Partial Palmar Fasciectomy for Dupuytren Disease

Thomas P. Lehman, PT, MD

Steven L. Peterson, MD, DVM

Ghazi M. Rayan, MD

Dr. Rayan or an immediate family member serves as a board member, owner, officer, or committee member of the American Society for Surgery of the Hand. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Lehman and Dr. Peterson.

INTRODUCTION

Dupuytren disease is a benign fibroproliferative disorder of the palmar fascial complex that leads to the development of pathologic tissue, which may extend from the palm to any digit. In its early stages, Dupuytren disease leads to the formation of nodules and cords; in its advanced stage, flexion contracture of the digits may develop. The presentation of the disease varies, depending on its severity and whether palmar or digital fascial structures are affected.

It is important to differentiate between two clinical types of palmar fascial proliferation: Dupuytren disease and non-Dupuytren disease. A patient with typical Dupuytren disease is usually a Caucasian male of Northern European ancestry, approximately 50 years of age, with bilateral progressive digital contracture, more than one hand or digit involved, and a positive family history with or without ectopic disease. In contrast, non-Dupuytren disease is a clinical entity in which the patient has palmar fascial proliferation that usually occurs following trauma or surgery to the hand. The patient can be of any age, sex, or race and may be diabetic with no family history of Dupuytren disease. The condition is unilateral, nonprogressive, and usually affects only one hand without digital involvement or contracture.¹

PATIENT SELECTION AND ALTERNATIVE TREATMENTS

Variations of open fasciectomy—total or subtotal—have been used to treat Dupuytren disease. Many other treatment alternatives have been rejected because of the lack of efficiency, including splinting, ultrasound therapy, radiation therapy, topical application of vitamins A and E, and gamma interferon, and steroid or dimethyl solfoxide injection.²^,³^,⁴ However, two other less invasive techniques have grown in popularity recently as nonsurgical alternatives to fasciectomy. These include needle aponeurotomy or fasciotomy and enzymatic lysis of the cords.

Needle aponeurotomy presents a less invasive surgical option to limited fasciectomy that may be performed as an office procedure with local anesthetic. This technique may be used independently or as an adjunct to partially correct a severely contracted finger before fasciectomy. In this procedure, the contracture-producing cord or cords are released by cutting the fibers with a needle inserted percutaneously. Careful consideration of the pathoanatomy of the abnormal cords is essential to avoid injury to adjacent neurovascular structures. For cords proximal to the metacarpophalangeal (MCP) joints, it is safer to initially release the deeper portion, followed by more superficial release. For cords distal to the MCP joints over the proximal phalanx, it is safest to approach the cord laterally to weaken the deeper, more dorsal portion of the cord while avoiding the palmarly displaced neurovascular structures. Cords are weakened by multiple passes of a 25-gauge needle mounted on a 10-mL syringe. Usually, more than one site is needled along the palpable course of the cord. Needle passages are performed with the cords under tension by passive extension of the involved digit. Often the cord will rupture during the course of therapy; however, if this does not occur and sufficient sites have been addressed, rupture can be achieved by more forceful extension. Following rupture, standard maneuvers are performed to ensure independently intact flexor digitorum superficialis and flexor digitorum profundus tendons. A soft dressing is applied, and nighttime extension splinting is provided for the next 4 to 6 weeks.

The second technique involves weakening the cord enzymatically by injecting collagenase 24 or more hours before rupturing the cord manually. Both needle fasciotomy and collagenase injection have been demonstrated to be safe and effective. Collagenase injection, however, has a high risk of complications. Most these are transient and resolve without treatment, but more severe complications, including flexor tendon rupture, have been reported.⁵

Careful consideration must be given to the risks, costs, and patient’ demands when planning treatment. Long-term results show trends toward better correction and a lower risk of recurrence with partial palmar fasciectomy.⁶ Partial fasciectomy remains the standard treatment for severe and recurrent cases of Dupuytren disease and is often appropriate for patients with less severe disease.

Indications

Although absolute indications for surgical treatment of Dupuytren disease have not been objectively established, some guidelines are generally accepted. Surgery is recommended for patients whose disease limits function, with MCP joint contracture of at least 30° and/or proximal interphalangeal (PIP) joint contracture of 15°. Prominent cords or nodules that do not restrict motion may also require excision if they interfere with hand function because of their location. The “table top test” represents a good way to remember and counsel patients regarding the indications for treatment of Dupuytren disease. When patients cannot place the hand flat on a table, intervention may be considered.

Contraindications

Contraindications for treatment include non-Dupuytren disease and infection. Additionally, some patients may be physiologically unable to undergo a major surgical procedure or may have low functional demands and would not benefit from surgery. A subset of these patients may, however, be candidates for the less invasive techniques mentioned earlier that can be performed in an office setting. Patients who are on chronic anticoagulation therapy that cannot be temporarily discontinued should be approached with caution, as hematoma formation in the hand can lead to adverse outcomes regardless of the technique used for treatment.

PREOPERATIVE IMAGING

Preoperative imaging is not routinely performed. However, in patients with underlying degenerative disease that may affect the reestablishment of joint motion, plain radiographs of the hand may be indicated.

PROCEDURE

Room Setup/Patient Positioning

The patient should be positioned supine with the upper extremity abducted at the shoulder and the hand resting on a surgical hand table. Some older patients with Dupuytren disease may have degenerative changes that limited shoulder range of motion. When this situation exists, care must be taken to ensure that the extremity is not placed in a position that will aggravate underlying shoulder disease. A padded pneumatic tourniquet is placed on the brachium. In the presence of severe deformity, it may be difficult to place the digits in a lead hand or similar device that maintains the desired position during the procedure.

Full-thickness skin grafts are sometimes necessary to complete wound closure. These are most often harvested from the volar wrist, but the proximal forearm can provide a larger graft for more extensive skin shortage. The surgeon must also be prepared to use flap coverage if vital structures such as tendons and neurovascular structures are exposed after reapproximation of the skin edges. The patient should be positioned and prepared so that the donor site of choice is readily available if grafts are needed. Alternatively, wounds as in the palm can be left open if vital structures are not exposed, to heal by secondary intention.

Special Instruments/Equipment

Partial fasciectomy can be completed with basic instrumentation appropriate for surgery of the hand. A No. 15C Bard-Parker surgical blade can be extremely valuable for dissecting adherent diseased tissue from dermis. Small Beaver blade scalpels may be also of value.

Limited fasciectomy does not require an operating microscope or microsurgical instruments. These items should be available, however, because injury to nerves and arteries are known risks associated with the surgical treatment of Dupuytren disease. If a nerve or vessel injury occurs at the time of fasciectomy, it should be immediately repaired.

Surgical Technique

Preoperative Planning

Fasciectomy for Dupuytren disease involves selective removal of the diseased tissue that is contributing to digital joint contracture. This tissue may distort the anatomy and displace digital nerves and vessels. Therefore, a thorough understanding of the normal palmar fascial anatomy and Dupuytren disease pathology is essential for the execution of a successful fasciectomy. Several anatomically distinct pathologic cords have been described in Dupuytren disease, and more than one cord may be present in the same hand/digit.

Dupuytren Cords

Pretendinous Cord

The pretendinous cord arises from the pretendinous band and is the most commonly encountered cord in the hand. Contracture of this cord results in flexion deformity of the MCP joint (Figure 1). This cord does not typically displace neurovascular structures.

Spiral Cord

The spiral cord arises from the pretendinous band proximally and continues distally to involve the spiral band, the lateral digital sheet, and the Grayson ligament. As these diseased structures coalesce and shorten, the adjacent digital neurovascular bundle spirals around the cord, which takes a straight-line course (Figure 2). This frequently affects the small finger and results in flexion deformity of the MCP joint as well as the PIP joint (Figure 3).

Lateral Cord

The lateral cord is the diseased lateral digital sheet and may result in contracture of the proximal and occasionally
the distal interphalangeal joints. It does not result in displacement of the neurovascular bundle, except by its bulk.