Primary osseous tumors of the hindfoot: why the delay in diagnosis and should we be concerned?

Abstract

Background: Bony tumors of the foot account for approximately 3% of all osseous tumors. Diagnosis is frequently delayed as a result of lack of clinician familiarity and as a result of their rarity. The reasons for the delays, however, are unclear.

Questions/purposes: We therefore determined (1) how hindfoot tumors present and the specific reasons for delay in diagnosis; (2) whether the spectrum of disease varies between the talus and calcaneus; and (3) how these patients were treated.

Methods: We retrospectively reviewed the medical notes and imaging for all patients with 34 calcaneal and 23 talar tumors recorded in the Scottish Bone Tumour Registry. Demographics, presentation, investigation, histology, management, recurrence, and mortality were recorded.

Results: Hindfoot tumors present with pain and often swelling around the heel (calcaneus) or ankle (talus), most often misdiagnosed as soft tissue injury. Calcaneal lesions were more likely to be malignant than talar lesions: 13 of 34 versus three of 23.

Conclusions: Clinicians should be aware that hindfoot tumors can be initially misdiagnosed as soft tissue injuries and suspicion of a tumor should be raised in the absence of trauma or persistent symptoms. Lesions affecting the calcaneus are more likely to be malignant. Early diagnosis and adjuvant therapy are important.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

Lateral calcaneal radiograph showing a well-defined, radiolucent unicameral bone cyst (Table 1, Case 7)

Fig. 2

AP ankle radiograph showing classic appearance of osteoid osteoma within the superomedial aspect of the talus (Table 3, Case 5)

Fig. 3

Lateral calcaneal radiograph showing extensive osteosarcoma with soft tissue involvement in osteosarcoma (Table 2, Case 11)

Fig. 4

Recommended diagnostic protocol for patients presenting with suspected hindfoot tumor. RFA = radiofrequency ablation; BKA = below-knee amputation