Wound Reconstruction After Wide Excision of Plantar Fibromatosis

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Dr. Chaffin discloses that she is a consultant for Aroa Biosurgery.

I'm Dr. Abigail Chaffin. I'd like to thank Podiatry Today and HMP Global for the invitation today to speak about this plantar fibromatosis case. I'm the Division Chief of Plastic Surgery at Tulane University and practice broad-based reconstructive plastic surgery. I'm also the director of the MedCentris Wound Healing Institute at Tulane.

I think the audience today is all very familiar with the challenges of plantar fibromatosis. It's a benign, hyperproliferative disorder of the plantar foot that leads to slow growth of enlarging painful nodules on the plantar fascia. This can lead to pain, difficulty with ambulation and quality of life concerns for these patients.

My poster at SAWC Fall is about this plantar fibromatosis case. This is a 60-year-old gentleman referred to me by an orthopedic surgeon. He's had three prior local resections of plantar fibromatosis on his left foot, which has recurred with multiple large nodules throughout nearly the entire plantar fascia. He presents with severe pain with ambulation and the orthopedic surgeon plans a wide resection of the total plantar fascia. This defect included all of the soft tissue over the first metatarsal phalangeal joint, which for me was the largest area of concern for reconstruction.

So I went to the operating room with the orthopedic surgeon and as you can see in the photos, the initial defect was 15 centimeters by eight centimeters by 1.5 centimeters in depth. We had a full thickness defect with exposed plantar flexor tendons, loss of the superficial plantar flexor muscles, and again, the area of highest concern to me was this exposed first metatarsal phalangeal weight-bearing joints on the foot. The orthopedic surgeon preferred to wait for permanent pathology margins so at the original operating session, I placed an ovine forestomach, three layer matrix graft to encourage a neodermis formation. This is the Myriad matrix graft. I also placed a negative pressure wound therapy dressing and awaited pathology. So as you can see in the photo, this is how I affixed the initial graft with absorbable sutures to the wound bed and staples with the graft covering the tendons and the metatarsal phalangeal joint.

The next week, pathology margins were thankfully negative. So my goal at this point, how I would approach this case is, I have a large defect. I need robust tissue to allow stable pain-free ambulation and typically many plastic surgeons would approach this with a free tissue transfer flap. My concern with that is, of course, the donor site morbidity and also commonly these flaps are very bulky and can be insensate leading to difficulties with ambulation and shoe fitting. So I decided to have this matrix help achieve this neodermis with continued once a week assessment in the outpatient wound center, negative pressure wound therapy dressing changes, and started to see pretty rapid granulation through the graft.

My area of concern was still thin coverage over that first metatarsal phalangeal joint. So at that point, twice a week, I applied a one-layer ovine forestomach matrix graft, also known as the Endoform dressing, just over this area, continuing the negative pressure wound therapy. I was very pleasantly surprised to see at four weeks, full granulation of this defect with good contour restoration. So at that point, I planned a split-thickness skin graft at 18/1000th of an inch depth thickness with negative pressure wound therapy dressing and then saw him again in one week in the office. He was strictly offloaded from this foot from any ambulation or pressure during this course. He used a knee scooter and immobilizing ankle boot. We were very pleased to see full take of his split-thickness skin graft and he healed very uneventfully.

The last photo shows him just two weeks ago at approximately four months post-op, and I was exceedingly pleased to see excellent healing of the graft with good contour restoration without a bulky flap. He was sent to an orthotist and wears regular shoes with a custom offloading orthotic and has been told to maintain a meticulous awareness of the foot for the rest of his life. But he is completely pleased. He had been for over 10 years, walking with severe pain and for the first time he's walking normally and very happy.

For me this was really a game changing case. This is probably the largest defect that I've seen with plantar fibromatosis and again, it was that decision tree of does he need a free tissue transferred flap or could this be accomplished with a simpler method, also sparing the donor site. So I was very pleasantly surprised to see, with this deep of a defect and this large, that we were able to achieve complete robust soft tissue coverage with just one operative placement of the ovine forestomach matrix graft and then weekly visits in the outpatient center, with what I would state, is an excellent result. That is, he fits in a regular shoe, and he's walking without pain. So this may change the paradigm a little bit for reconstruction of large defects on the plantar weight-bearing foot. So this is really exciting in the plastic surgery world as well and it offers these patients potentially a new, more easily achievable reconstruction that's robust for these complex recurrent plantar fibromatosis cases.