البروفيسور فريح ابوحسان – استشاري جراحة العظام في الاردن

1. Foot and Ankle Surgery 2002 8:59-62
Case report
Extragnathic fibromyxoma
report of a case
of the calcaneum:
F.O. ABU HASSAN
University of Jordan, Amman, Jordan
Summary
Fibromyxoma of the bone occurs mainly in the facial bones and it has
not been previously reported in the calcaneum. We present a rare case
of extragnathic fibromyxoma affecting the calcaneum in an adult male
patient who complained of persistent heel pain. Intraoperative char-acteristics
and histological examinations of the lesion demonstrated
fbromyxoma. Open curettage, local application of 5% phenol and
filling the cavity with bone cement relieved the patient's symptoms,
with no recurrence. This case represents another type of the benign
lesions affecting the calcaneum.
Keywords: fibromyxoma; calcaneum; foot; tumour; extragnathic;
mandible
Introduction
Fibromyxoma is an uncommon, intraosseus tumour
composed of fibrous tissues with variable myxoid
stroma, and uniform, stellate spindle cells [1-4]. It is
a tumour of the facial bones but extragnathic
localizations are described in the metaphysis of long
bones, rarely in the non-tubular bones [4-7]. As we
are concerned, this lesion was not previously repor-ted
to originate in the calcaneum.
We present a patient affected by such a tumour in
the calcaneum, which was successfully treated by
curettage and bone cement.
This is an unusual case concerning the type,
location and method of treatment. It illustrates the
difficulty in the radiological diagnosis and the
importance of biopsy before dealing with such
lesions, which have to be included into the list of
benign lesions of the calcaneum.
Correspondence: F.O. Abu Hassan, PO Box 73, Jubaiha 11941,
Jordan (e-maih freih@joinnet.com.jo).
Case report
A 54-year-old man presented with a 6-month history
of persistent right heel pain despite conventional
physiotherapy and local steroid injection.
The pain was dull, started gradually and
increased at night. Prolonged weight bearing mag-nified
the pain, whereas bed rest did not relieve it.
There was neither history of trauma to the foot, nor
any recent illness, fever or weight loss. Physical
examination did not reveal limping during walking.
There was no swelling, flush or local skin change.
The patient marked localized tenderness on the
lateral aspect of the heel. Active and passive ankle
and foot ranges of motion were normal compared
with the uninvolved site.
A lateral radiograph of the ankle demonstrated
faint, lytic lesion with well defned borders, invol-ving
the lower part of the calcaneum (Figure 1). The
calcaneal Harris view demonstrated well defined
lytic lesion in the lower lateral third of the calcaneum
(Figure 2).
© 2002 Blackwell Science Ltd 59

2. 60 F.O. ABU HASSAN
Figure 2
The calcaneal Harris view demonstrated well defined lytic lesion
in the lower lateral third of the calcaneum.
Figure 1
Lateral radiograph of the ankle demonstrating faint lytic lesion
with well defined margins, involving the lower part of the
calcaneum.
Routine blood investigations did not reveal any
abnormality.
A bone isotope scan demonstrated increased
uptake in the hindfoot, mainly related to the calca-neum.
A computed tomography scan demonstrated the
lytic lesion with a sclerotic, endosteal margin and
disruption of the outer cortex of the calcaneum with
no soft tissue invasion (Figure 3).
An attempt of needle aspiration did not reveal any
fluid content.
Incisional biopsy of the lesion was then performed
under general anaesthesia without using the tourni-quet.
The primary histological findings were uniform,
small, stellate, spindle-shaped cells with no mitosis
or pleomorphism in the stroma of the dense, fibrous
tissue, which were typical of fibromyxoma.
Figure 3
Computed tomography scan demonstrating the lyric lesion with
sclerotic endosteal margin and disruption of the outer cortex of
the calcaneum with no soft tissue invasion.
After 10 days, the lesion was explored through the
extension of the original incision, under general
anaesthesia, using the above ankle tourniquet.
Grossly, the tumour was soft grey to white and
gelatinous in consistency. Final histological diagno-sis
confirmed the fibromyxoma (Figure 4).
Complete curettage under direct vision was
followed by local application of 5% phenol.
The cavity was finally filled with bone cement.
Full weight bearing was allowed 25 clays after
surgery.
© 2002 Blackwell Science Ltd, Foot and Ankle Surgery 2002, 8, 59-62

3. FIBROMYXOMA OF THE CALCANEUM 61
Figure 4
Final histological diagnosis confirming the fibromyxoma.
There was no evidence of recurrence after 2 years
of follow-up.
Discussion
Fibromyxoma is a benign, bony lesion mainly
affecting the jaw [1-3]; extragnathic forms are
uncommon [4-8]. The metaphyseal ends of long
bones, especially the femoral ends, are the most
extragnathic localizations, which form 30% of the
cases [1,4,6]. The lesion rarely originates from the
periosteum of the femur [9].
Occasionally, fibromyxoma originates from flat
bones [1-3], but was not previously described in the
spongy bones as in our case.
Approximately 31 cases of the extragnathic variety
have been reported [1,3,4,6,8]. The lesion presents
with pain in various age groups. It is mainly
reported during the first two decades of life and
after the fifth decade [1,3,5]. The commonest radio-logical
feature is a well localized, radiolucent, lytic
defect or an expansile, medullary, metaphyseal
defect, with cortical destruction [1,3,4]. The tumour
may extend to the soft tissue but it does not cause
periosteal reaction [1,7,8]. Our case demonstrated
the well defined lyric lesion, and cortical destruction
of the outer third of the calcaneum, with no soft
tissue extension.
Extragnathic fibromyxoma can be radiologically
misdiagnosed with different benign lytic bone
lesions, for example, intraosseus lipoma [10-12],
intraosseus ganglion [13,14], chondromyxoid fibro-ma
[1,15], bone cysts [16,17], desmoplastic fibroma
[18,19] and giant cell tumour [15].
The cavity of the fibromyxoma lesion contains
soft grey to white gelatinous tissue. The histology
is distinctive, comprising uniform, small, stellate
and spindle-shaped cells with no mitosis or pleo-morphism
in the stroma of the dense fibrous tissue,
presence of areas of chondroid and osteoid tissues,
but no lobulation or fibrous capsule [1,3,4]. Secon-dary
aneurysmal bone cyst has been described
histologically [3]. Fibromyxoma should be differ-entiated
from malignant bone tumours, for exam-ple,
fibrosarcoma [15], chondrosarcoma [1,20], or
metastatic lesions of bone [15,21], by prominent
myxoid zones, absence of mitosis and pleomor-phism
[4].
In our case, incisional biopsy was necessary to
establish the presence of the typical uniform, stellate
and spindle-shaped cells in their fibrous and chon-droid
tissues. At a later stage, we carried out an
adequate curettage, local application of 5% phenol
and packed the cavity with bone cement to avoid
local recurrence of the tumour. Nevertheless, fibr-omyxoma
may recur after curettage [1,3,5,6]. In soft
tissue involvement, en bloc excision is recommended
[1,3,51.
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