Progressive pedal macrodactyly surgical history with 15 year follow-up

Intraneural lipomas: institutional and literature review

BACKGROUND

Adipose lesions of nerve can be envisioned as a spectrum ranging from intraneural/extraneural lipomas to lipomatosis of nerve (LN). We have noticed that intraneural lipomas are not as a homogenous group as previously thought and demonstrate differences which have clinical implications. To better understand intraneural lipomas, we conducted a search of cases at our institution and published cases in the world's literature.

MATERIALS AND METHODS

Mayo Clinic's database was searched between years 1994-2018. Published cases were identified using PubMed and Google Scholar databases. Following terms were used: intraneural lipoma, lipoma and nerve, lipoma and neuropathy, lipofibroma and nerve, fibrolipoma and nerve and neural lipoma as well as lipofibroma and fibrolipoma alone. Cases that could be clearly identified as intraneural lipomas by the location of the lipoma within the epineurium were included for analysis. These cases were then sub-classified as encapsulated intraneural lipomas or hybrid intraneural lipomas (demonstrating features of both intraneural/extraneural lipomas and LN) based on their characteristics.

RESULTS

We identified 12 cases at our institution (8 encapsulated, 4 hybrid) and 24 published cases (21 encapsulated, 3 hybrid). The most commonly affected nerve was median both at our institution and in the published cases. Encapsulated cases were found to be relatively easy to resect. Hybrid cases demonstrated variable degree of interdigitating fat between the fascicles and were relatively difficult to resect.

CONCLUSION

Intraneural lipomas exist as two separate entities with distinct clinical implications. Although rare, this should be taken in account when planning surgery. Terminology should be clarified to prevent ambiguity and confusion.

Two cases of macrodactyly of the foot: relevance in pediatric orthopedics

Congenital enlargement of one or several digits of the foot, known as macrodactyly, is a rare malformation. Macrodactyly impedes foot development and affects function and gait. Here, we describe a surgical technique used to correct macrodactyly in two pediatric patients. We performed amputation of the enlarged phalanx and debulking of the soft tissues to construct a normal-sized digit. This precise technique involves a simple surgical plan that preserves the metatarsus and cuneiform and does not result in a wide plantapedis. Both patients subsequently showed improved gait and were able to wear normal shoes.

Macrodystrophia lipomatosa of a fifth digit: a case report

Macrodystrophia lipomatosa (MDL) is a rare, nonhereditary, congenital malformation that primarily affects the proliferation of mesenchymal structures. It presents with localized macrodactyly of one or more digits. The characteristic pathology is associated with hypertrophic fibroadipose tissues, more so to the plantar aspect of the foot. This condition can pose a threat to vascular supply, innervation, and even joint function. We present a single case of a 4-year-old male patient who presented with progressive enlargement of a unilateral left fifth digit since birth. The patient became increasingly symptomatic. Amputation was the selected treatment, and on pathological review of the specimen, the diagnosis of MDL was confirmed. The patient is approximately 1 year postoperative and has recovered uneventfully with an improved quality of life. The purpose of this article is to raise awareness of this condition with an emphasis on diagnosis through ancillary imaging results.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case report.

Occult radiological effects of lipomatosis of the lumbosacral plexus

OBJECTIVE

Lipomatosis of nerve (LN) is a condition of massive peripheral nerve enlargement frequently associated with hypertrophy within the distribution of the nerve, and most commonly affecting the distal limbs. We sought to understand if LN of the lumbosacral plexus would be associated with the trophic effects of LN on surrounding tissue within the pelvis, which may be clinically occult, but present on MRI.

MATERIALS AND METHODS

Fifty-one cases of LN, confirmed by pathology or pathognomonic appearance on MRI, were reviewed. Patients with LN of the sciatic nerve were investigated for radiological signs suggestive of overgrowth.

RESULTS

Five patients had involvement of the sciatic nerve, 4 of whom had MR imaging of the pelvis. Three patients had LN involving the lumbosacral plexus, and one patient had isolated involvement of the sciatic nerve. All patients with involvement of the lumbosacral plexus demonstrated previously unrecognized evidence of nerve territory overgrowth in the pelvis, including: LN, profound adipose proliferation, muscle atrophy and fatty infiltration, and bone hypertrophy and ankylosis. The patient with LN involving the intrapelvic sciatic nerve, but not the lumbosacral plexus did not demonstrate any radiological evidence of pelvic overgrowth.

CONCLUSION

LN is broader in anatomical reach than previously understood. Proximal plexal innervation may be involved, with a consequent effect on axial skeleton and intrapelvic structures.

Fibroproliferative Neuromas May Occur After Iatrogenic Injury for Lipomatosis of Nerve

BACKGROUND:

Lipomatosis of nerve (LN) is a condition associated with nerve-territory overgrowth. We have noted a unique type of neuroma at sites of LN injury; the neuroma extends beyond the epineurium, enhances, and appears to enlarge over time.

OBJECTIVE:

We sought to understand the relationship between fibroproliferative scarring and surgery performed on the nerve.

METHODS:

A review of the searchable records for LN at our institution found 52 cases, confirmed by pathology or pathognomonic appearance on magnetic resonance imaging (MRI). Clinical histories were reviewed to categorize the surgeries performed by the degree of iatrogenic injury to the nerve. Postoperative MRI was performed in 22 of the 46 patients who had surgery, which was then retrospectively reviewed for fibroproliferative neuromas.

RESULTS:

Complex and masslike neuromas were found on MRI, correlating with the degree of iatrogenic injury to the nerve. These fibrous neuromas proliferated beyond the epineurium, disrupted fascicular architecture, were contrast enhancing when contrast was administered, indicative they were unique and unlike stump or traction neuromas. Of the 8 patients who underwent surgery involving nerve decompression alone, none developed fibroproliferative neuromas. Of the 7 patients who underwent surgery involving nerve debulking, fibroproliferative neuromas developed in 4. Of the 11 patients who underwent surgery involving nerve transection, all developed fibroproliferative neuromas (P < .001). There was also a high incidence of hypertrophic scarring of the skin incision (21.3%).

CONCLUSION:

Surgical injury of LN appears to be strongly associated with the development of fibroproliferative neuromas. It is possible that the pathological overgrowth stimulus associated with LN promotes exuberant scar formation.

Bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas

Macrodystrophia lipomatosa is a rare disease that causes congenital local gigantism of part of an extremity, which is characterised by an increase in all mesenchymal elements, particularly fibroadipose tissue. This is the first report to our knowledge of a case of histologically confirmed bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas.

Ray reduction of the foot in the treatment of macrodactyly and review of the literature

Macrodactyly of the foot is a rare disorder characterized by enlargement of the soft tissue and osseous elements of the foot that impedes the development of normal function and gait. Despite the morbidity associated with this condition, many surgeons are reluctant to perform surgical reduction. In the present report, we describe 3 pediatric patients with pedal macrodactyly, who underwent surgical correction consisting of amputation of the most enlarged ray, reduction of the adjacent rays, and ray transposition, combined with debulking of soft tissues. All 3 patients subsequently developed a normal gait and were able to wear normal, or minimally adjusted, shoes. We advocate early surgical treatment of macrodactyly of the foot to enhance the development of normal function and gait.

Treatment of macrodactyly in the adult foot: a case report

Level of Evidence: V, Case Report

Lipofibromatous Hamartoma of the Upper Extremity: A Review of the Radiologic Findings for 15 Patients

OBJECTIVE

The purpose of this study was to analyze the radiologic characteristics of lipofibromatous hamartomas affecting upper limb peripheral nerves.

CONCLUSION

Although there are pathognomonic features that characterize lipofibromatous hamartoma on MRI, the range of appearances is broad. Sonography appears to show equally characteristic features and may be a useful tool for assessing this condition.

Island nail transfer in the treatment of macrodactyly of the great toe: a case report

Macrodactyly involving the great toe is difficult to treat when both the functional and cosmetic problems are addressed simultaneously. Partial resection of the distal phalanx is an easy way to reduce the length of the involved toe. However, there are cosmetic concerns with loss of the toenail. The authors report on a clinical case in which shortening and debulking of the toe was performed while preserving the hallux nail. The nail complex was transferred as an island flap to the dorsal aspect of the proximal phalanx. At the 1-year follow-up, the length of the reconstructed toe was significantly decreased, with a normal-looking nail.