Incidence and treatment of recurrent plantar fibromatosis by surgery and postoperative radiotherapy

Soleful solutions: Advancements in treatment strategies for ledderhose disease

INTRODUCTION

Ledderhose disease (plantar fibromatosis) is a benign and progressive proliferative disorder of the plantar fascia that forms fixed and painful nodules within the fascia, causing functional disability and decreased quality of life.

METHODS

We conducted a narrative review using Pubmed (https://pubmed.ncbi.nlm.nih.gov/) and searched for the terms "Ledderhose disease" "plantar fibromatosis" "Ledderhose disease treatment" "plantar fibromatosis treatment" with further focused searches in Pubmed to supplement information regarding each intervention.

RESULTS

Many non-surgical therapeutic strategies are used in managing symptoms. These include pharmacological and non-pharmacological treatment options. Surgical treatment is employed when these therapies are not able to control the symptoms.

CONCLUSION

Understanding and exploring effective treatment modalities for Ledderhose disease (LD) is important in improving the functional disability and quality of life. This review aims to showcase a general outline of the condition and illustrate the present treatments used to manage the disease.

LEVELS OF EVIDENCE

Therapeutic study, Level V.

Clinical Presentation of Peyronie's Disease: A Retrospective Study of 564 Cases

Peyronie's disease (PD) affects the penile albuginea, resulting in penile deformity, pain, erectile dysfunction (ED), and an anxious-depressive state. PD diagnosis involves a thorough medical history, penile palpation, documentation of the penile deformation, a dynamic penile echo color Doppler ultrasound (PCDU), and the completion of questionnaires for the evaluation of pain, ED, and psychometric tests. The aim of this study was to evaluate the symptoms of PD and their prevalence in PD patients in the active phase who had access to our andrology clinic. Inclusion criteria: availability of data on patients diagnosed with PD, including detailed medical history, blood tests, penile palpation, photographic documentation of penile deformity, and penile PCDU. Exclusion criteria: PD patients in the stable phase or those without the specified tests and data mentioned above. Our study found a higher prevalence of PD in younger patients (24.2%), a higher coexistence of PD with chronic prostatitis (35.6%), a higher percentage of cases of association between penile deformity and penile curvature (84.4%), a higher prevalence of "significant anxiety" (88.4%), a higher presence of plaque calcification (35.6%), and the detection of a longer duration of the first phase of PD (>18 months). The most frequently observed type of penile curvature was dorsal, followed by left lateral, right lateral, and, less commonly, ventral. We observed a significant statistical correlation between patient age and IIEF score, indicating that patients over the age of 40 years are at a higher risk of experiencing ED. We found a strong statistical relationship between VAS score and age. As age increases, the VAS score decreases, suggesting that younger patients reported more penile pain compared to those who were older than 40 years. Furthermore, we found that penile pain has a significant impact on the psychological state of PD patients. We also found that 38.8% of PD patients suffered from severe anxiety. In relation to this, psychotherapy should be integrated into PD treatment to improve the quality of life and treatment adherence.

Ledderhose's Disease: An Up-to-Date Review of a Rare Non-Malignant Disorder

Plantar fibromatosis (or Ledderhose's disease) is a rare benign condition, difficult to treat, defined by gradual-growing nodules in the central medial part of the plantar fascia, with the possibility of sclerosis and shrinkage of the entire fascia or, rarely, contractures of the toes. From a histopathological point of view, it is linked to Dupuytren's contracture of the hand and Peyronie's disease of the penis, being part of a large group of fibromatoses, based on a proliferation of collagen and fibroblasts. Its etiology is still not fully understood, even though it has been associated with trauma, diabetes mellitus, use of anticonvulsants, frozen shoulder, alcohol consumption, and liver disease. Typically, ultrasound confirms the diagnosis, and magnetic resonance imaging is used for more aggressive and advanced types. Several conservative treatment techniques, such as steroid injections, verapamil, imatinib, radiation therapy, extracorporeal shock wave therapy, tamoxifen, sorafenib, mitomycin C, and collagenase, have been documented. When non-operative care fails, surgical measures may be considered, even though recurrence is expected. We attempted to provide a better understanding of this disease by covering all of the important aspects: its history, clinical and radiologic findings, diagnosis, pathophysiology features, conservative and surgical treatment, recurrence rate, and prognosis.

Presurgical Perspective and Posttreatment Evaluation of Soft Tissue Tumors of the Ankle and Foot in Adults

This article discusses soft tissue tumors of the ankle and foot region in adults, including tumors of the joints, and also briefly addresses tumor-simulating lesions. We offer general recommendations and describe specific aspects of common entities in that region, such as typical imaging appearance, therapeutic strategies, and posttherapeutic considerations. Focal masses and diffuse swelling are common in the foot and ankle region; most of them are non-neoplastic. Some of the tumors, such as plantar fibromatosis, tenosynovial giant cell tumor, synovial chondromatosis, or schwannoma, have a very typical appearance on magnetic resonance imaging. Sarcomas are rare among true soft tissue tumors; however, they can be small and well demarcated, may grow slowly, and are often misinterpreted as benign. This is especially true for synovial sarcoma, one of the most common sarcomas in this region. Densely packed tissues in the foot and ankle may hamper determining the tissue of origin. Adherence to diagnostic guidelines and cooperation with tumor centers is crucial including for posttherapeutic surveillance. We also describe typical posttherapeutic changes and complications after surgery, radiation therapy, and chemotherapy, as well as parameters for the detection and exclusion of recurrence of soft tissue tumors of the ankle and foot.

Radiotherapy for Plantar Fibromas (Ledderhose Disease)

Ledderhose disease (plantar fibromas) is histologically related to Dupuytren disease, which has been successfully treated for years with radiotherapy. Many conservative treatments have been advanced for plantar fibromas, including accommodative orthotic devices, which help but do not cure the disease. Surgery is considered the mainstay of treatment for this malady, but the failure rate has been as high as 100%, depending on the type of fasciectomy. Radiotherapy is a new, exciting modality that has shown promising results for treating plantar fibromas.

The successful use of collagenase for Ledderhose disease (plantar fibromatosis) in a paediatric patient: a case report

Ledderhose disease is a connective tissue disorder involving proliferation of fibrous tissue in the plantar fascia of the foot. Histologically identical manifestations exist in the hand (Dupuytren’s contracture) and penis (Peyronie’s disease), and collagenase injections are approved as a treatment in both, however not in Ledderhose, where the treatment of choice remains surgical resection. Surgery is associated with high rates of recurrence and need for further surgery, so alternative therapies should be sought. Due to their histological and physiological similarities, it is likely that therapies useful in Dupuytren’s and Peyronie’s would be useful in Ledderhose. Two previous case reports investigating collagenase injections for Ledderhose disease in adults have shown conflicting results; this study demonstrates the efficacy of collagenase injections in a paediatric patient at 1-year follow-up.

Follow-up of clinical and sonographic features after extracorporeal shock wave therapy in painful plantar fibromatosis

Background

Extracorporeal shock wave therapy (ESWT) has been used as a safe alternative treatment for refractory musculoskeletal diseases, such as plantar fasciitis, Achilles tendinopathy and gluteal tendinopathy, and various forms of fibromatosis including palmar or penile fibromatosis. However, there is limited published data for clinical and sonographic features of plantar fibromatosis after ESWT. The purpose of this study was to evaluate the long-term clinical outcome of ESWT in ultrasonography-confirmed plantar fibromatosis and ultrasonographic changes of plantar fibroma after ESWT.

Methods

Medical charts of 26 patients (30 feet) with plantar fibromatosis confirmed by ultrasonography were reviewed. Finally, a total of 10 feet who underwent ESWT for “Poor” or “Fair” grade of Roles-Maudsley Score (RMS) and symptoms persisted for >6 months were included in this study. Short-term follow-up was conducted one week after ESWT and long-term follow-up time averaged 34.0 months. The Numerical Rating Scale (NRS) and RMS were collected for the evaluation of clinical features. Follow-up ultrasonography was conducted at long-term follow-up and changes of plantar fibroma was assessed. A greater than 50% reduction in the NRS and achievement of a “good” or “excellent” grade in the RMS were regarded as treatment success. Additionally, medical charts of 144 patients (168 feet) with plantar fasciitis confirmed by ultrasonography were reviewed and subsequently, 42 feet who underwent ESWT with the same protocol were included for the comparison of clinical features.

Results

In plantar fibromatosis, baseline NRS (6.2 ± 1.3) and RMS (3.5 ± 0.5) were significantly improved at short-term follow-up (NRS, 1.8 ± 1.0; RMS, 2.0 ± 0.8, P < .001, respectively) and long-term follow-up (NRS, 0.6 ± 1.1; RMS, 1.4 ± 0.8, P < .001, respectively). Treatment success was recorded in seven feet (70.0%) at short-term follow-up and 8 feet (80%) at long-term follow-up, which is comparable to that of the plantar fasciitis group (28 feet, 66.7%; 35 feet, 83.3%, respectively). In long-term follow-up ultrasonography, mean fibroma thickness was reduced from 4.4±1.0 to 2.6±0.8 mm (P = .003); however, length and width were not significantly changed. There were no serious adverse effects.

Conclusion

While these are preliminary findings, and must be confirmed in a randomized placebo control study, ESWT can have a beneficial long-term effect on pain relief and functional outcomes in painful plantar fibromatosis. However, ESWT is unlikely to affect the ultrasonographic morphology of plantar fibroma, with the exception of reducing the thickness.

Level of evidence

Level III, retrospective cohort study.

Bilateral plantar fibromatosis complicated by Dupuytren's contracture

Plantar fibromatosis (PF) is a rare benign disease. Here we report bilateral PF accompanied by Dupuytren's contracture in the right palm. Magnetic resonance imaging was useful in diagnosing PF, although biopsy was needed to rule out hemangioma. As the patient had been receiving female hormone therapy since orchiectomy, there may be a possibility that estrogen accelerated the growth of PF. Local excision with a 1-cm margin was performed, followed by primary wound closure. Neither complication nor recurrence had occurred 6 months after the surgery.

The Effects of Collagenase Clostridium histolyticum on Plantar Fibromatosis: A Case Study

Plantar fibromatosis, also known as Ledderhose's disease, is a rare disorder of benign fibroblast proliferation involving the plantar aponeurosis (i.e., plantar fascia). Traditionally, surgical intervention has been the most common treatment for plantar fibromatosis. However, numerous studies have reported high recurrence rates of plantar fibromatosis after surgical intervention, as well as wound healing difficulties and nerve injury. Plantar fibromatosis often coexists with other superficial fibrous diseases such as Dupuytren's contracture and Peyronie's disease; immunohistochemical and ultrastructural analyses suggest a relationship between Ledderhose's disease and Dupuytren's contracture. The US Food and Drug Administration approved collagenase Clostridium histolyticum for the treatment of Dupuytren's contracture in 2010 and Peyronie's disease in 2013. This case study presents the successful treatment of Ledderhose's disease almost 4 years (45.5 months) after off-label use of collagenase C. histolyticum injection in a 22-year-old white female who had recurrent plantar fibromatosis after surgical intervention.

Current concepts about treatment options of plantar fibromatosis: A systematic review of the literature

BACKGROUND

Plantar fibromatosis, or Ledderhose disease, is a benign and hyperproliferative disease of the plantar aponeurosis. There have been described different therapeutic options regarding plantar fibromatosis, both conservative and surgical. The aim of this review is to systematically analyze conservative and operative treatments of plantar fibromatosis described in literature, evaluating which procedure shows the highest success rate and best functional outcome.

METHODS

A systematic review of PubMed, Google Scholar and Cochrane reviews computerized database was performed focusing on the different types of treatments for plantar fibromatosis. Research was performed using the keywords "plantar", "fibromatosis", "Ledderhose", "Dupuytren", "foot" in order to identify all papers regarding the treatment of plantar fibromatosis. In addition, the research was extended to the reference list of the relevant articles. A total of 25 citations were obtained from the research and included.

RESULTS

Considering all the studies, 233 patients were included in this systematic review. 5 studies reported conservative treatment of plantar fibromatosis, with a total of 35 patients included. Operative outcomes are reported for 178 patients (92 male, 86 female), with 196 feet treated.

CONCLUSIONS

Valid conservative methods are presented in literature, with debated results. Some operative options show high recurrence rate; wide excision is recommended in selected cases. Further clinical trials with well-defined and standardized outcome measurements should be necessary in future to better evaluate success rate and complications of the various procedures.

Clinics in diagnostic imaging (195). Plantar fibromatosis

A 46-year-old man presented with a six-month history of lumps in the sole of his left foot. Physical examination revealed two nodules, one tender and one firm, at the plantar left foot with no overlying skin changes. Although the initial radiographs were normal, magnetic resonance imaging of the left foot demonstrated two nodules along the medial band of the plantar fascia, characteristic of plantar fibromas. The patient opted for surgical excision. There was no further recurrence of symptoms after surgery. We describe the clinical and radiological features of plantar fibromatosis and briefly discuss other causes of lumps and pain in the sole of the foot.

Clinical features and management of superficial fibromatoses

Fibromatoses are a group of benign connective tissue tumors characterized by the infiltrative, aggressive proliferation of well-differentiated fibroblasts, leading to frequent local recurrence. Within this heterogeneous disease group, superficial fibromatoses show slower growth and more benign infiltration of surrounding tissues than deep fibromatoses. Superficial fibromatoses relevant to dermatology include palmar, plantar, and penile fibromatosis, knuckle pads, pachydermodactyly and infantile digital fibromatosis. They present clinically with subcutaneous nodules or cords that lead to local infiltration and limited mobility of the affected areas. Treatment options vary from watchful waiting, non-invasive methods such as radiotherapy and intralesional corticosteroid/collagenase injections to radical surgical procedures. Early intervention may disrupt disease progression and may even restore functional ability. These disorders should therefore be recognized and treated early in the course of the disease.

The etiology, evaluation, and management of plantar fibromatosis

Plantar fibromatosis (Ledderhose disease) is a rare, benign, hyperproliferative fibrous tissue disorder resulting in the formation of nodules along the plantar fascia. This condition can be locally aggressive, and often results in pain, functional disability, and decreased quality of life. Diagnosis is primarily clinical, but MRI and ultrasound are useful confirmatory adjuncts. Given the benign nature of this condition, treatment has historically involved symptomatic management. A multitude of conservative treatment strategies supported by varying levels of evidence have been described mostly in small-scale trials. These therapies include steroid injections, verapamil, radiation therapy, extracorporeal shock wave therapy, tamoxifen, and collagenase. When conservative measures fail, surgical removal of fibromas and adjacent plantar fascia is often done, although recurrence is common. This review aims to provide a broad overview of the clinical features of this disease as well as the current treatment strategies being employed in the management of this condition.

Effect of Mitomycin C on recurrence of plantar fibromas

Although certainly not the first line treatment for plantar fibromas, surgical resection is a treatment option for some patients with have failed exhaustive non-surgical treatment. The use of topical Mitomycin C has been recently shown to reduce the recurrence rate of other fibrous lesions. The purpose of this study was to determine the impact of topical application of Mitomycin C on recurrence rate of plantar fibromas. A retrospective analysis was done from a prospectively gathered database with a total 50 consecutive patients over a 16-month study period. The control group (n = 29) consisted of patients who underwent only surgical resection, while the study group (n = 21) consisted of patients who underwent surgical resection with adjuvant therapy using Mitomycin C. The primary endpoint was local recurrence after the procedure. Secondary end points included complications and toxicity associated with this medication. No patients were lost to follow up. Of the 29 patients in the control group, there were 17 patients (17/29, 58.6%) had recurrence of the plantar fibroma at a mean follow-up of 9.1 months. In contrast, in the experimental study group, all patients were free from local recurrence. No complications or side effects were associated with Mitomycin C use. The results demonstrate that the topical application of Mitomycin C to the tumor bed after surgical resection of plantar fibromas reduced the recurrence rate. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2554-2561, 2018.

Plantar Fibromatosis: Pathophysiology, Surgical and Nonsurgical Therapies: An Evidence-Based Review

Plantar fibromatosis (morbus Ledderhose), an extra-abdominal desmoid tumor of the plantar foot, is a rare benign hyperproliferative disorder of the plantar fascia with an unknown etiology. The main clinical characteristics include slow growing nodules on the medial and central bands of the plantar fascia, which may become painful and negatively affect ambulation. Most established conservative therapies today target symptomatic relief. As symptoms progress, therapies such as injections, shockwave ablation, radiation, and/or surgery may be required. This review aims to provide insight into the pathophysiology of this condition in addition to detailing current and investigational therapies for this disorder. Many therapies have been proven in similar conditions, which could lead to promising treatment options for plantar fibromatosis.

LEVELS OF EVIDENCE

Level V: Expert opinion.

Plantar fibromatosis: Surgical approach of a giant bilateral case

BACKGROUND

Plantar fibromatosis or Ledderhose disease is characterized by a benign fibroblastic proliferation of the plantar fascia. It is an illness with unknown etiology and a complex treatment in its most intense manifestation.

OBJECTIVE

The authors describe a surgical option for extensive cases where conservative treatments are not successful. Surgical techniques may vary according to the site and extent of the lesions.

METHODS

Surgical treatment with wide resection of the lesion and second intention healing using a hydrocolloid dressing.

RESULTS

After a 3-year follow-up with no recurrence, the authors demonstrated an excellent result, which led to an important improvement in the patient's quality of life.

CONCLUSION

Surgical treatment can be a good option for plantar fibromatosis. Giant lesions can be treated with wide excisions and second intention healing, with low risk of aesthetic and functional complications.

Percutaneous Ultrasound-Guided Cryoablation for Symptomatic Plantar Fibromas

PURPOSE

Here, we report our experience in treating painful plantar fibromas with percutaneous cryoablation.

METHODS

We retrospectively identified patients with symptomatic plantar fibromas who underwent percutaneous ultrasound-guided cryoablation between June 2014 and June 2015. In total, four patients (two male, two female) with five plantar fibromas undergoing a total of seven ablation procedures were identified. Each procedure was performed under general anesthesia using a single freeze-thaw cycle. The electronic medical record, procedure reports, and pain scores from a brief pain inventory administered before and after treatment were reviewed. Average and worst pain in 24 h, and time to peak symptom improvement post-procedure were compared. Complications were reviewed using the SIR classification.

RESULTS

Five plantar fibromas were treated (mean size 2.2 ± 1.6 cm). Four of five lesions were present for more than 6 years, and 1/5 was present for less than 1 year. Surgical excision was previously performed on 3/5 lesions, all with short-term recurrence. Mean worst pain score in 24 h and average pain score in 24 h (scale of 10) at initial evaluation were 7.1 ± 1.8 and 5.8 ± 1.9, reduced after cryoablation to 0.8 ± 0.8 and 0.4 ± 0.6, respectively. Average time to symptom improvement was 2.8 ± 0.98 weeks (range 2-4 weeks). All patients reported improved ambulation and weight-bearing, and complete cessation of pain medication after treatment. The improvement was sustained on follow-up at 12 months. No major complications occurred. Minor complications occurred in 3/5 patients.

CONCLUSIONS

Early experience with percutaneous ultrasound-guided cryoablation to treat painful plantar fibromas suggests that it is a safe and effective treatment option, with early and near-complete symptom improvement.

Partial fasciectomy is a useful treatment option for symptomatic plantar fibromatosis

Plantar fibromatosis is a rare, benign fibroproliferative disorder of the plantar fascia. It is considered as a low-grade tumour and it can be locally aggressive. It can present as painful swelling with impairment of local function. Upon failure of non-operative management, surgical treatment options include total fasciectomy or partial fasciectomy. Although surgical excision is the mainstay of treatment, recurrence rate can be up to 60%. The aim of this study was to determine the recurrence and complication rates of surgically treated plantar fibromatosis. A retrospective study was conducted involving patients who had a confirmed diagnosis and excision of plantar fibromatosis treated in our institution between 2011 and 2016. Demographic data, follow-up duration, recurrence and complications were reviewed. Eighteen patients underwent 19 operations. Mean age was 41.3 years (20-57). There were 12 male patients. The main presenting features were pain, swelling and impairment of function. They were investigated by ultrasound scan (12 feet, 63%) and/or magnetic resonance imaging (8 feet, 42%). Two patients (11%) had prior surgery at other institutions whilst 3 patients (17%) had multiple nodules at presentation. All patients underwent partial fasciectomy of the plantar fibromatosis. At up to 5 years follow-up, one patient (6%) had a recurrence in our series whilst 3 patients (17%) had scar related problems (2 patients with scar pain and one patient had hypersensitive scar that resolved after 12 months). Symptomatic plantar fibromatosis can be effectively treated with partial plantar fasciectomy.

Endoscopic Subtotal Fasciectomy of the Foot

Plantar fibromatosis is a rare benign but often locally aggressive tumor of the plantar aponeurosis. Nonsurgical treatment is the first line of treatment for symptomatic lesions. Because of the high recurrence rate associated with surgical treatment, operation is indicated only when the lesions are highly symptomatic and conservative measures fail or the diagnosis is in question. The purpose of this technical note is to report the details of endoscopic subtotal fasciectomy. This may reduce the risks of skin necrosis and dehiscence, infection, and formation of painful hypertrophic scars.

Dupuytren-Like Contracture of the Foot: Ledderhose Disease

Introduction  Plantar fibromatosis is a rare hyperproliferative disease of plantar aponeurosis and is also called Ledderhose disease. Case properties and treatment are discussed in this report.

Case Report  A 30-year-old man presented with painful bilateral plantar nodules. He had multiple and bilateral fixed and solid nodules on the plantar and medial side of his feet measuring 1 cm each. Ultrasound was performed and hypoechoic homogeneous nodules were detected. The patient underwent surgery, and the nodes were removed via a plantar incision with 2-cm safety distance.

Discussion  Ledderhose disease is a rare, hyperproliferative disorder of the plantar aponeurosis. The nodules are slow growing and found in the medial part of the plantar fascia. The precise etiology remains unknown. The treatment options are conservative management, steroid injections, radiotherapy, and surgery.

Conclusion  The main cause of this disease remains uncertain. Related conditions should be evaluated, and a patient who presents with Dupuytren or Peyronie disease should also be investigated for Ledderhose disease.

Primary Tumors of the Foot and Ankle

Tumors of the foot and ankle are rarely encountered in the general patient population. Even among studies of tumor patients, foot and ankle neoplasms are uncommon. Given the weight-bearing demands of the foot and its relatively small area, even small masses are likely to be symptomatic and/or palpable to both patient and physician. Only 3% of osseous neoplasms are found in this region, while 8% of benign soft tissue tumors and 5% of malignant soft tissue tumors are localized to the foot and ankle. Despite the rarity of presentation, it is important for orthopaedic surgeons to be familiar with the diagnostic criteria and therapeutic options for these patients, as each tumor varies in its presentation, level of aggressiveness, and natural history of the disease. With appropriate diagnostic tests and treatment, patients can anticipate a reasonable chance of survival and preservation of function. In this review article, the authors survey the current literature regarding the presentation, diagnostic workup, and treatment for the most common benign and malignant tumors of the foot and ankle.

LEVELS OF EVIDENCE

Level IV: Literature Review.

Surgical Treatment of a Case of Ledderhose's Disease: A Safe Plantar Approach to Subtotal Fasciectomy

Plantar fibromatosis, Ledderhose's disease, or Morbus Ledderhose is an uncommon benign nodular hyperplasia of the plantar aponeurosis. The aim of this paper was to report the case of a 47-year-old male patient who had concomitant Dupuytren's disease and failed all conservative measures. He was treated surgically with prompt and complete relief of symptoms postoperatively, and he has had no recurrence at the 2-year follow-up. In this richly documented case, we discuss details of the surgical technique and anatomy, which was important for a successful outcome and preventing complications. The technique for subtotal fasciectomy is reviewed and the relevance of the adequate choice of skin incision to prevent painful scarring, skin necrosis, and difficulties with shoe wearing is highlighted.

Desmoid tumors of the head and neck: a therapeutic challenge

Desmoid tumor, or aggressive fibromatosis, is a rare, histologically benign, fibroblastic lesion that infrequently presents in the head and neck. Desmoid tumors often grow locally, invasively, and may, in rare instances, be fatal secondary to invasion into critical structures, such as airway or major vessels. The most common treatment is surgery, but desmoid tumors are characteristically associated with a high local recurrence rate after resection. Although the margin status seems to be of importance, operations that avoid function loss and esthetic disfigurement should be the primary goal. The efficacy of postoperative radiotherapy is controversial. Its potential benefit should be carefully balanced against possible radiation-induced adverse effects. Alternative treatment modalities, such as primary radiotherapy and medical treatment or a wait-and-see policy, may be preferable to mutilating surgery. Considering all the aforementioned, it seems obvious that desmoid tumors of the head and neck present a therapeutic challenge and require an individualized approach.

Plantar fibromatosis--topical review

Morbus Ledderhose is a rare hyperproliferative disease of the plantar fascia, leading to the formation of nodules. Its origin is unknown. No causal therapy is available, and treatment remains symptomatic. Various therapeutic strategies to alleviate symptoms are available and are adapted to the severity of the disease. In early stages, conservative therapy including nonpharmacological, physical, and pharmacological treatments is applied. If the disease progresses, irradiation of the plantar surface, injections of steroids, shock wave therapy, and partial or complete fasciectomy as an ultimate therapy may be indicated. Novel experimental treatment options including application of fibrinolytic agents are currently being tested, but no controlled, randomized long-term studies are available. This review aims to provide a systematic overview of current established procedures and outlines novel experimental strategies for the treatment of morbus Ledderhose, including future avenues to treat this rare disease.

Squamous cell carcinoma and ledderhose disease: a case report

Ledderhose disease is disorder of the plantar aponeurosis. This disease is not so common and can be tackled with a surgical or conservative approach. A case of a 73-year-old man came to our attention who had a 26-year history of painless bilateral plantar nodules coalescing into an indurated mass. An ulcerative nodule had been noted in the last 16 months on the right foot, in the absence of trauma, not responsive to conservative treatment, so we decided to perform a biopsy. The histopatologic examination showed squamous cell carcinoma, with warty, well-differentiated, low-grade malignancy. Surgical treatment was suggested, so, in pneumoischemia, we made a surgical incision including the skin lesion. Then we proceeded to sculpture the anterolateral thigh fasciacutaneous flap to obtain adequate soft tissue coverage. The tumor was completely removed. Current reconstructive possibilities comprise a good anatomofunctional recovery even in the case of large demolition requests for the therapy of advanced cases of the disease described in this article. Correlation between Ledderhose disease and the formation of malignant tumors has not been made as yet, but perhaps an element that could unite these pathologies can be researched in the lively cell proliferation that characterizes both. It would be interesting to analyze the biological substrate, as well as the systemic and local levels, in patients where both diseases are manifested.

High-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis (Ledderhose's disease)

Background

Plantar fibromatosis is a benign disease creating nodules on the medial plantar side of affected patients. While surgical removal is regarded as the therapeutic mainstay, recurrence rates and impairment of daily activities remains substantial. High-energy focussed extracorporeal shockwave therapy has been suggested to be potentially effective in plantar fibromatosis in terms of pain reduction.

Hypothesis

High-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis.

Findings

A total number of six patients (5 males, 58±4 years) were included with plantar fibromatosis (Ledderhose’s disease) associated with pain. Three patients were operated on previously, one had concomitant Dupuytren’s contracture. High-energy focussed ESWT was applied using a Storz Duolith SD1 (2000 impulses, 3 Hz, 1.24 mJ/mm2) in two sessions with 7 days between. Pain was 6±2 at baseline, 2±1 after 14 days and 1±1 after 3 months. Softening of the nodules was noted by all patients. No adverse effects were noted.

Conclusions

High-energy focussed extracorporeal shockwave energy reduces pain in painful plantar fibromatosis (Morbus Ledderhose). Further large-scale prospective trials are warranted to elucidate the value of high-energy focussed extracorporeal shockwave therapy (ESWT) in plantar fibromatosis in terms of recurrence and efficacy.

Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results

BACKGROUND

Plantar fibromatosis is a rare, hyperproliferative, benign lesion of the plantar aponeurosis with an unknown cause. Surgical treatment is associated with a high recurrence rate and risk of complications. The goal of this study was to determine the recurrence rate of plantar fibromatosis after plantar fasciectomy at the authors' institute during the past three decades and the factors associated with an increased risk for recurrence.

METHODS

The study group contained 27 patients with plantar fibromatosis, who underwent 40 operations on 33 feet, including 13 right (39 percent) and 20 left (61 percent) feet.

RESULTS

The overall recurrence rate was 60 percent. Treating a primary lesion with total plantar fasciectomy was associated with the lowest (25 percent) and local resection of the lesion was associated with the highest recurrence rate (100 percent). There seemed to be a relation between the existence of multiple nodules in one foot and a higher recurrence rate. The recurrence of a primary lesion treated with fasciectomy combined with postoperative radiotherapy seemed to be lower in comparison with the recurrence rate after surgery only.

CONCLUSIONS

Surgical treatment of plantar fibromatosis is associated with a high recurrence rate and indicated only when the lesions are highly symptomatic and conservative measures fail. Total plantar fasciectomy is the most successful treatment in this study, particularly for primary lesions. The role of postoperative radiotherapy should be evaluated further. A prospective multicenter study comparing different surgical procedures will be needed to determine the type of operation that most effectively eliminates plantar fibromatosis.

Desmoid tumors: need for an individualized approach

Desmoid tumor, also known as aggressive fibromatosis or desmoid-type fibromatosis, is a rare monoclonal, fibroblastic proliferation arising in musculoaponeurotic structures. Although histologically benign, desmoids are often locally invasive and associated with a high local recurrence rate after resection. Since it is a heterogeneous disease, in particular regarding clinical presentation, anatomic location and biological behavior, treatment should be individualized to reduce local tumor control failure with concurrently acceptable morbidity and preservation of quality of life. Many issues regarding optimal treatment of desmoids remain controversial. However, wide surgical excision remains the treatment of choice, except when surgery is mutilating and is associated with considerable function loss or major morbidity. Involvement of surgical margins is probably associated with an increased risk of local recurrence. Postoperative radiotherapy results in a significant reduction of the local recurrence rate, but only in the case of involved surgical margins. Radiotherapy for gross disease is considerably effective, but is associated with a relatively high rate of complications, which are usually mild or moderate and radiation dose dependent. Radiotherapy should only be applied where anatomic constraints preclude complete resection and radiotherapy is not too toxic. Risk factors for local tumor control failure include young age, large size, presentation as recurrent disease, limb/girdle or intra-abdominal location, involved surgical margins, omission of radiotherapy, radiation dose less than 50 Gy and insufficient radiation field size. Increased comprehension of the pathogenesis and biological behavior of desmoids resulted in the emerging applicability of systemic therapies and a wait-and-see policy. Systemic treatment may be indicated in patients that have anatomic barriers to effective surgery or radiotherapy. Considering the significant morbidity of surgery and/or radiotherapy for certain locations, especially mutilation and loss of function, and the tumor's natural history, which is often characterized by prolonged periods of stability or even regression, a period of watchful waiting may compose the most appropriate management in selected asymptomatic patients. Attempts to complete eradication of the disease may be worse than the disease itself.

The treatment of severe flexion contracture of the great toe in a patient with Ledderhose's disease

We present the rare case of a patient with Ledderhose's disease causing severe, disabling flexion contracture of his right great toe. We discuss our treatment regimen relative to descriptions of this condition in the literature.

Pathologic and MR Imaging Features of Benign Fibrous Soft-Tissue Tumors in Adults

Benign fibrous (fibroblastic or myofibroblastic) soft-tissue tumors are a heterogeneous group of fibrous lesions with widely varied anatomic locations, biologic behavior, and pathologic features. The four broad categories of fibrous proliferation are benign fibrous proliferations, fibromatoses, fibrosarcomas, and fibrous proliferations of infancy and childhood. The first two categories include nonaggressive fibroblastic lesions such as nodular fasciitis, as well as fibromatoses that demonstrate more aggressive biologic behavior (eg, desmoid tumors). In adults, fibrous tumors are among the most common soft-tissue lesions encountered in clinical practice. MR imaging can be useful for defining the intrinsic signal characteristics, size, and compartmental extension of these lesions. Histologic features of the tumor also may be depicted on T2-weighted MR images. Hypocellular fibrous tumors with dense collagenous components tend to have lower signal intensity on T2-weighted images than do lesions that are more cellular or that contain greater amounts of extracellular myxoid matrix. When interpreting MR images of soft-tissue masses in adults, radiologists should be aware of the clinical behavior, common sites of occurrence, and histopathologic and imaging features of the common benign fibrous soft-tissue tumors.

A clonal reciprocal t(2;7)(p13;p13) in plantar fibromatosis

Cytogenetic reports of plantar fibromatosis are rare, and to our knowledge no clonal reciprocal translocations have been reported in these lesions. Reciprocal chromosome translocations have been identified in a number of solid tumors and in some cases have helped identify genes involved in their pathogenesis. We report a case of plantar fibromatosis with the novel finding of a t(2;7)(p13;p13) balanced reciprocal translocation as the sole cytogenetic abnormality.

Plantar fibromatosis

Plantar fibromatosis is defined as a benign fibrous disorder involving the plantar aponeurosis. Although its incidence is well described on the hands, it is less commonly seen on the feet, and its etiology is unknown. A differential diagnosis for the heel pain along the medial arch could be a benign thickening of the plantar fascia associated with plantar fibromatosis. Its high recurrence after surgical excision and problematic scarring and wound presents a significant challenge to the reconstructive foot and ankle surgeon. This article reviews the history, clinical presentation, pathologic findings, and surgical approaches to the treatment of plantar fibromatosis.