Rare Presentation of Calcaneal Tuberculosis Treated with Debridement and Antibiotic-impregnated Cement

ABSTRACT: Calcaneal tuberculosis (TB) is an uncommon manifestation of osteoarticular TB, accounting for <0.1% of skeletal cases. Its nonspecific features such as heel pain and swelling without systemic signs frequently mimic chronic osteomyelitis or bone tumors, often resulting in delayed diagnosis and risk of long-term disability. We report a case of a 20-year-old male presenting with progressive heel pain and swelling. Diagnostic evaluation included plain radiographs, which demonstrated a lytic lesion in the posterior-inferior calcaneus, and magnetic resonance imaging, which revealed marrow involvement. Histopathology of curetted material showed granulomatous inflammation with caseous necrosis. Cartridge-based nucleic acid amplification testing confirmed Mycobacterium tuberculosis. Surgical debridement was performed, and the residual cavity was filled with antibiotic-impregnated polymethylmethacrylate (PMMA) cement. Postoperatively, the patient was commenced on a bedaquiline-based antitubercular regimen as per drug susceptibility testing. The patient's postoperative course was uneventful. Serial follow-up radiographs showed stable cement position and progressive healing changes. By 5 months, the patient achieved pain-free ambulation with no evidence of recurrence or implant-related complications. This case highlights the need for high clinical suspicion of TB when evaluating lytic calcaneal lesions in endemic regions. In addition to systemic antitubercular therapy, the use of antibiotic-loaded PMMA cement after debridement can serve as an effective surgical adjunct by providing local infection control and immediate mechanical stability in the load-bearing hindfoot.