Saturday, 4 February 2012

Incidence and treatment of recurrent plantar fibromatosis by surgery and postoperative radiotherapy.

Today I am going to post a little review if you like of the following paper that is available here:

This is something that I am hoping to do whenever I new paper comes out, I will try to find some on Ledderhose but I think that it might be more fruitful if I also take into account the related diseases or anything else that I think is relevant.

Incidence and treatment of recurrent plantar fibromatosis by surgery and postoperative radiotherapy.
Am J Surg. 2004 Jan;187(1):33-8 Authors: de Bree EZoetmulder FAKeus RBPeterse HLvan Coevorden F.

Department of Surgical Oncology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Huis, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands.

My review:

I am not sure if it is freely accessible to all but I was able to access it no problems but then I work in a lab so maybe this had something to do with that.

So this paper is about the Incidence and treatment of recurrent plantar fibromatosis by surgery and postoperative radiotherapy. As with most things like this they start out with an introductions with many key points which I am sure a lot of you will know.

  • PF and related diseases have unknown cause though it may be triggered by trauma and there have been suggestions that some genetics is to blame as well. 
  • The disease is slowly progressive and generally responds, at least initially to treatments other than surgery. This treatments are like those I have received such as orthotics and steroid injections. 
  • Surgery is only considered for those that are highly symptomatic and has a very high reccurrence and can  result in many problems. 
  • In this article they are looking at patients from Holland and are looking at surgery and radiation as an aid for surgery. 
Of course in order to do a study like this you need patients and they gathered data from many sources and estimate that in Holland at least the rough frequency of this is about 1 in 100,000, so quite rare. I have tried to summarise their table 1 in the graphs below as I find it makes for easier viewing.

Graph 1: The total incidence in their records in men and women.

Graph 2: The incidence in men, women and total separated by age of onset.  
So what I think that graph 1 shows is that although I have seen quoted that it is 5-10 times more common in men here there is maybe a 1.2x greater prevalence in men which I doubt is particularly meaningful. I think graph 2 however does show that the age of onset in men is typically 10-20 years earlier with it peaking in in the 30 year old bracket whilst women peak in the 50 year old bracket. This is quite a clear trend and maybe explains why there is the misconception that men have a greater likelihood of getting when this data suggests otherwise. 

For the purposes of their studies they look in a select group that they have had access to with an average age of diagnosis of 25 years old and interestingly they found that those who suffered from it bilaterally typically had a family history of plantar fibromas or related illnesses and they were also more likely to have one of the related conditions. 

Of their group at diagnosis all but 3 were suffering and of those 3 -  2 were in pain within 3 1/2 years and the other one actually naturally regressed. I like to hear about natural regression and it is nice to hear of it happening.    

In total there were 26 operations on 9 patients and 11 feet. So as you can tell from that 2 of them had a bilateral case of this condition, from such a small sample group it is hard to tell the level of it appearing in both feet but I am sure that I have heard that it can be as high as 40% and some say only 20% of people get it in both feet and that is about what they are seeing here (approx 20%). 

They did have different kinds of operations, so for those who don't know you can either have the lump itself removed and very little else or you can essentially have the same but have more of the surrounding tissue removed or you can basically have the entire tendon in which the fibromas grow removed. In total they show that for 10 patients with the above operations there is a 90% rate of return. 

As I said near the start they also look at treatment post-op with radiation and on the face of it the results look good. 5/8 come back without radiation and 1/6 come back with radiation, they say that with radiation there is an increased risk of other problems and one person required a below the knee amputation. Note they are using a very small data set.

They do follow ups and I am not sure what they mean exactly when they say that all but 1 are disease free as they go on to say that 2 are unable to walk, 2 are sort of ok and 1 has had the below knee removal. Make of that what you will but for me is shows that surgery should only really be used as a last resort and that it is important to take everything into consideration before considering not only whether to have it but also whether to have the radiation chucked in as well.