for the patient subsequently. The mass should be sent for histological diagnosis to rule out malignancy. Conflict of interest
Fig. 2. The lipoma as it was discovered.
affect the structural integrity of the tendon, nor did it therefore predispose the patient to rupturing his tendon in the first place. The number of cases of lipomas found within tendon sheaths is low and the number of cases of lipomas found within the Achilles tendon sheath is very rare indeed. After extensive literature search only two such cases have been found to be recorded, both in 1928. Although it has been difficult to get hold of the original paper by Mannini, 1928 that documented these two cases, a literature review by Sullivan, 1956 as mentioned before [5], summarised the cases of lipomata in tendon sheaths and recorded the cases from the paper by Mannini. Sullivan et al. recorded 45 cases. Of these 30 involved only the hands or wrists, 9 in the ankle or foot, two cases had tumours of both upper and lower limbs and one had them in both hands and both ankles. In total 14 cases demonstrated lipomata bilaterally. Unfortunately two cases gathered gave no detail regarding anatomical site of the lipomata. Interestingly extensor tendons were more often involved than flexor tendons.
The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, centre, clinical practice, or other charitable or non-profit organization with which the authors, or a member of their immediate families, are affiliated or associated. References [1] Bancroft LW, KRansdorf MJ, Peterson JJ, O’Connor MI. Benign fatty tumours classification, clinical course, imaging appearance and treatment. Skeletal Radiol 2006;35(10):719–33. [2] Toy BR. Familial multiple lipomatosis. Dermatol Online J 2003;9(4):9. [3] Salam GA. Lipoma excision. Am Fam Physician 2002;65(5):901–4. [4] Dalal KM, Antonescu CR, Singer S. Diagnosis and management of lipomatous tumors. J Surg Oncol 2008;97(4):298–313. [5] Sullivan CR, Dahlin DC, Bryan RS. Lipoma of the tendon sheath. J Bone Joint Surg Am 1956;38:1275–80. [6] Schissel DJ, Elston DM. Achilles tendon nodule: inflammation, rupture, or tumor? Phys Sportsmed 1998;26(5):59–62.