Point-Counterpoint: Is Conservative Care The Best Approach For Plantar Fibromatosis?

Author(s): 
Michael S. Downey, DPM, FACFAS, and Byron Hutchinson, DPM, FACFAS

   There are a number of good evidence-based studies that support aggressive excision of the plantar fascia through several modified plantar approaches.8-9 A study by Van der Veer and colleagues focused on 27 patients with plantar fibromatosis who had 40 operations on 33 feet.8 The authors noted that treating a primary lesion with total plantar fasciectomy was associated with the lowest recurrence rate (25 percent) while local resection of the lesion was associated with the highest recurrence rate (100 percent). The study concluded that surgical treatment of plantar fibromatosis is indicated only when the lesions are highly symptomatic and conservative measures have failed to resolve the condition.

   The blood supply to the plantar skin overlying the medial band of the plantar fascia comes from multiple areas and this allows for adequate exposure with minimal risk to flap survival. The angiosomes have been well documented in this area.10 This does not mean that skin slough is not a risk. In certain cases when the nodules involve the subcutaneous tissue, complete removal can compromise the skin flap, causing a slough of the skin.

Keys To Success With The Surgical Technique

The incisional approach typically occurs along the medial band of the plantar fascia extending to just behind the metatarsal heads and ending proximally at the insertion of the plantar fascia. There are several modified approaches but in general, they all provide good access to the plantar fascia.

   The nodules are not well encapsulated so the key to success is taking an adequate amount of normal fascia around the diseased nodular fascia. This does decrease the chance of recurrence. Although there is a 15 percent recurrence rate for these lesions, I have had much more predictable results with surgical intervention than with conservative management.

   The vast majority of the nodules involve the central band of the plantar fascia and can be large enough to cause compression neuropathy to the medial plantar nerve. In my opinion, this requires surgical release rather than conservative care to avoid long-term damage to the nerve. When the lesions are attached to the overlying dermis, one must remove the involved skin as well and this area needs skin grafts to prevent local recurrence.

   Dr. Hutchinson is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified in Foot and Ankle Surgery by the American Board of Podiatric Surgery. He is the Secretary and President of the International Foot and Ankle Foundation for Education and Research. He is in private practice in Burien, Wash.

References
1. Landers PA, Yu GV, White JM, Farrer AK. Recurrent plantar fibromatosis. J Foot Ankle Surg. 1993; 32(1):85-93.
2. Headicke GJ, Sturim HS. Plantar fibromatosis: an isolated disease. Plast Reconstr Surg. 1989; 83(2):296-300.
3. Lauf E, Freedman BM, Steinberg JS. Autogenous free dermal fat grafts in the surgical approach to plantar fibromatosis. J Foot Ankle Surg. 1998; 37(3):227-34.
4. Delgadilo LA, Arenson DJ. Plantar fibromatosis: surgical considerations with case histories. J Foot Surg. 1985; 24(4):258-65.
5. Wapner KL, Ververeli PA, Moore, JH et al. Plantar fibromatosis a review of primary and recurrent surgical treatement. Foot Ankle Int. 1995; 16(9):548-51.
6. Durr HR, Krodel A, Trouillier H, Lienemann A, Refior, HJ. Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment. Foot Ankle Int 2001;20:13-7.
7. Sammarco GJ, Mangone PG. Classification and treatment of plantar fibromatosis. Foot Ankle Int 2000; 21(7):563-9.
8. Van der Veer WM, Hamburg SM, de Gast A, Niessen FB. Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results. Plast Reconstr Surg. Aug 2008; 122(2):486-91.
9. Zgonis T, Jolly GP, Vasilios P, Kanuck DM. Plantar fibromatosis. Clin Podiatr Med Surg 2005; 22(1):11-18.
10. Hidalgo DA, Shaw WW. Anatomic basis of plantar flap design. Plast Reconstr Surg. 1986; 78:627-36.

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