Indications of the Continuous Extension Technique (TEC) for Severe Dupuytren Disease and Recurrences

Fig. 42.1

Severe Dupuytren contracture of the little finger. This situation is presenting a difficult surgical approach; ankylosis of MP and IPP joints; contracture with important loss of digito-palmar and palmar skin (2–3 cm) and of digito-palmar fascia; severe retraction of collateral ligaments, checkreins and palmar plate of IPP joint; even the lateral and spiral cords are retracted as well as the natatory ligament. Due to complexity of reconstructive surgery, we suggested to utilize the Continuous Extension Technique

Many fibrous structures are involved in the progressive contracture due to the disease (Millesi 1986): collateral ligaments; checkreins, volar plate; flexor tendon sheaths together with the pretendinous band, lateral cord, natatory ligaments, spiral cords and collateral neurovascular bundles; and at last the dermal fibrous structures together with a real alteration of sensitivity and trophism of collateral nerve endings. Additionally, having to re-establish useful sliding of different thick, fibrotic and contracted layers of soft tissues, many surgical procedures utilized until today create new and worse biological damage and scarring as in fact happens after the total anterior teno-arthrolysis (TATA Operation) (Saffar 1983) or radical and total fasciectomy (McIndoe and Bear 1958; Skoog 1948) or a large dermofasciectomy (Hueston 1984). Today, in the presence of a progressive disease, there is a worsening post-operation healing of sliding tissues of fingers together with poor functionality even of the hand; surgeons suggest performing a secondary or tertiary surgery; this choice additionally worsens all soft finger tissues and may ultimately lead to the indication of partial or total amputation of the finger. On the other hand, it is known that even in some severe cases, loss of vascularity of the contracted finger or alteration of its sensibility and trophism often leads to the indication of amputation. The Continuous Extension Technique can be used in cases of severe progressive Dupuytren Disease; avoiding and may help avoid an amputation.

42.1.1 Advantages and Indications of the TEC Methodology

The Continuous Extension Technique (TEC) is a minimally traumatic, painless and advanced technique performed by an external device which allows the restoration of the extension of the fingers and their function.

The Continuous Extension Technique:

1.

Provides the option of conserving severely contracted fingers and restoring their functionality; this had previously strained the technical limits of classical operations or been downright impossible (progressive cases with persistent recurrences) (Messina 2011).
2.

Facilitates all procedures, greatly reducing surgical tissue trauma, the complexity, length and difficulties of the surgery in long-term retracted joint stiffness.
3.

Simplifies the finger and palmar skin incision and surgical approach; it avoids complementary articular procedures in the finger, such as capsulotomy and arthrolysis; the release of checkreins, collateral ligaments and palmar plate; and the release of the digital cord and the retracted lateral, spiral and natatory ligaments. This especially in advanced stage or in patients who have already been operated on.
4.

Avoids the sudden surgical extension of the contracted finger with consequent stretching and tearing of collateral neurovascular bundles which cause devascularization and trophic trouble in fingers that have been retracted for many years in severe flexion due to progressive disease and recurrences (Fig. 42.2).

Fig. 42.2

The TEC device. The TEC device is an advanced apparatus to perform continuous extension treatment of the retracted fingers. The device is not cumbersome (its size can be adapted to the elongated fingers and it weighs only 190 g). The extension is minimally traumatic and painless; it can be applied simultaneously to several retracted fingers. The TEC avoids the sudden surgical extension of the contracted finger with consequent stretching and tearing of collateral neurovascular bundles which may cause disturbance of blood circulation and trophic trouble in fingers that have been retracted for many years in severe flexion due to progressive disease and recurrences
5.

It is an alternative to dermofasciectomy and difficult plastic surgery for correcting severe digital or palmar skin loss and contracture.
6.

Surpasses the McCash “open palm” technique both in theory and in its practical applications (no exposure of deep and sensible palmar tissues, no secondary healing, no deep scarring risk, no risk of flogosis, no risk of palmar reflex dystrophy, etc.).
7.

TEC is a possible definitive solution in some cases of chronic Dupuytren contracture; this is confirmed by the disappearance of the pretendinous cord in the extended finger and of the contracted palmar fascia as well as the palmar nodules (compression test) (Fig. 42.3; Messina and Messina 1997).

Fig. 42.3

Complete extension of the little and ring fingers (also partially contracted) after 3 weeks. The elongation is carried out by the patient at home. The fasciectomy of diseased fascia must be performed at the same time the TEC device is removed. The surgical approach is as simple as in the first stage of Dupuytren Disease. Plastic skin surgery, including Z-plasties, skin graft, etc., was not necessary in this case and in other cases treated by TEC methodology
8.

TEC treatment might also benefit post-traumatic retraction scars accompanying flexion ankylosis and deformity of the fingers (caused by burns, tendon and osteoarticular trauma, skin loss, etc.).
9.

Finally, TEC is indicated in severe progressive recurrences and extensions of advanced Dupuytren, reducing stages III and IV to the first stage of beginning of contracture (Messina 2011).

Repeated surgery can potentially lead to amputation of the recontracted finger, and the TEC device reduces this risk. For severe pathological contracture, the Continuous Extension Technique methodology is indicated to ease surgery and reduce complications. By lengthening of the digito-palmar fascia and of the contracted skin as well as of all retracted soft tissues, it re-establishes the first stage of the disease (Fig. 42.3).

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