- Email: [email protected]
Surgical treatment for calcaneal intraosseous lipomas
The Foot 19 (2009) 93–97
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Surgical treatment for calcaneal intraosseous lipomas Cagatay Ulucay a,∗ , Faik Altintas a , Namik K. Ozkan b , Muharrem I˙ nan a , Ender Ugutmen b a b
Orthopedics and Traumatology Department, Yeditepe University, Istanbul, Turkey Medical Doctor, Orthopedics and Traumatology Department, Goztepe Training and Educational Hospital, Istanbul, Turkey
a r t i c l e
i n f o
Article history: Received 11 November 2007 Received in revised form 25 December 2008 Accepted 26 January 2009 Keywords: Calcaneal lipoma Curettage Autografting Milgram Foot pain
a b s t r a c t Intraosseous lipoma is among rare benign tumors of the bone. The aim of the present study was to evaluate the long-term surgical results of calcaneal lipomas, representing a relatively rare localization for this type of tumors. The present study included 21 calcaneal lipoma cases (22 feet) referred to our podiatry clinic between 1991 and 2001 with complaints of foot and heel pain resistant to conservative treatment for the last 3–6 months. In all cases, the diagnosis of calcaneal intraosseous lipoma was first confirmed radiologically, then histologically. The mean age was 39 years (range 16–62), 15 were females (71%) and 6 were males (29%). One patient had bilateral disease, whereas 11 and 9 patients had right and left calcaneal involvement, respectively. None of the patients have a palpable mass in their foot. For pre-operative differential diagnosis, 3 patients had computerized tomography examination (CT scan) and 8 patients underwent magnetic resonance imaging (MRI). All lesions were totally curetted out with angled curettes. The defect was filled with cancellous autografts taken from the ipsilateral iliac crest. In only four patients, the amount of autograft was not sufficient, so a combination of cancellous allograft and autograft was used. No drain was used. An elastic bandage was wrapped around the foot and ankle, and cold packs were applied to the surgical site. The mean duration of follow up was 94 (45–143) months. Pain improved in 17 feet at 4 months, in an additional 4 feet at 8 months and in the remaining one foot at 12 months. The mean time to the graft consolidation was 5 months (range 3–7 months). There were no recurrences or pathological fractures during the follow up. No wound infection or necrosis was seen at the surgical sites. There were no neurovascular complications. Five cases experienced pain in the iliac bone for 1 month, due to grafting procedures. Although calcaneal intraosseous lipoma accounts for a small portion of cases in the huge differential diagnosis chart for foot pain, it should be kept in mind as a possible diagnosis in unresolved cases. Most of the patients would benefit from non-surgical treatments. But if this is not the case, surgical treatment is indicated. In conclusion, curettage and autogenous bone grafting is an easy and effective method for the surgical treatment of calcaneal intraosseous lipomas. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction Intraosseous lipomas are benign tumors derived from mature lipocytes mostly seen at the metaphysis of the long bones in men. Foot and heel pain are the common symptoms of calcaneal intraosseous lipoma. Non-surgical options such as NSAIDs, cold compression, use of non-weight bearing devices such as cane, use of silicone sole plate and preventive measures for pathological fractures are the most commonly used treatment modalities for
this condition. Surgery is indicated in the presence of pain resistant to conservative treatment methods, impending or pathological fractures and when a histopathological differential diagnosis is required for aneurismal bone cyst, giant cell tumor, pseudocyst formation or unicameral bone cyst. Although surgical treatment with curettage and autogenous bone grafting has been reported as a treatment choice, only small case series have been reported so far. In this study, we present 21 calcaneal intraosseous lipoma patients treated with curettage and autogenous bone grafting. 2. Patients and method
∗ Corresponding author at: Orthopedics and Traumatology Department, Yeditepe University, Devlet Yolu Ankara Caddesi no: 102-104, 34752 Kozyata˘gı, Istanbul, Turkey. Tel.: +90 532 7284719; fax: +90 216 5663636. E-mail address: [email protected] (C. Ulucay). 0958-2592/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2009.01.005
The present study included 21 calcaneal lipoma cases (22 feet) referred to our podiatry clinic between 1991 and 2001 with complaints of foot and heel pain resistant to conservative treatment
94
C. Ulucay et al. / The Foot 19 (2009) 93–97
methods for the last 3–6 months including NSAIDs, cold compression or the use of non-weight bearing devices (such as cane) and silicone sole plate. In all cases, the diagnosis of calcaneal intraosseous lipoma was first confirmed radiologically, then histologically. The mean age was 39 years (range 16–62), 15 were females (71%) and 6 were males (29%). One patient had bilateral calcaneal involvement, whereas unilateral right sided and left sided involvement was seen in 11 and 9 patients, respectively. Radiological examinations of all patients showed an expansile osteolytic lesion in calcaneus. For radiological staging, Milgram’s classification [5] for intraosseous lipomas was used and the distribution of 22 feet was as follows: stage 1, 11 feet; stage 2, 9 feet and stage 3, 2 feet. None of the patients had a palpable mass. For preoperative differential diagnosis, 3 patients had computerized tomography examination (CT scan) and 8 patients underwent magnetic resonance imaging (MRI) (Figs. 1 and 2 ). Prior to the operation, the lesion was localized fluoroscopically and its localization was marked on the skin. Under tourniquet control, a straight lateral skin incision was performed over the lesion and the periosteum was incised longitudinally. The lesion and a portion of the adjacent normal tissue were exposed at one end of the lesion using a 1 cm × 1 cm rectangular cortical window opened
Fig. 1. Plain radiograph of a calcaneal lipoma.
Fig. 2. MRI appearances of different calcaneal lipomas.
C. Ulucay et al. / The Foot 19 (2009) 93–97
95
Fig. 2. (Continued).
using a sharp osteotome or an oscillating saw. An irregular, bulky, semi-fluid and very oily lesion with some bone spicules was seen in the medulla of calcaneus (Fig. 3). The lesion was totally curetted out with angled curettes through the window. The defect was filled with cancellous autograft taken from the ipsilateral iliac crest. In only four patients, the amount of autograft was not sufficient, so a combination of cancellous allograft and autograft was used. No drain was used. An elastic bandage was wrapped around the foot and ankle, and cold packs were applied to the surgical site. Acetaminophen tablets were prescribed for pain relief. The patients were mobilized with no weight bearing for 3 weeks, with
toe touch weight bearing for the next 3 weeks, followed by weight bearing as tolerated for the next postoperative weeks. Clinical and radiological examinations were done on the first postoperative day, at 6 weeks, at 12 weeks and every other month thereafter, until the radiological confirmation of graft consolidation (Fig. 4). 3. Results Patients were followed for a mean period of 94 (45–143) months after surgery. At the first 4 months, improvement in pain could be achieved in 17 feet. Such an improvement could be achieved in
96
C. Ulucay et al. / The Foot 19 (2009) 93–97
Fig. 3. Gross appearance of the curettaged lesion.
Fig. 6. Plain radiograph of an calcaneal lipoma, postoperative 10 years.
Fig. 4. Early postoperative plain radiograph of an operated calcaneal lipoma.
Fig. 7. Plain radiograph of an calcaneal lipoma, postoperative 14 years.
4. Discussion an additional 4 feet at 8 months and in one remaining foot at 12 months. The mean time to graft consolidation was 5 months (3–7 months) (Figs. 5–7). Graft consolidation was confirmed using only plain radiographs. There was no recurrence or pathological fracture during the follow up. No wound infection or necrosis was seen at surgical sites. There were no neurovascular complications. Five cases experienced pain in the iliac bone for 1 month, due to grafting procedures.
Intraosseous lipoma is among the very rare benign tumors of the bone [1]. According to Unni, they account for only 0.1% of all bone tumors [2]. Intraosseous lipoma was first reported by Brault in 1868 at the femoral shaft. In 1976, 26 cases of intraosseous lipoma were compiled and reported by Moorefield et al. [3]. Poussa and Holmstrom published the first calcaneal intraosseous lipoma as a case report in 1976 [4]. The largest series consisting of 66 cases
Fig. 5. CT of an operated calcaneal lipoma, postoperative 5 years.
C. Ulucay et al. / The Foot 19 (2009) 93–97
97
Fig. 8. Milgram’s classification for intraosseous lipomas.
was published in 1998 by Milgram. According to Milgram, the most common site for intraosseous lipoma was the intertrochanteric and subtrochanteric regions of the femur (21 cases), followed by calcaneus bone (5 cases). In that series, 25 patients had no symptoms and they were accidentally diagnosed; 14 patients had pain and 7 had a palpable mass. In the present study, all patients had pain but none presented with a palpable mass [5]. Milgram classified intraosseous lipomas into three histological groups depending on their degree of involution [6] (Fig. 8). Radiographic features are parallel with histopathological characteristics. We used Milgram’s classification for these calcaneal intraosseous lipoma cases because it is a reliable staging method for lipomas and plain X-rays give results parallel to the histopathological findings. But currently, in our institution, we use CT and MRI for the evaluation of such patients. Treatment of intraosseous lipomas is still controversial. Goto et al. [7] and Hirata et al. [8] suggested that surgical treatment is not necessary owing to the potential for spontaneous regression and very low rate of malignant transformation. But according to Hatori et al. [9] and Weinfeld et al. [10] curettage and grafting is the best choice of treatment. Schneider stated that the need for surgical treatment relies on the risk of malignant transformation [11]. Bertram reported a 33% rate of accidental diagnosis among 54 patients and surgery was only required when the patient was clinically symptomatic [12]. Neuber’s conclusion was similar to Bertram and stated that the majority of calcaneal intraosseous lipomas are seen in Ward’s triangle [13]. According to Huch et al. [14] and Radl et al. [15] curettage and grafting is a good choice for permanent treatment and can be performed if the patient is symptomatic. In the present study, we operated only symptomatic patients. All were resistant to conservative treatment for the last 3–6 months. None was operated due to a pathological fracture or for the purposes of differential diagnosis. All our patients recovered with full benefit and did not have any complaints. Although calcaneal intraosseous lipoma accounts for a small portion of cases in the huge differential diagnosis chart for foot pain,
it should be kept in mind as a possible diagnosis in unresolved cases. Most of the patients benefit from non-surgical treatments. But if this is not the case, surgical treatment is indicated. In conclusion, curettage and autogenous bone grafting is an easy and effective method for the surgical treatment of calcaneal intraosseous lipomas. References [1] Schatz SG, Dipaola JD, D’Agostino A, Hanna R, Quinn SF. Intraosseous lipoma of the calcaneus. J Foot Surg 1992;31(July–August (4)):381–4. [2] Unni KK. Classification of bone tumours. Can J Surg 1977;20(November (6)):504–9. [3] Moorefield Jr WG, Urbaniak JR, Gonzalvo AA. Intramedullary lipoma of the distal femur. South Med J 1976;69(September (9)):1210–1. [4] Poussa M, Holmstrom T. Intraosseous lipoma of the calcaneus. Report of a case and a short review of the literature. Acta Orthop Scand 1976;47(October (5)):570–4. [5] Milgram JW. Intraosseous lipomas A clinicopathologic study of 66 cases. Clin Orthop Relat Res 1988;231(June):277–302. [6] Milgram JW. Malignant transformation in bone lipomas. Skeletal Radiol 1990;19(5):347–52. [7] 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(2):274–80. [8] Hirata M, Kusuzaki K, Hirasawa Y. Eleven cases of intraosseous lipoma of the calcaneus. Anticancer Res 2001;21(November–December (6A)): 4099–103. [9] Hatori M, Hosaka M, Ehara S, Kokubun S. Imaging features of intraosseous lipomas of the calcaneus. Arch Orthop Trauma Surg 2001;121(September (8)):429–32. [10] Weinfeld GD, Yu GV, Good JJ. Intraosseous lipoma of the calcaneus: a review and report of four cases. J Foot Ankle Surg 2002;41(November–December (6)):398–411. [11] Schneider O, Mischo J, Puschel W. Intraosseous lipoma of the calcaneus. Chirurg 1994;65(January (1)):74–6. [12] Bertram C, Popken F, Rutt J. Intraosseous lipoma of the calcaneus. Langenbecks Arch Surg 2001;386(August (5)):313–7. [13] Neuber M, Heier J, Vordemvenne T, Schult M. Surgical indications in intraosseous lipoma of the calcaneus. Case report and critical review of the literature. Unfallchirurg 2004;107(January (1)):59–63. [14] Huch K, Werner M, Puhl W, Delling G. Calcaneal cyst: a classical simple bone cyst? Z Orthop Ihre Grenzgeb 2004;142(September–October (5)):625–30. [15] Radl R, Leithner A, Machacek F, Cetin E, Koehler W, Koppany B, et al. Intraosseous lipoma: retrospective analysis of 29 patients. Int Orthop 2004;December (28)(6):374–8.
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Surgical treatment for calcaneal intraosseous lipomas Cagatay Ulucay a,∗ , Faik Altintas a , Namik K. Ozkan b , Muharrem I˙ nan a , Ender Ugutmen b a b
Orthopedics and Traumatology Department, Yeditepe University, Istanbul, Turkey Medical Doctor, Orthopedics and Traumatology Department, Goztepe Training and Educational Hospital, Istanbul, Turkey
a r t i c l e
i n f o
Article history: Received 11 November 2007 Received in revised form 25 December 2008 Accepted 26 January 2009 Keywords: Calcaneal lipoma Curettage Autografting Milgram Foot pain
a b s t r a c t Intraosseous lipoma is among rare benign tumors of the bone. The aim of the present study was to evaluate the long-term surgical results of calcaneal lipomas, representing a relatively rare localization for this type of tumors. The present study included 21 calcaneal lipoma cases (22 feet) referred to our podiatry clinic between 1991 and 2001 with complaints of foot and heel pain resistant to conservative treatment for the last 3–6 months. In all cases, the diagnosis of calcaneal intraosseous lipoma was first confirmed radiologically, then histologically. The mean age was 39 years (range 16–62), 15 were females (71%) and 6 were males (29%). One patient had bilateral disease, whereas 11 and 9 patients had right and left calcaneal involvement, respectively. None of the patients have a palpable mass in their foot. For pre-operative differential diagnosis, 3 patients had computerized tomography examination (CT scan) and 8 patients underwent magnetic resonance imaging (MRI). All lesions were totally curetted out with angled curettes. The defect was filled with cancellous autografts taken from the ipsilateral iliac crest. In only four patients, the amount of autograft was not sufficient, so a combination of cancellous allograft and autograft was used. No drain was used. An elastic bandage was wrapped around the foot and ankle, and cold packs were applied to the surgical site. The mean duration of follow up was 94 (45–143) months. Pain improved in 17 feet at 4 months, in an additional 4 feet at 8 months and in the remaining one foot at 12 months. The mean time to the graft consolidation was 5 months (range 3–7 months). There were no recurrences or pathological fractures during the follow up. No wound infection or necrosis was seen at the surgical sites. There were no neurovascular complications. Five cases experienced pain in the iliac bone for 1 month, due to grafting procedures. Although calcaneal intraosseous lipoma accounts for a small portion of cases in the huge differential diagnosis chart for foot pain, it should be kept in mind as a possible diagnosis in unresolved cases. Most of the patients would benefit from non-surgical treatments. But if this is not the case, surgical treatment is indicated. In conclusion, curettage and autogenous bone grafting is an easy and effective method for the surgical treatment of calcaneal intraosseous lipomas. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction Intraosseous lipomas are benign tumors derived from mature lipocytes mostly seen at the metaphysis of the long bones in men. Foot and heel pain are the common symptoms of calcaneal intraosseous lipoma. Non-surgical options such as NSAIDs, cold compression, use of non-weight bearing devices such as cane, use of silicone sole plate and preventive measures for pathological fractures are the most commonly used treatment modalities for
this condition. Surgery is indicated in the presence of pain resistant to conservative treatment methods, impending or pathological fractures and when a histopathological differential diagnosis is required for aneurismal bone cyst, giant cell tumor, pseudocyst formation or unicameral bone cyst. Although surgical treatment with curettage and autogenous bone grafting has been reported as a treatment choice, only small case series have been reported so far. In this study, we present 21 calcaneal intraosseous lipoma patients treated with curettage and autogenous bone grafting. 2. Patients and method
∗ Corresponding author at: Orthopedics and Traumatology Department, Yeditepe University, Devlet Yolu Ankara Caddesi no: 102-104, 34752 Kozyata˘gı, Istanbul, Turkey. Tel.: +90 532 7284719; fax: +90 216 5663636. E-mail address: [email protected] (C. Ulucay). 0958-2592/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2009.01.005
The present study included 21 calcaneal lipoma cases (22 feet) referred to our podiatry clinic between 1991 and 2001 with complaints of foot and heel pain resistant to conservative treatment
94
C. Ulucay et al. / The Foot 19 (2009) 93–97
methods for the last 3–6 months including NSAIDs, cold compression or the use of non-weight bearing devices (such as cane) and silicone sole plate. In all cases, the diagnosis of calcaneal intraosseous lipoma was first confirmed radiologically, then histologically. The mean age was 39 years (range 16–62), 15 were females (71%) and 6 were males (29%). One patient had bilateral calcaneal involvement, whereas unilateral right sided and left sided involvement was seen in 11 and 9 patients, respectively. Radiological examinations of all patients showed an expansile osteolytic lesion in calcaneus. For radiological staging, Milgram’s classification [5] for intraosseous lipomas was used and the distribution of 22 feet was as follows: stage 1, 11 feet; stage 2, 9 feet and stage 3, 2 feet. None of the patients had a palpable mass. For preoperative differential diagnosis, 3 patients had computerized tomography examination (CT scan) and 8 patients underwent magnetic resonance imaging (MRI) (Figs. 1 and 2 ). Prior to the operation, the lesion was localized fluoroscopically and its localization was marked on the skin. Under tourniquet control, a straight lateral skin incision was performed over the lesion and the periosteum was incised longitudinally. The lesion and a portion of the adjacent normal tissue were exposed at one end of the lesion using a 1 cm × 1 cm rectangular cortical window opened
Fig. 1. Plain radiograph of a calcaneal lipoma.
Fig. 2. MRI appearances of different calcaneal lipomas.
C. Ulucay et al. / The Foot 19 (2009) 93–97
95
Fig. 2. (Continued).
using a sharp osteotome or an oscillating saw. An irregular, bulky, semi-fluid and very oily lesion with some bone spicules was seen in the medulla of calcaneus (Fig. 3). The lesion was totally curetted out with angled curettes through the window. The defect was filled with cancellous autograft taken from the ipsilateral iliac crest. In only four patients, the amount of autograft was not sufficient, so a combination of cancellous allograft and autograft was used. No drain was used. An elastic bandage was wrapped around the foot and ankle, and cold packs were applied to the surgical site. Acetaminophen tablets were prescribed for pain relief. The patients were mobilized with no weight bearing for 3 weeks, with
toe touch weight bearing for the next 3 weeks, followed by weight bearing as tolerated for the next postoperative weeks. Clinical and radiological examinations were done on the first postoperative day, at 6 weeks, at 12 weeks and every other month thereafter, until the radiological confirmation of graft consolidation (Fig. 4). 3. Results Patients were followed for a mean period of 94 (45–143) months after surgery. At the first 4 months, improvement in pain could be achieved in 17 feet. Such an improvement could be achieved in
96
C. Ulucay et al. / The Foot 19 (2009) 93–97
Fig. 3. Gross appearance of the curettaged lesion.
Fig. 6. Plain radiograph of an calcaneal lipoma, postoperative 10 years.
Fig. 4. Early postoperative plain radiograph of an operated calcaneal lipoma.
Fig. 7. Plain radiograph of an calcaneal lipoma, postoperative 14 years.
4. Discussion an additional 4 feet at 8 months and in one remaining foot at 12 months. The mean time to graft consolidation was 5 months (3–7 months) (Figs. 5–7). Graft consolidation was confirmed using only plain radiographs. There was no recurrence or pathological fracture during the follow up. No wound infection or necrosis was seen at surgical sites. There were no neurovascular complications. Five cases experienced pain in the iliac bone for 1 month, due to grafting procedures.
Intraosseous lipoma is among the very rare benign tumors of the bone [1]. According to Unni, they account for only 0.1% of all bone tumors [2]. Intraosseous lipoma was first reported by Brault in 1868 at the femoral shaft. In 1976, 26 cases of intraosseous lipoma were compiled and reported by Moorefield et al. [3]. Poussa and Holmstrom published the first calcaneal intraosseous lipoma as a case report in 1976 [4]. The largest series consisting of 66 cases
Fig. 5. CT of an operated calcaneal lipoma, postoperative 5 years.
C. Ulucay et al. / The Foot 19 (2009) 93–97
97
Fig. 8. Milgram’s classification for intraosseous lipomas.
was published in 1998 by Milgram. According to Milgram, the most common site for intraosseous lipoma was the intertrochanteric and subtrochanteric regions of the femur (21 cases), followed by calcaneus bone (5 cases). In that series, 25 patients had no symptoms and they were accidentally diagnosed; 14 patients had pain and 7 had a palpable mass. In the present study, all patients had pain but none presented with a palpable mass [5]. Milgram classified intraosseous lipomas into three histological groups depending on their degree of involution [6] (Fig. 8). Radiographic features are parallel with histopathological characteristics. We used Milgram’s classification for these calcaneal intraosseous lipoma cases because it is a reliable staging method for lipomas and plain X-rays give results parallel to the histopathological findings. But currently, in our institution, we use CT and MRI for the evaluation of such patients. Treatment of intraosseous lipomas is still controversial. Goto et al. [7] and Hirata et al. [8] suggested that surgical treatment is not necessary owing to the potential for spontaneous regression and very low rate of malignant transformation. But according to Hatori et al. [9] and Weinfeld et al. [10] curettage and grafting is the best choice of treatment. Schneider stated that the need for surgical treatment relies on the risk of malignant transformation [11]. Bertram reported a 33% rate of accidental diagnosis among 54 patients and surgery was only required when the patient was clinically symptomatic [12]. Neuber’s conclusion was similar to Bertram and stated that the majority of calcaneal intraosseous lipomas are seen in Ward’s triangle [13]. According to Huch et al. [14] and Radl et al. [15] curettage and grafting is a good choice for permanent treatment and can be performed if the patient is symptomatic. In the present study, we operated only symptomatic patients. All were resistant to conservative treatment for the last 3–6 months. None was operated due to a pathological fracture or for the purposes of differential diagnosis. All our patients recovered with full benefit and did not have any complaints. Although calcaneal intraosseous lipoma accounts for a small portion of cases in the huge differential diagnosis chart for foot pain,
it should be kept in mind as a possible diagnosis in unresolved cases. Most of the patients benefit from non-surgical treatments. But if this is not the case, surgical treatment is indicated. In conclusion, curettage and autogenous bone grafting is an easy and effective method for the surgical treatment of calcaneal intraosseous lipomas. References [1] Schatz SG, Dipaola JD, D’Agostino A, Hanna R, Quinn SF. Intraosseous lipoma of the calcaneus. J Foot Surg 1992;31(July–August (4)):381–4. [2] Unni KK. Classification of bone tumours. Can J Surg 1977;20(November (6)):504–9. [3] Moorefield Jr WG, Urbaniak JR, Gonzalvo AA. Intramedullary lipoma of the distal femur. South Med J 1976;69(September (9)):1210–1. [4] Poussa M, Holmstrom T. Intraosseous lipoma of the calcaneus. Report of a case and a short review of the literature. Acta Orthop Scand 1976;47(October (5)):570–4. [5] Milgram JW. Intraosseous lipomas A clinicopathologic study of 66 cases. Clin Orthop Relat Res 1988;231(June):277–302. [6] Milgram JW. Malignant transformation in bone lipomas. Skeletal Radiol 1990;19(5):347–52. [7] 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(2):274–80. [8] Hirata M, Kusuzaki K, Hirasawa Y. Eleven cases of intraosseous lipoma of the calcaneus. Anticancer Res 2001;21(November–December (6A)): 4099–103. [9] Hatori M, Hosaka M, Ehara S, Kokubun S. Imaging features of intraosseous lipomas of the calcaneus. Arch Orthop Trauma Surg 2001;121(September (8)):429–32. [10] Weinfeld GD, Yu GV, Good JJ. Intraosseous lipoma of the calcaneus: a review and report of four cases. J Foot Ankle Surg 2002;41(November–December (6)):398–411. [11] Schneider O, Mischo J, Puschel W. Intraosseous lipoma of the calcaneus. Chirurg 1994;65(January (1)):74–6. [12] Bertram C, Popken F, Rutt J. Intraosseous lipoma of the calcaneus. Langenbecks Arch Surg 2001;386(August (5)):313–7. [13] Neuber M, Heier J, Vordemvenne T, Schult M. Surgical indications in intraosseous lipoma of the calcaneus. Case report and critical review of the literature. Unfallchirurg 2004;107(January (1)):59–63. [14] Huch K, Werner M, Puhl W, Delling G. Calcaneal cyst: a classical simple bone cyst? Z Orthop Ihre Grenzgeb 2004;142(September–October (5)):625–30. [15] Radl R, Leithner A, Machacek F, Cetin E, Koehler W, Koppany B, et al. Intraosseous lipoma: retrospective analysis of 29 patients. Int Orthop 2004;December (28)(6):374–8.