Xanthomas of the Achilles tendon: report of a bilateral case and review of the literature

A Rare Case of Bilateral Achilles Tendon Xanthomas in a Teenager, Successfully Treated with Tendon Sparing Technique

Background

Xanthoma of the Achilles tendon, even though being benign, is a surgically challenging orthopaedic condition. Causality is believed to be due to a pathological error in the metabolism of low-density lipoprotein and their resultant accumulation, as foam cells within the tendon. Tendon xanthomas are often found to accompany heterozygous familial hypercholesterolemia. Case Presentation. A 19-year-old girl presented to our institution (a District General Hospital), with soft tissue lumps over posterior aspect of the ankle on both sides for several years. She had noticed a rapid increase in size in recent 3 months and sought medical advice. During investigation, she was diagnosed having bilateral Achilles tendon xanthomas clinically, confirmed by ultrasound scan and magnetic resonance imaging, and familial hypercholesterolemia concomitantly. The former was managed with intralesion subtotal resection where the histology further confirmed the diagnosis. The patient was commenced on statins and followed up while assessing the functional outcome and recurrences up to 2 years, with favourable results.

Conclusion

Subtotal resection of Achilles tendon xanthoma (tendon sparingly) offers cosmetically and functionally acceptable outcomes, with faster recovery and no recurrences over 2 years.

Cholesterol level in non-insertional Achilles tendonopathy

Familial hypercholesterolaemia is an autosomal dominant disease, with a prevalence of 1 in 500, where lipid deposits occur in the skin, tendons (particularly Achilles tendon) and arteries. It has a high risk of early coronary artery disease and mortality but is treatable with cholesterol lowering strategies if patients are diagnosed early. Studies in patients attending lipid clinics have shown that half the patients may have suffered from Achilles tendon symptoms 20 years earlier and it has been proposed that all patients presenting with Achilles tendon pain should have a serum cholesterol test. All consecutive patients seen in an adult foot and ankle clinic with non-insertional Achilles tendonopathy between April 2012 and March 2014 had their serum cholesterol measured. Only one patient in 83 (p=0.19) was diagnosed with heterozygous familial hypercholesterolaemia but 3 relatives of the proband patient were also diagnosed by cascade testing. Measurement of cholesterol in all patients presenting with achillodynia does not seem to be justified but the literature suggests that it should probably be considered in patients with bilateral extensive disease or those who give a history of intermittent episodes of severe pain lasting a few days.

[Achilles tendon xanthoma imaging on ultrasound and magnetic resonance imaging]

The Achilles tendon xanthoma is a rare disease and has a high association with primary hyperlipidemia. An early diagnosis is essential to start treatment and change the disease course. Imaging exams can enhance diagnosis. This study reports the case of a 60-year-old man having painless nodules on his elbows and Achilles tendons without typical gout crisis, followed in the microcrystalline disease clinic of Unifesp for diagnostic workup. Laboratory tests obtained showed dyslipidemia. The ultrasound (US) showed a diffuse Achilles tendon thickening with hypoechoic areas. Magnetic resonance imaging (MRI) showed a diffuse tendon thickening with intermediate signal areas, and a reticulate pattern within. Imaging studies showed relevant aspects to diagnose a xanthoma, thus helping in the differential diagnosis.

Reconstruction of bilateral tendoachilles with fascia lata graft

A 19 year old male presented with progressive enlargement of both tendoachilles for 2 years and difficulty in walking for 3 months. The neurological history and examination revealed progressive mental deterioration and ataxia. The blood investigation revealed hypercholesterolemia. We report this rare case of cerebrotendinous xanthomatosis with bilateral tendoachilles enlargement, which was treated by excision of bilateral tendoachilles and reconstruction with fascia lata. The American Orthopedic Foot and Ankle Society hindfoot score was 93/100 bilaterally and the subjective evaluation of the patient showed very good results.

Resection of bilateral massive Achilles tendon xanthomata with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap: A case report and literature review

Tumours of the Achilles tendon are rare. Reconstruction of the large defect following excision, however, is often a challenge and is sometimes a factor in deciding against operative treatment of a benign lesion. We report a case of excision of bilateral Achilles tendon xanthomata, with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap.

Direct plantar approach to Henry's knot for flexor hallucis longus transfer

BACKGROUND

Transfer of the flexor hallucis longus (FHL) tendon is an established method to replace a dysfunctional Achilles tendon. When using a single incision, the FHL tendon has to be transferred as a single stranded graft into the calcaneus and the distal FHL stump cannot be directly attached to the flexor digitorum longus tendon (FDL). Another concern with tendon retrieval is neurovascular damage. We report our results with a direct plantar approach for tendon harvest.

METHODS

A direct plantar approach to the master knot of Henry with reattachment to its distal stump while protecting the medial plantar nerve was used allowing a double stranded FHL-transfer in 25 cases of a severely dysfunctional Achilles tendon in 24 consecutive patients. Patients were evaluated prospectively and at an average followup of 73 (range, 20 to 121) months.

RESULTS

No wound healing problems and no lesion of the medial plantar nerve occurred. The subjective result was rated as excellent in 18 (72%), good in five (20%), and fair in one case (8%).The AOFAS hindfoot score averaged 95.4 (range, 61 to 100) points and the AOFAS hallux score averaged 97.6 (range, 87 to 100) points. No loss of plantarflexion force was observed in the big toe as compared to the contralateral side.

CONCLUSION

The plantar approach to Henry's knot allowed the use of a double stranded FHL transplant. The distal stump was attached to the FDL tendon to preserve flexion at the great toe without damaging to the medial plantar nerve.

Nodular excision for painful localized Achilles tendon xanthomas in type II hyperlipoproteinemia: a case report

Achilles tendon xanthomas are often associated with type II hyperlipoproteinemia, in which low-density lipoprotein derived from the circulation accumulates in the tendons. Sometimes coronary artery disease can jeopardize the life of the patient if the condition is neglected. We describe the case of bilateral painful Achilles tendon xanthomas in a heterozygous type II hyperlipoproteinemia family. Her symptoms were not alleviated despite anti-inflammatory medication and eccentric exercise for 6 months. She was treated with nodular excision of the xanthomas bilaterally and then with postoperative statins to avoid recurrence.

Cadaver bone-tendon graft for xanthomatosis of the tendo Achillis

We describe a 63-year-old man who had xanthomatosis of the right tendo Achillis. He had undergone excision of the left tendo Achillis 17 years earlier without reconstruction for the same condition. The neurological history and examination were normal. Blood investigations showed hypercholestrolaemia, for which he was being treated with statins.

He was referred with pain in the right tendo Achillis and problems with footwear.

He was treated by excision of the right tendo Achillis, the xanthomatous nodules and the involved skin, followed by reconstruction with a cadaver bone-tendon graft. At follow-up eight months postoperatively, the scar had healed well. He walked without pain and could wear any type of shoe. Plain radiographs showed that the bone graft had healed. The American Orthopaedic Foot and Ankle Society hindfoot score was 95/100. The patient’s subjective evaluation of the result was very good.