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Dupuytrens contracture- Limited fasciectomy plus Z-plasties

    Overview

    Learn the Dupuytrens contracture: Limited fasciectomy plus Z-plasties surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Dupuytrens contracture: Limited fasciectomy plus Z-plasties surgical procedure.

    Dupuytren’s disease is a fibroproliferative disorder affecting the hands. It has a variable clinical course and in most cases it causes contractures of the fingers requiring treatment. The highest incidence of this disease is in the Scandinavian countries, giving it the nickname ‘Viking disease’. It is common in Northern Europe and the incidence decreases towards the Eastern hemisphere. It is very rare in the African and Asian subcontinents. Japan interestingly has a high incidence of Dupuytren’s disease though it appears to be a milder form of disease.
    There seem to be genetic and environmental factors involved in the aetiology of this disease. Alcoholic liver disease, anti-epileptic medication, smoking and Diabetes all seem to be risk factors for Dupuytren’s disease. It is commoner in men and the incidence is higher in the fourth and fifth decades of life.
    The exact pathogenesis of Dupuytren’s disease is still not clear. There have been several theories about the origin of the disease. One of the theories is that it is a fibrosis of the intrinsic palmar fascia(McFarlane). The other theories are that it is an extrinsic disease which spreads along the palm and fingers(Hueston), or it is a combination of both(Gosset). The most widely accepted theory is that of Murrell which states that there is microangiopathy which releases free radicals which in turn start the fibrotic process.
    In 1971, Gabbiani, an Italian scientist discovered a specialised cell called Myofibroblast in Dupuytren’s tissue. This cell is the key to the fibrotic process and has later been discovered in scar tissue.
    Dupuytren’s disease can also affect feet, where it is called Ledderhosen’s disease and penis where it is termed Peyronie’s disease. Patients with disease in these ectopic sites have a more aggressive form of disease and it is termed a ‘Dupuytren’s diathesis’.
    The decision to treat is made and the treatment method is chosen based on patient’s preference, functional disabilities and pattern of disease.

    Indications

    INDICATIONS: Patients typically present either intrigued by the lumps and in the hand or due to the contractures limiting their function. Indications for treatment is dependent on patient’s functional limitations but generally accepted ones are:
    MCP joint contracture more than 30 degrees
    Any degree of PIP joint contracture.
    Presence of tender nodules in the palm can cause functional problems in certain professions. In these cases a trial of steroid injection into the nodules can be tried. If not successful they can be excised.
    There is no indication to treat Dupuytren’s disease without a contracture. The only exception to this may be in patients where radiotherapy is considered as a treatment option. Radiotherapy cannot correct a contracture but can arrest the progression of the disease. The benefit has to be weighed against the potential risks. In patients who have Dupuytren’s diathesis with previous poor outcome to surgery, radiotherapy can be considered in early disease in other fingers.

    SYMPTOMS & EXAMINATION
    Patients either present intrigued by the lumps and cords in the palm or because the contracture causes them functional problems. As most of the hand function is manageable by the radial side of the hand and Dupuytren’s contracture does not limit flexion of the fingers, patient usually manage quite well with advanced degrees of contracture. The typical patient who presents is a middle-aged Caucasian man who had noticed contractures in the fingers and is starting to have functional problems.
    The history is usually of an insidious onset lumpiness in the hand which slowly developed into contractures. The common complaint is of washing the face or putting hands in the pocket. Many patients have a family history of the disease though it is not a well defined inheritance pattern. While taking a history it is important to be systematic and the key points are:
    Age, Occupation, handedness and hobbies
    Duration of the disease
    Functional problems
    Other areas of involvement: Feet, penis
    Previous treatment
    Medical history: Liver disease, epilepsy, diabetes, smoking
    Drug history: Anti-epileptic medications
    Social history
    On examination the presence of lumps and contractures is noted. The affected fingers and the joints as well as the degrees of contractures in noted. Skin involvement and previous scars are noted.Garrod’s pads are looked for on the dorsum and the other hand is inspected. Sensations are noted as well as the range of flexion.
    A summary of the clinical problems and a treatment plan is made based on the history and the contractures in various joints.
    IMAGING
    Dupuytren’s disease is a clinical diagnosis and imaging is not necessary. The only exception is a patient presenting with a fibromatous lump in the hand where a soft tissue sarcoma is suspected and in this case an MRI scan is useful. This however is an extremely rare situation.
    ALTERNATIVE OPERATIVE TREATMENT
    The surgical treatment options for Dupuytren’s disease are needle fasciotomy where a hypodermic needle is used to perforate the cord which is manipulated and finger straightened, open fasciotomy, where the fascia is divided through a small incision, limited fasciectomy, where the disease causing contracture is excised from the finger, segmental fasciectomy where segments of the cords are excised through small incisions and dermofasciectomy where the skin and cords are excised and a skin graft used to resurface the wound.
    NON-OPERATIVE MANAGEMENT
    In cases where there are tender nodules in the palm, steroid injection can be used as intralesional injections.
    For patients with cords causing contractures, the only non-operative treatment which is useful is collagenase injection, which is an enzyme injected into the cords. The finger is manipulated under local anaesthetic on the following day. Collagenase can be used for MCP and PIP joint contractures and has been shown to be successful in several trials against placebo.
    Radiotherapy can be used to stop of the progression of the disease. This however cannot correct a contracture.
    CONTRAINDICATIONS
    Contraindication to surgical treatment is a patient who is unfit for surgery from co-morbidities. Patients on anticoagulation which cannot be stopped is a relative contra-indication.
    Patients with advanced contractures with finger in the palm, are not candidates for fasciectomy. They may be treated by amputation or arthrodesis of the PIP joint in a more functional position.

    Setup

    Limited fasciectomy can be performed under a Brachial block or General anaesthetic. There is a trend towards performing it under local anaesthetic with adrenaline as a wide awake local anaesthetic procedure though this is not my practice.
    The arm is positioned on a hand table with an upper arm tourniquet in place. Loupe magnification is essential while doing Dupuytren’s surgery to visualise digital arteries and vessels. The surgeon and assistant are seated on either side of the hand. The hand is positioned on a Lead hand.

    Operation – 1

    Demonstration of the contractures over the ring and little fingers
    The volar aspect of the hand showing significant deformities of both the ring and little fingers.

    Positioning the hand in a Lead handThe hand is positioned on the Lead hand. A huck towel under the Lead hand is helpful in avoiding pressure on the dorsum. The Dupuytren’s cords affecting the ring and little fingers can be seen.

    Incisions are markedThe incisions are marked. There are several incisions used in Dupuytren’s surgery. The ones used here are vertical incisions in the fingers which are joined up by transverse incisions in the palm. The vertical incisions will later be broken into z-plasties before closure.
    These incisions are named after the surgeon Tord Skoog. Please note that the incisions in the fingers are in the midline and have to extend beyond the visible cord. A small proximal extension of the transverse palmar incision can be seen. This is to access the cord extending into the palm.

    Tourniquet is inflated after exsanguinating the hand using an Esmarch bandage. Incisions are made using a No.15 blade. It is important to make the incisions superficial.

    Making incisions and raising skin flapsThe assistant lifts up the edge of the skin flap using a skin hook. Please note that there is no plane between the Dupuytren’s cords and skin. It is an artificial plane created using a sharp scalpel. When there is skin involvement, some of the Dupuytren’s tissue may be left on the skin flap. This is acceptable as otherwise the skin flaps end up being very thin and may suffer necrosis.

    The incisions are continued and skin flaps raised exposing the Dupuytren’s cords. This is a slow and meticulous process and should not be rushed. Making the flaps very thick and leave significant disease behind and making them very think compromise the circulation of the flaps.

    I find that a small self-retainer such as the one used here is useful to retract the flaps. This will free up the assistant’s hands for retraction of tissues.

    Identification of digital nerves and vesselsAt this point, I try and find the digital nerves and vessels on either side. This can be done by dissecting using a tenotomy scissors in the fat on either side of the flexor sheath. Vertical spreading of the scissors is what is recommended. While doing Dupuytren’s surgery one has to be wary of a spiral nerve which is medially displaced and can get accidentally injured.

    Dissection of Dupuytren’s cordOnce the cord is defined in the palm and digital neurovascular bundles are identified on either side, the cord can be divided and lifted off. The transverse fibres in the palm, seen in the picture are called Skoog’s fibres and these run over the neurovascular bundles. They are not involved in Dupuytren’s disease and should be preserved during Dupuytren’s surgery.

    The Dupuytren’s cord is dissected using tenotomy scissors. Traction using an artery forceps applied to the cord helps to separate the cord from the deeper tissues. The cord being dissected here is the pretendinous cord, named so, as it lies over the flexor tendon sheath.

    As the cord is dissected the neurovascular bundles can be seen clearly. It is important that the digital artery is preserved as well as the digital nerve.

    Excision of the Dupuytren’s cordThe cord is excised and the , neurovascular bundles, flexor sheath and Skoog’s fibres can be seen.

    The excised cord is displayed. The tissue is discarded and not routinely sent for histology.

    Incisions extended into the little finger.

    Identifying the neurovascular bundleThe radial neurovascular bundle of the little finger can be seen. There is lateral cord overlying the neurovascular bundle which is retracted. The fibrofatty layer over the neurovascular bundle is called Grayson’s ligament which sometimes can be involved in Dupuytren’s disease.

    The lateral cord is divided and lifted off the neurovascular bundle.

    The vertical spreading action of the scissors help to dissect the neurovascular bundles distally.

    The lateral cord has been excised and he neurovascular bundles can be seen clearly.

    Full straightening of both the fingers can be seen.

    Z-plasties are performedZ-plasties are designed over the fingers. Z-plasties help to prevent scar contracture from a vertical scar and also helps to lengthen the scar.
    The angles are about 60 degrees and each of them give about 75% lengthening of the segment of the scar. One to two z-plasties are usually performed per finger. They can be performed anywhere along the finger and does not have to correspond to the joints.

    Incisions are made over the z-plasties and the flaps are transposed.

    Wound closureFlaps are transposed and sutured using 4-0 Nylon.

    The corners of the z-plasty are sutured first and the remaining wound closure then completed.

    The closed wound can be seen. There is a mild residual PIP joint contracture of the little finger. This is difficult to correct even if a joint release is attempted and is best accepted.

    Dressings and POP backslab appliedDressings are applied. My preference for dressings are jelonet, gauze, velband, a volar POP backslab keeping the fingers in extension and a crepe bandage.

    Operation – 2
    Post Operative

    The arm is elevated in a sling for 24 hours.
    Patients are discharged home the same day.
    They are advised to take regular analgesics and to continue elevating the arm.
    Patients are reviewed between five to seven days when dressings are changed.
    A simple dressing such as Mepore is applied and they are referred to the Hand OTs to have a Thermoplastic splint made. This hand based splint keeps the fingers in extension and they are advised to wear it at night time for the next six weeks. They are advised to mobilise the fingers actively and passively during the day. Patients may have some numbness of the fingers from the dissection of the digital nerves which should settle down over the next four to six weeks.
    Sutures are removed at 2 weeks.
    At this time patients can resume their normal activities including driving. They are also advised to massage the scar using moisturising cream.
    Hand therapy is continued and patients are reviewed at six weeks. At this time one expects to see full flexion of the fingers.
    Patients are reviewed again in six weeks to monitor for any recurrence of the contracture or new disease.

    Recommended Reading

    Worrell M1.Dupuytren’s disease. Orthopaedics.2012 Jan;35(1):52-60
    Dupuytren’s disease is a benign contractile disorder of the hand. The condition commonly affects older men of Celtic descent. Although fibroproliferation and collagen alteration play a role in its etiology, defining a cause remains elusive. Nonoperative intervention for advanced disease has shown only short-term benefit. Therefore, open fasciectomy has become the mainstay of treatment. Associated morbidity and recurrence have prompted investigation into less invasive techniques, including needle aponeurotomy and enzymatic fasciotomy. Data from phase III studies using injectable collagenase are changing treatment algorithms. Postoperative rehabilitation includes night time splinting and immediate active range of motion exercises to facilitate return to function.
    Rodrigues JN1, Zhang W2, Scammell BE2, Chakrabarti I3, Russell PG4, Fullilove S5, Davidson D6, Davis TR2 Functional outcome and complications following surgery for Dupuytren’s disease: a multi-centre cross-sectional study. J Hand Surg Eur Vol. 2016 Jul 29. pii: 1753193416660045.
    Outcomes 1 or 5 years after an aponeurotomy, fasciectomy or dermofasciectomy were assessed by patient interview and examination at five UK centres. Over 400 procedures were studied. The reoperation rate did not differ at 1 year , but was higher after aponeurotomy in the 5-year group . Loss of function (DASH>15) did not differ between procedures at 5 years, even when reoperation and other variables were controlled. Diabetes, female gender and previous ipsilateral surgery were associated with poorer function . Aponeurotomy had lower complication rates than fasciectomy and dermofasciectomy.
    Rodrigues JN1, Becker GW, Ball C, Zhang W, Giele H, Hobby J, Pratt AL, Davis T.Surgery for Dupuytren’s contracture of the fingers. Cochrane Database Syst Rev. 2015 Dec 9;(12):CD010143.
    Currently, insufficient evidence is available to show the relative superiority of different surgical procedures (needle fasciotomy vs fasciectomy, or interposition firebreak skin grafting vs z-plasty closure of fasciectomy). Low-quality evidence suggests that postoperative splinting may not improve outcomes and may impair outcomes by reducing active flexion. Further trials on this topic are urgently required.


    Reference

    • orthoracle.com

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