Tag Archives: tibia-calcaneal arthrodesis

Giant Cell Tumor of Talus: A case report of late presentation with extensive involvement

by Mohan Kumar J.1 , Narayan Gowda2

The Foot and Ankle Online Journal 4 (1): 1

Giant cell tumor (GCT) of bone, or osteoclastoma, is classically described as a locally invasive tumor that occurs close to the joint of a mature bone. It is generally considered to be a benign tumor. In our rural setup, a substantial proportion of patients seek traditional means of treatment before medical consultation. A case of GCT in a 20 year-old boy which had led to extensive destruction of the talus is reported. In view of the extensive involvement, total talectomy along with tibio – calcaneal arthrodesis was performed. At 6 months of follow-up, the patient had a painless and well arthrodesed ankle. There was no evidence of recurrence at 18 months of follow-up.

Key words: GCT, osteoclastoma of the talus ,tibiocalcaneal ,arthrodesis.

Accepted: December, 2010
Published: January, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0401.0001

In the talus, giant cell tumor (GCT) of bone is an infrequent primary bone tumor that can present late with extensive involvement of soft tissue and articular surface changes often making the joint preservation difficult or impossible. [1] GCT account for approximately 5-8% of all primary bone tumors. [2,3,4] The authors report a GCT which had led to destruction of the entire talus in a 20 year-old boy. In view of the extensive involvement, total talectomy along with tibiocalcaneal arthrodesis was performed with the aim of achieving a stiff but painless joint.

Case presentation

A 20 year-old boy presented with chief complaints of insidious onset pain in the left ankle since the last two years, swelling in the left ankle since the last six months and inability to bear weight on right side since the last six months. The patient was treated elsewhere with intralesional steroid. There was no history of fever, loss of appetite, loss of weight, similar complaints in other joints or history of similar complaints in the past. The family, occupational, recreational and drug histories were not significant. The general physical and systemic examinations were within normal limits. On local examination, the attitude of the limb was neutral. There was a 5 × 4 cm swelling over medial and anterior aspect of left ankle joint. (Fig. 1)

Figure 1 Clinical photo of the left ankle.

There were no visible veins, sinus or discharge from the swelling. There was hypopigmentation and the swelling was tender. All movements at the ankle joint were painfully restricted. Serum biochemistry studies were within normal limits. Anterior posterior (AP) and lateral radiographs of the ankle showed a radiolucent lesion occupying the whole talus. (Fig. 2) The magnetic resonance scan (MRI) revealed an expansible soft tissue mass in the talus causing cortical destruction and extension into soft tissues. (Fig. 3) A fine needle aspiration of the mass was performed and a provisional diagnosis of GCT was rendered.

Figure2 Radiograph showing the lesion (left ankle).

Figure 3 Preoperative MRI showing GCT extensive involvement of the left ankle.

The condition, its prognosis and various treatment modalities were discussed with the patient and his family. Because of extensive involvement of talus, total talectomy with tibiocalcaneal arthrodesis was planned. The patient was a manual labourer and therefore opted for a stiff but painless joint. Total talectomy was performed through an anterolateral approach. (Fig. 4) Fusion was achieved by autologous iliac crest graft and stabilization with a Steinmann pin and Chamley’s clamp. (Fig. 5) The patient was advised non weight bearing on the affected limb for 8 weeks and mobilized in a short leg walking cast thereafter.

Figure 4 Intraoperative image showing the lesion.

Figure 5 Immediate post-operative radiograph showing complete talectomy and pan talar fusion using external fixator.

At 6 months of follow-up (Fig. 6), the patient had a smooth healed scar with a painless and well arthrodesed ankle and no evidence of recurrence. He had shortening of 2 cms which he managed with a shoe rise. There was no evidence of recurrence at 18 months of follow-up.

Figure 6 Clinical photo 6 months after surgery.


GCT, also known as osteoclastoma, is a fairly common bone tumor accounting for 5% of all the primary bone tumors. It is a benign tumor with a tendency for local aggressiveness and high chances of recurrence. GCT is most commonly seen in the distal femur proximal tibia, distal radius and the proximal humerus in descending order of frequency. [5]

The foot is an unusual site of presentation and GCTs involving hand and foot bones appear to occur in a younger age group and tend to be multicentric. [6] The clinical picture is that of insidious onset pain, which in many cases may be mismanaged as ankle sprain. A history of preceding trivial trauma may be present. Other features are non specific. Radiologically; the tumor appears as an eccentric lytic lesion with cortical thinning and expansion. There is absence of reactive new bone formation. The tumor may erode the cortex and invade the joint. Pathological fracture may also be seen. [7] MRI scanning permits accurate delineation of the tumor extent and helps in deciding the line of management i.e. (curettage versus talectomy).

Many authors have reported satisfactory results with intralesional curettage and bone grafting. [8] However, curettage alone has a high rate of recurrence and adjuvants like Methylmethacrylate (bone cement), cryotherapy and phenol have been suggested.

Partial or total talectomy may be contemplated in cases where there is extensive involvement of the talus. Arthrodesis may or may not be done, but it is said that arthrodesis is essential after resection of all tarsal bones except calcaneum. [9]

Fresh frozen osteochondral allograft reconstruction has also been described for an aggressive GCT of talus but there is paucity of literature on this particular modality of treatment. [10] The trend is towards limb salvage and amputation is reserved for recurrences and only rarely done. In conclusion, in a case of GCT of talus presenting late with extensive involvement and in a manual labourer, total excision and tibiocalcaneal arthrodesis is an valuable treatment option.


1. Ng ES, Saw A, Sengupta S. Giant cell tumour of bone with late presentation: review of treatment and outcome Journal of Orthopaedic Surgery 2002: 10(2): 120–128.
2. Huvos AG Bone Tumours: Diagnosis, Treatment and Prognosis. 1979, 1st Edition, Saunders, Philadelphia p265.
3. Schajowicz F. Tumors and Tumor Like Lesions of Bone and Joints. New York, NY: Springer; 1981.p 205.
4. Dahlin DC. Bone Tumours: General Aspects and Data on 6221 cases. 1981, 3rd Edition. Charles C Thomas Publisher, Springfield p99.
5. Stoker DJ. Bone tumors (1): general characteristics benign lesions. In: Grainger RG, Allison DJ (Editors). Diagnostic radiology a textbook of medical imaging. 3rd Edition. New York: Churchill Livingston; 1997. p. 629–1660,
6. Wold LE, Swee RG. Giant cell tumor of the small bones of the hand and feet. Semin Diagn Pathol 1984, 1:173-184.
7. Carrasco CH, Murray JA. Giant cell tumours. Orthop Clin North Am 1989, 20: 395- 405.
8. Bapat MR, Narlawar RS, Pimple MK, Bhosale PB. Giant cell tumour of talar body. J Postgrad Med 2000, 46:110.
9. Dhillon MS, Singh B, Gill SS, Walker R, Nagi ON. Management of giant cell tumor of the tarsal bones: a report of nine cases and a review of the literature. Foot Ankle 1993, 14(5):265-272.
10. Schoenfeld AJ, Leeson MC, Grossman JP. Fresh-frozen osteochondral allograft reconstruction of a giant cell tumor of the talus. J Foot Ankle Surg 2007, 46(3):144-148.

Address correspondence to: Department of Orthopaedics PESIMSR. Kuppam AP India 517425

1 Assistant professor, Dept of Orthopaedics PESIMSR.
2 Assistant professor, Dept of Orthopaedics PESIMSR.

© The Foot and Ankle Online Journal, 2011

Pirogoff’s Amputation after Shotgun Injury of the Foot: A case report

by Oestern, S.1 , Trompetter, R.2, Lippross, S.1, Daniels, M., Varoga, D.1, Mailänder, P.3, Weuster, M.1, Klüter T.1, Seekamp, A.4

The Foot & Ankle Journal 1 (10): 1

Introduction: A gunshot injury can cause extended soft-tissue injury and traumatic contamination leading to infection. The aim of the Pirogoff amputation is to eliminate infection and remove as little of the extremity as possible. This will result in a functional stump with tissues capable of tolerating weight-bearing stress.

Case report: We present a case of a 73-year-old male with extended soft-tissue injury of the left foot and multiple pellets in the surrounding tissues after shotgun injury. Aside from arterial hypertension and non-insulin-dependent diabetes mellitus, the patient suffered from obesity and peripheral peroneal paresis after thromboembolectomy in 1997. Systemic and local examination showed no neurological or vascular compromise to the foot. Radiographs revealed comminuted fractures of the talus, navicular and medial cuneiform. A Priogoff amputation was chosen as the amputation of choice.

Conclusion: When higher amputation of the foot is necessary, Pirogoff´s amputation is a useful procedure and offers satisfying results in patients without vascular defects. This amputation preserves more of the limb than a below-the-knee amputation and appears more functional and resilient than a Syme’s amputation. It also provides a lesser degree of limb length discrepancy than the Syme’s amputation.

Key words: Pirogoff’s amputation, tibia-calcaneal arthrodesis, shotgun injury

This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: September, 2008
Published: October, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0110.0001

Irreversible destruction of the forefoot and midfoot generally leads to amputation. Transmetatarsal, Chopart or Syme’s amputations can often result in poor clinical outcomes. [4]

Prostheses for such stumps can be difficult to fit. This reduces the mobility of the patient and reamputations are sometimes necessary. [4]

Pirogoff´s arthrodesis was first described by Pirogoff in 1854. [4] It can serve as a surgical salvage procedure in complex injuries of the forefoot where considerable osseous and soft tissue defects are present. This paper presents a case report of gunshot injury to the left foot.

Case presentation

A 73 year-old male suffered a shotgun injury to the left foot while loading a shotgun. He sustained extensive soft-tissue injury to the medial aspect of the mid foot and comminuted fractures of the talus, navicular and medial cuneiform. (Figs.1AB)


Figure 1AB   Shotgun injury of the left foot with extended soft-tissue injury.  Multiple pellets in surrounded tissue is shown on radiograph.

The patient had the following comorbidities: morbid obesity, arterial hypertension, and non-insulin-dependent diabetes mellitus. After thrombembolectomy in 1997, the patient regularly took warfarin. The patient was referred to the author`s trauma center. Initial digital angiography showed an occlusion of the anterior tibial artery and perfusion of the posterior tibial and peroneal arteries.

On the day of injury, a wound debridement was performed and the foot was stabilized by external fixation. Two days later, a vacuum assisted closure therapy was started. Due to the extensive soft-tissue defect and destruction of the medial column of left foot, Pirogoff´s forefoot amputation was performed by rotation of the dorsal part of calcaneus to 70 degrees. This was performed in cooperation with the department of plastic surgery at the University of Schleswig-Holstein Campus, Lübeck, Germany. (Figs. 2AB)


Figure 2AB  Pirogoff´s forefoot amputation was performed by rotation of dorsal part of calcaneus up to 70 degrees and fused to the tibial plafond.

The wound defect was covered with a dorsalis pedis flap. Three days later, the drain was removed. Apart from a postoperative hematoma, the operation proceeded without complication. One month after operative treatment, the patient was referred to another hospital for functional rehabilitation. Three months after amputation the patient was fitted with a prothesis. (Fig. 3)

Figure 3  The patient was fitted with a prothesis three months after the Pirogoff amputation.


Severe injuries require a coordinated approach in treatment. Goals of this treatment are to assure functional limb salvage. [1] When determining the level of amputation, comorbidities such as diabetes and occlusive vascular disease should be considered.

Gunshot wounds, as in the described case, are frequently accompanied by extended soft-tissue infection and fractures. Compartment syndromes should not be overlooked in open fractures as the adjacent compartments are still at risk. A compartment syndrome can communicate with the lower leg and can compromise limb salvage. A low threshold for fasciotomy should be maintained in these complicated injuries.  A compartment syndrome can communicate with the lower leg and can compromise limb salvage.

Large crush injuries, as is often seen with shotgun wounds, are also predisposed to higher rates of infection due to the concomitant muscle hypoxia and secondary necrosis. [1] An analysis of outcomes of reconstruction or amputation after leg-threatening injuries showed that the outcomes among patients who underwent reconstruction were not significantly different from those patients who underwent amputation. [2] Irreversible destruction of the forefoot and midfoot with concomitant wound contamination generally leads to amputation.

The decision to amputate may be immediate within the first 24 hours or delayed as a procedure within the first hospitalization. Several authors have developed scoring algorithms to help guide this decision. [3,6] However, reconstruction compared to amputation is associated with a higher risk of complication, additional surgical treatment and rehospitalization.

Before operative treatment, sufficient diagnostics and imaging must be performed. A retrospective review was undertaken by Odland to determine risk factors associated with amputation after open fractures of the lower extremity that were complicated by vascular injury. [8] The prognosis remains unfavorable for the patient with polytrauma who is admitted with a crushed limb in shock. The degree and length of ischemia are critical factors that should be addressed. Vascular repair, debridement of devitalized tissue and stabilization of the bone is essential for successful outcome. [8]

In this case, digital angiography revealed good perfusion of the posterior tibial and peroneal arteries. The anterior tibial artery showed an occlusion which was not of overriding importance for the blood supply to the calcaneus. Some studies have shown that Lisfranc, Chopart and Syme’s amputations are associated with wound healing complications and the need for revisional amputation. [5,7] Therefore, the indication on level of amputation should to be carefully considered.9 Prostheses after transmetatarsal amputation are also difficult to fit. The mobility of these patients is sometimes reduced and further revision may be necessary. [4]

The tibiocalcaneal arthrodesis introduced by Pirogoff in 1854 can be a useful surgical alternative in selected cases. [4] The Pirogoff ankle disarticulation maintains limb length by rotating the calcaneus and does not cause severe pain because of the existence of the calcaneus and fat pad for weightbearing. [10]

Injuries limited to the forefoot, especially in shotgun wounds, when reconstruction of the forefoot is not possible are an indication for forefoot amputation with arthrodesis between tibia and calcaneus. Absolute contraindications to the Pirogoff´s arthrodesis are the destruction of the calcaneus, osteomyelitis of the lower tibia and calcaneus and malignancy of the heel. [11]

The Pirogoff amputation offers a more stable stump and higher mobility compared to the Syme’s amputation. [11] The healed flap is less vulnerable than in a Syme’s amputation and the stump offers a minimum of limb length shortening. This fascilitates a better fit of the stump into a prothesis and allows some limited barefoot mobility.

Deep infection or osteoporosis may delay or prevent fusion between tibia and calcaneus. This seems to be one of the most important considerations when making a decision to perform the Pirogoff arthrodesis.

However, difficulties such as bony fixation and healing of the arthrodesis can be minimized by using an external ring fixation system.


Large zone crush injuries are predisposed to high rates of infection due to muscle hypoxia and secondary necrosis. Therefore, the procedure of choice in many of these cases is amputation. When ankle disarticulation is necessary, surgeons have various options. The Syme amputation can result in a leg-length discrepancy and Chopart’s amputation may lead to dropfoot, which can compromise walking. [10]

The Pirogoff ankle disarticulation can be a viable procedure alternative. Our case, therefore, recommends Pirogoff amputation in patients with irreversible destruction of the forefoot and midfoot. It maintains leg length by rotating the calcaneus. Comorbidities and other factors such as age and risk of infection should however be considered before surgery.


1. Agnew S: Lower Extremity Limb Salvage: Decision Making & Technical Challenges. Jacksonville Medicine, 1998. [online]
2. Bosse MJ, MacKenzie, EJ, Kellum, JF, et al.: An analysis of outcomes reconstruction or amputation after leg-threatening injuries. The New England Journal of Medicine: 347: 1924-1931, 2002.
3. Dirschl DR, Dabners LE: The mangled extremity: when should it be amputated? Journal of American Academy of Orthopaedic Surgeons: (Volume 4) 182-190, 1996.
4. Einsiedel T, Dieterich J, Kinzl L et al: Lower limb salvage using Pirogoff ankle arthrodesis: Minimally invasive and effective fixation with the Ilizarov external ring fixator. Orthopäde 37(2): 143-152, February 2008.
5. Krieghoff R: The Pirogoff amputation from the current viewpoint. Beit Orthop Traumatologie: 29(8): 434-438, August 1982.
6. Lange RH: Limb reconstruction vs. Amputation decision making in massive lower extremity trauma. Clinical Orthopaedics: Volume 243: 92-99, 1989.
7. Pollard J. Hamilton S, Rush S et al: Mortality and morbidity after transmetatarsal amputation: retrospective review of 101 cases. The Journal of Foot & Ankle Surgery: 45(2): 91-97, March, 2006.
8. Odland MD, Gisbert VL, Gustilo RB et al: Combined orthopedic and vascular injury in the lower extremities: indications for amputation. Surgery; 108(4): 664-666, 1980.
9. Siev-Ner I, Heim M, Warshawski M et al: A review of the aetiological factors and results of trans-ankle (Syme) disarticulations. Disability & Rehabilitation: 28(4): 239-242, February, 2006.
10. Taniguchi A, Tanaka Y, Kadono K et al: Pirogoff ankle disarticulation as an option for ankle disarticulation. Clinical Orthopaedics and related research: 414: 322-328, 2003.
11. Warren G. Conservative Amputation of the neuropathic Foot-The Pirogoff Procedure. Operative Orthopädie und Traumatologie: 9 (1): 49-58, March, 1997.

Address correspondence to: Dr. Stefanie Oestern. Department of Trauma Surgery, University of Schleswig-Holstein, Campus Kiel. Arnold-Heller-Straße 3, 24105 Kiel, Germany Email: Stefanie.Oestern@uksh-kiel.de

1Resident of Trauma Surgery, UK-Schleswig-Holstein, Campus Kiel, Germany.
2Senior Physician of Trauma Surgery, UK-Schleswig-Holstein, Campus Kiel, Germany.
3Chief of Plastic Surgery, UK-Schleswig-Holstein, Lübeck, Germany.
4Chief of Trauma Surgery, UK-Schleswig-Holstein, Campus Kiel, Germany.

© The Foot & Ankle Journal, 2008