Treatment of Dupuytren’s Contracture

Abstract

Of 359 hands treated surgically for Dupuytren’s contracture, 135 were available for study after two years or more, often because of recurrence. Of the sixty-five hands treated by excision of the involved fascia (subtotal fasciectomy), 63 per cent had recurrences in the area operated on but only 15 per cent had sufficient deformity to warrant another operation. Of the forty-one hands treated by pahmar fasciotomy, 43 per cent had recurrent deformities severe enough to warrant further surgical treatment. After palmar fasciotomy, improvement at the metacarpophalangeal joint persisted; but, as expected, the deformity at the proximal interphalangeal joint progressed just as it did in an untreated control group. The average postoperative period of disability was fifty-nine days after fasciectomy and twenty-one days after fasciotomy. Stiffness and hematoma occurred after fasciectomy but were not observed after fasciotomy. A digital nerve was severed during one fasciotomy and one fasciectomy. Excision of the involved fascia, therefore, gave the best long-term results but was associated with a higher incidence of postoperative complications. Dupuytren’s contracture is a disease of fascia, principally the palmar fascia, and is seen most often in middleaged white men. It is characterized by progressive contracture of the pahmar fascia, with extension of the contracture particularly into the ring and little fingers. The contractures may also arise in areas where the fascia is sparse, such as the thumb web space, but most commonly they are in the ulnar part of the hand. The pathological findings vary with the stage of the disease, progressing from the typical early cellular nodule to a dense fibrous cord 21.25.29#{149} The cause of the disease is unknown, but there is a definite correlation with the male sex, alcoholism, epilepsy, and heredity 3.27,33, The diagnosis is made on clinical grounds and is usually not a problem. Treatment is primarily surgical; vitamin E, cortisone, and radiotherapy have all been tried, but the over-all hong-term results with these treatments have not been satisfactory iO.iI.I9,3O,34 The controversy over the use of fasciotomy as op* Read at the Annual Meeting of the Western Orthopedic Society, Houston, Texas, November 2, 1972. ± University of California, San Francisco. California 94143. posed to fascial excision has existed for a long time. In 1823 Cooper recommended fasciotomy , and shortly thereafter Dupuytren also endorsed a special method of fasciotomy : multiple transverse incisions and fasciotomies of the contracted cords . Goyrand “ criticized Dupuytren’s operation of multiple transverse incisions and advocated a longitudinal incision and excision of the cord in an attempt to prevent recurrence of the disease process. Fasciotomy fell into disrepute over the years because of the frequent complication of inadvertent section of a digital nerve when the operation was performed in a finger. As is well known, the digital nerve often follows a tortuous course through the fibrous cord in the finger, but this does not occur proximal to the distal palmar crease 18. With the advent of improved surgical facilities and antibiotics, fascial excision became popular 5.12.16.18.24.27.28,31.32#{149} Some authors recommended excision of the entire palmar fascia, whereas others advocated excision of only the diseased portion. Howard 18 advocated percutaneous fasciotomy in the treatment of older patients who are unable to undergo the more extensive operation of excision of the involved fascia (subtotal fasciectomy). He also recommended this type of fasciotomy as a preliminary to fasciectomy for patients who have extensive contractures of the fingers. More recently, Gonzalez ‘ proposed open fasciotomy in the proximal part of the contracted fingers as the sole treatment of Dupuytren’s contracture. He advocated a transverse incision with skin-grafting if a skin deficit occurred on straightening of the finger. At the present time enzymatic fasciotomy is being tried in some centers 2.21, but long-term results and comparison with other types of fasciotomy have yet to be published. The purpose of this study was to review the results of 129 palmar fasciotomies and 230 subtotal fasciectomies, and the progression and outcome of the disease with no treatment in two control groups, the first composed of twenty-four hands with no or mild contractures and the second, oftwenty-three hands with moderate to severe contractures, which did not have surgical treatment and which were observed over a number of years. Materials and Methods Data concerning treatment and results were obtained from a study of patients from the private practices of Dr. L. D. Howard, Jr. , Dr. J. J. Niebauer, Dr. D. R. Pratt, FIG. I TREATMENT OF DUPUYTREN’S CONTRACTURE 381 VOL. 58-A, NO. 3. APRIL 1976 Method of measuring loss of over-all motion of fingers and of joints. A . lack of extension in centimeters, is determined by placing a ruler on the dorsum of the hand and measuring the perpendicular distance from it to the tips of the finger nails. B. lack of extension in degrees. is measured at the metacarpophalangeal and proximal interphalangeal joints as shown (modified, with permission, from Howard 1$) C. loss of flexion expressed as the distance from the finger tips to the mid-palmar crease, is measured with the fingers flexed as much as possible. Dr. R. L. Brown, and Dr. J. R. Doyle. At the time of the initial examination, the ranges of motion of the metacarpophahangeal and proximal interphahangeal joints were recorded. At specific postoperative intervals and at final examination, the flexion contractures (in degrees) of these two joints were compared with the preoperative contractures (Fig. 1 ). In addition, with the finger in maximum extension the perpendicular distance from the tip of the finger nail to a straight line projected from the dorsum of the metacarpal was determined as a linear measurement of the over-all loss of finger extension (Fig. 1 , 4 ). In very advanced cases this linear measurement could not be made because the finger tips were flexed into the palm. The following grading system was used to give some idea of the over-all hand disability of each patient: Grade I nodules or cords present, but no contractures; Grade Ii nodules or cords present, flexion contractures not more than 50 degrees in any one joint, no contracture of the thumb web that reduced thumb abduction by more than 30 degrees, and no loss of over-all extension in any finger in excess of 6.4 centimeters (measured as previously described); and Grade Ill nodules or cords present, contracture of any finger joint exceeding 50 degrees, a thumb-web contracture reducing abduction of the thumb more than 30 degrees, and loss of extension of any finger in excess of 6.4 centimeters. Of the 359 hands operated on, 250 had sufficient preoperative measurements to allow grading by this system. One hundred and forty-nine of these operations were performed on patients with Grade-Ill lesions and fifty-six, on patients with Grade-Il lesions. Thus, about 75 per cent of the hands operated on had Grade -Ill lesions . Postoperati ye grades were compared with the preoperative grades, as were the changes in flexion and extension observed at intervals during