RE: Excision of Plantar Fibroma (Ivar Roth, DPM)
These benign lesions may overlap with nodular
fasciitis and appear as well circumscribed,
lobulated tumor attached to tendons/tendon
sheaths. This will require
removal of portion of the plantar fascia as you
have indicated. The proper code would be
28060/Fasciectomy-partial plantar fascia.
Elle Farajian, DPM
Atlanta, GA
RE: Excision of Plantar Fibromas (Walter
Pedowitz, MD)
From: Multiple Respondents
I agree with Dr. Pedowitz about the regrowth of
plantar fibromas. However, no matter what the
size of the fibroma, if it is painful enough to
affect the patient's average daily living
activities, surgical excision must be
considered.
Whenever I excise a plantar mass, whether it be
a fibroma or not, I always keep the patient non-
weightbearing for at least two weeks.
Obviously, this has no effect on the possibility
of regrowth or not.
Barrett E Sachs, DPM
Plantation, FL
The casual use of language can often belie all
credibility, especially when you want to make a
point. For example, statements made in support
of plantar fibroma excision include
practitioners who have done "hundreds"
and "dozens" of these cases. These large sample
loads are not needed to make the point if you
feel that the surgical management is best. In my
first 15 years of practice, I saw this entity
about three to five times per year at most. In
the last 6 years, where I practice with a foot
and ankle orthopedist and a musculoskeletal
oncologist, I see the entity with a little more
frequency. Very little more. Based on my
experience with my "small" sample, I have
performed a total of one excision of a plantar
fibroma. The outcome was fine. Based on all
other presentations (I am sure not much more
than 100 in my entire professional life), and
the cases of my present colleagues, my total
experience leaves me agreeing wholeheartedly
with Dr. Pedowitz, not only in view of
recurrences, but the biomechanical sequelae that
may occur as well.
I have one question for the readers - How often
do you really see this entity (plantar
fibromatosis) annually?
Bryan C. Markinson, DPM
New York, NY
I've resected 55-60 of these over the years, the
largest of which was about the size of a plum
and have had zero rate of dehiscence of the
incision and 1 recurrence. I have no idea what
the ortho community is talking about here, as it
makes no sense to tell the patient to ‘live with
it’ and doesn't follow anyone’s normal, clinical
experience. Doing a fairly wide excision of
these things has allowed my low recurrence rate,
although I've only taken the entire fascia in 1
patient (bilateral case done on different
surgical dates). This lack of correlation
doesn't necessarily concern me, however. The
orthopods recommend weightbearing on 5th met
fractures, with the assurance that they will
heal and they all state that type III PT tendon
tears should go to osteotomy/arthrodesis. I see
an average of 15-18 5th met fractures a year
previously treated by orthopods with post-op
shoe/Camwalker and unrestricted weightbearing
which went on to non-union and my surgical
reconstruction. I've also done a number of PT
tears that were type I going to type II on MRI
and were clearly type III intra-op and instead
of doing a transfer or fusion, I did a primary
repair and all of these patients have had
complete return of strength and function. My
conclusion: the ortho community doesn't always
have it right.
David Secord, DPM
Corpus Christi, TX
David5603@POL.net
RE: Excision of Plantar Fibromas (Walter
Pedowitz, MD)
I also read this posting with some confusion
about the recommendation by the Orthopedic
community to avoid excision of these tumor. I
have excised, not hundreds, but dozens over the
years and have not had complications with
recurrences, a few dehisences though over the
years.
What does the orthopedic community recommend
about toleration of a 1/2-golf-ball sized firm
nodule or mass on the now weightbearing surface
of the foot...?
Nicholas Varveris, DPM
Hilliard, OH
RE: Excision of Plantar Fibromas (Walter
Pedowitz, MD)
From: Sloan Gordon, DPM
Aside from 'coding' issues, I have done hundreds
of these cases and find that if the entire
fascial band is removed, careful resection of
the tumor is performed and a drain is used,
there are little complications with this
procedures. In 21 years of practice, I have
been fortunate to have seen only 2 recurrences.
In fact, I performed one of these yesterday with
was a revision from another physician and the
fibroma was wrapped around the medial plantar
nerve and was quite difficult to dissect. With
the aid of microscopy, the tumor was excised in-
toto without any apparent damage to the nerve.
In preparing this response, I did not perform a
literature search, however, would suspect the
podiatric and plastic surgery literature would
have some good results with respect to this
procedure. I'd be interested to hear some other
responses as well.
Sloan Gordon, DPM
Houston, TX
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