Case Presentation On May 5, 2008, a 42 year old male presented to clinic complaining of painful calluses and masses on the balls of both feet. The masses had been present on his feet for several years and seemed to slowly enlarge, with progressive discomfort. At the time of presentation, he had a negative past medical history. A focused physical exam revealed bilateral large masses noted in the lesser metatarsal and sulcus areas. These areas were mildly tender to palpation, and were firm, non-mobile structures, non pulsatile without fluctuance. These masses did not trans-illuminate. No erythema or edema was appreciated here. Lesser MPJ’s showed limited range of motion, and attempted ROM produced pain, particularly with end range dorsiflexion. Initial x-ray evaluation of both feet demonstrated increased soft tissue density, otherwise a benign radiograph. Bilateral MRI evaluations were then obtained, revealing fairly well defined, large masses on the bilateral forefoot. T1 and T2 weighted images demonstrated intermediate intensity. Neoplastic process could not be ruled out. For definitive confirmation the patient was then consented to a core needle biopsy of bilateral feet. Core needle biopsy was performed on May 30, 2008 under fluoroscopic guidance. Three samples were taken from each foot to ensure adequate sample for pathological evaluation. Subsequent pathological evaluation showed fibroblastic proliferation in all samples. Immunohistochemical staining was consistent with plantar fibromatosis. After a period of failed conservative therapy surgical excision was decided upon by the patient and surgeon. Excision of the left foot mass was performed on September 4, 2008. A curvilinear shaped incision was created following the contour of the plantar sulcus. A large skin flap was created using blunt and sharp maneuvers. Finding a well defined tissue plain was difficult due to the large, lobular, irregular lesion, and areas of the mass were adhered to the overlying skin. The mass was excised and soft tissue was successfully closed. Excision of the right foot plantar fibroma was performed on March 4, 2010. A similar incision was utilized, again following the contour of the plantar sulcus and a large flap was raised. The mass was visualized and blunt and sharp maneuvers were used to dissect out the mass. The mass was again extremely irregular in contour and tissue planes were poorly defined due to invasion of the mass into adjacent tissue. The mass had investments that extended well up into the 2nd, 3rd, and 4th intermetatarsal spaces making dissection and preservation of tendon and neurovascular structures challenging. The mass was successfully excised, and again sent to pathology. Plantar fibromatosis was again confirmed.  

Discussion Although plantar fibroma's commonly occur in the medial band of the plantar fascia they can occur anywhere within plantar foot. We experienced an usual location within the sulcus. All three surgical specimens had similar sizes. The ranged from 5-6.0 cm x 2.4-2.5 cm x 1.5-2.4 cm. Pathological evaluation was performed both at Cleveland Clinic as well as Kaiser Permanente due to the unusual location. Both confirmed plantar fibroma as the diagnosis. The revisional surgery on the left foot was technically difficult due to prior scar tissue as well as the invasive size of the mass. It was difficult to appreciate any “normal” anatomy with the revisional surgery. This may account for the residual numbness that the patient is currently experiencing. Consistent with a typical fibroma presentation/course the lesion within the sulcus can recur despite extensive debridement.

 

   

Statement of Purpose Plantar Fibromatosis is a common pathology encountered by the foot and ankle surgeon. Typical presentation is within the medial band of the plantar fascia. We present an unusual presentation within the sulcus and surgical management of the case.

     

Literature Review

Plantar fibromatosis, aka Ledderhose Disease, is a condition best described as a benign proliferative soft tissue tumor located within the plantar fascia. It most commonly affects the medial band of the plantar fascia as palpable nodules. Although encountered regularly by the foot and ankle physician, plantar fibromatosis is quite rare. Its incidence varies in the literature, and it exact incidence is unknown10. Pickren et al. reviewed plantar fibromatosis at their institution and found the incidence to be 1.75 per 100,000 hospital admissions8. Plantar fibromatosis is more common in Caucasians versus African Americans8,9 and also has a slight male predilection 3. Most commonly it is observed in patients within their four and fifth decade 3. Although it has been associated with multiple disorders its etiology remains largely uknown2,8,9,10 . Progression begins with small, asymptomatic nodules that enlarge and become symptomatic due to their space occupying nature. On occasion they can extend beyond the fascia into overlying skin or deeper into muscle, tendon or neurovascular structures9,11. Diagnosis is often clinical, however MRI can aid surgical planning. Lesions can show signal intensity heterogeneity on MR7 , but classically are described as low signal intensity on T1 weighted image, low to intermediate signal intensity on T2 weighted images, and high signal intensity on fat-suppressed sequences 11. Differential diagnosis includes both malignant and benign soft tissue lesions8,9. Conservative treatment consists of: shoe gear modification, custom molded foot orthotics with offloading accommodations, aperture padding, activity modification, physical therapy and intra-lesion steroid injections have all been utilized to manage this disease with varying effectiveness 2,8,12. Surgical intervention is warranted when conservative therapy fails. Due to the lesions recalcitrant nature and high rate of recurrence, wide excision, subtotal fasciectomy, and total fasciectomy have been advocated by multiple authors. Recurrent lesions typically manifest between 2 and 12 months postoperatively 9. Recurrence rates are reported at 60 - 100% 6 and 8 to 20%. 1,4,5,6,10 for local and wide excision, subtotal or total fasciectomy respectively. Due to the recurrent nature of the lesions, other adjuvant therapies have been investigated to help reduce recurrence. These include skin excision if skin involvement has occurred with subsequent skin grafting at the time of surgery, the use of Methotrexate postoperatively, and radiation therapy postoperatively 2,10.          

 

References 1. De Bree, E, Zoetmulder, FAN, et al. Incidence and Treatment of Recurrent Plantar Fibromatosis by Surgery and Postoperative Radiotherapy. Am J Surg 2004; 187 : 33-38. 2. Lee, TH, Wapner, KL et al. Current Concepts Review: Plantar Fibromatosis. J Bone Joint Surg Am 1993; 75 :1080-1084. 3. Wu, KK. Tumor Review. Plantar Fibromatosis of the Foot. J Foot Ankle Surg 1994; 33: 98-101. 4. Durr, HR, Krodel, A et al. Fibromatosis of the Plantar Fascia: Diagnosis and Indications for Surgical Treatment. Foot Ankle Int 1999; 20: 13-17. 5. Aluisio, FV, Mair, SD et al. Plantar Fibromatosis: Treatment of Primary and Recurrent Lesions and Factors Associated with Recurrence. Foot Ankle Int 1996; 17: 672-678. 6. Wapner, KL, Ververeli, PA et al. Plantar Fibromatosis: A Review of Primary and Recurrent Surgical Treatment. Foot Ankle Int 1995; 16: 548-551. 7. Zgonis, T, Jolly, GP et al. Plantar Fibromatosis. Clin Podiatr Med Surg 2005; 22: 11-18. 8. Johnston, FE, Collis SC et al. Plantar Fibromatosis: Literature Review and a Unique Case Report. J Foot Surg 1992; 31: 400-5. 9. Landers, PA, Yu, GV et al. Recurrent Plantar Fibromatosis. J Foot Ankle Surg 1993; 32: 85-93. 10. van der Veer, WM, Hamburg SM et al. Recurrence of Plantar Fibromatosis after Plantar Fasciectomy: Single-Center Long-Term Results. Plast Reconstr Surg 2008; 122: 486-491. 11. Watson-Ramirez, ML et al. Plantar Fibromatosis: Use of Magnetic Resonance Imaging in Diagnosis. Cutis 2001; 68 : 219-222. 12. Pentland, AP et al. Plantar Fibromatosis Responds to Intralesional Steroids. J Am Acad Dermatol 1985; 12: 212-214.    

 

Results Continued Due to the patients complicated previous post-op course, an aggressive NWB protocol was used for three weeks of strict NWB with posterior splint and crutches. He was given Keflex for infection prophylaxis for one week postoperatively and also received DVT prophylaxis with Lovenox while immobilized. At 3 weeks sutures were removed. The patient did develop a small area of focal necrosis along the proximal, central aspect of the incision. This went on to heal fully without any further intervention or debridement over a few week period. At 3 weeks postoperatively, sutures were removed and the patient was allowed protected full WB as tolerated in a postoperative shoe, and was later transitioned back to regular shoe gear, with no pain or disability in the right foot. Between December 2010 and August 2011 the patient was lost due to a drop in insurance. He returned to clinic in August 2011 with a painful recurrence of the left plantar fibroma. Surgery was performed in August 2011 with a similar approach/course to the right foot case. Currently he has not had a recurrence of either lesion. He has some residual numbness in his left 2nd and 3rd toes from the second surgery due to the extensive nature of the mass. He has no other complaints status post surgery.    

 

 

Results During the first excision the patient developed a late wound dehiscence with infection at post-op week 4. He was seen at an ER in Florida and placed on Keflex and Bactrim. Upon his return, the patient’s wound still appeared infected with surrounding cellulitis and mild serosanguinous drainage. Debridement of the wound was performed at follow up and daily dressing changes were instituted. Due to failure of oral antibiotics, a PICC line was placed and Zosyn was administered for two weeks. After several weeks the patient finally healed and was able to resume full weight bearing without pain or disability on the left side.  

Right Foot Mass Visualized

Right Foot Mass Excision

Right Foot Mass Right Foot Mass - 40x - Plump

spindle shaped fibroblasts with

variable number of mitotic figures. They

are intimately associated with

small to moderate amount of collagen.

Right Foot Incision with focal necrosis

Left Foot Excision Recurrent Mass

Left Foot Pre-op Revisional Surgery

Left Foot Recurrent Mass