Point-Counterpoint: Is Conservative Care The Best Approach For Plantar Fibromatosis?
Most experienced surgeons today advocate greater exposure and more wide excision of the plantar fibromatosis when surgery is necessary.3,5,13,20-27 Since the preferred approach is wide excision, the primary remaining issues that we still debate today are how much of the plantar fascia to remove and what is the best incisional approach for removing the mass and surrounding plantar fascia.
Regarding how much normal fascia one must remove around the nodular mass, Landers and associates felt the margins needed to be “at least 1 to 2 cm.”20 Sammarco and Mangone advocated dividing the fascia “at least 1.5 cm beyond the most distal part of the tumor.”3 Lee and colleagues recommended “at least a 2 cm margin of normal fascia proximal and distal to the nodule.”24
Removal of these amounts of the plantar fascia will necessitate larger incisions and the resulting greater potential for wound healing problems, skin compromise and nerve entrapment make conservative measures appear desirable.
Even with wide excision and subtotal plantar fasciectomy, recurrence remains a problem. Alexander and colleagues reported an 8 percent recurrence rate with complete plantar fasciectomy.28 Sammarco and Mangone found a slight decrease in the height of the arch after subtotal plantar fasciectomy, both clinically and radiographically, in their series of 14 patients (19 feet), although they reported no associated symptomatology.3
Although conservative treatment does not always resolve a plantar fibroma, conservative treatment does frequently reduce or eliminate the symptomatology, and soften and/or shrink the nodular mass. We should not abandon surgery for this condition but due to the need for wide excision of the plantar fibromatosis with good margins and the high incidence of incisional problems, wound problems, recurrence and potential mechanical changes to the foot, we should usually reserve surgery for recalcitrant cases that fail conservative treatment attempts.
Dr. Downey is the Chief of the Division of Podiatric Surgery at Penn Presbyterian Medical Center in Philadelphia. He is in private practice in Philadelphia, Radnor and Doylestown, Pa.