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Radical fasciectomy for plantar fibroma

Submitted by henryd on Mon, 11/28/2011 - 15:05
Case Identification
Case ID Number: 
20111128RF
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

This 54 year old professional male is very active. He has had a mass on both feet for 20 years or more. The mass on the left has always been larger and is now problematic because of pain and swelling after activities.

Radiological findings:: 
Examination of the foot shows a substantial mass that measures 4 cm x 3.5 cm, in the middle of the instep or arch, it appears to be close to or attached to the medial band of the plantar fascia. Parts of it are very firm especially around the edges, but the center is quite compressible the area is slightly red. It is nontender. An MRI that was made in 2009 is examined. There is a mass that is contiguous with the plantar fascia, and portions of it have features consistent with plantar fascia, but other portions are essentially identical to the nearby plantar musculature. The features of this lesion do not suggest sarcoma. MRI's of both feet were made, and showed essentially identical features, except for size.
Laboratory results:: 
No labs were requested
Differential Diagnosis: 
Plantar fibroma, synovial sarcoma
Further Work Up Needed:: 
In a case such as this one, where bilateral, similar lesions, located in the medial part of the plantar fascia,have been slowly growing for more than 20 years, the diagnosis is fairly straightforward. In addition, if the MRIs of both feet have features entirely consistent with plantar fibroma, then a sarcoma is extremely unlikely. In this case sarcoma can be eliminated from the differential, and treatment of this lesion based on the mechanical and functional problems it presents can proceed. Successful surgical treatment of plantar fibroma requires radical fasciectomy, where the entire lesion and a sufficient margin of normal fascia and normal muscle would be entirely excised. If a more conservative surgery is performed, recurrence is virtually guaranteed.
Treatment Options:: 
Initial management should consist of shoe modifications and pain medication. Surgical removal is reserved for large lesions that are causing significant disability that have failed a well-documented course of non-operative care. Because recurrence is frequent following inadequate surgical removal, practitioners who are not prepared to undertake an aggressive and comprehensive resection of the lesion should not attempt to the procedure. Aggressive resection with a wide margin, as shown in the accompanying photos, is necessary to avoid recurrence, but may associated with significant complications. Although the procedure of choice has been given a term "radical fasciectomy", radical resection margins are not achieved. The actual margin achieved is typically a marginal to wide margin, where wide margins are achieved at the fascial boundaries of the lesion, but marginal margins are achieved on the skin surface of the lesion in order so that the skin may be closed without grafting, and marginal margins are achieved at the deep surface of the lesion in order to preserve the medial and lateral neurovascular bundles.
Special Features of this Case:: 
Surgical technique: A longitudinal incision roughly along a line between the midpoint between the 1st and 2nd metatarsal heads and the medial aspect of the calcaneus tuberosity is made. A large ellipsoid portion of skin is resected in continuity with the lesion. in order to make it possible to separate the lesion from skin at the resected margins. Thus, on the medial side, the dissection proceeds medial along the arch of the foot and deep to the mass nea the knot of Henry where the medial branch of the plantar artery and plantar nerve are located. The flexor digitorum longus is exposed at the deep margin of the dissection. Proximally, a transverse fascial incision at least 2 full centimeters or more proximal to the most proximal extent of the lesion is created, elevating and completing resection the origin of the plantar aponeurosis. Dissecting deep and lateral, the cutaneous branches of the lateral plantar artery and nerve, are seen. Elevating the mass from proximal to distal, the deep surface of the mass must be freed from the flexor digitorum brevis, some of which is resected en bloc along with the tumor in order to preserve the best possible margin. The proper digital nerves require careful dissection in order to prevent neurovascular injury. The individual 5 or 6 separate slips of the plantar aponeurosis, are identified at their most distal extent,. Each slip was transected transversely at the level of the metatarsal head, several centimeters from the tumor. The tumor should be marked with a long suture on the lateral portion, and a short suture on the proximal portion, and the orientation of the lesion and the clinical and pathological concerns must be discussed with the pathologist.
Image Reference: 
Plantar fibroma - Foot and AnklePlantar fibroma - Foot and Ankle
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