Complications Following Treatment of Dupuytren’s Disease and Their Management

20 Complications Following Treatment of Dupuytren’s Disease and Their Management

Paul M.N. Werker and Ilse Degreef

Abstract

There is a variety of surgical and nonsurgical options for the treatment of Dupuytren’s disease. Understandably, they all have their advantages and disadvantages. Important disadvantages include complications. The purpose of this chapter is to list the most relevant treatment options and their complications and management. Ultimately, prevention is prime priority, but if complications occur, proper treatment and open communication with the patient are paramount. Prior to treatment it is important to allow for information-based decision making after sufficient explanation followed by properly reporting of the decision.

Keywords: Dupuytren’s disease, complications, fasciectomy, fasciotomy, collagenase, radiotherapy, steroids, systemic treatment

20.1 Introduction

Dupuytren’s disease (DD) is a very common benign hand infliction. It is a disease of all ages, but is most prevalent in people of over 60 years. Prevalence investigations in our countries has shown that more than 20% of the population of over 50 years of age has signs of the disease and 4% of these people have actual contractures.1 Histopathologically, DD is a fibromatosis that develops and spreads along the palmar fascia of the hand. First, nodules form that harbor conglomerates of myofibroblasts that deposit superfluous extracellular matrix. This process may progress into the formation of cords, which ultimately may contract, causing extension deficits foremost of the ulnar fingers. Similar diseases occur in the soles of the feet (M. Ledderhose) and in the tunica albuginea of the penis (M. Peyronie) and pads may form on the dorsum of the proximal interphalangeal (PIP) knuckles (Garrod’s pads). Pain is often a sign of early disease, which usually subsides when the disease advances. Functional problems in most people only occur after substantial contractures have formed, turning the affected fingers into hooks that catch on handles and crockery, and make the use of gloves cumbersome. Many tasks of daily living that require straight fingers also become more difficult (washing, shaking hands, caressing, etc.).

The disease has a genetic basis and runs in families: using Genome Wide Association Studies (GWAS), over 25 loci in the genome have been associated with it.² Its emergence is possibly triggered by direct repetitive microtrauma and even more remote trauma to the extremity, for instance, following distal radial fractures seem to influence the disease. Exposure to vibration, diabetes mellitus, liver disease, antiepileptic drug use, alcohol abuse, and smoking have also been indicated as being influential.³^,⁴ Both hands may be affected, but usually in a different phase and the disease in general starts in the little and ring fingers, although all fingers may be affected.

As clinicians we only see the more advanced stages of the disease, and relatively little is known about the natural course of the disease. Recent research has shown that, in general, DD progresses at a constant pace, but it may also be stable for a considerable time and in some cases even regress.⁵

The disease is chronic and at present cannot be cured. When an affected hand can no longer be put flat on the table (table top test), a patient should be referred to a specialist to discuss treatment. Flexion contractures of the metacarpophalangeal joints (MCPJ) usually can be redressed during treatment. Those of the proximal interphalangeal joints (PIPJ) are more difficult to correct, especially once they are over 60 degrees of flexion, possibly because the joint capsule also becomes involved and the central slip of the extensor tendon attenuates. Treatment for the last 200 years has been symptomatic and surgical, although some local treatments (steroid injections, local radiotherapy, and TNF-alfa blockers) aim at stabilizing the disease or even inducing regression of early disease.⁶ During surgery, which still is the mainstay of treatment, cords causing contractures can be transected or excised, with or without replacement of the overlying skin. Besides, in recent decades, collagenase has been introduced into the market for the treatment of flexion contractures. It has now become clear that it is just as effective in the short and long run as percutaneous needle fasciotomy (PNF) and has recently been taken off the market in Europe.

Every treatment has its advantages and disadvantages (including complications) and every surgeon involved in the treatment of DD should develop a treatment algorithm that is adapted to the population one sees, and apply treatments that are effective in the short term with a limited risk of complications and with an acceptable durability of the results. Most less invasive treatments such as PNF and collagenase have a very low chance at causing complications, but pay a price of a more limited durability. However, these treatments often can be repeated more than once and as such postpone more aggressive treatments.

Each patient should be involved in the choice for the best fitting treatment at the most appropriate time. Recurrences after the more extensive surgical interventions should be treated by specialists, since there is a much higher likelihood of complications and any further recurrence should be prevented at any cost.⁷

The prime subject of this chapter is to provide an overview of potential complications, a way to prevent and a way to deal with them. There have been a number of excellent papers dedicated to this topic and the aim of this chapter is to summarize these and add our personal experience which we have collected over the past decades as specialists in the treatment of this disease in Belgium (ID) and The Netherlands (PW).8^,⁹^,¹⁰ The discussion will be treatment-based and therefore some overlap is unavoidable. For young less experienced colleagues an important message at this stage is: apply shared decision-making, explain the most common possible complications to the patient before you embark on any treatment. Make sure the patient understands the choices and risks. Please try to avoid complications during surgery. Don’t get depressed when they occur, because they will, and if they do, treat them as best as you can and explain everything in detail to the patient, and—last but not least—report them appropriately in your operating notes, so that for subsequent surgeries they are well documented, informing the next surgeon about the situation so he/she can take them into account when confronted with yet another recurrence.

20.2 General Overview of Complications of Fasciectomy

Fasciectomy can be performed segmentally, limited to the areas of pathology, or radically. In any case, it entails incision of the skin and the elevation of skin flaps.

Wound-healing disturbances including skin sloughing (22.9%, range 0–86) and incisional scar pain (17.4%) were the most frequently found complications in the review of Denkler in 2010.⁸ The authors have experienced this problem more often following Bruner’s incisions than following Z-plasties. Skin slough should be treated depending on its extent: small areas can be left alone, larger areas (complete flap loss) should be surgically debrided and primarily or secondarily skin grafted.

Neuropraxia of one or both digital nerves is very common after fasciectomy and may occur in up to 50% of cases.⁹ It is due to the fact that the nerves are manipulated on one hand (neuropraxia), and vascularly segmentally supplied on the other. In the more extensive procedures, these tiny vessels are easily damaged (devascularization), especially when the neurovascular (nv-) bundle is completely encased by pathology. This neuropraxia can be a complete conduction block and by definition temporary and usually recovers in 2 to 3 months. However, if the sensation only recovers partially and the digital nerve was macroscopically intact, it must have suffered more internal damage due to ischemia which may have caused some axonotmesis, while visually intact. Not much can be done in such a situation, although sensory re-education may improve the quality of the sensibility to some extent. Besides all this, it is good to realize that in the areas of fasciectomy the sensibility in the elevated skin flaps usually diminishes to the level that is normally achieved following skin grafting. This is only seldom reported in the literature, but good to bring across to our patients. The same goes for the incidence of cold intolerance, which has been found to be as high as 44% following fasciectomy.¹¹

The incidence of iatrogenic division of the digital nerves in primary cases is about 2% and may increase to up to 20% in recurrent cases.⁸ The high numbers of nv-bundle injuries in recurrent cases is caused by the presence of scar tissue, making it sometimes impossible to distinguish the digital nerve from the pathology. The patient should be warned beforehand for this situation.

Similar figures apply for digital artery injuries, although the reported incidence may be lower than factual. The reason for this is that this injury may be simply overlooked, especially on the ulnar side of the little finger and the radial side of the thumb and index, where the smallest nondominant digital arteries are situated. These are often tiny, in the long fingers especially distal to PIPJ and when operating using a tourniquet and after exsanguination of the extremity. We therefore plea strongly against the latter maneuver: elevating the arm while disinfecting or after draping is in general enough to evacuate the blood to such an extent that it leaves a bloodless field, without emptying the blood vessels completely. Operating using wide-awake local anesthesia no tourniquet (WLANT) may be an alternative, with which we have no experience.

A sharp digital nerve transection that occurs during surgery should always be repaired microsurgically. The result of such a repair is often quite good and the sensibility may return to the same level as that of a digital nerve that has been completely freed from its surroundings but left anatomically in continuity for the reasons mentioned earlier. A transected nerve that is not repaired will form a neuroma. Eight percent of these neuromas may cause neuropathic pain.¹² Repair of the nondominant digital artery is a questionable act in our view if very small (<0.5 mm), because the other digital artery will be able to feed the whole finger. Injury to the dominant artery (usually situated at the side closest to the middle finger) should always be repaired with microsurgical techniques. Most often, insufficient pinking up of a treated finger immediately after tourniquet release following fasciectomy is caused by vasospasm rather than arterial transection. A wait-and-see policy usually may suffice. In addition, the digit can be warmed, or treated with antispasm agents such as papaverine or lidocaine, and/or placed in slight flexion to relieve undue tension on the vessel. Within 10 minutes, the digit will usually pink up. If not, amputation of part of the finger may be unavoidable, but may also be postponed for a few days. The level of amputation usually is transarticular at the PIPJ and closure can usually be achieved using a dorsal flap. This level of amputation does leave an unsightly hand and some patients prefer ray amputation or transposition if indicated at the risk of painful neuroma formation.

20.2.1 Specific Complications of Limited Fasciectomy (LF)

Limited fasciectomy (LF) is still the most commonly performed treatment modality for DD. It entails the preoperative identification of the pathology that needs to be removed, the elevation of the skin off the pathology and its excision, taking care to protect the neurovascular (nv-) bundles.

A plethora of incisions are described for getting access to the finger, These incisions can be grouped into the straight-line incision that is closed after the incorporation of Z-plasties, the Bruner Zig-Zag incision that can be closed using Y-V-plasties, or the McCash transverse incisions at the level of the transverse ligament of the palmar aponeurosis that crease more distally. The transpositions serve two purposes: recruitment of extra skin from the side to increase the length and in case of the straight-line incision the prevention of skin contractures. Remaining skin defects in the McCash technique can be left to heal by secondary intention. An additional benefit of this technique is that there is hardly any risk for a hematoma collection after surgery. Downsides are the more limited surgical exposure and the longer healing time of the wounds, for which the patient should be warned. A longitudinal incision with Z-plasties offers—especially once the Z-plasties are cut—a better access to the whole finger than the McCash technique. A longitudinal incision with Z-plasties carries less risk for skin slough, since the flaps usually are of more even thickness, or at least the thinnest at their apex and not halfway as is often the case with zig-zag incisions. Downside of the Z-plasties may be the development of a transverse contracture where the flaps of the Z-plasty meet, which may hamper flexion in the early phases of the rehabilitation. An extra word of caution is needed for mirroring zig-zag incisions of joining fingers that meet too distal in the webspace. They may cause a web space contracture that is not only unsightly, but also cumbersome for the patient, since it limits abduction of the fingers. Iatrogenic longitudinal skin contractures should be prevented (by performing Z-plasties before skin closure) or treated as soon as the wounds have healed and the hand function has recovered substantially, since they may hinder further functional recovery. Another word of caution about Z-plasties: there is usually ample surplus to be recruited from the sides at the level of the proximal phalanx half way the palm-finger and the PIP-creases, but there is very little skin to be recruited from the sides in the distal palm. As a consequence, the Z-plasty at the level of the proximal phalanx can be big and include most of the skin between the earlier named creased, whereas a Z-plasty in the distal palm of especially the ring and middle finger can only have limbs of 0.75 cm.

Elevation of the skin off the pathology and its excision can be a challenge, since the nv-bundles can be displaced. A classical place of displacement is just proximal to natatory ligament, where the nv-bundle can be displaced toward the middle of the ray and lie superficial to a spiral cord, which originates from McGrouther’s layer 2 of the pretendinous cord. Pathognomonic of this is the presence of fat in between the skin and the cord in the distal palm (Short-Watson sign). More distally, the pathology may develop in the palmodigital spiraling system, the lateral digital sheet fibers, and in Grayson’s and Cleland’s ligaments and since they are all interconnected and originally run in different planes, they can also cause spiraling of the nv-bundles at various places in the finger as described by Hettiaratchy and Tonkin in 2010.13^,¹⁴ In primary cases, the nv-bundles are usually easily identifiable just distal to the transverse ligament of the palmar aponeurosis and can be traced distally, or can be identified distal of the pathology and traced proximally. In recurrent cases, the plain between the pathology and the nv-bundles may be less clear and there may even be pathology between the digital artery and nerve, placing either of them extra at risk for injury.

Reduced sensibility at physical examination in a previously operated finger is a warning sign for earlier damage to the corresponding nerve and artery. In such cases, an extra warning to the patient that the finger may lose its sensation completely on that side of the finger, or worse, even become ischemic and may ultimately turn into gangrene.

In 2% of cases a hematoma may form after LF; in theory, more often it may form if skin closure and bandaging is performed before tourniquet release. If not evacuated, this may cause skin flap problems and often is the beginning of an early recurrence. For this reason, we see every patient after LF back on the day after surgery, inspect the wound, and act if necessary.

A rare complication of fasciectomy is infection and should be treated as any other infection: with antibiotics if superficial, and by incision, drainage, and wash out if deep.

Cold sensitivity is almost inevitable after any (surgical) trauma to the hand or a finger and especially people who work in the cold should be warned against it, since it occurs in 44% of cases. In 50% of cases it gradually disappears.¹¹

Residual contracture following fasciectomy may be substantial in the treatment of PIPJ contractures of over 60 degrees, and intraoperative gentle manipulation after completion of fasciectomy has been found to have the same outcome as surgical division of the flexor sheath, check reign, and collateral ligaments.¹⁵

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