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A Novel Surgical Treatment for Fat Pad Atrophy




The Graft Jacket, from Wright Medical, was developed for ulcer repair and tendon repair and is used to treat fat pad atrophy.

One common complaint that we get in our office is "I feel like I am walking on my bones." During weight bearing the plantar foot is cushioned and protected by the plantar fat pad. This anatomic structure is organized as fat lobules held in place by surrounding fiberous septa.

Five individual sub-metatarsal pads combine to form the metatarsal plantar pad. The metatarsal fat pad is constrained dorsally by attachments to the capsule of the metatarsal heads and to the more plantar sub-dermal layer. These fat pads act as a shock absorber to cushion, defuse force, and resist shear during weight bearing. This fat pad also acts to protect and cushion the underlying bone, tendons and neurovascular structures of the foot. This plantar fat pad can become displaced or atrophied from any number of traumatic events including multiple surgical incisions, fractures, or chronic metatarsal plantar flexion. These conditions often result in a painful plantar weight bearing surface that can lead to callus, or worse, ulceration.

Several attempts at surgical correction over the years have been attempted with little success. Most of these lacked long-term correction and pain relief due to the migration, short resorption profile, or inconsistent delivery characteristics of the material. A couple of years ago, a novel surgical treatment was introduced using Graft Jacket from Wright Medical which was developed for ulcer repair and tendon repair. Graft Jacket is a human dermal collagen template that is readily incorporated into the body. The matrix undergoes a patented process that renders that material essentially acellular and is freeze dried with a proprietary process that prevents the formation of ice crystals to preserve the intact matrix including vascular channels. Graft Jacket Matrix contains collagen, elastin, hyualuronan, fibronectin, blood vessel channels, and proteoglycans.

A key factor to Graft Jacket is an intact, three-dimensional matrix to build on. The three-demensional structure provides a means for the body to rebuild the area of missing tissue. Another important aspect of Graft Jacket is that it is readily revascularized by the body. This means that new blood vessels gain access through preserved blood vessel channels and allows the conversion of Graft Jacket into the host tissue.

The surgical procedure involves a minimal incision near the area of interest to create a pocket for the graft in the deep subcutaneous tissue layer. Next, with a suture technique the graft is pulled into the pre-determined position. Then the subcutaneous layer is closed, the skin is repaired, and the foot is placed in a soft compressive dressing. The patient should remain non weight-bearing for 2 weeks. Using diagnostic ultrasound pre- and post-operatively, we can see the change in the thickness of the fat pad.

This minimally invasive procedure provides a new technique to treat fat pad atrophy when previous surgical attempts had been unsuccessful. I believe that over time this surgical procedure will become a common way to prevent ulceration and restore a patient's normal fat pad.

MD News March/April 2010


COMMENT ON THIS ARTICLE


32 comments for “A Novel Surgical Treatment for Fat Pad Atrophy”

  1. Gravatar of CarolynCarolyn
    Posted Tuesday, February 22, 2011 at 9:14:37 AM

    I have this fat pad atrophy in both feet I am in excrciating pain most days and can hardly walk for a duration. I wouldlike more information about this surgery and where can I find a Dr that will help me. I have been to numerous Poditrists and none have helped me.

  2. Gravatar of debra klinedebra kline
    Posted Monday, July 18, 2011 at 11:11:37 AM

    can this condition cause stress fractures or did stress fractures cause this condition because i have both and as a letter carrier for 31 years i am now out of work for at least a couple of months and trying to figure out ways to heal faster

  3. Gravatar of beverly ricebeverly rice
    Posted Saturday, July 23, 2011 at 1:40:44 PM

    I have fat pad atrophy in both feet. I have been to several doctors. Orthotics were made which still after a year aren't very comfortable. I wear metatarsal foot pads and gel heel pads on top of the orthotic with not much relief. I would like to know what kind of orthotic I should be wearing and what kind of shoe would give me the best padding. The podiatrists I have seen know very little about how to help me. I am 69 years old and have suffered with this for about five years. I recently saw another podiatrist who said my fat pad will never be back and I would have to live with it and do the best I could. Can you give me some advice?

  4. Gravatar of evaeva
    Posted Wednesday, August 03, 2011 at 2:32:54 PM

    I have extreme thin fat pads on both feet as a consequence of two years of not being able to walk (injuries in the hips, that after being operated are now OK). The plantar fat pads are very thin and very loosy, not firm. Can you please answer me whether my fat pads will recover (get thicker and firmed) with the time if I keep walking. I am 39 years old and 55 kg weight?. The problem is that at the moment I cannot walk long because of heel pain but I plan to walk in the dry beach sand for one year or so and hope to achieve stronger fat pads. What is your opinion?

  5. Gravatar of JennetteJennette
    Posted Wednesday, September 28, 2011 at 10:18:19 AM

    I am a 39 year old busy mother of five. For the last 10 years I run three days a week and play basketball three days a week. I developed plantar fasciitis in my left foot. The podiatrist gave me two cortisone shots, the second has cause atrophy in my heel. I didn't have much of a fat pad to begin with, now what little I did have is disintegrating. Now I can't even walk my kindergartener 100 yards to the bus stop and plantar fasciitis is the least of my problems. I am so depressed to find out there is little that can be done about this deterioration. Is there anyone out there that has had this graft jacket done and had success with it?

  6. Gravatar of Dr. KhosroabadyDr. Khosroabady
    Posted Thursday, November 03, 2011 at 6:35:32 PM

    I have performed this procedure and the results are promising . I am located in Los Angeles california . you can contact me via my website fixmyfoot

  7. Gravatar of JohnJohn
    Posted Wednesday, December 21, 2011 at 5:08:30 PM

    I feel your pain - literally. A podiatrist recently diagnosed me with fat pad atrophy in one heel using ultrasound imaging. Before that I was incorrectly diagnosed with plantar fasciitis and bursitis by podiatrists who didn't have the ultrasound machine. Like you all have said, it is excrutiating to just walk or stand! I am a 33 year athletic man, 5'8 tall and 150 lbs. I was told that this is just the way I was built but I don't fully believe that. I was given 2 cortisone shots 6 months apart, and told that this minimal amount of cortisone could never have caused the degeneration, but again I am not fully accepting this. It sounds like GraftJacket should help, but it hasn't been used much for fat pad augmentation so podiatrists don't have enough evidence to recommend it.

  8. Gravatar of Pedro N PartidaPedro N Partida
    Posted Saturday, January 14, 2012 at 10:14:06 PM

    I am 52 and have been dancing for more than 30 yrs. Flamenco for 26. Out of no where pain after a walk. since then I have been in pain. Indomythacin, Gabapentin, Hydrocordone and Alieve. Still have cold feet and stabbing pain on and off. I want to be able to dance flamenco again. Would this work for me or will I be limited to just walking with orthotics the rest of my life. No one seems to be able to give a straight answer.
    Hoping to dance again.
    Pedro

  9. Gravatar of Georgia PeeplesGeorgia Peeples
    Posted Friday, February 17, 2012 at 6:28:47 PM

    I did have this procedure, and, about a year and a half later, I'm no better. The Graftjacket implant, although it sounded quite promising, has not appreciably increased the padding under my metatarsal heads, and now, unfortunately, I have scar tissue, too. I have very limited walking, and I'm a formerly active 58-year-old woman.

    A very qualified orthopedic surgeon saw my feet yesterday, and he told me that there's really not much that can be done for this condition. He noted that my implant really hadn't helped at all, confirming what I knew already.

    So, it's possible that this might help someone, but, unfortunately, not me. I wish you all the best--be careful with this procedure.

  10. Gravatar of cindy newmancindy newman
    Posted Wednesday, March 07, 2012 at 9:57:00 AM

    I saw the posting from the patient that had this surgery without good results. Are there any patients that have had success? I suffer from this condition and have tried many approaches for improvement with no help.

  11. Gravatar of Lyn TaliaferroLyn Taliaferro
    Posted Monday, April 23, 2012 at 11:12:05 AM

    Is there anyone in Chicago area who would do this surgery?

  12. Gravatar of GregGreg
    Posted Tuesday, April 24, 2012 at 2:36:28 AM

    Ig seems to me that a lot more people are having problems with their feet recently. I too have this problem. I also have another problem that many of you many have too, and that is podiatrist who don't know what they are talking about in many cases. I also have posterior tibial tendonititis, which my former podiatrist missed at first. Thd guy who originally diagnosed it was some guy at a shoe store. There are sw really good poditatrist out there and some that should find another type of work.

  13. Gravatar of Carole SteadmanCarole Steadman
    Posted Friday, June 15, 2012 at 4:23:06 PM

    How can I find a qualified, experienced doctor for this surgery?

  14. Gravatar of judith gravesjudith graves
    Posted Thursday, September 20, 2012 at 6:45:44 PM

    I would like to locate a doctor who does the graft jacket
    procedure. The best location for me is in Ventura County or the
    northern greater Los Angeles area. Thank you.

  15. Gravatar of josephjoseph
    Posted Tuesday, October 30, 2012 at 1:39:25 PM

    i have been diagnosed with chronic tenosinovitis. I sprained my ankle so many times and I think the last did it. ive had heard many pops from the sprains but i think the last one was the worst as it was a eversion roll. Now I feel pain all the time. My heel fat pad is so much thinner than my left foots its sad. I've been to many podiatrists with no results. They tell made me a orthotic and recommend aleve. I dont know what to do as I need to walk. Can someone please help?

  16. Gravatar of kimkim
    Posted Wednesday, March 06, 2013 at 3:42:46 PM

    i already had 2 morton neuroma surgeries on my foot and now maybe a third i also have every little fat pad in the ball of my foot is the reason for the neuromas coming back

  17. Gravatar of PenniePennie
    Posted Friday, April 05, 2013 at 7:20:04 PM

    Is this treatment approved by most
    Insurances.

  18. Gravatar of MarinaMarina
    Posted Thursday, April 18, 2013 at 11:31:23 AM

    I also have had the same stabbing, intense, unremitting pain twenty-four hours daily. I experienced the disabling pain in both feet at identically the same time. Therefore, I have to spend half my day sitting down to get any relief. I initially thought it was irritation caused from the rubbing of my Asic running shoes and put about ten bandaids and callus pads on the metatarsal area of my foot with little avail. I tried over the counter nsaids with little pain reduction. In addition, I applied "Voltaren" prescription strength arthritic pain reduction gel. Again, no relief!

    I consulted a Podiatrist who diagnosed me with Osteoarthritis and hammertoes (three in each foot). I questioned him about surgery and told me that operations are not highly successful and that there could be a reoccurrence. He basically gave me no hope. I am totally speechless that there is no reliable cure of this problem. I am having difficulty with my activities of daily living and had to stop my two mile daily walks.

    I have heard about fad pad injection (Restylene and Human Fat) to plump up metatarsal tissue). This is used for models who war spike heels. I have also read about a surgery uses biodegradle discs that are implanted between joints and act as a scaffold for new cartilage to grow.

    Lastly, I am a healthy active 67 year old who is now sidelined with this disability. I have seen a Neurologist and had a test to determine whether I have peripheral neuropathy. I have been diagnosed with both motor and sensory nerve damage in both feet.

    We need to lobby the medical community to come up with a fix for this medical condition so that we can lead a more active life.

    Hope this helps. Marina

  19. Gravatar of Connie HermanConnie Herman
    Posted Wednesday, October 23, 2013 at 2:59:17 PM

    My husband had 4 neuromas taken out of his left foot something he regrets, so for those that are considering more surgeries I can tell you that that is what made his problem worst, the more surgeries the more the nerves were damaged and the less cushion left on his foot . Through extensive research, he found a podiatrist in the LA area that treated his neuromas by injecting them with some time of frozen treatment and that saved my husband from more unnecessary and painful surgeries. This doctor also injected the ball of his foot with silicone injections to plump up the metatarsal tissue and that was the ONLY remedy that minimized his pain and was able to go back to work (he still have to take pain meds but not as much) As far as I know, he is the only doctor that gives this type of injections but they are not covered by insurance. Cost was around 250 per injection. He got about 4 or 5 and that was about 2 years ago the cushioning is still there but there is an area where he wants more cushion so he is ready to go and get another treatment.

  20. Gravatar of Stewart LoweStewart Lowe
    Posted Sunday, January 05, 2014 at 8:00:06 AM

    Hi to all of you and let me just start by saying that I feel sorry for your pain with regards to fat pad atrophy. On one hand I feel a lump in my throat for you all as I know exactly how you all are feeling, but on the other hand I am absolutely ecstatic that I have this very morning found out what my problem is after 8 years of it going undiagnosed. I stumbled on this article by accident and its relieving to know that I am not on my own out there. I have always been a healthy and athletic outdoors person who has done 2 half marathons, I jogged 6 miles three times each week and have been a regular gym member and badminton player. In 2004 I even back packed around the whole of America in 9 weeks with just a rucksack and sandals whilst covering 33 towns and cities in 23 states, so this should give you a clear level of my activity. I am almost positive that because my body physique has always been athletic, toned and healthy whilst I have had this foot problem, any Podiatrist, Doctor or Orthotist that I have seen in the last 8 years have disregarded the pain that I have been in because I looked so normal. However, had I now been obese as a result of having to stay off my feet then they might have believed how much pain I have been in. The interesting thing is that I actually studied Physiotherapy for 4 years so I know a bit about the anatomy and workings of the human body and so you can imagine how angry and frustrated I got when having numerous medical appointments to sort out my feet problem, and all to no avail. I have seen the same podiatrist 3 times who has had my feet x-rayed in several positions, he has had me sent for ultrasound and all he has come back to me with is that there were no sign of arthritis on the ultrasound and nothing wrong with my foot posture on the X-ray. This made me feel as though I was lying or exaggerating about my condition because he couldn't find anything wrong and never even mentioned the possibility of fat pad atrophy. In all honesty its almost like having a mental health problem because there are no obvious physical symptoms that you can actually see. I wanted to be a football coach as I have had football trials for 3 football clubs in the past but when I tried taking the training sessions I could barely stand and was almost in tears after 1 hour of standing, so I had to give it up. I decided to go self employed as a restorer of antique windows because I am an ambitious person but I just cant do the work because when I stand to do it even for 20 minutes I could cry because of the pain. I cant use the gym anymore because most things in a gym you require your feet to use. I had a girlfriend for 6 years and we couldn't go on walks or go to town for a few drinks with friends because my feet were in bits to stand and I know that even she thought I was exaggerating the pain because she couldn't see a physical symptom. I am still not obese but now I cant exercise anymore I am not toned and not athletic and I get depressed a lot because of it. Now that I have seen this surgical procedure I will take the issue back to my doctor and see where I can go from there. But let me say to you all that I know how you all feel and your not on your own. Maybe we should have a forum where people with this painful condition can come together and chat because if one of us found something that could be helpful to the rest, then it has to be worth it. Feel free to contact me if you would like to chat on: stewartlowes@hotmail.co.uk (I am from Sheffield in England)

  21. Gravatar of  paulette                                    paulette
    Posted Wednesday, February 19, 2014 at 10:05:57 AM

    lost my fat pad left foot...am in terrible pain use othhotics pads creams sneakers and am still in pain

  22. Gravatar of KarlKarl
    Posted Wednesday, February 26, 2014 at 7:05:52 PM

    Where are you located? How can I get an evaluation?

  23. Gravatar of DebbieDebbie
    Posted Wednesday, March 05, 2014 at 3:27:29 PM

    I too have metatarsal footpad atrophy. Feels like I'm constantly walking on split peas. Saw 2 Dr's and both said steer clear of The Graft Jacket. Also feet are always cold and I use a heating pad on them for relief while watching TV. So I started doing research for finding the perfect shoe. Well, for my issue there is no perfect shoe. I did however find the perfect sandal that allows me to walk pain free for 8-10 hrs. I feel like I'm plugging a commercial ad but I'm not. I was in Woodstock NY and stopped in to the sandal shop Pegasus. I tried on several sandals. MAGIC!!!! OOFOS. I ask anyone with footpad atrophy to try. Not too pricey (29.00). I immediately bought 7 pairs in every color they came in. The now offer flip-flop, slip ons and clogs. If you never try another remedy for walking try these. They've given me new life. I do wear them when it's a bite chilly out even though they are geared for summer. Clogs let me put on bulky socks. Needless to say I do not look forward to formal events since I cannot wear anything but these shoes. I will include 1 link. See for yourselves. http://www.oofos.com/
    To die for. Truly. Feel free to contact me. bellmom718@hotmail.com

  24. Gravatar of PamelaPamela
    Posted Thursday, April 03, 2014 at 5:58:30 PM

    Connie Herman - could you possibly email me your husband's doctor in LA who did his foot pad surgery? pearly1515@yahoo.com Is it still working well for your husband? Does he still recommend this surgery?

    Lastly, for others - my foot doc in Chicago recommended some great sneakers/ walking shoes by New Balance (style number 928). They're the best for any ball of foot pain - and maybe other foot pain - because they are very sturdy and they do not bend at the tip of foot.

    I'm only 49 - very athletic - and now having chronic inflammation on my left ball of foot. Seems to be trauma to the area - capsulitis and a plantars plate injury that keeps returning. I'm certain it's from lack of padding (due to my age and lots of sports) - an atrophy of my ball of foot padding.

    Thank you in advance for any help. Pam

  25. Gravatar of NHDanNHDan
    Posted Monday, April 28, 2014 at 2:39:20 PM

    I can relate to all who have Heep Pad Atrophy. I have had this condition for many years and been disabled completely as a result of the pain for 15 years! For anyone who doesn't believe how bad the pain is...Let me describe it the way I have to the 20 or so doctors and specialists I have describe it to! Imagine having your feet up on a chair and have someone hit the heels wit a baseball bat! Thats what it feels like to stand for 15 or 20 minutes.Unfortunately, I finally had my condition diagnosed and there is no cure for the condition. I know what it means to have tears in my eyes from the pain and have everyone around me not believe the pain I am in.I have been treaded for the pain itself and the strong patches I am on give me some semblance of quality of life but I suffer in other ways now, When the meds wear off The pain comes back and I am bed ridden which does not please my partner. I have had it with people who say you look fine when they have no idea! Orthotics DO NOT HELP! I have paid thousands for special made ones and cortizone shots in the heels, my GOD that doesn't help at all! Plus who the hell wants a shot in their heels anyway! I relate to all of you and I had even considered having my feet amputated so the pain would go away but As long as the pain meds allow me to walk a while with reduced pain...That is the way I will go! God Bless

  26. Gravatar of Lisa MaslenLisa Maslen
    Posted Thursday, May 01, 2014 at 4:31:15 PM

    Please how do we learn more. Foot pad atrophy is rampant in our family. Who does this procedure?

  27. Gravatar of Dianne BrimsDianne Brims
    Posted Thursday, May 15, 2014 at 2:05:55 AM

    Is there anyone in Australia doing this procedure, or even researching it??? I have had this problem with increasing severity for years and now cannot walk without using a cane, and very little even then.I am unable to do the most basic of things like go to the supermarket.

  28. Gravatar of Sharon DelaneySharon Delaney
    Posted Friday, May 23, 2014 at 4:09:48 PM

    I need this treatment. I am under care of acupressurist for pain. I was unable to walk due to no padding under my callous. The acupressurist has helped but is not able to end the problem. I need to awaken my family doctor to take care of my problem. How can I convince him that I need this procedure to end my problem?

  29. Gravatar of EdEd
    Posted Sunday, June 08, 2014 at 12:30:11 PM

    I hear all of you. I started with plantar fasciitis one side then became bilateral for no reason. Surgery eventually fixed the PF but both heels were now like standing on a big nail. Did a lot of research on radio frequency ablation of the heel nerves ie. Inferior and medial plantar calcanial since anotomically I can point to the pain which is the inferior calcanial turbercal, ie. where the nerve ends. I have lower back issues but have had many diagnostic tests which rule it out as the source of pain in my feet. I am also looking at fat pad atrophy since the pain has become broader and not as defined, probably due to 11 years of limited standing and walking, just to add to the problem. I did have the RF done some years ago by a fly by the pants foot doctor who abated beyond and only by guesswork the nerves in each foot. I seem to experience some minor relief some months later but can't attribute the procedure for sure since the dr. Did the procedure incorrectly.
    I am now searching for dr. Who can do it correctly according to current literature and procedural successes. RF ablation works for a year or so as I have had my facet joints done to relieve sever thoracic pain 18 months ago only to begin feeling the familiar knife in the back at that location.
    Will need it done again but it Works, if done right, hence my current stalled search for a competent podiatrist who does the heel nerves with success.
    Good luck

  30. Gravatar of EdEd
    Posted Friday, June 20, 2014 at 12:39:57 PM

    Re all who suffer with heel pain,
    I read your description of me, I mean you on the graft site. I know that with so many of us out here with the same symptoms there has to be current research and procedures happening, Somewhere??! I have spent too much money and time on standardized DPMs who have no need to expand their expertise due to patient overload and a steady stream of income. I flew Army copters, had 44 rental properties and was quite the type A entrepreneur till 2003 when I strained my plantar fascia. Then the slow destruction of lively hood began leaving me a reclusive dependent husband, disgraceful and embarrassing. But I look fine right!!
    I just want stand and walk enough to be productive in any sustainable way.
    Doctors are clueless but O will not give up. I'm just 50 now and can't envision the rest of my life as a invalid by otherwise invisible causes.
    I like your idea of a support and share group as this could provide the elusive answers we seek.
    The nerve ablation was the answer alas I now realize my fat pads have also atrophied which complicates things even more. I would fly to anyplace in the world if I thought a fix was possible. Problem is I can find none and no doctor of any consequence.
    Feel free to share with me any ideas you may have discovered and I will as well.
    Empathetically,
    Ed

  31. Gravatar of EdEd
    Posted Friday, June 20, 2014 at 12:42:20 PM

    Also, please share any discovered research papers by bibliography you may have discovered.

  32. Gravatar of sharmansharman
    Posted Wednesday, June 25, 2014 at 12:43:24 PM

    i have the fat pad atrophy in the balls of both feet....live in los angeles in the valley....i need an ankle surgeon asap that can help me!...this has been 4 years of hell and it needs to stop...thanks....