ABSTRACT
Objectives:
In this study, we aimed to evaluate short-term outcomes of partial fasciectomy in patients with Dupuytren’s contracture.
Materials and Methods:
A total of 29 patients who underwent partial fasciectomy between October 2019 and March 2022 were retrospectively analyzed. Demographic and clinical characteristics of patients, degree of contracture, functional outcomes, recurrence rate, and satisfaction rate were recorded. All patients underwent Q-DASH scoring. Complications such as wound infection and neurovascular injuries after surgery were evaluated.
Results:
Of the patients, 26 were males and three were females. The median age was 57 (range, 40 to 74) years. The median follow-up was 12 (range, 11 to 17) months. Pathological examination result was compatible with fibromatosis. Maceration in the wound site was seen in two patients. The mean Q-DASH score is 7.36 (0-22.8). A butterfly drain was placed after surgery in all patients. No recurrence was observed. All patients were satisfied with the surgical treatment.
Conclusion:
Partial fasciectomy is a useful treatment method with low recurrence and complication rates and high patient satisfaction rates in patients with Dupuytren’s contracture.
Introduction
Dupuytren’s contracture is a benign fibroproliferative disease of the palmar fascia characterized by flexion contracture of the fingers. It was first described by Guillaume Dupuytren in detail (1,2).
Although the exact etiology of Dupuytren’s contractureis unclear, its incidence is high in male elderly in the North Europe, while it rarely affects Asian population. It has been thought that Dupuytren’s contracture has a genetic mode of inheritance (3,4). In addition, its prevalence is higher in individuals with a history of alcoholism or smoking, renal and liver impairment, diabetes mellitus, and epilepsy (5,6).
The initial manifestations of Dupuytren’s contracture include abnormal thickening and tightening of the skin in the palm. In later stages, nodules, contractures and pretendinous band may occur (7,8). The Tubiana’s staging system is used for clinical staging of Dupuytren’s contracture. It has been classified clinically by Tubiana in 3 stages as early, active and advanced stage. The predominant cell type is fibroblast in the early stage, myofibroblast in the active stage, and fibrocyte in the advanced stage. Clinically, nodules, contractures, and tendon-like bands are seen, respectively (8). Histopathological staging proposed by Luck classifies the disease into three stages: proliferative, involution, and residual (9).
Management of Dupuytren’s contracture includes observation, non-operative management, and operative management (10). Non-operative management includes physiotherapy, radiation, steroids, anti-tumor necrosis factor agents and clostridium histolyticum collagenase (11-15).
Conservative treatment is first-line option in early stage (16). Surgery is indicated in the presence of a ≥30° flexion contracture in the metacarpophalangeal (MCP) joint and painful nodules (17). Surgical treatment includes partial fasciectomy, total fasciectomy, fasciotomy, dermofasciectomy, and percutaneous needle fasciotomy (18,19). Partial fasciectomy is the most widely used method currently (20).
In the present study, we aimed to evaluate short-term outcomes of partial fasciectomy in patients with Dupuytren’s contracture.
Materials and Methods
This single-center, retrospective study was conducted at the Clinic of Orthopedics and Traumatology of a tertiary care center between October 2019 and March 2022. A total of 34 fingers of 29 patients who underwent partial fasciectomy were included. Diagnosis was based on medical history and physical examination findings. The degree of contracture in the MCP joint of the fingers with the highest contracture was measured using a goniometer preoperatively. Surgery was indicated in the presence of ≥30° flexion contracture of the MCP joint with a painful nodule. All of our patients present as advanced stage according to the Tubiana classification. Patients who were operated in an external center, presence of ≥30° flexion contracture of the MCP joint with a painless nodule and pediatric cases were excluded from the study. Demographic and clinical characteristics of patients, degree of contracture, functional outcomes, recurrence rate, and satisfaction rate were recorded. All patients underwent Q-DASH scoring. A written informed consent was obtained from each patient. The study was approved by the Ankara City Hospital, No. 1 Clinical Research Ethics Committee Presidency (Approval no: 2586, Date: 24.04.2022) and conducted in accordance with the principles of the Declaration of Helsinki.
Patient satisfaction was assessed using the visual analog scale with the scoring ranging between 0 and 10 (21): 1-3, very dissatisfied, 4-5, dissatisfied; 6-7, satisfied, and >7 very satisfied. Complications such as wound infection and neurovascular injuries after surgery were evaluated.
Surgical Technique
As a standard procedure, all patients were operated under regional anesthesia (block) and tourniquet. All operations were performed by a single hand surgeon. A Brunner skin incision was applied (Figure 1). A surgical loupe with 4.3 magnification was used. During surgery, digital arteries and nerves of both sides of the fingers were preserved (Figure 2). After hemostasis, the skin was anatomically closed using 4/0 prolene sutures. A butterfly drain was placed in all patients after surgery (Figure 3). All patients underwent partial fasciectomy. The fascia layers excised were sent for pathological examination. After wound dressing, bulky bandage (thick and compressive) was applied to the patients with 30 to 50° flexion contracture in the MCP joint before surgery (Figure 4), while short arm cast extending to the fingertip was applied to the patients with ≥50° flexion contracture (Figure 5). The bulky bandage and short arm cast were applied for five days. In the postoperative day 1, active and passive finger movements were allowed. In the patients we applied splint, the splint was wrapped with an elastic bandage and the patients were informed about this. The patients were taught to re-wrap the splint with an elastic bandage after opening the elastic bandage and performing the movements. All patients and patient relatives were informed about the instructions for frequent mobilization to preserve the full range of motion. In the early postoperative period, the importance of full flexion and extension was emphasized with analgesic support.
Postoperatively non-steroidal anti-inflammatory drugs and oral antibiotherapy (cefazolin tablet 1 g, b.i.d.) were initiated for one week. On day 5, bulky bandage and cast were removed and a smaller dressing was preferred to achieve full range of motion of the joint. Wound dressing was repeated every three days and terminated after suture removal. At week 3, sutures were removed and all patients were scheduled for follow-up at weeks 6 and 12 as the final visit (Figure 6). Our patients were evaluated in the outpatient clinic periodically at intervals of three and six months after the final visit.
Statistical Analysis
Statistical analysis was performed using the NCSS version 2007 and PASS version 2008 software (NCSS LLC, Kaysville, UT, USA). Descriptive data were expressed in median (min.-max.) or number and frequency. A p-value of <0.05 was considered statistically significant.
Results
Of the patients, 26 (89.7%) were males and three (10.3%) were females. The median age was 57 (range, 40 to 74) years. The median follow-up was 12 (range, 11 to 17) months. The mean Q-DASH score is 7.36 (0-22,8). A single finger was affected in 24 patients, while two fingers were affected in five patients. The fourth finger was the most affected finger, followed by little finger and middle finger. Nineteen patients had right hand involvement, while 10 patients had left hand involvement. Demographic and clinical characteristics of the patients are shown in Table 1.
Pathological examination result was compatible with fibromatosis. Maceration in the wound site was seen in two patients (p=0.08). No recurrence was observed. On physical examination, it was considered as the absence of re-contracture in the fingers in the early period. All patients were satisfied and very satisfied with the surgical treatment (Table 2).
Discussion
Dupuytren’s contracture is a progressive fibroproliferative condition, although its etiology remains unclear. Except for the early stage, surgical is usually the first-line treatment (22). Surgical treatment includes two types: fasciotomy and fasciectomy. The follow-up study showed a higher recurrence rate after 5 years in the percutaneous needle fasciotomy group (85% versus 21%) (23). During surgery, it is of utmost importance to release the contracture of the affected fascia and removal of the affected tissue. Several studies have suggested partial fasciectomy, which is a more widely used technique, in the treatment with varying recurrence and complication rates (24). The literature highlights the importance of proper incision, use of loupes, intraoperative hemostasis, postoperative elevation, analgesic use, and active/passive range of motion exercises to reduce complication and recurrence (25). In a study, there was no significant difference in the recurrence rates between Brunner incision and Z-plasty incision (26). In our study, a Brunner skin incision was made and a surgical loupe was used in all patients. In addition, all patients and relatives were strictly instructed about the range of motion exercises after surgery. Our patients did not need Z-plasty.
On the other hand, surgical treatment of Dupuytren’s contracture is associated with several complications including neuropraxia, digital artery and nerve injuries, infections, hematoma, and skin problems (27). In our study, maceration in the wound site was seen in two patients. In particular, skin infection due to hematoma and postoperative pain have been extensively reported in the literature. In the current study, we used a negative pressure drainage with a butterfly drain and biochemistry tube and no hematoma occurred in any of the patients. This system after surgery appears to be useful in the comparison of Penrose drain and/or mini-Redon drain which are routinely used in daily practice.
The most common risk factors of Dupuytren’s contracture include alcoholism, smoking, renal and liver impairment, diabetes mellitus, epilepsy, miyocardial infarction, and human immunodeficiency virus (28). In our study, smoking and diabetes mellitus were the most common risk factors.
There is no consensus on the use of splint after surgical treatment of Dupuytren’s contracture in the literature (29,30). In our study, bulky bandage (thick and compressive) was applied to the patients with 30 to 50° flexion contracture in the MCP joint before surgery, while short arm cast extending to the fingertip was applied to the patients with ≥50° flexion contracture. Both protocols were discontinued on postoperative Day 5. No additional splint was used in any of the patients. Based on our experience, we believe that early active and passive joint exercises and a thorough education for range of motion seem to be more successful than splint applications.
In the literature, recurrence and complications rates tend to increase in the long term after surgical treatment of Dupuytren’s contracture. In a study with a median follow-up of 3.45 years, Högemann et al. (31) reported a recurrence rate as 10.8% and complication rate as 13.8%. In another study, Moermans (32) followed the patients for a median of 2.9 years and reported a complication rate of 5.6%. In our study, the median follow-up was 12 months and no recurrence was observed. Maceration in the wound site was seen in only two patients.
Study Limitations
The small number of patients and the absence of a control group are the limitations of the study.
Conclusion
In conclusion, partial fasciectomy is a useful treatment method with low recurrence and complication rates and high patient satisfaction rates in patients with Dupuytren’s contracture. In addition, our surgical treatment seems to be a useful guide for long-term outcomes of patients with Dupuytren’s contracture.
