MRI diagnosis of plantar fibromatosis—a rare anatomic location

Plantar fibromatosis is a relatively uncommon benign, focally invasive fibrous neoplasm. It is most often found to invest the central and medial portions of the plantar fascia. Since the lesion is not encapsulated, clinical margins are often difficult to define. Inadequate excision is the primary cause of recurrence. While it is accepted that the principal use of magnetic resonance imaging (MRI) is showing the extent of a lesion and that it is limited in its ability to provide information regarding likely histology, recognition of the imaging characteristics of plantar fibromatoses can help in the clinical diagnosis. The exception to this role of MRI is when plantar fibromatosis presents itself in an uncharacteristic location. Knowledge of the uncharacteristic locations of these lesions will certainly help radiologists guide the often difficult and protracted therapy of these lesions.The authors present a unique case report of plantar fibromatosis affecting the plantar aspect of the 2nd toe of the foot.     

Clinical presentation of pedunculated, amelanotic melanoma: plantar aspect

An historical review and case history of amelanotic malignant melanoma presenting as a pedunculated mass on the plantar aspect of the foot is discussed. The patient presented with a rapidly growing, cauliflower-like lesion on the plantar aspect of the left foot. Excisional biopsy revealed amelanotic malignancy. Subsequent surgical intervention was performed to effect a radical excision of local tissues with grafting and inguinal lymphadenectomy.     

Hourglass Ganglion Cyst of the Foot: A Case Report

Ganglion cyst, a common benign soft tissue lesion, is not uncommon in the foot, with the most common location being the dorsal aspect. We describe a case where the ganglion had an unusual radiographic appearance in the form of an hourglass, extending from dorsum into the planter compartments of the foot. A 74-year-old woman presented with longstanding pain in her midfoot. Clinical examination revealed a soft tissue swelling with minimal tenderness in the first webspace of the right foot. The initial radiograph was normal. Ultrasound examination revealed a cystic swelling filled with hemorrhagic fluid with an hourglass appearance. Magnetic resonance imaging examination confirmed the cystic nature of the swelling and depicted the hourglass-shaped ganglion extending from the dorsal to plantar aspect of foot. Complete excision was possible with a combined dorsal and plantar approach. Ganglion cyst can present in the foot in locations other than the dorsum and could have extensions into the plantar aspect. This variation needs to be considered when planning surgical excision, which could be aided by preoperative magnetic resonance imaging.     

Surgical treatment of a hindfoot plantar leiomyoma: A case study

Leiomyomas within the foot are rare and are difficult to diagnose with only the radiographic and clinical picture. They are benign, slow growing, and very rarely cause pain. We present an unusual case of a dermatology referral patient complaining of callus formation on the plantar aspect of the foot as well as shoe discomfort. The mass was believed to be a lipoma or a fibroma but after surgical excision was found to be a leiomyoma. Our case highlights the rarity of this diagnosis and presents a unique surgical technique utilizing a medial approach to the plantar hindfoot for lesion removal.     

足底主要韧带损伤对足底压力分布的影响

目的 分析足底主要韧带损伤后足底压力及接触面积的变化情况. 方法 7例正常成人新鲜尸体足标本,解剖显露并依次切断足底跖筋膜,弹簧韧带、跖长韧带、跖短韧带,模拟足底主要韧带损伤.经电子万能试验机逐级加载至700 N,利用F-scan足底压力测鼍系统,测量足底韧带损伤前后足底压力峰值及接触面积的变化情况,对结果进行统计分析. 结果 标本后足部位一直为压力峰值区,当足弓内在维持结构损伤后,前足压力增加,峰值压力位于第3跖骨头下;而足底接触总面积无明显改变. 结论 足底韧带损伤后,足底压力分布将发生改变,足外侧的应力集中,可能是出现临床症状的一个重要原因.     

Epithelioma cuniculatum: A case report

Epithelioma cuniculatum (carcinoma cuniculatum) is a rare, low-grade verrucous carcinoma of the foot first described in 1954. We present a case report of a 55-year-old man with an enlarging lesion on the sole of his right foot. Despite initial benign pathology the lesion continued to grow, soften in consistency and develop a foul odour. Repeat biopsy showed a well-differentiated squamous cell carcinoma and below-the-knee amputation was required. Epithelioma cuniculatum presents as a slow growing mass on the plantar aspect of the foot. Diagnosis is often delayed and may require multiple biopsies. Lesions rarely metastasise but more commonly invade locally requiring wide surgical excision.     

The Weil osteotomy for the treatment of painful plantar keratoses

Management of painful plantar corns remains challenging. Failure of conservative treatment may necessitate surgical intervention. The aim of this study was to assess the effectiveness of the Weil osteotomy in the treatment of painful plantar corns. A total of 29 patients (33 feet) underwent Weil osteotomy combined with plantar lesion excision of a single metatarsal of either the second, third or fourth metatarsals. These were reviewed post-operatively at an average of 42.4 months. At final review, nine feet (27%) presented with a corn. Four feet (12%) developed transfer metatarsalgia with a total of seven feet (21%) requiring revision surgery. The average metatarsal shortening was 4.5 mm. Requirement for regular clinical lesion reduction fell from an average of 5.6 weeks to 12 weeks (P<0.001) between treatments and the American Orthopaedic Foot And Ankle Society clinical rating scale improved by an average of 48 points (P<0.001). The Weil osteotomy is a moderately effective intervention which should be considered in planning the treatment of intractable plantar corns.     

Percutaneous fixation of avulsion fracture at the plantar lateral base of the first metatarsal using ZipTight Fixation System: A case report

Isolated avulsion fracture of the peroneus longus tendon insertion at the base of the first metatarsal without injury of the tarsometatarsal joint is very rare. Similar to most avulsion fractures, this type of injury is caused by strong tension exerted by the peroneus longus tendon. The mechanism leading to this lesion and treatment options are not clearly defined. Several surgical techniques have been advocated for this fracture, including excision of an avulsion fragment and open reduction for internal fixation through the medial aspect of the foot or minimal plantar incision. We have described a method of percutaneous fixing of the avulsion fracture at the plantar lateral base of the first metatarsal using the ZipTight Fixation System (Zimmer Biomet Warsaw, Indiana, USA), which offers the advantage of allowing a rigid fixation and minimal invasive surgical technique for a small fragment.     

Giant cell tumour of the flexor tendon sheath of the foot.

Giant cell tumour of tendon sheath (GCTTS) is a benign, soft-tissue tumour arising from synovial cells of tendon sheaths. Because of the high incidence of recurrence, radical surgical excision is the treatment of choice. Presented here is a rare case of this lesion originating from flexor tendon sheaths of the foot. A 40-year-old Russian white female presented to the clinic with a slightly painful soft tissue mass in her right foot along the medial aspect of her ankle. She gave a one-year history of the mass and was concerned about increasing size, pain, and plantar numbness as well as limitation in her movements to some extent. Interpretation of the magnetic resonance imaging failed to include giant cell tumours in the preoperative differential diagnosis. Considering the proximity of the tumour to important anatomic structures, less radical but grossly complete excision was employed, followed by appropriate periodic re-evaluation. Pedal involvement of GCTTS is rare with a reported predilection for dorsal and lateral localisations around the ankle. Our case presents an unusual occurrence of this tumour with medial localisation of the lesion in the foot, extending through the tarsal tunnel.     

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

BackgroundPlantar 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.MethodsA 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.ResultsConsidering 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.ConclusionsValid 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.     

Percutaneous plantar fasciotomy: An anatomical study about its safety and efficacy

BackgroundPercutaneous plantar fasciotomy is one of the available options for recalcitrant cases of plantar fasciopathy, but there is a mismatch in the clinical results between different author’s experience, possibly due to variability when choosing the exact cutaneous entry point. The purpose of this study is to validate the plantar approach in the surgical treatment of plantar fasciopathy, describing a safe path and cutaneous entry point to perform a percutaneous plantar fasciotomy with a 2 mm incision testing the procedure on cadavers.Methodsa unicentric cross-sectional analytical study was conducted in 12 cadaveric feet to verify the accuracy of the percutaneous fasciotomy entry point. Independent variables analysed were: extent of fasciotomy, entry point location, spur resection, and soft tissues injuries. A double evaluation was performed: an indirect evaluation under fluoroscopic vision, and a direct evaluation after anatomical dissection.ResultsNo cases of plantar cortical lesion on the calcaneus was observed. Satisfactory fasciotomy was performed in 91.7% of the cases. An optimal entry point was noticed in all cases with a mean distance to the tip of tibial malleolus of 22.5 mm (±6.9; 35.1?12.1) and a mean distance to foot midline of 7.8 mm (±1.7; 11.8?5.1). No neurological nor vascular lesions were found. In all the feet, a laceration of the plantar part of flexor digitorum brevis muscle was noted.Conclusionthe plantar approach for percutaneous total plantar fasciotomy is a safe procedure. The current study provides an intraoperative guideline for minimising the possible risks.     

Ruptured plantar epidermal inclusion cyst with foreign body giant cell reaction.

The case of a ruptured, multilobular, plantar epidermal inclusion cyst is presented. The case is notable because the lesion involved the fourth common digital nerve. Magnetic resonance images of the foot are demonstrated. Treatment consisted of surgical excision without recurrence.     

Epithelioma cuniculatum plantare

Epithelioma cuniculatum plantare is a tumor of epithelial origin occurring on the plantar aspect of the foot. It is an uncommon, locally aggressive neoplasm, not limited to this area, and in other body sites is referred to as verrucous carcinoma. The history and treatment of a patient with plantar verrucous carcinoma is presented; a survey of the literature reflects difficulty in establishing an early diagnosis. This, however, can be facilitated when the gross appearance and a history of prior surgical attempts to excise the lesion are known to the surgeon and the pathologist, and the surgical specimen ideally encompasses the deeper portions of the lesion.     

Pseudoaneurysm after foot surgery

Pseudoaneurysm (PA) is recognized as a rare complication after pediatric foot surgery. We identified the incidence, pertinent clinical features, and response to surgical intervention in PA as a complication of foot surgery. Four PAs were identified after 2,756 foot operations, an overall incidence of 0.14%. These patients typically had symptoms between 2 and 3 months after index operation with an enlarging, pulsatile, compressible mass in the plantar medial aspect of the foot. Arteriography was helpful in planning surgical intervention. Operative treatment consisted of ligation and excision of PA in all patients. Final outcome of foot deformity surgery was not compromised.     

Plantar fibromatosis (Ledderhose's disease)

The authors describe the concomitant presence of plantar fibromatosis and Dupuytren's disease in a 33-year-old man. A lesion located under the sesamoid bones of the first metatarsophalangeal joint on the right showed an aggressive tendency (rapid growth, pain, impossibility to put weight on the medial side of the foot). Another lesion located proximal to the first one was smaller and painless. Neither plain radiography nor computed tomography showed any structural changes of the skeleton. Contrast-enhancement on magnetic resonance imaging revealed two lesions on the sole of the foot. Since a concurrence of plantar fibromatosis and malignant tumour could not be ruled out, an excision of both lesions and the adjacent plantar aponeurosis was made for biopsy examination. The operative procedure was carried out from two incisions.The intra-operative findings included proliferative growth and bleeding in the lesion located under the first metatarsophalangeal joint, and delimited growth without noticeable bleeding in the other lesion. Based on histological examination, the diagnosis of plantar fibromatosis was made for both lesions.The differential diagnosis and therapy of plantar fibromatosis is discussed.     

Plantar fibromatosis: surgical considerations with case histories

Plantar fibromatosis characteristically is found in the central and medial bands of plantar fascia, although it has been reported in other areas of the foot and, through continued growth and extension, has become adherent to tendons and overlying structures. Clinically, the lesion is somewhat uncommon, usually accompanied with minimal pain and benign in nature. However, it must be distinguished from other possibly malignant lesions that may also localize in the foot. The treatment of choice is surgical extirpation of the mass. Unfortunately, the outer limits of the lesion are difficult to define, and incomplete excision often results in return of the lesion postoperatively. Therefore, a complete fasciectomy of the involved fascia is the procedure of choice in order to reduce markedly the possibility of recurrence of the fibromatosis lesion.     

A review of the effects of external pressure on skin blood flow

The human foot is a complex mechanical structure consisting of bones, ligaments and joints. They act together to provide a robust system capable of absorbing and dissipating the intermitted pressure that is subjected to its plantar surface during walking to prevent soft tissue breakdown. Current studies suggest that plantar foot pressure may lead to soft tissue breakdown (e.g. neuropathic ulceration) and hence research has so far concentrated on investigating the mechanical effects of plantar foot pressure on the foot’s integrity. This has been possible through the widely available pressure and force platforms as well as in-shoe pressure systems. However, to understand how plantar foot pressure causes soft tissue breakdown it is vital to investigate both the physiological–mechanical interactions between the skin and plantar foot pressure. This review suggests that with the current advances in technology, the physiological response of skin blood flow to mechanical plantar foot pressure should be investigated and correlated further, both during static and dynamic loading, by developing a new system capable of either measuring both variables simultaneously or by synchronising two systems in real time.     

High probability of healing without amputation of plantar forefoot ulcers in patients with diabetes

Diabetic foot ulcer is an important entity which in many cases is the first serious complication in diabetes. Although a plantar forefoot location is common, there are few studies on larger cohorts and in such studies there is often a combination of various types of ulcer and ulcer locations. The purpose of this study is to discern the outcome of plantar forefoot ulcers and their specific characteristics in a large cohort. All patients (n = 770), presenting with a plantar forefoot ulcer at a multidisciplinary diabetes foot clinic from January 1, 1983 to December 31, 2012 were considered for the study. Seven hundred one patients (median age 67 [22–95]) fulfilled the inclusion criteria and were followed according to a preset protocol until final outcome (healing or death). Severe peripheral vascular disease was present in 26% of the patients and 14% had evidence of deep infection upon arrival at the foot clinic. Fifty‐five percent (385/701) of the patients healed without foot surgery, 25% (173/701) healed after major debridement, 9% (60/701) healed after minor or major amputation and 12% (83/701) died unhealed. Median healing time was 17 weeks. An ulcer classified as Wagner grade 1 or 2 at inclusion and independent living were factors associated with a higher healing rate. Seventy‐nine percent of 701 patients with diabetes and a plantar forefoot ulcer treated at a multidisciplinary diabetes foot clinic healed without amputation. For one third some form of foot surgery was needed to achieve healing.     

Treatment of “plantar fasciitis”/Plantar Heel Pain Syndrome with botulinum toxin — A novel injection paradigm pilot study

Randomized controlled trials over the last two decades, although promising with favorable results, have shown varied efficacy in treatment of “plantar fasciitis” with botulinum toxin injection¹. One reason may be due to conflating the variabilities of plantar heel conditions solely as plantar fasciitis. Plantar Heel Pain Syndrome can be of one or more etiologies and symptoms which refutes the mistaken tendency to categorize all plantar heel pain singularly as either plantar fasciitis or fasciosis. Recognizing that there is likely an interplay of inflammatory, degenerative, and neuropathic etiologic conditions of this often-difficult malady to treat, a novel injection paradigm of botulinum toxin is explored in the treatment of 4 distinct presentations of Plantar Heel Pain Syndrome with encouraging results. Botulinum toxin injection into two intrinsic foot muscles; Abductor Hallucis and Quadratus Plantae at their origins with electrical stimulation is presented as novel method to treat four distinct etiologies of Plantar Heel Pain Syndrome. This method of botulinum toxin injection resulted in significant prolonged improvement of patient function and pain reduction in four variations of Plantar Heel Pain Syndrome. A precise injection paradigm facilitated with direct intrinsic muscle stimulation of the Abductor Hallucis and Quadratus Plantae at their origins may prove to be effective in reducing the disabilities of Plantar Heel Pain Syndrome and its associated pain.