[ ISSN : 2576-5442 ]
Foot; Plantar aponeurosis; Ledderhose’s disease
Plantar fibromatosis of the foot (i.e. Ledderhose’s disease) is a rare benign but local aggressive disease of the plantar aponeurosis (i.e. fascia) with unknown etiology. Histopathological findings in plantar fibromatosis reveal similar findings to those in palmar fibromatosis (i.e. Dupuytren’s disease), and genetic factors (i.e. familial history) for its appearance seems to be of relevance. Treatment options include various non-surgical and surgical procedures; however, progression of disease after non-surgical treatment and recurrence after surgery is a concern. But in trend, total plantar fasciectomy seems to be superior compared to all other procedures. The aim of this short review article is to give practicable interdisciplinary insights on a surgeon’s perspective for all clinicians who are confronted with this rare disease including various differential diagnoses related to chronic plantar foot pain, and possible complications after its treatment.
Plantar fibromatosis of the foot is a rare benign, hyperproliferative, and local aggressive disease of the plantar aponeurosis (i.e. fascia) (Figure 1A) of unknown etiology and included among the extra-abdominal desmoids tumors, this entity was first described in 1894 bythe German physician Georg Ledderhose (1855-1925), and it is accompanied by a high recurrence rate [1-3].
Figure 1: (54-year-old female, plantar fibromatosis, right foot): (A) Preoperative clinical findings and magnetic resonance imaging, the nodule is partially adherent to the skin (arrows). (B) Intraoperative, after careful dissection of the nodule (arrow) from the skin. (C) Intraoperative, after total fasciectomy. (D) Intraoperative, primary closure of wound, the further course was uneventful.
Regarding etiology, it has been described to be most frequent in patients with diabetes, low body weight, epilepsy, alcohol abuse, and smoking, and a familial history in up to 19.1% of cases is observed as well [2,4]. Occurrence is observed at all ages ranging from 2 to 83 years (N=178), but especially in the 4th and 5th decade of life in the absence of significant sex-related differences (51.7% male vs. 48.3% female in 178 patients), and bilateral involvement is reported to be 20-50% of cases [2,4]. It can be associated in 5-21.3% of cases with the palmar fibromatosis of the hand (Figure 2A-D) first described quite earlier in 1831by the French physician Baron Guillaume Dupuytren (1777- 1835) which can also be associated with the fibrous subcutaneous nodules (i.e. knuckle pads) upon the proximal interphalangeal finger joints (Figure 3) first described in1904 by the British physician SirArchibald Edward Garrod (1857-1936), and in 1-3% of cases with the penile fibromatosis first described substantial quite earlier in 1743 by the French physician François Gigot de la Peyronie (1678-1747) [2,5-12].
Figure 2: (57-year-oldmale, advanced stage of palmar fibromatosis, left hand): (A) Preoperative, passive fixed flexion contractures of the 4th and 5th finger. (B) Intraoperative, the total fasciectomy was performed; all neurovascular bundles and pulleys were safely spared. (C) Intraoperative, primary closure wound, the further course was partially complicated by delayed wound healing without the need of secondary coverage. (D) At the 1-year follow-up there was a good restoration of the overall hand function.
Figure 3: (67-year-old female, right hand): Palmar fibromatosis associated with the typical knuckle pads upon the proximal interphalangeal joints of the index and middle finger.
Histopathological findings in plantar fibromatosis reveal similar findings to those in palmar fibromatosis [13]. In the literature, it has been proposed for palmar fibromatosis that growth factors, such as platelet-derived growth factor and transforming growth factor-beta, free oxidized radicals, increased levels of plasminogen activator enzymes, and expression of Ki-67 antigen contribute the etiology, and it was found that the number of androgen receptors in specimens of palmar fibromatoses was considerably higher than in normal palmar fascia [14-19]. Noted that expression of the Ki-67 antigen plays an important role in detection of malignancies [20]. For the palmar fibromatosis, family history probably has the strongest influence on the age at time of first surgery compared to environmental factors, followed by male sex, and the percentage of familial cases decreased with age of onset from 55% in patients aged 40-49 years to 17% in patientsaged80 years and older, and men are upto 15 times more likely to suffer from this disease but during the 8th and 9th decade of life the ratio between affected men and women is equal [21,22]. Moreover, palmar fibromatosis is more frequently observed in the white Caucasian and Nordic race than in Africa or Asia [23]. Noted that the incidence of palmar fibromatosis in elderly men is reported to be up to 25.3% in Australia [24], up to 28.9% in Ireland [25], and up to 13.75% in England [26].
The differential diagnosis of plantar fibromatosis should include stenosing tenosynovitis, ganglion cyst of the ankle with medial plantar nerve entrapment (i.e. tarsal tunnel syndrome) (Figure 4A-B),
Figure 4: (29-year-old male, right ankle medial, tarsal tunnel syndrome): (A) Intraoperative, ganglion cyst led to entrapment of both plantar nerves at the bifurcation of the tibialis posterior nerve (arrow). (B) Intraoperative, after resection of ganglion cyst and decompression/neurolysis of both plantar nerves.
other conditions leading to entrapment of plantar digital nerves such as the primary Morton’s neuroma (Figure 5A-C),
Figure 5: (53-year-old female, Morton’s neuromas, left forefoot, plantar): (A) Preoperative magnetic resonance imaging showing the lesion between the metatarsophalangeal joints III and IV (arrow). (B) Intraoperative, dissection of the neuroma (arrow). (C) Intraoperative, after excision of the neuroma.
or secondary post-traumatic/post-operative neuroma (Figure 6A-C),
Figure 6: (59-year-old male, postoperative neuroma, right foot, plantar): (A) The patient sustained a total first metatarsophalangeal joint replacement for treatment of hallux rigidus with a good functional outcome for gait. (B) But postoperative, he reported progredient disability with loss of sensitivity of the great toe plantar-medial associated with a positive painful HoffmannTinel sign (circle/cross) suggesting a partial lesion of the proper nerve branch and resulting in a neuroma that was confirmed intraoperatively. (C) Intraoperative, after interfascicular neurolysis of the proper nerve branch to the great toe. The further course was uneventful with a satisfactory pain relief and improvement of sensitivity.
plantar fasciitis or rupture with or without plantar calacaneal spurs (Figure 7 compared to Figure 8), heel bursitis with or without Haglund’s exostosis (Figure 7 compared to Figure 8),
Figure 7: (69-year-old female, chronic heel and plantar foot pain, left): Typical flatfoot (i.e. pes planus) with a decreased calcaneal inclination angle to 10° (red lines and points) and a normal Böhler’s angle with 25° (yellow lines and points) that means that the talocalcaneal joint is not involved in flat foot in this case. The flatfoot typically led to an overstretching-related plantar fasciitis that results in a periosteal reaction with occurrence of a plantar calcaneal spur at the origin of the plantar aponeurosis (yellow arrow). Moreover, the flatfoot is combined with a pes valgus that led to a decentralization of the achilles tendon, and resulting in a tendinitis and bursitis, and occurrence of a typical dorsal Haglund’s exostosis at its insertion (light blue arrow) similar to the plantar calcaneal spur.
Figure 8: (43-year old male, normal sagittal static arc architecture of foot, left): Normal calcaneal inclination angle with 20 to 30° (red lines and points) that means that there is neither insufficiency of tibialis posterior tendon nor overstretching (or damage) of plantar aponeurosis, and normal Böhler’s angle with 20 to 40° that means that there is neither misalignment nor instability in talonavicular joint.
aseptic osteonecrosis such as Köhler’s disease (Figure 9), or other benign or malignant lesions (Figure 10), including fibrosarcoma [27,28].
Figure 9: (36-year-old female, chronic plantar foot pain, left): Aseptic osteonecrosis of the 2nd metatarsal head (Köhler’s disease II, yellow circle).
Figure 10: (16-year-old girl, chronic plantar metatarsalgia, left): Symptoms are based on hereditary syndactyly of the 2nd with the 3rd toe resulting in metatarsalgia due to impaired function in the 2nd and 3rd metatarsophalangeal joint, pre- and intraoperative after its microsurgical separation.
Plantar fibromatosis usually starting with 1 or more asymptomatic or painful subcutaneous nodules, most frequently at the longitudinal medial arc and/or central division of the plantar aponeurosis (Figure 1A) which can be adherent to the overlying skin and muscles, and potentially leading over time to entrapment of the proper digital nerve branch to the great toe (or others), and flexion contractures unless the slips to the toes are involved which are analogues of the palmar cords [1,29]. It can also additionally occurs in deep plantar fascia, or isolated at the distal aspect of the great toe [30,31].
Histopathological, the1st stage is characterized by cellular proliferation (often associated with unspecific plantar foot pain only), the 2nd stage by nodule proliferation, and the 3rd stage by tissue contraction [32]. In order to reduce the risks of postoperative wound dehiscence and/or recurrence, an additional intraoperative staging is recommended that involves the extent of plantar fascial involvement, the presence of skin adherence, and the depth of tumor extension [32].
Plantar fibromatosis in childhood is very rare, nodules usually found in the anteromedial region of plantar aponeurosis, and unlike the adult presentation the nodules are mainly asymptomatic and not aggressive, and they have no association with palmar and penile fibromatosis [33-35]. In order to detection of nodule’s infiltration into the overlying skin and into the deeper muscle layers, and especially to exclude malignancies such as the fibrosarcoma, ultrasound and/or magnetic resonance imaging (Figure 1A) should be done in every instance. With ultrasound, most of the plantar nodules are sagittally elongated, hypoechoic in the absence of intrinsic vascularity, and echogenicity does not correlate with the size of nodules and duration of symptoms [36,37].
The advantage of magnetic resonance imaging, which is considered to be the gold standard technique for surgical planning, is that hypo- or hypercellular lesions can be assessed which are directly associated with early stages of disease or may define a more aggressive lesion [38-41]. Post-gadolinium T1 weighted magnetic resonance imaging of the nodules often showing enhancement with intravenous paramagnetic contrast fluid [2].
Plantar fibromatosis can primarily treat non-surgically (stretching, orthotics, anti-inflammatory drugs, physical therapy, shockwave therapy, radiotherapy, intralesional injections of cortisone or collagenase) [12], however, there is large lack of information in the overall literature about regression vs. progression of disease over time. In the trend, intralesional cortisone injections are mostly used, radiotherapy showed good clinical outcomes but the benefits compared to the side effects are unclear, shockwave therapy reveals promising outcome in the absence of knowledge about possible complications, and intralesional collagenase injection is not already recommended recently [2]. Surgical treatment becomes necessary when in primarily nonsurgically treated patients a satisfactory pain relief does not appear and the disease progresses. It includes total plantar fasciectomy (Figure 1B-D), subtotal procedures with some inconsistencies in their methodological descriptions (marginal excision, local excision, wide local excision, staged excision, wide excision, subtotal fasciectomy, partial fasciectomy), and others such described as dermofasciectomy and surgery with or without radiotherapy; but due to the low number of patients and the heterogeneity of data of most published studies it is not possible to standardize the various procedures with its specific outcomes [2].
However, the overall recurrence rate including all procedures after first surgery is 74.3%, and 25.7% after recurrence surgery, but in trend, local excisions are associated with the highest recurrence rate and should not be recommended neither in primary nor in recurrent cases whereas procedures with wide operative margins (i.e. R0 resection) seems to be superior [2]. Noted that in recurrent cases a below-knee amputation becomes necessary as well in single cases [42]. The most important postoperative complication is delayed wound healing in up to 47.8% of cases accompanied by the necessity of additional skin grafting in 17.4% of them [35].
The plantar aponeurosis (i.e. fascia) originates punctually at the plantar-medial aspect of calcaneus, then it passes the foot subcutaneously to distal creating a V-shaped divergent configuration, divides near the metatarsal heads into 5 sections, and inserts with its slips at the bases of all 5 proximal phalanges. It contributes to support of arch of the foot by acting as a tie-rod, where it undergoes tension when the foot bears weight (Figure 8). When the plantar aponeurosis was more than 50% removed, some degree of support to the foot is lost, potentially leading to increased peak pressures under the metatarsal heads which can followed by metatarsalgia, painful lateral column instability, sinus tarsitis, medial arch pain and fatigue,collapse of the arc in the sagittal plane (flatfoot, i.e. pes planus)and subsequently followed by valgus and/or s play deformities at hind- and fore foot in frontal plane accompanied by hallux valgus and/or claw toe deformities at the forefoot in frontal plane as well (Figures 7 and 11-13),
Figure 11: (67-year-old male, chronic plantar foot pain, combined deformities, left, all assessments under fully loaded conditions by body weight): (A) Severely collapsed flat foot in sagittal plane (red points and lines). Note the plantar calcaneal spur, and the prominent head of talus (white arrow). (B) Valgus deformity of the hindfoot in frontal plane (black and red lines). (C) Splay foot (black double arrow) and serpentine foot (red angled lines) in frontal plane. Note the advanced stage of secondary osteoarthritis in 1st metatarsophalangeal joint.
Figure 12: (57-year-old female, chronic plantar foot pain, flat foot, right): The flat foot typically led to a splay foot in frontal plane with pronounced widening of the intermetatarsal angle (red lines, normal ≤ 9°), and resulting in hallux valgus and claw toe deformities, and metatarsalgia due to displacements of the metatarsal heads II-IV plantarwards. It was surgically treated by corrective arthrodesis of the 1st tarsometatarsal joint, release of the lateral capsule of the 1st metatarsophalangeal joint, removal of medial exostosis at the 1st metatarsal head, and subcapital shortening osteotomy of the 2nd metatarsal bone. Intraoperatively, a correct alignment of the 1st ray could be achieved (3 angled black lines at the left side vs. 1 non-angled black line at the right side of Figure).
Figure 13: (63-year-old female, chronic plantar foot pain, flat foot, right): The flat foot led to a ligamentous insufficiency in talonavicular joint with its displacement (red angled lines, acquired serpentine foot), and secondarily to advanced stage of osteoarthritis (yellow arrow), and chronic hyperkeratotic skin ulceration upon the medial aspect of the head of talus.
Figure 14: (73-year-old female, chronic plantar foot pain, right): Pronounced flat foot (red points and lines) subsequently leading to tarsal bone displacement plantarwards due to ligamentous insufficiencies (white arrows, computed tomography of the same patient).
or by acquired serpentine foot (i.e. tarsus abductus/metatarsus adductus, skew foot) when the talonavicular and/or other intertalar joints become ligamentous unstable (Figure 14) with or without bone displacements or internal pressure-related skin ulceration upon the medial aspect of the head of talus (Figures 11, 13 and 14), secondary osteoarthritis in 1st metatarsophalangeal joint (Figure 11A-C), and with continued strain, stress fracture first described in Prussian soldiers in 1855 by the Prussian military physician Breithaupt may also arise particularly at the 2nd and/or 3rd metatarsal (Figure 15) [43-49].
Figure 15: (59-year-old female, chronic plantar foot pain, flat and splay foot, both sides): Primarily undiagnosed stress fractures of the 3rd metatarsal bones that led to a non-union right whereas the left fracture was healed spontaneously with callus formation. The non-union right was treated by internal plate fixation without the need of additional bone grafting, and healed with callus formation as well. Note that there was an additional ligamentous instability at the 2nd tarsometatarsal joint right with displacement tendency of the 2nd metatarsal bone plantarwards (assessed intraoperatively) that was additionally treated by open reduction and Kirschner-wire transfixation.
In contrast, acquired varus deformity of hind foot or flat foot with a decreased Böhler’s angle appears to be more frequent in (post) traumatic condition (Figures 16A-C and 17A-B) [50].
Figure 16: (68-year-old female, posttraumatic varus deformity right hind foot based on a previously sustained talus fracture that was treated conservatively [50]): (A) The talus fracture healed with misalignment that led to pronounced varus deformity of hind foot (yellow and black angled lines) accompanied by advanced posttraumatic osteoarthritis in ankle. (B) Intraoperatively, a corrective arthrodesis of the ankle was performed. (C) A satisfactory outcome with complete restoration of varus deformity could be achieved (black line).
Figure 17: (54-year old male, calcaneal fracture, left): (A) Initial findings and open reduction and internal locking plate fixation, note the completely collapsed Böhler’s angle in 3D computed tomography (red points and lines) that means that there is a traumatic fracture-related flat foot. (B) The Böhler’s angle could be good restored (green points and lines).
It is recommended in postoperative care for the patients to use an orthotic device such as an insole with arch support (Figure 18A-C),
Figure 18: (8-year-old boy from Uzbekistan who sustained a burn trauma at his left lower leg and foot with age of 3 years that led to marked scar formation with talus verticalis and valgus contracture in ankle, and resulting in severely collapsed and fixed flat foot): (A) Preoperative situation with planning the large Z-plasties. (B) Intraoperative, performing the Z-plasties, lengthening procedures of the extensor tendons, and open reduction of talus verticalis with temporary Kirschner-wire transfixation. (C) Two months after surgery, uneventful wound healing, and in order to prevent recurrence of flat foot, insoles with arc support and orthopaedic shoes stabilizing the ankle were customized.
and the duration of its use is dependent on the patient’s comfort level [1,51,52]. The second notable late complication after wide surgery can be painful plantar scarring, and difficulties with shoe wearing [12]. When bony architecture of foot is damaged, then total plantar fasciectomy should be avoided in order to obtain its sagittal arc (Figure 19A-C) [53].
Figure 19: (28-year-old female who sustained a traumatic right midfoot amputation with age of 8 years [53]): (A) Primary midfoot replantation. (B) Despite some bony support of foot is lost, she is able to perform highdemand activities in her work and leisure. (C) There is no posttraumatic flat foot (red points and lines), however, in order to obtain the sagittal foot arc, plantar fasciectomy should be avoided.
Furthermore, when planning total plantar fasciectomy, pre-existent tears of tendons which play an important role for stabilizing and balancing the foot arc, such as the tibialis posterior tendon and the long peroneal tendon, should be reconstructed in every instance before performing total plantar fasciectomy (Figure 20A-C).
Figure 20: (73-year-old male, active runner, right chronic disruption of the long peroneal tendon accompanied by complete lateral ligamentous instability of the ankle): (A) Pre- and intraoperative, note the complete ligamentous instability both in upper and lower ankle (white and blue arrows). (B) Intraoperative, reconstruction of the long peroneal tendon and ligamentous complex in upper and lower ankle (light blue circle). (C) Sixmonths after surgery, a stable ankle was present, and the patient was able again to perform his runner’s activities.
Another main contraindication for total plantar fasciectomy is unstable soft tissue situation around the foot (Figure 21).
Figure 21: (57-year-old female, unstable soft tissue situation right ankle): (A) Wound dehiscence with exposure of osteosynthesis plate after open reduction of distal fibula fracture, primary treated by negative-pressure vacuum assisted closure therapy to control bacterial contamination. (B) Coverage of the exposed plate utilizing the distally pedicled peroneus brevis muscle flap and split-thickness skin grafts by preserving both peroneal nerves (white arrows). (C) Three months after coverage, uneventful wound healing.
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Occlusion is biologically defined as the coordinated functional interaction between the various cell populations forming the masticatory system as they differentiate, model, remodel, fail and repair
Talia Becker*
Achilles tendon is a common site of foot and ankle discomfort but its rupture is not frequent. It’s a superficial tendon and this lends it to excellent evaluation by sonography instead of magnetic resonance imaging. Recently ultrasonography has been widely used in musculoskeletal practice. We present a case of Achilles tendon ruptures diagnosed based on fundamental sonographic findings.
Arash Babaei-Ghazani¹,², Safoora Ebadi¹,², Bijan Forogh¹,³, and Bina Eftekharsadat⁴*
Osteoarthritis (OA), one of the most common skeletal disorders characterized by cartilage degradation and osteophyte formation in joints, is induced by accumulated mechanical stress; however, little is known about the underlying molecular mechanism. Several experimental OA models in mice by producing instability in the knee joints have been developed to apply approaches from mouse genetics. Although proteinases like matrix metalloproteases and aggrecanases have now been proven to be the principal initiators of OA progression, clinical trials of proteinase inhibitors have not been successful for the treatment, turning the interest of researchers to the upstream signals of proteinase induction. These signals include under graded and fragmented matrix proteins like type II collagen or fibronection that affects chondrocytes through distinct receptors. Another signal is pro inflammatory factors that are produced by chondrocytes and synovial cells; however, recent studies that used mouse OA models in knockout mice did not support that these factors have a role in the central contribution to OA development. Our mouse genetic approaches found that the induction of a transcriptional activator Runx2 in chondrocytes under mechanical stress contributes to the pathogenesis of OA through chondrocyte hypertrophy. In addition, chondrocyte apoptosis has recently been identified as being involved in OA progression. We hereby propose that these endochondral ossification signals may be important for the OA progression, suggesting that the related molecules can clinically be therapeutic targets of this disease.
Hiroshi Kawaguchi
Estimating the Knee Functional Axis (KFA) is crucial to both correctly implanting the prosthesis and accessing the joint kinematics. Researchers have mainly reported KFA by manual management of flexion extension movements, which are passively performed without any voluntary movements. Active touch and movement refers to what is ordinarily called as touching, which is defined as variations in skin stimulation caused by variations in a person’s motor activity.
The difference is very important for the individual. However, it has not been emphasized in the biomechanical literatures. This study aims to confirm the distinction between touching and being touched. We are particularly interested in measuring the Instantaneous Axes of the Knee (IAK) during locomotion. This geometrical “pattern” of the IAK is altered along with the touch pattern by the mechanical necessities of terrestrial movement.
Wangdo Kim¹, Young Choi², and Hong-Gi Lee³*
Although fractures of the epiphyseal cartilage injuries are common in childhood, epiphyseal fractures involving the proximal tibia entities are very rare and are usually caused by high-energy trauma, with an incidence ranging between 0.5 and 3.1% of patients; peak incidence between the ages 12-14 years in male patients. The aim of this report is describe a case of fracture of the epiphyseal cartilage of a 13 year old boy, a victim of sports trauma showing lateral tibial plateau fracture and epiphyseal cartilage fracture at the same side, not compatible with the classifications of fractures in children.
Omar Ferreira Miguel
In the last few years, clinical applications of regenerative medicine have been increasing their way in medical practice.
Valerio Di Nicola¹,² and Mauro Di Pietrantonio³*
The twentieth century epidemic of low back pain has continued unabated into the 21st century. Up to 20% of the Australian population will experience low back pain at some stage of their lives
J Saunders¹, M Cusi¹,³ and H Van der Wall¹,²*
Music is the most essential ingredient of any entertainment. In order to create successful entertaining event musicians plays an imperative role. Musicians are wizards who spread the fragrance of joy by absorbing woes, in the form of Playing Related Musculoskeletal Disorders (PRMDs), for themselves. Like other occupations, musicians also suffer from work related musculoskeletal disorders which are often disabling
Wricha Mishra
Dupuytren’s Contracture (DC) is a fibro-proliferative tumor according to ICD 10 - fascial fibromatosis of unknown etiology (M 720), accompanied by a stable bending contracture of fingers. In CD in the postoperative period extremely high rate of surgical complications is observed: intraoperative (injury of blood vessels, nerves, tendons), general postoperative (hematoma, necrosis, odema, stiffness, etc.), late postoperative (recurrence, spread, progression). In the last case according to the data of different authors, complications frequency is depend upon the degree (from partial up to the total) and the accuracy of excision of the affected aponeurosis ?almaris. One of the problems in choosing the type of operation and technology is the complexity of the cutoff determination boundaries of the affected CD. Up to now there is no suitable for use in the practical CD surgery algorithm of the affected aponeurosis ?almaris spread non invasive visualization in a particular patient. The most appropriate method for the solution of this problem is a method of MRI. The technology of identifying the boundaries of surgery of the affected aponeurosis palmaris in Dupuytren’s contracture by means of MRI has been elaborated. It has been shown that MRI is a highly informative method in the assessment of topographic anatomy of aponeurosis palmaris in normal and CD states. PD, T1, T2 - weighed images allow objectively to visualize the border areas of the affected aponeurosis in I - III stages of CD. PD fsat (fat tissues signal saturation) MRI mode is not recommended for use.
Baikeev RF¹, Mikusev GI², Osmonaliyev IZh², Zakirov RH² and Afletonov EN²*
Metallosis is an aseptic fibrosis, local necrosis, inflammation, or loosening of an implant device secondary to metallic corrosion and release of wear debris. The condition has been highlighted recent years due to the clinical complications caused by metal-on-metal (MoM) hip replacement. Although some major types of MoM hip prostheses have been recalled from the market, metallosis is far from over as not only there are still a million implanted MoM hip prosthetic cases worldwide, but also it has been found in non-MoM hip prostheses and other metal implants. This mini review aims to provide recent findings of implants related metallosisin skeletal tissue.
Zhidao Xia