Point-Counterpoint: Is Conservative Care The Best Approach For Plantar Fibromatosis?
27. Durr HR, Krodel A, Trouillier H, Lienemann A and Refior HJ. Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment. Foot Ankle Int. 1999; 20(1):13-17.
28. Alexander IJ, Johnson KA, Shives TC, Reiman HM and Johnson JE. Aggressive fibromatosis of the plantar aspect of the foot. A case report. Bull Hosp Jt Dis Orthop Inst. 1987; 47(2):103-108.
Citing a lack of evidence-based studies on conservative care, this author says various studies in the literature have advocated surgical techniques and recommendations to reduce recurrence risk.
By Byron Hutchinson, DPM, FACFAS
The clinical presentation of plantar fibromatosis typically dictates the effectiveness of management in most patients. Most forms of fibromatosis are slow growing but at some point can begin rapid and unexpected growth. The etiology is unknown but there is a predictable progression of this painful condition.
Clinical and pathologic studies have classified plantar fibromatosis into three stages: proliferative, involutional and residual. The first stage is described by cellular proliferation, the second stage by nodule formation and the third stage by tissue contraction.1,2
Conservative care for this condition is palliative and not curative. There are no evidenced-based studies on any conservative therapy for plantar fibromatosis and most discussion on options is purely anecdotal.
In contrast, there are numerous articles on the surgical management of plantar fibromatosis. Based on many of these studies, we have surgical techniques that have become more successful due in part to recommendations made within these articles to avoid reported complications.3-6
Surgical Recommendations For Decreasing The Risk Of Recurrence
In particular, Lauf and colleagues note that techniques to lessen the recurrence of plantar fibromatosis include the use of split-thickness skin grafts and placing Marlex mesh although they concede such procedures have potential complications, including recurrence, foreign body reactions, scarring and inadequate soft tissue coverage.3 The authors advocate using dermal fat grafting following primary excision. They say this reduces the chance of recurrence while preserving the anatomic architecture of the foot and maintaining a soft, supple weightbearing surface with the formation of minimal scar tissue.
Similarly, Delgadillo and colleagues note that the preferred treatment for plantar fibromatosis is surgical extirpation of the mass.4 However, they note that it can be difficult to define the outer limits of the lesion and incomplete excision frequently results in postoperative recurrence of the lesion. They argue that a complete fasciectomy of the involved fascia is an effective technique to reduce the likelihood of a recurring fibromatosis lesion.
It is my opinion that early on when there is a small isolated nodule, conservative care can be effective but once there is a coalescence of these nodules or they become bigger than 1 cm in depth, conservative management is ineffective and frankly is rarely even palliative. When patients cannot walk because of the pain, the only option becomes surgical intervention for a consistent, predictable outcome. This is also true for those individuals who have a family history of the disease or other conditions such as Peyronie’s disease. These patients tend to do extremely poor with conservative care in particular and can have a higher recurrence with surgical intervention unless they receive a total fasciectomy.
Sammarco and Mangone proposed an operative staging system for plantar fibromatosis.7 The authors’ staging system, ranging from stage I to IV, incorporates the extent of plantar fascia involvement, the presence of skin adherence and the depth of tumor extension. They note the stage of the tumor in the study correlated well with postoperative wound healing, skin necrosis and recurrence. Preoperative and intraoperative staging helps decrease the risk for wound dehiscence and recurrence.