Apr-11
What You Should Know About Plantar Fibromas And Recalcitrant Plantar Heel Pain
By Brian McCurdy, Senior Editor
Investigating plantar fibromas as an etiology for recalcitrant heel pain, the authors of a recently published study suggest that 25 percent of recalcitrant heel pain is neoplastic in origin. The study authors also maintain that patients presenting with proximal plantar fibromas require excision and not fasciotomy.
The retrospective study, which was published in the Journal of Foot and Ankle Surgery, involved 101 pathology specimens from 97 patients who had been diagnosed with recalcitrant plantar fasciitis. The specimens were medial and central bands of the fascia obtained from transverse plantar fasciectomies performed between July 1994 and March 2008, according to the study. Researchers note that one-quarter of the cases had a histological appearance of plantar fibroma.
The authors noted three groups of histologic findings of the specimens: neoplastic involvement (25 percent); inflammation without neoplastic involvement (21 percent); and “other,” which consisted of having no inflammatory or neoplastic response (54 percent).
All of the patients had failed a three- to six-month conservative treatment regimen, which consisted of anti-inflammatory medication, modification of activities, injection of corticosteroids, night splints, custom-molded orthotics and physical therapy, according to the study. Researchers note that only four patients underwent bilateral plantar fasciectomies and no patients required a revisional procedure.
As lead study author Martin Pressman, DPM, explains, his patients are mostly happy with fasciotomy. He says his team is currently performing percutaneous fasciotomy with ultrasound guidance for those patients with recalcitrant plantar fasciitis who have not responded to conservative care.
“Our dilemma is we now know that 25 percent of these patients may have a benign tumor (fibroma),” notes Dr. Pressman. “It is clearly not appropriate to incise a tumor and leave it.”
If one performs a partial fasciotomy, Matthew Sabo, DPM, says recurrence can happen and the patient would need a radical plantar fasciotomy. With a radical plantar fasciotomy, he says scars can cause difficulties and there can be progressive development of hammertoes. Injections, topical modalities and/or orthotics can help with scarring while one can correct hammertoes either by an arthroplasty or arthrodesis, according to Dr. Sabo, who practices at Western Pennsylvania Hospital in Pittsburgh. He says the advantages of plantar fasciectomy include relief of pain and improved quality of life.
Patients who fail fasciotomy may have a fibroma, notes Dr. Pressman, an Assistant Professor of Orthopaedics and Rehabilitation at the Yale School of Medicine. He is currently investigating core needle aspiration biopsy as a method to diagnose fibroma and re-evaluation of MRIs in cases with histologically documented proximal fibroma. Dr. Pressman says this may help determine when a fasciectomy is appropriate.
Dr. Pressman notes patients with proximal plantar fibromas of the heel are better served with fasciectomy as total removal of the fibrous mass under the heel is curative. Disadvantages of fasciectomy are the disruption of the fascia and the biomechanical consequences, according to Dr. Pressman. Although such sequelae are infrequent, he notes they can also occur with fasciotomy even if the lateral band is spared.
Dr. Sabo cites disadvantages of plantar fasciectomy that may include recurrence, scar formation, infection, hematoma and delayed wound healing.
Study Suggests Allograft More Effective Than Skin Substitute For DFUs
By Brian McCurdy, Senior Editor
A cryopreserved human allograft may have better efficacy in healing diabetic foot wounds than a biologic skin substitute, according to an abstract submitted to the Symposium on Advanced Wound Care (SAWC) Spring.
The retrospective study compared TheraSkin (Soluble Systems) with Dermagraft (Advanced BioHealing) with 10 patients in each of two cohorts. All patients had a diabetic wound between 1 and 10 cm2 on a weightbearing surface for at least one month, according to the abstract.
Researchers found wounds closed more quickly and required fewer grafts with TheraSkin in comparison to Dermagraft. The authors say the abstract represents the first direct comparison of these products by a single group of physicians and all other aspects of treatment were essentially the same.
Lead study author Adam Landsman, DPM, PhD, says there are very few head-to-head studies, noting that such studies are expensive and the involved companies assume a lot of risk. He also reviewed the use of TheraSkin and Dermagraft for diabetic foot ulcers in 188 patients in a recent study published in Foot and Ankle Specialist.
When it comes to the ease of use of Dermagraft and TheraSkin, Dr. Landsman says it is probably a matter of surgeon preference. Given that TheraSkin is a split thickness skin graft, he notes it is much more durable and, in his experience, easier to handle. He will normally stitch or staple TheraSkin in place. When it comes to Dermagraft, he focuses on dressings that will not slip, noting the skin substitute would be difficult to sew or staple.
Ryan Fitzgerald, DPM, notes that while Dermagraft theoretically provides some marginal wound coverage, he believes it is more appropriate to think of it as a “growth factor factory” in place in the wound bed. As he explains, the living fibroblasts contained in Dermagraft secrete growth factors that promote tissue regeneration and wound healing rather than simply providing a dermo-inductive scaffold. Conversely, Dr. Landsman feels the cellular contribution of growth factors is minimal and the real source of growth factors is the extracellular matrix. He says the allograft has a much more developed ECM than Dermagraft.
The disadvantages of Dermagraft include preparation time and the therapy’s expense, according to Dr. Fitzgerald, who practices at Hess Orthopaedics and Sports Medicine in Harrisonburg, Va. Although there are regional variations in cost, TheraSkin’s costs are generally about half of Dermagraft’s, according to Dr. Landsman, an Assistant Professor of Surgery at Harvard Medical School.
The SAWC Spring will be April 14-17 at the Gaylord Texan Hotel and Convention Center in Dallas. For more info, visit https://spring.sawc.net/.
Study Of Two NPWT Devices Finds Similar Efficacy For Wounds
By Brian McCurdy, Senior Editor
A recent study in Wound Repair and Regeneration compares two negative pressure wound therapy (NPWT) devices and found equal efficacy in terms of reducing wound area.
The study compared the Smart Negative Pressure (SNaP) Wound Care System (Spiracur) with Vacuum Assisted Closure therapy (VAC therapy, KCI). The randomized study evaluated 65 patients with non-infected, non-ischemic, non-plantar lower extremity wounds who received NPWT for 16 weeks or until the wounds achieved complete closure.
The interim analysis revealed no significant differences between the two devices in regard to the proportion of healed patients. Assessing follow-up results at four, eight and 12 weeks, the study authors also found no significant differences between treatment groups in regard to the percent of wound size reduction.
Lead study author David Armstrong, DPM, PhD, MD, cites advantages in the SNaP’s ease of use. The SNaP does not use an electrical pump but uses special springs to generate subatmospheric pressure, according to the study.
“The concept of a small, non-powered device that works well is very attractive,” notes Dr. Armstrong.
Negative pressure devices that run on low or no power will be most effective against superficial wounds, according to Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance in Tucson, Ariz. He speculates that the dressing interface (foam versus gauze) may not be as critical in those types of wounds.
Dr. Armstrong advocates comparing NPWT devices “head to head” in future research.
“While industry and the FDA often do not want to do this, I think that it will become another type of study design to provide more information to us as practitioners,” says Dr. Armstrong.
In Brief
Healthpoint recently announced its new corporate identity as Healthpoint Biotherapeutics with a new corporate tagline, The Science of Healing.™ The company says the changes will reflect its commitment to scientific innovations in tissue repair and healing.
