Surgical Treatment Options For Plantar Fibromatosis
There are two traditional surgical approaches to the nodules of plantar fibromatosis.
- Excision of the the fibromas. This generally involves an incision or incision on the bottom (plantar surface) of the foot. Plantar incisions require a period of non-weight bearing from 2 to 3 weeks to prevent the incisions from gapping. Incisions on weight bearing surfaces can heal with considerable thickness and cause discomfort. The chance of thick plantar scars with patients who had plantar fibromatosis surgically removed may be increased as such patients already have a disorder of scar formation. The recurrence rate with simple excision is as high as 70 percent.
- Radical excision of fibromatosis. This procedure involves surgically removing the fibromatosis plus good surrounding tissue, generally fascia, around the fibromatosis. The recurrence rate is reduced to 30 percent but there is increased healing time and potential morbidity due to the amount of tissue removed. The plantar fascia has an important function in human gait. Upon contact of the foot with the ground, the medial longitudinal arch lowers to absorb shock with the amount and speed of arch lowering modulated by the fascia which bowstrings across the bottom of the foot. The fascia also acts like a spring, storing potential energy upon being stretched which is converted to kinetic energy in toe off or propulsion of the foot. Loss of fascia can compromise foot function.
The last excision or radical excision I performed was about 15 years ago. I had incorporated a dacron mesh into the fascia in an attempt to create a scaffolding for the fascia to repair itself. The results were only fair as there was lumpiness in the fascia, albeit better than before and the patient required use of prescription orthotics to aid gait.
Conventional surgical approaches to plantar fibromatosis (Ledderhose disease), in my opinion, are not viable options.
Newer “surgical options” for plantar fibromatosis. Surgical treatment is traumatic and may induce formation of scar tissue. That is even more so the case in a patient who tends to create excessive fibrosis or scar tissue which is the case with with Ledderhose disease. Procedures which are minimally invasive are less likely to induce fibrosis. Two minimally invasive surgical options are discussed: Topaz procedure and the TenexTX procedures.
1. Topaz Procedure. This procedure utilizes a radiofrequency wand produced by Arthrocare. The wand is small, like a pen and has a small tip that is inserted through small openings in the skin, pinhole like openings. A small tube with sterile saline drips through the wand to provide cooling. The procedure is also called “coblation therapy,” that is, cold ablation. It provides a relatively atraumatic means to “vaporize” abnormal tissue.
2. TenexTx Procedure. This is the brainchild of Dr. Jagi Gill, MD. He observed the means by which cataract surgery is perform, phacoemulsification. A small needle is inserted which uses ultrasound energy to dissolve the abnormal lens and vacuum out the diseased tissue before a new lens can be inserted. The Tenex wand is inserted into abnormal tissue using sonographic (ultrasound) guidance. Different tissue have different resonance or harmonics. The ultrasound frequency of the Tenex wand selectively liquefies the abnormal tissue and removes the tissue via suction. http://sanantoniopodiatrist.typepad.com/my-blog/2014/06/tenex-tx-procedure-a-new-minimally-invasive-option-for-treatment-of-heel-pain.html