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Calcifying Aponeurotic Fibroma of the Hallux
A Case Report
Calcifying aponeurotic fibroma is a rare benign fibrous tumor predominantly seen in children and adolescents younger than 20 years. This tumor is often treated with complete surgical excision, although the recurrence rate is approximately 50%. The distal upper and distal lower extremities are most commonly involved, with only three cases published to date involving pedal digits. We discuss a case of calcifying aponeurotic fibroma in a 25-year-old woman localized to the medial aspect of the distal hallux. Clinical, radiographic, and magnetic resonance imaging findings are described. After an incisional biopsy and histopathologic findings confirmed that the lesion was benign, a complete excision was performed, and diagnosis was established for calcifying aponeurotic fibroma. At 6 months, the patient had healed uneventfully, and no recurrence has been noted. Malignant transformation is rare but has been documented, warranting concern for clinicians and patients.
Nail pathologies have a broad range of origin and may sometimes be complicated in presentation or clinical course, specifically when the pathology remains recalcitrant after treatment. In this case report we discuss a pathologic disorder that was initially misdiagnosed as a pyogenic granuloma surrounding an ingrown nail but was later found to be a benign neoplastic bone growth, Dupuytren exostosis, also known as a subungual exostosis. Operative treatment was deemed appropriate for the patient, and the exostosis was resected, leaving a soft-tissue void at the distal toe. The remaining void was filled with a perinatal graft, the use of which has been deemed effective anecdotally in both chronic and acute lower-extremity wounds but has not been widely discussed in the lower-extremity literature. This graft was placed to aid in wound healing over a potentially difficult wound bed. As amniotic, chorionic, and umbilical grafts become more prevalent in lower-extremity surgery, its antitumor effects should be further explored and published. This is the first case report, to our knowledge, of the successful use of a perinatal graft in the setting of a bone tumor, and it demonstrates that certain benign neoplasms can be treated with resection and placement of a perinatal graft while helping to prevent chronic wounds at surgical sites.
Acral lentiginous melanoma (ALM) is a disease that is found on the palms, soles, and nail beds. Because these areas are not often examined during general medical examinations, the presence of ALM often goes unnoticed or the diagnosis is delayed. Research shows that the misdiagnosis of ALM is common, reported between 20% and 34%. We present three cases of ALM that were initially misdiagnosed and referred to the senior author (B.C.M.) in an effort to assess why misdiagnosis is common. The existing literature illuminates clinical pitfalls in diagnosing ALM. The differential diagnosis of many different podiatric skin and nail disorders should include ALM. Although making the correct diagnosis is essential, the prognosis is affected by the duration of the disease and level of invasiveness. Unfortunately, most of the reported misdiagnosed cases are of a later stage and worse prognosis. This review highlights that foot and ankle specialists should meet suspect lesions with a heightened index of suspicion and perform biopsy when acral nonhealing wounds and/or lesions are nonresponsive to treatment.
