Keywords
Dupuytren - fasciectomy - pull-through - minimally invasive - recurrence
Introduction
Dupuytren's disease is a benign fibroproliferative disorder of the palmar fascia that
can significantly impair hand function.[1]
Several procedures have been described for the treatment of this pathology, including
radical fasciectomy (RF), limited fasciectomy (LF), percutaneous needle aponeurotomy
(PNA), and enzymatic fasciotomy through collagenase injections (collagenase Clostridium histolyticum [CCH]) with the LF and the PNA as the surgical techniques most commonly performed.
Nevertheless, the gold standard treatment is yet to be defined.[2]
[3]
Needle aponeurotomy has recently gained popularity as a minimally invasive technique
that can be performed on an outpatient basis. However, this technique is associated
with a 5-year recurrence rate of over 80% compared with only 20% with open surgery.[4]
Enzymatic fasciotomy with CCH (Xiapex, Swedish Orphan Biovitrum AB, Stockholm, Sweden),
although proven to be an effective procedure, has high recurrence rates and complications.[5] Furthermore, in 2019, the drug approved by the European Medicines Agency (EMA) was
withdrawn from the European market.
In this scenario, the hand surgeon plays a crucial role having the responsibility
to combine digital extension improvement, soft tissue preservation, and disease recurrence
prevention in the chosen surgical technique.
The aim of this study was to present our approach for the surgical treatment of Dupuytren's
disease through a minimally invasive pull-through technique.
Methods
A retrospective review of prospectively collected data was performed from January
2016 to January 2020. All patients with Dupuytren's contracture who met the inclusion
criteria and underwent minimally invasive pull-through procedure were included in
this study.
Inclusion criteria were as follows:
-
passive extension deficit > 30 degrees at the metacarpophalangeal joint (MCPJ),
-
passive extension deficit > 30 degrees at the MCPJ and more than 20 degrees at the
proximal interphalangeal joints (PIPJs),
-
stage 1–3 Dupuytren's disease according to Tubiana's classification,[6]
-
existence of a clearly defined palmar cord,
-
recurrence of disease after enzymatic fasciotomy or PNA, and
-
patients followed up for at least 24 months.
All patients with isolated PIPJ contracture, stage 4 disease, complications after
a previous treatment (infection, neurovascular injury, complex regional pain syndrome),
severe osteoarthritis involving MCPJ or PIPJ in the affected finger were excluded
from the study.
The Dupuytren's disease was diagnosed by clinical examination, evaluating patient's
history and physical tests such as the Hueston's table-top test.[7] A preoperative ultrasound imaging was performed for each patient to evaluate the
presence and extent of the pathological tissue.
Patient age, body mass index (BMI), smoking habits, alcohol consumption, diabetes,
type of work, family history, the number of fingers involved, joints involved, extent
of deformity before treatment, and previous interventions were recorded. Range of
movement measurements for each joint were made in the clinic by an experienced hand
therapist using a goniometer. These were then used to calculate the extension deficit,
which was measured from 0 degrees.
All patients were rigorously followed up with periodic visits at 1, 6, 12, and 24
months.
During the scheduled appointments, a hand surgeon and a hand therapist, not involved
in surgical treatment, recorded all reported or observed adverse events. At the 1-month
follow-up visit, a sensory evaluation was performed using the two-point discrimination
test to assess sensibility of the digits.
The work has been reported to be in-line with Strengthening the Reporting of Observational
Studies in Epidemiology guidelines. No donor or funder had a role in the design or
conduct of the study, the collection or analyses of the data, or the preparation of
the article.
The research complies with the provisions of the Declaration of Helsinki (revised
in 2013). The institutional review board of the hospital involved approved this study
(No. 6911). Written informed consent was obtained from all patients prior to their
enrollment.
Operative Technique
All operations were performed on an outpatient basis under local anesthesia.
After having identified the palpable cords, three to four transverse incisions with
a length of 1 cm and spaced approximately 2 to 3 cm from each other were made on the
skin overlying the contracture. The incisions were made at the beginning and at the
end of the palpable cord, near the distal palmar flexion crease and the digital creases
([Fig. 1A]).
Fig. 1 (A) Opening along the preoperative marking of four transverse incisions with a length
of 1 cm. (B) Dissection of the pathological cord from the underlying soft tissues. (C) Preparation of subcutaneous tunnels between the incisions. (D) Isolation of the cord from the deep planes with umbilical ribbons. (E) Protection of the underlying tissues with grooved directors. (F) Lifting and pulling through the subcutaneous tunnels of the pathological tissue.
The cords were then isolated from the overlying skin and from the underlying flexor
tendons preserving the common and proper palmar digital nerves ([Fig. 1B]). Subcutaneous tunnels were set up between the incisions using blunt-tipped iris
scissors ([Fig. 1C]).
The pathological tissue was then isolated from the deep planes with umbilical ribbons
([Fig. 1D]). Grooved directors were inserted through the incisions to protect the vessels of
the superficial palmar arch before performing the proximal incision to the retracting
cord ([Fig. 1E]). The cords were then lifted and pulled through the previously created subcutaneous
tunnels and finally excised ([Fig. 1F]).
In this way, selective fasciotomies were performed aimed at removing the retracting
tissue.
The surgical incisions were sutured with absorbable monofilament sutures (monocryl
4/0). If excessive tension was detected at the time of closure, healing by secondary
intention was opted.
All patients were provided with a thermoplastic extension splint for 1 week. After
7 days, an overnight splint was adopted to be used for the following month. The splint
was molded again to a correct fit at 2 to 3 weeks as local swelling settled.
All patients underwent physiotherapy supervised by a hand therapist.
Outcome Analysis
The primary endpoint of the study was to evaluate efficacy and durability of the presented
technique at 24 months of follow-up. The outcome was defined by the assessment of
the correction of the deformity, physical function and symptoms of patients, and the
changes in quality of life. Complete correction of the deformity was defined as residual
deformity of <5 degrees.[8] Physical function and symptoms of patients were assessed through the quick disabilities
of the arm, shoulder, and hand (QuickDASH) system questionnaire.[9]
[10] Health-related quality of life was evaluated with the EuroQol five dimensions—five
levels (EQ-5D-5L) index.[11] A comparison of pre- and postoperative findings was performed. Moreover, a correlation
between QuickDASH score and duration of symptoms was investigated.
As additional data, recurrence rate at the latest follow-up was investigated as well
as an existent correlation between the preoperative finding (relapsing Dupuytren's
disease or primary disease and duration of symptoms) and the outcomes were assessed.
Recurrence was defined as the occurrence of >20 degrees of deformity after treatment.[12]
[13] Moreover, an ultrasound evaluation was performed 12 months after treatment to assess
the recurrence of the disease.[8]
Surgical complications were recorded. They were divided into early complications,
including edema, pain, skin tears, hemorrhage and late complications (wound dehiscence,
infection, residual deformity, presence of hypoesthesia, tendon rupture, and complex
regional pain syndrome).
Statistical Analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS) software
for Windows, version 23.0 (IBM SPSS, IBM Corp., Armonk, NY). Confidence interval was
set at 95%. Kolmogorov–Smirnov normality test was adopted to assume the normal distribution
of statistical variables. Statistical means were compared using the parametric Student's
t-test (when the normal distribution of variables was assumed) and the nonparametric
Wilcoxon's signed-rank test (when the normal distribution of variables was not assumed).
Statistical frequencies were compared by means of chi-square test. The strength of
correlation between different variables was quantified using Pearson's r correlation coefficient. A p-value <0.05 was considered statistically significant.
Results
A total of 52 consecutive patients (40 males and 12 females) with 61 fingers underwent
selective fasciectomies with minimally invasive pull-through technique.
Eight patients had concurrent fingers treated in the same sitting. Forty-one fingers
had isolated MCPJ involvement while 20 had MCPJ and PIPJ involvement.
Mean follow-up was 36 months from the initial procedure (range: 24–60 months).
The average patient age was 57.5 years (range: 39–78 years) and the mean BMI was 29.7 kg/m2 (range: 26.1–32.3 kg/m2). The average duration of symptomatology before the surgical intervention was 14
months. Details regarding patients' characteristics are provided in [Table 1].
Table 1
Demographics and patient characteristics
|
n
|
Percentage (%)
|
|
Number of patients
|
52
|
–
|
|
Number of fingers
|
61
|
–
|
|
Age, mean ± SD (range), y
|
57.5 ± 12.2 (39–78)
|
|
Male
|
40
|
76,9
|
|
Female
|
12
|
23,1
|
|
BMI, mean ± SD (range), kg/m2
|
29.7 ± 2.0 (26.1–32.3)
|
|
Type of worker
|
|
Office worker
|
13
|
25.0
|
|
Heavy worker
|
31
|
59.6
|
|
Housewife
|
8
|
15.4
|
|
Diabetes
|
11
|
21.2
|
|
Alcohol use
|
14
|
26.9
|
|
Active smoking
|
24
|
46.2
|
|
Family history
|
22
|
42.3
|
|
Hand with contracture
|
|
Right
|
35
|
67.3
|
|
Left
|
17
|
32.7
|
|
Number of digits affected, percentage (%)
|
|
1
|
45
|
86.5
|
|
2
|
5
|
9.6
|
|
3
|
2
|
3.8
|
|
Finger involved
|
|
Thumb
|
0
|
0
|
|
Index
|
5
|
8.2
|
|
Middle
|
11
|
18.0
|
|
Ring
|
19
|
31.1
|
|
Little
|
26
|
42.6
|
|
Joints involved
|
|
MCPJ
|
41
|
67.2
|
|
MCPJ and PIPJ
|
20
|
32.8
|
|
Duration of symptoms ± SD (range), months
|
14 ± 4.9 (6–24)
|
|
Previous interventions
|
14
|
26.9
|
|
CCH
|
8
|
15.3
|
|
PNA
|
6
|
11.5
|
|
Time to disease recurrence ± SD (range), years
|
2 ± 0.4 (1.5–2.5)
|
|
Healing process
|
|
First intention
|
55
|
90.2
|
|
Second intention
|
6
|
9.8
|
|
Skin graft
|
0
|
–
|
Abbreviations: BMI, body mass index; CCH, collagenase Clostridium histolyticum; MCPJ, metacarpophalangeal joint; PIPJ proximal interphalangeal joint; PNA, percutaneous
needle aponeurotomy; SD, standard deviation.
Of the patients included in this study, eight patients had previously undergone treatment
with enzymatic fasciotomy, six had undergone PNA, having a disease relapse after approximately
2 years ([Table 1]).
The average initial total extension deficit was 47.5 degrees for PIPJ (range: 29–67 degrees)
and 53 degrees for MCPJ (range: 32–75 degrees) which were corrected to an average
3.4 degrees (range: 0–12 degrees) after treatment ([Fig. 2]).
Fig. 2 Sixty-one-year-old male with recurrence of Dupuytren's contracture after injection
of collagenase Clostridium histolyticum. (Above) Preoperative images showing extension deficits in the metacarpophalangeal
and proximal interphalangeal joints of the IV and V fingers. (Below) Patient follow-up
at 36 months.
At the last follow-up, the mean active range of motion of the MCP and PIP joints were,
respectively, 91.8 ± 2.9 degrees (range: 96–85 degrees) and 83.2 ± 2.1 degrees (range:
87–80 degrees).
Of treated fingers, 86.9% had full correction of the deformity at the metacarpophalangeal
and proximal interphalangeal joint. Of the residual deformity, 9.8% was in PIPJ and
3.3% in MCPJ.
Minor wound healing complications were found in 8.2% patients, which improved with
regular dressings, and 11.5% of patients experienced pain and swelling after treatment
which settled within a month. No patient had tendon tears or neurovascular bundle
injuries.
The wound healing process took place in 55 cases by first intention and in six digits
by second intention. It was never necessary to resort to a skin graft ([Table 2]).
Table 2
Surgical complications
|
Number
|
Percentage (%)
|
|
Early
|
|
Edema
|
7
|
11.5
|
|
Pain
|
7
|
11.5
|
|
Skin tear
|
0
|
0
|
|
Hemorrhage
|
0
|
0
|
|
Numbness
|
0
|
0
|
|
Late
|
|
Wound dehiscence
|
5
|
8.2
|
|
Infection
|
0
|
0
|
|
Hypo/Anesthesia
|
0
|
0
|
|
Tendon rupture
|
0
|
0
|
|
Complex regional pain syndrome
|
0
|
0
|
|
Residual deformity
|
|
|
MCPJ
|
2.0
|
3.3
|
|
PIPJ
|
6.0
|
9.8
|
Abbreviations: MCPJ, metacarpophalangeal joint; PIPJ, proximal interphalangeal joint.
Clinical or instrumental disease recurrence (defined as reappearance of pathological
fibromatous tissue in the treated areas) was observed in 15.4% of patients at the
latest follow-up.[14]
All patients were able to perform the Hueston table-top test at 24 months and returned
to their precontracture activities with a mean of 6.2 ± 1.1 (range: 5–8) weeks after
surgery. ([Table 3]). None of the patients exhibited any difficulty in performing flexion–extension
movements of the involved digits.
Table 3
Patient outcomes and comparison of the pre- and postintervention variables
|
N
|
Percentage (%)
|
p-Value
|
|
Reduction of MCPJ or PIPJ contracture <5 degrees
|
53.0
|
86.9
|
–
|
|
Preoperative total active extension deficit ± SD (range), degrees
|
84.0 ± 23.3 (55–130)
|
<0.001
|
|
Postoperative total active extension deficit ± SD (range), degrees
|
3.4 ± 2.3 (0–12)
|
|
Mean active range of motion of the MCP ± SD (range), degrees
|
90.5 ± 3.3 (85–96)
|
|
|
Mean active range of motion of the PIP ± SD (range), degrees
|
82.7 ± 2.5 (80–87)
|
|
|
Preoperative QuickDASH ± SD (range)
|
<0.001
|
|
Disability/symptoms score
|
22.8 ± 10.2 (9.1–47.7)
|
|
Postoperative QuickDASH ± SD (range)
|
|
Disability/symptoms score
|
12.1 ± 6.7 (0–27.3)
|
|
Preoperative EQ-5D-5L index ± SD
|
0.684 ± 0.3
|
0.01
|
|
Postoperative EQ-5D-5L index ± SD
|
0.882 ± 0.2
|
|
Recurrence
|
8
|
15.4
|
|
|
Returned to precontracture activities ± SD (range), wk
|
6.2 ± 1.1 (5–8)
|
Abbreviations: EQ-5D-5L index, EuroQol five dimensions—five levels index; MCPJ, metacarpophalangeal
joint; PIPJ, proximal interphalangeal joint; QuickDASH, quick disabilities of the
arm, shoulder, and hand; SD, standard deviation.
The QuickDASH score improved significantly (p < 0.001) decreasing from a mean value of 22.8 ± 10.2 (range: 9.1–47.7) to 12.1 ± 6.7
(range: 0–27.3) after treatment.
Total active extension deficit, and EQ-5D-5L improvement was registered in all patients,
p < 0.001, p = 0.01, respectively. Details and graphics concerning the main outcomes are described
in [Table 3] and [Fig. 3].
Fig. 3 Boxplot of QuickDASH, EQ-5D-5L, and total active extension deficit measurements before
and after pull-through technique. All variables improved significantly after treatment.
EQ-5D-5L, EuroQol five dimensions—five levels; QuickDASH, quick disabilities of the
arm, shoulder, and hand.
Patients with a relapsing Dupuytren's contracture did not have a difference in improvement
compared with patients with a primary contracture.
No correlation was noted between QuickDASH scores and duration of symptoms at the
Pearson's r collection test. There was a statistically significant correlation between the QuickDASH
score and the total active extension deficit (r = 0.652; p < 0.001).
Discussion
Dupuytren's disease is a common problem in most hand surgery practices. It is usually
easily diagnosed by the presence of its primary palmar manifestations: the nodule,
the cord, and the digital flexion contracture.
In 1991, Smith described what the three goals of treatment for Dupuytren's contracture
were, precisely, to improve the functional capacity of the affected hand, reduce the
deformity associated with contractures, and ultimately prevent disease recurrence.[15]
Nowadays, we would emphasize another goal of treatment: the preservation of noble
structures like the common and proper palmar digital nerves, the flexor tendons, and
digital arteries.
Duputyren's disease poses a real challenge for many hand surgeons since no standard
consensus exists on the procedure to be performed. Several factors must be considered
in the treatment decision, including the severity of the disease, the risk of complications,
and the rate of relapse.[16]
RF and dermatofasciectomy have fallen out of favor as more aggressive techniques,
with higher complication rates, often requiring skin grafts and a prolonged postoperative
rehabilitation process.[17]
Percutaneous needle aponeurotomy (PNA) is a technique that has gained popularity in
the recent period, as it is a simple procedure, which can be performed under local
anesthesia on an outpatient basis. The main complications of PNA are temporary digital
numbness and tendon tears. Additionally, there may be a greater risk of disease recurrence,
as the weakened pathological tissue remains present at the site.[18]
[19] Van Rijssen et al compared LF and percutaneous fasciotomy in 5-year randomized clinical
trial, demonstrating that PNA has a recurrence rate of 84.9%, compared with 20.9%
for fasciectomy.[20] In a separate study, Van Rijssen et al reported that passive extension deficit was
significantly improved in those with advanced Tubiana staging who underwent fasciectomy.[21] PNA allows for good recovery of hand function, but full extension (<5 degrees) is
usually not achieved.[22]
Another minimally invasive alternative approach to Dupuytren's contracture was the
use of the CCH (Xiapex, Swedish Orphan Biovitrum AB). It produced comparable results
to LF with improved effectiveness when administered to the MCPJ compared with PIPJ
contractures.[23]
[24] However, the EMA withdrew Xiapex from the European market in 2019.[25] Hurst showed that recurrence with recurrent contractures more than 20 degrees was
35% at 3 years and 47% at 5 years.[26] It was an expensive treatment and had complications related to collagenase injection
including localized swelling, pain and bruising, itching, tenderness, skin tears,
and transient lymphadenopathy, and less commonly complex regional pain syndrome and
tendon rupture.[27]
[28]
To the best of our knowledge, a minimally invasive pull-through technique has not
been previously described as a minimally invasive surgical treatment for Dupuytren's
disease. In our analysis, the described technique demonstrated to be effective resulting
in a complete correction in 86.9% of patients. The difference in finger range of motion
between pre- and postoperative was shown to be statistically significant (p < 0.05). Furthermore, the comparison of the data collected through the QuickDASH
and EuroQol 5-dimension questionnaires before and after treatment confirmed the validity
of the recovery of hand function after treatment (p < 0.05). Improvements registered after pull-through technique were neither correlated
to the symptoms' duration, nor were the differences in patients who had already undergone
a previous treatment. Compared with the enzymatic treatment, our approach, although
more complex and invasive, reported a low recurrence rate and none of the complications
associated with the collagenase.[29]
[30]
[31] Conversely, no major adverse events were reported in our study population.
Recurrence rate was 15.4%, indicating that excising the diseased fascia of affected
digits and palm is very effective for treating contractures with a relatively low
long-term recurrence rate. The hypothesis is that reducing the extent of incisions
and dissection would also reduce the production of collagen that can cause further
retraction and disease recurrence.
Considering our results as a whole, we believe that the minimally invasive pull-through
technique has several advantages. First, it is an open technique, therefore it allows
to visualize and to preserve the anatomical structures that need to be protected,
such as the common and proper palmar digital nerve and the flexor tendon. Second,
the role of the mini-incisions is crucial, as they allow the surgeon to extract the
cord without the need for a larger and more elaborate dissection such as that required
in LF with Bruner incisions decreasing operative time.
Setting up subcutaneous tunnels during the procedure requires meticulous attention
to avoid any damage to the skin. In our experience, we have found that it is possible
to separate the skin from the fibrotic tissue without encountering real ulcerations.
We acknowledge that the risk of thin skin flaps is present, but we have not observed
any skin necrosis in our patient cohort. We believe that the absence of stitches in
cases of extreme tension reduces the ischemia of the margins and helps to minimize
the risk of complications.
The 12-month ultrasound evaluation allowed us to perform a comprehensive assessment
of tendon gliding following the operative technique. This enabled us to observe any
residual deformities that may have remained following treatment. Overall, the inclusion
of ultrasound evaluation in our study allowed for a more thorough evaluation of the
effectiveness of the procedure.
Other minimally invasive surgical techniques have been described in the literature,
however, based on segmental aponeurectomies and not on “pull-thorugh” complete fasciectomies.[32]
[33]
[34]
Attention should be drawn to the anatomical differences that the pathology could have
at the PIP joint. At this level it is possible to encounter retrovascular or spiral
cords. The neurovascular bundle often courses between contracted Grayson's ligaments
and the lateral cords. These conditions can be problematic as digital neurovascular
bundles are often displaced central, proximal, and superficial. In these tough cases,
if it is not possible to easily separate the retrovascular cord from the neurovascular
bundle, the surgical access could be widened joining the two transverse incisions
at the level of the PIPJ, making a modified Bruner-type incision. In this way, the
surgeon can always rely on a backup plan in case of troubles, switching from minimally
invasive technique to a full-open approach with adequate visualization of the neurovascular
bundle. All patients in which the incision was widened into a Z fashion were excluded
by this study. Proper patient selection and careful consideration of potential risks
and complications are important for a successful outcome.
Based on our results, this novel minimally invasive approach is a safe and effective
alternative treatment for Dupuytren's contracture, allows the surgeon to deal with
cases of advanced contractures as well as relapses, and could represent an added value
for the functional outcome of patients.
The limitations of the study are to be found in the retrospective design, in the heterogeneity
of the study population, lack of a control group, and in the need for a longer follow-up.
This technique requires further validation with a multicenter study and comparative
trial with other procedures.
