Marco Rizzo

Editor

Dupuytrens
Contracture
A Clinical Casebook

123

Dupuytrens Contracture

Marco Rizzo
Editor

Dupuytrens Contracture
A Clinical Casebook

Editor
Marco Rizzo, MD
Professor, Department of Orthopedic Surgery
Chair, Division of Hand Surgery
Mayo Clinic
Rochester, MN, USA

ISBN 978-3-319-23840-1
ISBN 978-3-319-23841-8
DOI 10.1007/978-3-319-23841-8

(eBook)

Library of Congress Control Number: 2016943432

Springer International Publishing Switzerland 2016
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Preface

Dupuytrens contracture is a disease of the fascia. This genetic

condition tends to affect persons of northern European ancestry,
with predominance in men. Most patients seek intervention when
their motion is compromised enough to affect function. There is
no known cure and recurrence is a constant concern.
Over the last 1015 years, multiple treatment options for
the management of Dupuytrens have come to light. Both
office-based and surgical management are available. We are
pleased to offer this textbook highlighting the current treatment options for this often challenging disease.
The format of this textbook is case-based. Through the use of
individual cases, the authors have highlighted the presentation,
indications, technical aspects/pearls, outcomes of treatment, and
conclude with a brief discussion. We hope that the book will be a
reliable quick reference for the various clinical presentations of
Dupuytrens contracture and their treatments. It is my hope that
this book will be an excellent resource for surgeons of all levels of
experience.
The table of contents highlights the spectrum of treatment
options for Dupuytrens disease. The initial chapters discuss nonoperative treatments ranging from orthosis/tissue mobilization,
corticosteroid injections, needle aponeurotomy and collagenase
injections. Various surgical interventions/techniques follow including: fasciotomy, fasciectomy, open palm, and dermatofasciectomy.
Treatment of recurrent disease and its special considerations are
also discussed. Chapters discussing the use of skin grafting, illustrating the special challenges associated with revision surgery, and
end of the line interventions such as arthrodesis and amputation

vi

Preface

are also included. Less common aspects of Dupuytrens are

reviewed as well. Case vignettes that address treatment and special
consideration in younger patients, the role/use of dynamic external
fixators in Dupuytrens care, correction of distal interphalangeal
(DIP) joint contractures and treatment of dorsal finger (Garrods)
nodes round out the chapters of the textbook.
There are many persons to thank for making this book a reality.
I am greatly indebted to all the authors for their generosity in providing the chapters. I sincerely appreciate the sacrifice from their
busy schedules to share their expertise and experience and to give
selflessly. I learned so much from all of them and know that the
reader will agree. I cannot thank you enough.
I also am most grateful to all the staff at Springer including
Patrick Carr and Kristopher Spring as well as Ms. Hemachandrane
Sarumathi and everyone as SPI Global. Their guidance through
this process from its inception through completion has helped
make this experience a joy rather than chore. I remain indebted to
their generosity.
Finally, I am eternally grateful to my family: Hope (my wife)
and Hope (my daughter), whom I love dearly. While I do not
acknowledge it enough, I sincerely appreciate their love, sacrifice
and continued support of my academic endeavors. They remain
the greatest inspiration and joy of my life. When you love someone, you see them the way God intended them to be. Fyodor
Dostoyevsky.
Rochester, MN, USA

Marco Rizzo, MD

The original version of this book was revised. An erratum to this book can be
found at DOI 10.1007/978-3-319-23841-8_20

Contents

Nonoperative Management of Finger

Flexion Contracture in Dupuytrens Disease:
Orthotic Intervention and Tissue
Mobilization Techniques .............................................
Juliana Larocerie-Salgado and John S.D. Davidson

Needle Aponeurotomy in the Management

of Dupuytrens Contracture .......................................
Clifford T. Pereira and Prosper Benhaim

13

Ultrasound Assisted Needle Aponeurotomy

in the Management of Dupuytrens Contracture .....
Vasileios I. Sakellariou and Marco Rizzo

39

Corticosteroid Injections and Needle

Aponeurotomy in the Management
of Dupuytrens Contracture .......................................
Paul Binhammer
Clostridial Collagenase Injections
in the Treatment of Dupuytrens Contracture ..........
Jan-Ragnar Haugstvedt

Minimally Invasive Partial Fasciectomy ...................

Sidney M. Jacoby and Justin D. Stull

Surgical Fasciotomy for Dupuytrens

Contracture...................................................................
Reid W. Draeger and Peter J. Stern

53

59

71

83
vii

viii

Contents

Surgical Fasciectomy for Dupuytrens

Contracture...................................................................
Nathan Douglass and Jeffrey Yao

97

Wide Awake Dupuytrens Fasciectomy:

A Pathoanatomical Approach..................................... 117
Quamar M.K. Bismil and M.S.K. Bismil

10

Surgical Open Palm (McCash) Technique ................ 137

Panayotis N. Soucacos, Zinon Kokkalis,
Aristides B. Zoubos, and Elizabeth O. Johnson

11

Treatment of Dupuytrens Contracture

with Dermofasciectomy ............................................... 147
Nathan A. Monaco, C. Liam Dwyer,
and John D. Lubahn

12

Surgical Fasciectomy for Recurrent Disease............. 161

Ombretta Spingardi and Mario Igor Rosello

13

Use of Dynamic External Fixator (Digit Widget)

in Dupuytrens Contracture ....................................... 175
Atanu Biswas and Anthony Smith

14

The Distal Interphalangeal Joint

in Dupuytrens Disease ................................................ 189
Michael A. Tonkin and Jonathan P.A. Bellity

15

Knuckle Pads (Garrods Nodules) of the Fingers:

Painful Dorsal Nodules on the PIP Joints
of the Fingers and Concomitant Recurrent
Dupuytrens Contracture ............................................ 203
Karsten Knobloch

16

Arthrodesis in Treatment of Dupuytren

Contracture................................................................... 213
Ali Izadpanah and Marco Rizzo

Contents

ix

17

Amputation in Management of Severe

Dupuytrens Contracture ............................................ 223
Ali Izadpanah and Marco Rizzo

18

Treatment of Dupuytrens Contracture

in the Young .................................................................. 231
Nathan A. Monaco, Scott W. Rogers,
and John D. Lubahn

19

Recurrent Dupuytren Contracture Treated

with Fasciectomy and Skin Grafting ......................... 253
Reid W. Draeger and Peter J. Stern

Erratum ................................................................................

E1

Index ...................................................................................... 267

Contributors

Jonathan P.A. Bellity, MD Department of Hand Surgery &

Peripheral Nerve Surgery, Royal North Shore Hospital, University
of Sydney, St. Leonards, NSW, Australia
Prosper Benhaim, MD Department of Orthopedics, Division of
Plastic Surgery, University of CaliforniaLos Angeles, Los
Angeles, CA, USA
Paul Binhammer, MD, FRCS(C) Hand Wrist and Microvascular
Surgery, Sunnybrook Health Sciences Centre, Toronto, ON,
Canada
M.S.K. Bismil, MBBS, MS, FRCSEd, DLM The World Wide
Awake Hand Surgery Group, Queen Anne Street Medical Centre,
London, UK
Quamar M.K. Bismil, MBChB, MRCS DipSEM MFSEM
DMSMed FRCSEd The World Wide Awake Hand Surgery
Group, Queen Anne Street Medical Centre, London, UK
Atanu Biswas, MD, MS Mayo Clinic Hospital, Phoenix, AZ,
USA
John S.D. Davidson, MD, FRCSC Division of Plastic Surgery,
Hotel Dieu Hospital, Kingston, ON, Canada
Nathan Douglass, MD Department of Orthopedic Surgery,
Stanford University Medical Center, Redwood City, CA, USA

xi

xii

Contributors

Reid W. Draeger, MD Department of Orthopaedics, School of

Medicine, University of North Carolina, Chapel Hill, NC, USA
C. Liam Dwyer, MD Department of Orthopaedic Surgery,
UPMC-Hamot, Erie, PA, USA
Jan-Ragnar Haugstvedt, MD, PhD Department of Orthopedics,
stfold Hospital Trust, Moss, Norway
Ali Izadpanah, MD, FRCSC Department of Plastic Surgery,
Centre Hospitalie de lUniversite de Montreal, Montreal, QC,
Canada
Sidney M. Jacoby, MD Department of Orthopaedic Surgery,
Thomas Jefferson University Hospital, The Philadelphia Hand
Center, PC, Philadelphia, PA, USA
Elizabeth O. Johnson, PhD Department of Anatomy, School of
Medicine, National & Kapodistrian University of Athens, Athens,
Greece
Karsten Knobloch, MD, PhD, FACS SportPraxis, Hannover,
Germany
Zinon Kokkalis, MD Department of Orthopaedics, School of
Medicine, University of Patras, Patras, Greece
Juliana Larocerie-Salgado, MSc, OT Reg (Ont) Department of
Hand Therapy, Roth-McFarlane Hand and Upper Limb Centre, St.
Josephs Health Care Centre, London, ON, Canada
John D. Lubahn, MD Department of Orthopaedic Surgery,
UPMC-Hamot, Erie, PA, USA
Nathan A. Monaco, MD Department of Orthopaedic Surgery,
UPMC-Hamot, Erie, PA, USA
Clifford T. Pereira, MD, FRCS (Eng) Division of Plastic
Surgery, Department of Orthopedics, University of CaliforniaLos
Angeles, Los Angeles, CA, USA
Marco Rizzo, MD Department of Orthopedic Surgery, Division
of Hand Surgery, Mayo Clinic, Rochester, MN, USA

Contributors

xiii

Scott W. Rogers, MD Department of Orthopaedic Surgery,

UPMC - Hamot, Erie, PA, USA
Mario Igor Rosello, MD Department of Hand Surgery, San
Paolo Hospital, Savona, Italy
Vasileios I. Sakellariou, MD, MSc, PhD Department of
Orthopedic Surgery, Attikon University Hospital, Athens, Greece
Anthony Smith, MD Mayo Clinic Hospital, Phoenix, AZ, USA
Panayotis N. Soucacos, MD, FACS The Panayotis N.
Soucacos Orthopaedic Research & Education Center, Attikon
University Hospital, National & Kapodistrian University of
Athens, Athens, Greece
Ombretta Spingardi, MD Department of Hand Surgery, San
Paolo Hospital, Savona, Italy
Peter J. Stern, MD Department of Orthopaedic Surgery, College
of Medicine, University of Cincinnati, Cincinnati, OH, USA
Justin D. Stull, BA Sidney Kimmel Medical College at Thomas
Jefferson University, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
Michael A. Tonkin, MD Department of Hand Surgery &
Peripheral Nerve Surgery, Royal North Shore Hospital, University
of Sydney, St. Leonards, NSW, Australia
Jeffrey Yao, MD Department of Orthopaedic Surgery, Stanford
University Medical Center, Redwood City, CA, USA
Aristides B. Zoubos, MD The Panayotis N. Soucacos
Orthopaedic Research & Education Center, Attikon University
Hospital, National & Kapodistrian University of Athens, Athens,
Greece

Chapter 1

Nonoperative Management of Finger

Flexion Contracture in Dupuytrens
Disease: Orthotic Intervention
and Tissue Mobilization Techniques
Juliana Larocerie-Salgado and John S.D. Davidson

Introduction
Not all patients with deformational Dupuytrens disease are necessarily suitable candidates for surgical or medical/enzymatic management. Not only may there be contraindications due to associated
medical comorbidities or the socioeconomic burdens of cost of
treatment and/or time off work, but there are some disease presentations in particular that lend themselves to unpredictable and frequently unsatisfactory outcomes. Nowhere is this more evident
than for disease associated with contractures of the proximal interphalangeal joints (PIPJ) of the little and ring fingers, where surgical intervention can sometimes result in recurrence or worsening of

J. Larocerie-Salgado, MSc, OT Reg (Ont)

Department of Hand Therapy, Roth-McFarlane Hand and Upper Limb Centre,
St. Josephs Health Care Centre,
268 Grosvenor Street, London, ON, Canada, N6H 3X5
e-mail: [email protected]
J.S.D. Davidson, MD, FRCSC ()
Division of Plastic Surgery, Hotel Dieu Hospital,
166 Brock St., Kingston, ON, Canada, K7L 5G2
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_1

J. Larocerie-Salgado and J.S.D. Davidson

the contracture, decreased range of motion, dystrophic pain, and

protracted rehabilitation [15].
At the same time, it is not as if there is nothing that can be
offered to these patients. We have determined that the application
of simple low load forces through the use of orthosis, stretching
exercises and massage, can in most situations help stabilize the
progression and in some cases improve the general state of the
deformity, particularly in early presentations of the disease [6].

Case Presentation
A 71-year-old right-handed man presented to the hand clinic with
a 4-year history of palpable nodules and progressive flexion contractures of the little finger bilaterally. He underwent an open fasciectomy in the left hand, with close to full correction of the flexion
deformity and excellent hand function, with complete recovery
after 8 weeks. To address the flexion contracture in the right little
finger, he instead elected to undergo a trial of nonoperative intervention, to avoid the protracted recovery he experienced with the
surgery on his other hand.
The intervention protocol comprised fabrication of an extension
orthosis, to be worn at nighttime, and the demonstration of tissue
mobilization techniques, including friction massage and gentle,
prolonged extension stretches to be carried out over the course of
the day [6]. Patients enrolled in this protocol were seen 0, 2, 4, and
6 months for review, adjustments, encouragement, and goniometry
measurements of joint deformation. Ultrasound imaging, including
elastography, was conducted before and after the intervention protocol in an attempt to objectively measure the dimensions and
consistency of the diseased fascia [7].

Diagnosis/Assessment
Physical examination of the right hand demonstrated that the diseased
fascia affected both the PIP and MCP joints of the little finger only,
resulting in moderate flexion contractures of both joints (Fig. 1.1).

Fig. 1.1 Finger extension at the time of initial assessment

1 Nonoperative Management of Finger Flexion

3

J. Larocerie-Salgado and J.S.D. Davidson

Measurements of active extension using a stainless steel finger

goniometer revealed a total active extension of 50, in which the
MCP joint showed 25 of active extension, the PIP joint, 25, and
the DIP joint, 0. In order to ensure that the flexor tendon and
Dupuytrens cord were slack, MCP extension was measured with
the PIP in a relaxed, slightly flexed position, and PIP joint extension with the MCP joint in flexion [8, 9].
Ultrasound imaging conducted before the initial assessment
showed a long nodule over the fifth ray, distal to the distal palmar
crease, measuring 28.6 4.0 5.6 mm (volume = 335.4 mm3).
Ultrasound elastography was also performed providing a characterization of the consistency of the diseased fascia being
measured.

Management
Following initial assessment, the patient was placed in a static
hand-based volar extension orthosis, with an adjustable strap
placed over involved PIP joint, as shown in Fig. 1.2. He was
instructed to wear the orthosis at nighttime (68 h a day) subjecting
the contracted tissues to prolonged application of low load forces,

Fig. 1.2 Sample of hand-based volar extension static orthosis

1 Nonoperative Management of Finger Flexion

while permitting unrestricted use of the hand during the day. The
patient was also instructed to perform stretching exercises of the
MCP and PIP joints into extension within a pain-free range and
friction massage to contracted tissue (i.e., nodules and cords)
throughout the course of the day.
At his 2-month visit, the orthosis was adjusted to increase extension and create a minimal space between the orthosis and the volar
aspect of the PIP joint. The MCP joint was placed in as much
extension as possible, and a wider strap was placed over this joint.
The intent of these measures was to provide for the application of
progressive low load extension forces over the involved joints during the course of therapy. Stretching and massage exercises were
reviewed and emphasized.
At the time of the 4- and 6-month visit, the orthosis was further
adjusted to accommodate for any improvement in extension.

Outcome
The patient had an improvement of approximately 15 in total
active extension following the 6-month intervention protocol. At
that time, his PIPJ extended to 15, and the MCP joint to 20
(Table 1.1; Fig. 1.3).
Ultrasound imaging at the completion of the intervention protocol showed a reduction in the size of the nodule, which by then
measured 9.7 4.1 5.6 mm representing a greater than 60 %
decrease in measurable volume of the disease (116.6 mm3).

Table 1.1 MCP and PIP joints extension at the time of the rst and last clinic
visits
Pre-intervention
Post-intervention
MCP ext
25
20
PIP ext

25

DIP ext

Nodule volume

15
0
3

335.4 mm

116.6 mm3

Fig. 1.3 Finger extension, pre- and post-intervention (lateral view and tabletop test)

6
J. Larocerie-Salgado and J.S.D. Davidson

1 Nonoperative Management of Finger Flexion

Changes in the measurement parameters of the ultrasound

elastography suggested a compositional softening of the diseased
fascia over this time, as noted by decreased red coloration within
the demarcated borders of the diseased fascia (Fig. 1.4).

Clinical Pearls/Pitfalls
Outcomes from surgical management of flexion contractures in
Dupuytrens disease, and of the PIPJ in the little finger in particular, are at best inconsistent [1, 4]. Once considered an absolute
indication for surgical intervention, PIPJ contractures are
approached with surgical foreboding with suboptimal correction or
stabilization of the progression of the disease often being the modest therapeutic goal [2, 810]. The experience at our center has
been no different and consequently we have considered alternative
approaches to the management of contractures particularly in the
early stages of presentation. We have determined that low load
force application techniques though conventional orthosis and
stretching exercises in patients with mild to moderate flexion contractures, particularly of the PIPJ, can obviate or at least delay
surgical intervention [6].
Our experience challenges a long held dogma that massage,
stretching, and splinting are of little or no benefit in the primary
management of Dupuytrens disease. It has even been argued that
the application of tension load forces to Dupuytrens related contractures may in fact be counterproductive and potentially accelerate the progression of deformity [11]. However, this has always
seemed counterintuitive given the demonstrated benefit of static
orthosis and the application of longitudinal load forces on collagen
remodeling in traumatic scars not to mention their important role
in rehabilitation of patients undergoing surgical treatment of
Dupuytrens. Notwithstanding our treatment protocol of nighttime
orthosis and tissue mobilization, is based on an established premise
of tissue remodeling shown to be related to the exposure to a maximum tolerable, prolonged low load torque applied at its end range
[12, 13].

Fig. 1.4 Pre- and post-treatment sagittal images of focal fibromatosis superficial to the fifth MCP joint. On the elastography images
(colored), red = hard tissue, blue = soft tissue

8
J. Larocerie-Salgado and J.S.D. Davidson

1 Nonoperative Management of Finger Flexion

The use of external physical forces to address contracted fascia

is not an original concept in the management of Dupuytrens disease. Elliot [14] noted that as early as 1826, Charles Boyer, a not
impartial contemporary of Dupuytren had outlined in his important Traite des Maladies Chirurgicales that one can perhaps stop
the progression of the disease in its early stages by placing on the
dorsum of the finger a small splint fixed with a bandage, and applying lotion and relaxants to the palm of the hand.
More recently the principle of primary static stretch in
Dupuytrens disease has been applied, with the aid of fairly elaborate skeletal traction devices, to people with advanced disease as a
precursor to surgical correction to reduce preoperative deformity,
especially at the PIPJ, stretching the skin to avert the need for skin
grafting or flaps, and gradually elongate the neurovascular structures [8, 1518]. There have also been reports of treatment of
remaining flexion contractures in the PIPJ following collagenase
injection with the continuous use of orthosis [19, 20].
As we have gained experience with this modality, not only have
we noted improvements in the degree of joint deformity and range
of motion, as demonstrated in this case presentation, we have also
noted changes in the quantitative as well as qualitative nature of the
disease in the fascia. Although some might argue that our observations may be due to stretching of other underlying contracted tissues, we have specifically seen, using ultrasound imaging
modalities, measurable volume loss and softening of the
Dupuytrens disease in many patients. In a recent series, we
observed an average decrease of over 30 % in the volume of disease in the fascia (unpublished data).
Patients have frequently commented that the fascia seems softer
and more compliant while undergoing treatment. Additionally,
Christie and colleagues [21] demonstrated an increase in ROM and
decrease in the visual appearance of fibrous adhesions associated
with Dupuytrens disease with the use of cross-frictional massage.
While difficult to objectively demonstrate changes in the consistency of Dupuytrens fascia, there is anatomical data from light
microscopy as well as biochemical studies corroborating changes
in clinical consistency of palpable disease following the application of static stretching with skeletal traction devices [8, 1518].

10

J. Larocerie-Salgado and J.S.D. Davidson

Instead we have used Ultrasound Elastography to monitor changes

in the mechanical consistency of the diseased fascia. It is a medical
imaging modality that maps the elastic properties of soft tissue.
The main premise is to distinguish whether tissue is hard or soft to
give diagnostic information about the presence or status of disease.
Using Elastography we have consistently observed changes in the
fascia over the course of the therapy to suggest favorable changes
in consistency of the disease.
As is the case for surgery, administering nonsurgical modalities
also relies on careful patient selection. This relates to patient motivation and adherence, not to mention a clear understanding of the
therapeutic goals of the intervention. Such is the case for prescribing a protracted rehabilitation therapy protocol involving frequent
and repetitive massage and stretching of the digits and the consistent use of an orthosis to be worn at night. As well the success of
the treatment would appear to depend on the extent and pattern of
disease or deformity. It seems that our protocol is most effective
for patients with mild to moderate degrees of contracture isolated
to one or two fingers, and who simply wish to maintain their current level of function without having to submit to surgery or other
medical interventions. The most consistent results in our population were seen in patients with isolated PIPJ flexion contracture
that could fully adhere to the orthosis regimen. Those with more
diffuse presentation of Dupuytrens disease or having difficulty
adhering to the proposed treatment showed minimal or no
improvement [6].
In summary, mild to moderate flexion contractures associated
with Dupuytrens disease are responsive to the application of prolonged, low load forces. The use of a nighttime extension orthosis
combined with intermittent stretching exercises and massage to
contracted tissue can delay the progression and frequently improve
the degree and consistency of flexion contractures primarily of the
PIPJ. This protocol can be considered an effective alternative management strategy, at least in the short term, for those who may not
want or be suitable for other types of interventions surgical or
otherwise. The time course for the use of an orthosis protocol,
patient selection, combination with adjuvant therapies, and management of treatment failures still remain to be determined.

1 Nonoperative Management of Finger Flexion

11

Acknowledgements The authors would like to thank Dr. Paul Fenton, MD

Radiologist, and Kim Fletcher, US technician, for their invaluable contribution
to this project.

References
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Dupuytrens disease: a 20-year review of the English literature. Eplasty.
2010;10:e15.
2. Eaton C. Evidence-based medicine: Dupuytren contracture. Plast Reconstr
Surg. 2014;133:124151.
3. Townley WA, Baker R, Sheppard N, Grobbelaar AO. Dupuytrens
unfolded. BMJ. 2006;332(7538):397400.
4. Weinzneig N, Culver JE, Fleeger EJ. Severe contractures of the PIP joint
in Dupuytrens disease: combined fasciectomy with capsuloligamentous
release versus fasciectomy alone. Plast Reconstr Surg. 1996;97:5606.
5. Worrell M. Dupuytrens disease. Orthopedics. 2012;35(1):5260.
6. Larocerie-Salgado J, Davidson J. Nonoperative treatment of PIPJ flexion
contractures associated with Dupuytren's disease. J Hand Surg Eur Vol.
2012;37(8):7227.
7. Dewall RJ. Ultrasound elastography: principles, techniques, and clinical
applications. Crit Rev Biomed Eng. 2013;41(1):119.
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of life before and after fasciectomy for Dupuytren contracture. J Hand
Surg Am. 2014;39(7):133343.
9. Hurst L. Dupuytrens contracture. In: Wolfe SW, Hotchkiss RN, Pederson
WC, Kozin SH, editors. Greens operative hand surgery, vol 5, cap 5.
Philadelphia: Elsevier; 2011. p. 14158.
10. Agee JM, Goss BC. The use of skeletal extension torque in reversing
Dupuytren contractures of the proximal interphalangeal joint. J Hand Surg.
2012;37A:146774.
11. Bisson MA, Mudera V, McGrouther DA, Grobbelaar AO. The contractile
properties and responses to tensional loading of Dupuytrens diseasederived fibroblasts are altered: a cause of the contracture? Plast Reconstr
Surg. 2004;113:61121.
12. Flowers KR, LaStayo P. Effect of total end range time on improving passive range of motion. J Hand Ther. 1994;7:1507.
13. Glasglow C, Wilton J, Tooth J. Optimal daily total end range time for
contracture: resolution in hand splinting. J Hand Ther. 2003;16:20718.
14. Elliot D. The early history of contracture of the palmar fascia: Part 1: the
origin of the disease: the curse of the MacCrimmons: the hand of benediction: Clines contracture. J Hand Surg Br. 1988;13:24653.

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15. Bailey AJ, Tarlton JF, Van der Stappen J, Sims TJ, Messina A. The continuous elongation technique for severe Dupuytrens disease. A biochemical mechanism. J Hand Surg Br. 1994;19:5227.
16. Brandes G, Messina A, Reale E. The palmar fascia after treatment by the
continuous extension technique for Dupuytrens contracture. J Hand Surg
Br. 1994;19:52833.
17. Messina A, Messina J. The continuous elongation treatment by the TEC
device for severe Dupuytrens contracture of the fingers. Plast Reconstr
Surg. 1993;92:8490.
18. Rajesh KR, Rex C, Mehdi H, et al. Severe Dupuytrens contracture of the
proximal interphalangeal joint: treatment by two-stage technique. J Hand
Surg Br. 2000;25(B):4424.
19. Skirven TM, Bachoura A, Jacoby SM, et al. The effect of a therapy protocol for increasing correction of severely contracted proximal interphalangeal joints caused by Dupuytren Disease and treated with collagenase
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20. Sweet S, Blackmore S. Surgical and therapy update on the management of
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a prospective study. Man Ther. 2012;17:47982.

Chapter 2

Needle Aponeurotomy
in the Management of Dupuytrens
Contracture
Clifford T. Pereira and Prosper Benhaim

Introduction
Dupuytrens contractures (DC) is a benign fibroproliferative disorder
of the fascia of the hand and fingers, resulting in progressive thickening and shortening of the palmar fascia. This results in the formation of cords, flexion deformities of the digits, and ultimately
loss of range of motion, especially loss of functional finger extension [1]. The aim of surgical intervention involves the preservation
and improvement of hand function by either division of (fasciotomy)
or removal of (fasciectomy) the diseased tissue. Standard treatment

C.T. Pereira, MD, FRCS (Eng) P. Benhaim, MD ()

Department of Orthopedics Surgery and Division of Plastic Surgery,
University of CaliforniaLos Angeles, Box 957326,
10945 LeConte Avenue, Room 33-55 PVUB,
Los Angeles, CA 90095-7326, USA
e-mail: [email protected]; [email protected]

Springer International Publishing Switzerland 2016

M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_2

13

14

C.T. Pereira and P. Benhaim

indications include metacarpophalangeal (MCP) joint contracture

of greater than 30 and/or any proximal interphalangeal (PIP) joint
contracture. Current treatment options for DC include open fasciectomy (OF), limited fasciectomy (LF), needle aponeurotomy
(NA), and Clostridial collagenase injections. Percutaneous needle
fasciotomy or needle aponeurotomy (NA) is a minimally invasive
technique that uses a small hypodermic needle as a percutaneous
scalpel blade to perforate, weaken, and/or divide the cord to the
point where finger manipulation can result in rupture of the cord
and improvement in finger extension. This chapter focuses on the
use of NA, its indications, advantages, disadvantages, technical
pearls, and literature review. A detailed discussion on other treatment options including open fasciectomy or collagenase injections
is beyond the scope of this chapter and will be presented in other
chapters. Pertinent comparisons between NA and other treatment
options, however, will be discussed.

Case Presentation
History
The patient is a 72-year-old right hand dominant retired aerospace
engineer who presented with a 10-year history of bilateral hand
Dupuytrens contractures. The right side was worse than the left,
with progressive worsening of the contractures over the previous
year. The contractures had advanced to a point where they interfered with his ability to play tennis and a number of other activities
of daily living. The patient had had no prior treatment for this on
either hand. He had no numbness or tingling. He did not remember
any specific inciting event or trauma. His family history was negative for DC. His ancestry included French and Belgian lineage. He
denied any involvement of the soles of his feet (Ledderhose disease) or shaft of his penis (Peyronies disease). He was not diabetic
or epileptic. He denied abuse of tobacco or recreational drugs, and
consumed alcohol only socially.

Needle Aponeurotomy in the Management

15

Examination
The right hand had evidence of Dupuytrens disease, including a
distal first web space commissural cord and pretendinous cords over
the first, second, third, fourth, and fifth metacarpals. The most predominant of these was the fifth metacarpal pretendinous cord. There
was no natatory cord formation in the web spaces. The right thumb
had a radial lateral cord at the radial border of the proximal phalanx,
with a Dupuytrens nodule at the A1 pulley level. The ring finger
had an ulnar lateral cord at the ulnar border of the proximal phalanx.
The small finger had a radial lateral cord at the radial border of the
proximal/middle phalanges and a central cord at the proximal/middle phalanx level. The small finger also had a Dupuytrens nodule
at the A1 pulley level and at the proximal phalanx level. There were
no dorsal proximal interphalangeal joint Garrods pads noted.
Contractures in the right hand included 15 at the middle finger MP
joint, 35 at the ring finger MP joint, 85 at the small finger MP
joint, 60 at the small finger PIP joint, and 30 at the small finger
DIP joint. The other finger joints of the right hand had full extension
and all joints had full flexion. Sensation was intact in all digits. No
triggering of any of the digits was noted. All extensor and flexor
tendons were intact, without any evidence for extensor tendon subluxation or sagittal band rupture (Fig. 2.1).
The left hand had evidence of Dupuytrens disease, including a
distal first web space contracture cord and pretendinous cords over
the first, second, third, fourth, and fifth metacarpals. The fifth
metacarpal pretendinous cord was the most prominent cord. There
was no natatory cord formation in the web spaces. The small finger
had a central cord at the proximal phalanx level and nodule formation over the A1 pulley and proximal phalanx in the small finger.
There were no Garrods pads noted. Contractures in the left hand
included 15 at the ring finger MP joint and 50 at the small finger
MP joint. The other finger joints of the left hand had full extension
and all joints had full flexion. Sensation was intact in all digits. No
triggering of any of the digits was noted. All extensor and flexor
tendons were intact, without any evidence for extensor tendon
subluxation or sagittal band rupture.

Fig. 2.1 Dupuytrens contracture of right handbefore needle aponeurotomy, (a) anterior-posterior view, (b) oblique view, (c) lateral
view, (d) composite fist

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C.T. Pereira and P. Benhaim

Needle Aponeurotomy in the Management

17

Diagnosis and Assessment

The patient had bilateral hand Dupuytrens disease involving both
MP and PIP joints, right side worse than left. Treatment options
offered to the patient included conservative management with
splints and hand therapy vs. needle aponeurotomy vs. a combination of needle aponeurotomy and limited fasciectomy vs. open
palmar fasciectomy vs. collagenase injection. The relative advantages, disadvantages, potential complications, and alternatives of
each of these approaches were discussed with the patient in detail.
The patient carefully considered these options and elected to
undergo needle aponeurotomy (NA). Specific to NA, in addition to
general procedure-related risks, the patient was explained that it is
a blind percutaneous procedure that carries a risk of injury to
nerves, vessels, tendons, and a higher risk of recurrence when compared to conventional Dupuytrens contracture release surgery. We
also explained the risk of skin tears that may occur as a result of
the procedure, which would necessitate local wound care postoperatively. Such skin tears can take 14 weeks to heal fully, depending on their size and location. Finally, the patient also understood
that no surgical approach, whether conventional or needle aponeurotomy, could guarantee full range of motion following surgery,
either immediately or in the long run.
Management and Outcome
The patient underwent NA initially on the right hand (Fig. 2.2).
The fifth metacarpal pretendinous cord was approached first at the
proximal portion of the palm and extended all the way to the MP
flexion crease of the small finger. Caution was taken to remain
central on the cord in order to avoid injury to the nearby neurovascular bundles. In addition, care was taken to avoid going too deeply
with the needle in order to avoid injury to the underlying flexor
tendons and neurovascular structures. With each pass of the needle,
there was progressive release of the Dupuytrens contracture in the
small finger, especially at the MP joint. A nearly identical procedure was repeated for the second, third, and fourth metacarpal

Fig. 2.2 Dupuytrens contracture of right handimmediately after needle aponeurotomy, (a) anterior-posterior view, (b) lateral view,
(c) composite fist

18
C.T. Pereira and P. Benhaim

Needle Aponeurotomy in the Management

19

pretendinous cords, as well as for the first metacarpal pretendinous

cord extending to the thumb. The first web space contracture cords
were also released in this fashion. The Dupuytrens contracture in
the small finger was next addressed at the proximal and middle
phalanx level using the same needle aponeurotomy technique, this
time addressing the central cord and radial lateral cord at the proximal and middle phalanx level. As in the palm, great care was taken
to avoid injury to the neurovascular structures and to the underlying flexor tendons. Marked improvement was achieved in extension of both the PIP and DIP joints with this technique. In a similar
fashion, the ring finger Dupuytrens contracture release was performed at the proximal phalanx level by releasing the ulnar lateral
cord in the ring finger at the proximal phalanx level, at multiple
locations. The right thumb radial lateral cord at the radial border of
the proximal phalanx was released in a similar fashion at the thumb
level, with care being taken to avoid injury to the radial digital
nerve and artery. The needle aponeurotomy technique was able to
achieve full extension in the thumb, index finger, middle finger,
and ring finger. However, the small finger PIP joint still had a
residual contracture secondary to an independent PIP joint volar
capsular contracture. This was addressed at the end of the procedure, by infiltrating all the fingers with 0.5 % Marcaine to achieve
a digital block in all digits. The fingers were manipulated with
forceful extension to achieve completion rupture of the cords,
thereby further improving extension and even hyperextension of
the MP joints. In addition, we specifically performed a PIP joint
closed capsulotomy to increase the extension of the small finger
PIP joint. This was successful in achieving full extension of the PIP
joint in the small finger. The procedure did produce several skin
tears, including a skin tear at the distal palmar crease over the fifth
metacarpal, a skin tear at the MP flexion crease of the small finger,
and a skin tear at the PIP flexion crease of the small finger. All
three tears were less than 1 cm in diameter and did not involve
exposure of the flexor tendon sheath or neurovascular bundles. The
remaining discontinuous segments of the pretendinous cords and
associated nodules were locally infiltrated with a total of 50 mg of
triamcinolone to minimize the risk of a flare reaction postoperatively and to minimize the risk of recurrence. The skin tears were

20

C.T. Pereira and P. Benhaim

dressed with antibiotic ointment and a sterile soft dressing. The

patient commenced supervised hand therapy on postoperative day
1, including use of a nighttime extension splint to maintain the
fingers at full extension at night for 4 months following the procedure. At his 2-month postoperative visit, the patients right hand
wounds had fully healed with no residual open wounds. All extensor and flexor tendons were intact. Light touch sensation was normal in all digits. All fingers of the right hand had full range of
motion, including full active and passive extension of the digits
(Fig. 2.3). The patient subsequently returned in 5 months and had
NA performed on his left hand, which was also successfully corrected. At his 2-year follow-up, his right hand still had full flexion
and extension with no signs of recurrence (Fig. 2.4).

Technique
Preoperative preparation: Needle aponeurotomy can be performed
in either an office setting or an outpatient surgery center, the choice
of which may be dictated by patient preference, surgeon preference, and/or insurance coverage eligibility issues. Some insurance
companies will require that this type of procedure be performed in
a Medicare-approved procedure room, which may or may not be
available in every surgeons office. Some surgeons prefer the formal setting of an outpatient surgery center with better lighting and
monitoring by a nurse. The procedure is performed under local
anesthesia, without intravenous sedation, regional block, or monitored anesthesia care. Patients are asked to stop anticoagulation
before the procedure, if possible. However, anticoagulation is not
considered an absolute contraindication to the procedure. The
patient is placed recumbent to minimize possible vasovagal
responses. The technique is explained to the patient in detail,
including the importance of reporting paresthesias that may
develop during the procedure and of avoiding sudden movements.
Short excursion fingertip flexion/extension is explained to the
patient and demonstrated.

Needle Aponeurotomy in the Management

Fig. 2.3 Dupuytrens contracture of right hand2 months after needle aponeurotomy, (a) anterior-posterior view, (b) oblique view, (c)
lateral view, (d) composite fist

2
21

Fig. 2.4 Dupuytrens contracture of right hand2 years after needle aponeurotomy, (a) anterior-posterior view, (b) lateral view, (c)
composite fist

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C.T. Pereira and P. Benhaim

Needle Aponeurotomy in the Management

23

Local anesthetic field block: Sensory end organs of the skin are
located in the deep dermis, but the subdermal fat, palmar aponeurosis, and cords are insensate. Digital nerves are sensitive to pressure or direct contact; joint capsules and flexor tendon sheaths are
innervated as well [2]. Thus, vital structures are sensate and cords
are not, allowing NA to be performed safely under local anesthesia.
This also makes it imperative that just the skin overlying the cords
is blocked by the local anesthetic injected, performing a superficial
intradermal anesthetic injection only and carefully avoiding deeper
injection that may block the digital nerves. It is critical that the
subcutaneous tissues and underlying nerves are not blocked, since
that would eliminate the ability of the nerves to respond to direct
contact. As the NA procedure is performed, since it is a blind procedure that does not allow direct visualization of the digital nerves,
the primary method by which one avoids injury to the underlying
nerves is to rely on a Tinels type of response from the nerve if the
needle comes into contact or even just close proximity to the nerve.
Report by the fully awake patient of Tinels-like paresthesias
would indicate that the needle is too close to the nerve, allowing
the surgeon to redirect the needle to another location and avoid
injury to the digital nerves. This is especially important in high-risk
areas such as spiral cords at the base of fingers, where digital
nerves can be displaced from their normal anatomical location.
To achieve the local dermal block, the upper extremity is
prepped and draped in the usual sterile fashion. Under standard
sterile and antiseptic conditions, the selected area is infiltrated with
1 % lidocaine (with 1:100,000 epinephrine) in a 3 ml syringe with
a luer lock and a short 30-gauge needle in order to achieve the local
dermal block. Infiltration pain can be reduced by buffering the
local anesthetic with sodium bicarbonate. For precise surface anesthesia, 0.050.1 ml intradermal injections are infiltrated at multiple
focal positions along the entire length of the cords targeted for
release (Fig. 2.5). Despite careful technique, anesthetic diffusion
can cause partial digital nerve block. Loss of light touch denoting
complete digital nerve block may be an indication that the procedure may need to be aborted until such time that light touch returns.
To minimize this possibility, some surgeons will advocate a progressive sequential local anesthetic injection approach, starting distally,
releasing a portion of the cords distally, and then subsequent more

Fig. 2.5 (a) Local anesthetic injection technique demonstrating intradermal injection. (b) Blanched skin demonstrating area injected
with 1 % lidocaine with 1:100,000 epinephrine

24
C.T. Pereira and P. Benhaim

Needle Aponeurotomy in the Management

25

proximal local anesthetic injection in multiple stages. With this

modification, the Tinels sign response proximally can be preserved, even if the distal portion of the nerve is inadvertently
blocked. No tourniquet is required for the procedure.
Technique: The needle aponeurotomy is performed with a hypodermic needle, with different surgeons preferring different gauged
needles ranging in size from 25-gauge to 18 gauge. The smaller-25
gauge needle will typically be employed using a combination of
perforation and sweeping maneuvers designed to weaken the
cords, while a larger 18-gauge needle is more typically utilized as
a percutaneous fasciotome in a windshield wiper back and forth
fashion with the goal to create a transverse percutaneous fasciotomy. Treatment portals are best planned in areas of maximal bowstringing of cords, especially if the cords become more taut on joint
extension [3]. Nodules are firm regardless of joint position and
should be avoided unless directly contributing to the contracture
and only if proven to be so after proximal and/or distal non-nodular
cord segments are released [3]. Placing portals over flexor creases
is not preferred due to the proximity of the flexor sheath and the
increased likelihood of skin tears, although release at creases is
sometimes necessary for successful release. Cords are tensioned,
palpated, and pinched between the fingertips of the surgeons nondominant hand to stabilize the cord. Gentle skin traction is placed
over the cords to accentuate the bowstringing of the cord, thus
pulling the cord away from deeper structures. Extreme extension
of the finger is avoided and the patient asked to relax the fingers to
keep the flexor tendons slack, reducing the risk of inadvertent tendon injury. This is especially important at the volar aspect of the
MP joint, where hyperextension of the MP joint brings the flexor
tendons in close approximation to the overlying skin in the region
of the distal palmar crease, placing the flexor tendons at greater
risk for injury or even complete transection [3].
Fasciotomy portals are usually made equal to the cord width.
Once the dermis is penetrated, the needle is oriented tangentially to
create a plane between the dermis and cord. The needle tip is then
reoriented perpendicular to the cords longitudinal axis, with the
bevel transverse to the cord. A repeated side-to-side sweeping
movement is made with the needle tip to graze or scratch the cord.

26

C.T. Pereira and P. Benhaim

If using a smaller 25-gauge needle, multiple perforations of the

cord are also used to weaken the cord for subsequent manipulation/
cord rupture at the end of the procedure. A constant proprioceptive
feedback is obtained during the cord division. This is in the form
of a gristly and firm feel with a concomitant scraping sound as the
needle scratches through the cord. The needle is changed frequently to maintain sharpness. The end point of the fasciotomy at
each point is reached when firm feedback at the needle tip stops,
and further gentle probing yields a soft feel. A trampoline fingertip bouncing can also be used to assess the adequacy of the cord
rupture [3].
Some surgeons prefer release that commences proximally and
progresses distally to the MP and/or PIP joints, as required. Others
prefer a distal-to-proximal technique. Portals are placed an average
of 5 mm apart. Care is taken to remain central on the cord in order
to avoid injury to the adjacent neurovascular bundles. Care is also
taken to avoid going too deeply in order to avoid injury to the
underlying flexor tendons and neurovascular structures, including
superficial palmar arch and proximal branches of the median and/
or ulnar nerves as they exit from the carpal and ulnar tunnels,
respectively. Fingertip sensation to light touch stimulation is
repeatedly checked throughout the procedure. Each pass with the
needle is made deliberately, allowing the patient enough time to
react. The slicing or perforating motion of the needle is stopped
and the needle redirected immediately if the patient reports electric
current sensation or the equivalent of a Tinels sign down the
treated finger. Tendon proximity is checked regularly by leaving
the needle in place and watching for the presence or absence of
needle motion with short gentle active tendon excursion.
Areas of pitting are best avoided, since portal placement can
transect a dimple sinus, with higher risk for multiple skin tears in
close proximity. The skin at the depths of the pits is also likely not
well anesthetized, causing pain. Spiral cords usually occur at the
junction of the palm and the base of the finger; caution must be
exercised in these areas since they can displace the neurovascular
bundle superficially and centrally. Since the neurovascular bundles
are embedded in subcutaneous fat, the presence of fat between
the dermis and the cord should alert the surgeon to a displaced

Needle Aponeurotomy in the Management

27

neurovascular bundle. These areas should be avoided, if possible.

Eaton describes the use of Doppler or ultrasound, especially in
areas of a suspected spiral cord, to identify the neurovascular
bundle [3]. The senior author does not generally use this in his
practice, relying instead on Tinels sign feedback. Finally, sometimes release of a radial or ulnar lateral cord does not result in full
extension of the proximal interphalangeal joint (PIPJ). This may be
secondary to a nonpalpable central extension of the cord. An additional release centrally, just proximal to the PIPJ flexion crease,
usually completes the correction, although release in this area can
carry higher risk for tendon injury since the central cord will often
blend into the A3 pulley in this area. Some patients will also have
independent PIP joint volar capsular contractures or relative shortening/tightening of the flexor tendon sheath specifically at the A3
pulley level, which may need to be addressed separately during the
manipulation portion of the procedure.
Final manipulation: Once the cords have been adequately weakened/divided at multiple sites, the patient is tested in a formal
fashion to confirm that all flexor tendons (individual testing of the
flexor digitorum superficialis and profundus tendons going to each
digit) and all individual digital nerves remain intact. Once so verified, the treated sites are injected with local anesthetic to achieve
combined palmar and digital blocks that will allow forceful manipulation of the fingers without significant pain. Our preference is to
use 0.5 % bupivacaine without epinephrine, while others prefer 1 %
lidocaine instead. After good digital block and palmar anesthesia
has been established, the fingers are passively stretched to achieve
completion rupture of the cords and to break any residual tethering.
The wrist should be flexed as the finger is being extended to minimize risk of tendon rupture [3]. Manipulation of the digits under
local anesthesia also allows release of a tight flexor tendon sheath
and/or PIP joint closed volar capsulotomy, as needed. Intraarticular local anesthetic injection of the PIP and MCP joints has
been employed by some prior to the final manipulation, after all
needle manipulations are completed. This enables the patient to
tolerate a greater amount of force during the finger extension process to facilitate residual cord rupture, and enhance the results.

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C.T. Pereira and P. Benhaim

Post-procedure: Once all cords have been released, nodules and

segmental areas of the released cords can be injected with depot
corticosteroid such as triamcinolone acetate 10 mg/cc or betamethasone 6 mg/cc to minimize the risk of recurrence and to minimize the risk of a Dupuytrens flare reaction postoperatively. Skin
tears are dressed with ample antibiotic ointment to prevent desiccation of underlying structures, nonadherent gauze (e.g., Xeroform
gauze), and a light gauze bandage. Coverage with antibiotic ointment to prevent tissue desiccation is especially critical if there is
any exposed tendon noted at the base of a skin tear. The patient is
instructed to change the dressings after 48 h, and daily thereafter.
Depending on the severity of the initial contracture, the hand may
be placed in a volar short arm splint extending to the finger tips,
with the involved digits placed at full extension. The patient is
referred to hand therapy for active flexion and extension range of
motion exercises and gentle passive extension stretching. Heavy
grasping is deferred until the wounds have healed completely.
Nighttime extension splinting is continued for 616 weeks.

Literature Review
Dupuytrens contracture was first described by a Swiss physicianFelix Plater, in his book titled Observationum in Hominis
Affectibus in 1614. Sir Henry Cline, in 1777, recognized the
involvement of the palmar fascia and described the first treatment
of this disease, which consisted of division of the pathologic cords,
although he incorrectly conceptualized the underlying cause of the
palmar fascia contracture as secondary to trauma to the underlying
tendons [4]. Later in 1831, a French military surgeonBaron
Guillaume Dupuytrendescribed and operated on the palmar
fibrosis that now takes his name [5]. The first closed percutaneous
fasciotomy was performed by Cooper in 1822. The technique now
bears his nameCoopers fasciotomy [3]. With the advent of anesthesia, Goyrand [6] introduced limited fasciectomy (LF); and
Fergusson [7] introduced open fasciectomy (OF). Thereafter, surgery became more aggressive until the 1950s, when total palmar
fasciectomy was popularized by McIndoe and Beare [8]. However,

Needle Aponeurotomy in the Management

29

the high complication rates associated with this technique forced

surgeons to return to LFs. J. Vernon Luck reestablished the concept
of a percutaneous fasciotomy approach in 1959 with a specially
designed percutaneous fasciotome (Luck fasciotome). It was not
until 1972, however, that French rheumatologists Lermusiaux and
Debeyre [9] reintroduced and repopularized the Cooper fasciotomy, but performed it using 25-gauge needles under local anesthesia. They called it percutaneous needle fasciotomy (PNF). The
technique is now also called Needle Aponeurotomy (NA).
Currently, the four requirements to perform NA in Dupuytrens
disease as described by Eaton [3] include (1) a contracture, secondary to a (2) palpable cord that lies beneath (3) redundant skin,
in a (4) cooperative patient. It should not be performed in the
absence of a palpable cord or overlying scarred tissue/skin,
although prior surgery or scar tissue is not an absolute contraindication if there is still an appropriate and identifiable cord that
can be safely released by NA. Needle aponeurotomy should not
be performed on contractures not due to Dupuytrens disease,
such as postsurgical scarring, PIP joint volar capsular contractures, scleroderma-related contracture, or burn scar contractures.
It should also be performed with particular precaution in PIP joint
contractures when there is a large nodule or cord between the
PIPJ flexion crease and the proximal digital crease [10]. Finally,
NA should never be performed in infiltrative disease, Dupuytrens
diathesis, or constitutionally treatment-resistant Dupuytrens,
since this will likely result in rapid recurrence [11]. Young age is
a relative contraindication for NA, due to the high likelihood of
recurrence and a relatively more aggressive disease presentation
in the patient who presents at a younger age.
Several groups of surgeons and rheumatologists have reported
the French experience with NA [1215]. In 1993, Badois et al.
performed NA in 138 patients and found that 81 % had good or
excellent primary results with a Tubiana Class I or II Dupuytrens
contracture. In the group of patients with Tubiana stage IV disease, 48 % had good results. There were no major complications,
although there was skin tear in 16 %, digital dysesthesia in 2 %,
and infection in 2 % [12]. Bleton et al. documented the results of
a prospective study of NA on 59 patients [13]. Sixty-one percent

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C.T. Pereira and P. Benhaim

of patients had a good result, with an improvement of more than

50 %. Lermusiaux et al. reported the results of a large experience
with NA, with an improvement of over 70 % in 81 % of hands. The
complication rate was 0.05 % for both tendon and digital nerve
injuries [14]. Foucher et al. reported an average 79 % gain in
extension for the MCP joints and 65 % for the PIP joints in their
cohort of patients. All complications were minor, including skin
tear in 4 %, temporary paresthesias in 2 %, and superficial infection in 1 % [15].
It should be noted that published studies on Dupuytrens contracture tend to use a variety of definitions of both correction of
contracture and recurrence [1018]. For instance, Huestons definition for Dupuytrens contracture recurrence was the most widely
accepted definition. Hueston used appearance of new Dupuytrens
tissue within the area cleared at operation [19]. This definition,
however, could not be utilized in NA treatment series, since tissue
is never removed. This makes it difficult to compare the results of
NA with other techniques. Older studies therefore never clearly
defined recurrence in Dupuytrens disease [1215]. Van Rijssen
et al. redefined recurrence indirectly, as an increase of the total passive extension deficit of 30 or more in a ray [16]. A worsening of
digital extension of 30 was chosen because it corresponds to the
Hueston tabletop test and is considered the minimal contracture
required to qualify for surgery. This measure is reproducible and
clinically more relevant. The issue of recurrence of disease versus
progression of disease in previously untreated areas of the hand is
not necessarily well defined in the literature, as well.
Needle aponeurotomy has also been tried in recurrent
Dupuytrens disease. Van Rijssen et al. performed a retrospective
review of recurrent Dupuytrens disease (defined as total passive
extension deficit (TPED) of at least 30 in one or more rays) in
patients previously treated with NA or LF. Needle aponeurotomy
was performed on all these patients. They found NA to be especially effective for the MCP joint, with an average improvement in
TPED of 93 % at MP joints, compared to 57 % in PIP joints. They
concluded that NA leads to good immediate results for both
post-NA and post-LF recurrence. A secondary recurrence
occurred in 50 % cases after 4.4 years on an average, and these
were successfully treated with LF. By using NA at the first

31

Needle Aponeurotomy in the Management

recurrence, they were able to postpone the LF procedure by

2.9 years, and the LF was not more complicated than in cases of
primary disease [20].
Needle aponeurotomy has several advantages over LF and OF,
namely being able to be done in an office/ambulatory surgical setting; optimal return of hand function usually within a week postprocedure; and allows both hands to be treated fairly quickly and
more safely in high-risk patients (e.g., those on anticoagulants or
with significant medical comorbidities that increase risk of anesthesia) [3, 10]. Disadvantages of NA include more rapid and higher
overall recurrence rate than with open surgery [10]. There is also
an inability to correct skin shortage and to address severe or fixed
capsular contractures of the PIP joint [10]. The NA technique itself
does require good knowledge of the pathologic anatomy seen in
Dupuytrens contracture, with a definite learning curve associated
with its adoption and application by the treating surgeon, especially
in the context of a blind procedure that places digital neurovascular
structures at significant risk if the technique is not performed in a
precise and cautious manner.
One of the few available randomized, controlled studies showed
NA and LF to be similarly effective for contracture release in lower
Tubiana stages (see Table 2.1) [16]. This report also demonstrated
recovery after NA to be much faster than after LF. Compared to
NA, limited fasciectomy has a cumulative complication rate of
19 % [17]. Another disadvantage of LF is the relatively long recovery period of 2158 days [18]. Despite these differences, many
patients prefer NA over LF because it is minimally invasive and
has a short recovery period [16].

Table 2.1 Tubiana

classication of Dupuytrens
contracture of the ngers

Tubiana class
I
II
III
IV

TPED ()
045
4690
91135
>135

TPED total passive extension

decit

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C.T. Pereira and P. Benhaim

In 2010, the U.S. Food and Drug Administration granted

American approval for clinical use of injectable collagenase produced by the Clostridium histolyticum species. To date, clinical
efficacy and safety of Dupuytrens treatment with collagenase has
been demonstrated in two double-blind, placebo-controlled studies, the Collagenase Option for Reduction of Dupuytrens I and II
trials [21, 22]. The CORD I study obtained clinical success in 130
of 203 patients (64 %), with a mean of 1.7 injections required per
affected joint to reach the desired end point of joint motion to
within 05 of full extension [21]. A mean of 1.5 injections was
required to achieve clinical success in 20 of 45 patients (44 %) in
the CORD II study [22]. In a recent v review comparing NA to
collagenase, Nydick et al. showed that short-term (3 months) clinical outcomes and patient satisfaction were equal. Both clinical
success (defined as reduction of contracture to within 05 of normal) and mean reduction in contracture were similar between
groups [23]. The number of required or recommended collagenase
injections is not known and is currently being investigated. The
optimum timing of post-injection manipulation after collagenase
injection remains unanswered, although a number of treating physicians have manipulated the treated fingers as long as 12 weeks
after the initial collagenase injection. Although NA can be accomplished during one office visit, as opposed to two office visits for
the collagenase-treated patient, NA routinely requires more treatment time when compared with collagenase injection.
The three currently available techniques for treating Dupuytrens
contracture, i.e., FA, NA, and collagenase, have been compared
with regard to cost-effectiveness. Using a cost-effective treatment
based on the traditional willingness-to-pay of $50,000 per qualityadjusted life years (QALY) gained, Chen et al. showed that open
partial fasciectomy is not cost-effective ($820,114 per QALY
gained over no treatment). Needle aponeurotomy is only costeffective if the success rate is 100 % ($49,631 per QALY gained
over no treatment). Collagenase injection is cost-effective when
priced under $945 per injection ($49,995 per QALY gained over no
treatment). However, if priced at market price of approximately
$5400 per injection, the cost was $166,268 per QALY gained [24].
Finally, since during the initial NA, the cord is directly accessible, studies have been conducted to inject substances at the time

Needle Aponeurotomy in the Management

33

in order to augment the outcome of NA. Depot steroid injections

such as triamcinolone acetonide (TA) and autologous fat transfers
have shown promising results. To answer the question if steroid
injections are beneficial at the time of NA, McMillan and
Binhammer performed a randomized controlled study on 47
patients with DC. Patients were randomized to either receive TA
injections immediately following, 6 weeks, and 3 months after the
procedure, or not receive any injections. Injections were administered into the cords. Total active extension deficit (TAED) was
measured at 6 months post-procedure. There was a statistically
significant improvement in TAED in the steroid-injected group
(87 %), vs. the non-injected group (64 %). They conclude that at
least in the short term (6 months), steroid injections improve NA
outcomes. The authors also report subjective observation of fat
survival, which is both palpable and visible between the skin and
the released cords. They theorize that fat grafts help to decrease
adhesions and separate strands of cord scar in the hand. The study
did have some limitations. The short follow-up period of 6 months
is not adequate to judge the long-term effectiveness of their technique. Furthermore, the baseline TAED was 103 in the steroidinjected group vs. 80 in the non-injected group. The result of
increase in percentage of correction could well have been due to
the greater potential for correction in the steroid-injected group.
Although steroid injection may prove to be a promising adjunct to
NA, longer-term studies with equivalent cohorts are therefore
needed [25].
Hovius et al. reported their experience of 91 patients (99 hands)
where a novel combination of percutaneous release with percutaneous autologous fat grafting was performed. The procedure consists
of an extensive percutaneous aponeurotomy that completely disintegrates the cord and separates it from the dermis. Subsequently,
the authors injected the subcutaneous plane of dissection with
autologous lipoaspirate obtained by liposuction. Patients were
placed in an extension splint for 1 week and continued with nighttime splinting for 36 months. The average contracture at the
proximal interphalangeal joint improved significantly from 61 to
27, and contracture at the MCP joint improved from 37 to 5.
Ninety-four percent of patients returned to normal use of the hand

34

C.T. Pereira and P. Benhaim

within 24 weeks and 95 % were very satisfied with the result. No

new scars were added, and a supple palmar fat pad was mostly
restored [26]. Thus, preliminary results appear to support autologous fat and steroid injections to augment NA outcomes. It seems
likely that combinations of surgery, needle aponeurotomy, collagenase, steroids, and fat grafting will be the future of treatment for
Dupuytrens contracture. Much work needs to be still done to
clarify the best indications and combinations of these treatment
modalities.

Clinical Pearls/Pitfalls
1. Precision supercial inltration of local anesthetic limited to
just the skin overlying the cords and not deeper structures, in
order to prevent digital nerve block.
2. Abort the procedure if light touch is lost due to local anesthetic
diffusion and inadvertent digital nerve block.
3. Use an appropriate needle size, based on surgeon preference,
ranging from 25 gauge to 18 gauge needle.
4. Needle tip is placed perpendicular to the cords longitudinal
axis, with the bevel transverse to the cord.
5. Change needle frequently to maintain sharpness.
6. A windshield wiper back and forth slicing motion used for
larger gauge needles; perforating technique for smaller gauge
needles.
7. Fasciotomy portals placed at areas of maximal bowstringing of
the contracture cords.
8. Avoid exor creases or pits.
9. Avoid forceful hyperextension of ngers to tense cords, especially when releasing at the MP joint (distal palmar crease)
level.
10. Monitor constantly for proprioceptive feedback.
11. Stop if patient complains of paraesthesias or resistance to the
needle tip stops.
12. Release is commenced either proximally and progressing
distally to the MP and/or PIP joints, or vice versa, based on
surgeon preference.

13.
14.
15.
16.

17.
18.

19.
20.
21.

22.

Needle Aponeurotomy in the Management

35

Portals are placed an average of 5 mm apart.

Care is taken to remain central on the cord.
Fingertip sensitivity is checked repeatedly.
Each move is made deliberately, allowing the patient enough
time to react with a possible Tinels sign type of response that
would indicate close proximity to the nerve.
Tendon proximity is checked regularly with short gentle active
tendon excursion.
Once the cord has been adequately weakened/divided at multiple sites, the nger is passively stretched under local anesthesia to achieve completion rupture of the cords.
After nal manipulation, nodules can be injected with depot
corticosteroid.
Skin tears are dressed with ample antibiotic ointment.
Aggressive active/passive range of motion exercises with or
without supervised hand therapy commenced as soon as
possible.
Nighttime extension splinting continued for 616 weeks.

References
1. Shih B, Bayat A. Scientific understanding and clinical management of
Dupuytren disease. Nat Rev Rheumatol. 2010;6:71526.
2. Schultz RJ, Krishnamurthy S, Johnston AD. A gross anatomic and histologic study of the innervation of the proximal interphalangeal joint. J Hand
Surg. 1984;9A:66974.
3. Eaton C. Percutaneous fasciotomy for Dupuytrens contracture. J Hand
Surg. 2011;36A:9105.
4. Cline H. Notes on pathology. London: St. Thomass Hospital Medical
School Library; 1777. p. 185.
5. Elliot D. The early history of contracture of the palmar fascia. J Hand Surg.
1988;13B:24653.
6. Goyrand G. Nouvellesrecherchessur la retraction permanente des doigts.
Gazette Medicale Paris. 1883;3:4816.
7. Fergusson W. A system of practical surgery. London: Churchill; 1842.
8. McIndoe AH, Beare RL. The surgical management of Dupuytrens contracture. Am J Surg. 1958;95:197203.
9. Lermusiaux JL, Debeyre N. Le traitement medical de la malidie de
Dupuytren. Rhumatologique. Paris: Expansion Scientifique; 1979.
p. 33843.

36

C.T. Pereira and P. Benhaim

10. Van Rijssen AL, Gerbrandy FSJ, Linden HT, Klip H, Werker PMN. A
comparison of the direct outcomes of percutaneous needle fasciotomy and
limited fasciectomy for Dupuytrens disease: a 6-week follow-up study.
J Hand Surg. 2006;31A:71725.
11. Degreeef I, De Smet L. Risk factors in Dupuytrens diathesis: is recurrence
after surgery predictable? In: Degreef I, editor. Therapy resisting
Dupuytrens disease. New perspectives in adjuvant treatment. Leuven:
KatholickeUniversiteit; 2009. p. 505.
12. Badois FJ, Lermusiaux C, Masse C, Kuntz D. Nonsurgical treatment of
Dupuytren disease using needle fasciotomy. Rev Rhum Engl Ed. 1993;
60:6927.
13. Bleton R, Marcireau D, Almot J-Y. Treatment of Dupuytren disease by
percutaneous needle fasciotomy. In: Saffer P, Amadio PC, Foucher G, editors. Current practice in hand surgery. London: Martin Dunitz; 1997.
p. 18793.
14. Lermusiaux JL, Lellouche H, Badois F, Kuntz D. How should Dupuytren
contracture be managed in 1997? Rev Rhum Engl Ed. 1997;64:7756.
15. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy:
complications and results. J Hand Surg. 2003;28B:42731.
16. Van Rijssen AL, Ter Linden H, Werker PM. 5-year results of randomized
clinical trial on treatment in Dupuytrens disease: percutaneous needle
fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;
129:46977.
17. McFarlane RM, McGrouther DA. Complications and their management.
In: McFarlane RM, McGrouther DA, Flint M, editors. Dupuytrens disease: biology and treatment. Edinburgh: Churchill Livingstone; 1990.
p. 37782.
18. Rodrigo JJ, Niebauer JJ, Brown JL, Doyle JR. Treatment of Dupuytrens
contracture. Long-term results after fasciotomy and fascial excision.
J Bone Joint Surg. 1976;58A:3807.
19. Hueston JT. Current state of treatment of Dupuytrens disease. Ann Chir
Main. 1984;3:8192.
20. Van Rijssen AL, Paul MN, Werker MN. Percutaneous needle fasciotomy
for recurrent Dupuytren disease. J Hand Surg. 2002;37A:18203.
21. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytrens contracture. N Engl J Med.
2009;361(3):96879.
22. Gilpin D, Coleman S, Hall S, Houston A, Karrasch J, Jones N. Injectable
collagenase clostridium histolyticum: a new nonsurgical treatment for
Dupuytrens disease. J Hand Surg Am. 2010;35(12):202738.
23. Nydick JA, Olliff BW, Garcia MJ, Hess AV, Stone JD. A comparison of
percutaneous needle fasciotomy and collagenase injection for Dupuytren
Disease. J Hand Surg Am. 2013;38(12):237780.
24. Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial
fasciectomy, needle aponeurotomy and collagenase injection for Dupuytren
Contracture. J Hand Surg. 2011;36A:182634.

Needle Aponeurotomy in the Management

37

25. McMillan C, Binhammer P. Steroid injection and needle aponeurotomy for

Dupuytren contracture: a randomized, controlled study. J Hand Surg.
2012;37A:130712.
26. Hovius SE, Kan HJ, Smit X, Selles RW, Cardoso E, Khouri RK. Extensive
percutaneous aponeurotomy and lipografting: a new treatment for
Dupuytren disease. Plast Reconstr Surg. 2011;128:2218.

Chapter 3

Ultrasound Assisted Needle

Aponeurotomy in the Management
of Dupuytrens Contracture
Vasileios I. Sakellariou and Marco Rizzo

Case Presentation
Herein, we present the case of a 75-years-old malea retired sales
engineerwith a 10-year history of progressive contracture of the
ring finger of his dominant right hand. The chief complaint was a
right ring finger contracture and diminished dexterity. The patient
denied pain. However, he did have difficulty with activities such as
putting on gloves and shaking hands, which worsened significantly
over the last 2 years. He also complained of bilateral basal thumb
pain and difficulty with grip related activities.
His medical history was positive for hypertension and ankle
osteoarthritis. The surgical history included a laparoscopic cholecystectomy and an ankle arthrodesis. The patient received occasionally

V.I. Sakellariou, MD, MSc, PhD

Department of Orthopaedic Surgery, Attikon University Hospital,
1, Rimini Str, P.C. 124 62, Chaidari, Athens, Greece
M. Rizzo, MD ()
Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic,
200 First St. SW, Rochester, MN 55905, USA
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_3

39

40

V.I. Sakellariou and M. Rizzo

nonsteroidal anti-inflammatory medication. The patient had a social

history of occasional alcohol consumption. No known drug allergies
were referred.

Diagnosis/Assessment
Physical exam revealed his grip strength to be 24 kg on the right,
and 27 kg on the left side. Appositional pinch was 4.5 kg on the
right, and 4 kg on the left hand; oppositional pinch was 5 kg on the
right, and 4 kg on the left hand. Motion of his right hand at the ring
finger was 63100 at the metacarpophalangeal (MP) joint; proximal interphalangeal (PIP) hyperextended about 5, and flexed to
115. Distal interphalangeal (DIP) range of motion was 050.
Wrist flexion was 60 and extension 70, bilaterally. The patient
had tenderness at the CMC joint bilaterally with a positive grind
bilaterally. He had significant hyperextension of both MP joints.
Palmar abduction of the thumb was 45 bilaterally and radial
abduction was 30 bilaterally (Figs. 3.1 and 3.2).

Fig. 3.1 Preoperative palmar view of the hand. Note the cord over the fourth
MCP joint and the resulting contracture of the ring finger

Ultrasound Assisted Needle Aponeurotomy

41

Fig. 3.2 Preoperative sagittal view of the hand showing the amount of the
MCP extension deficit

Peripheral vascular examination showed an excellent cap refill.

Neurologically, two-point discrimination using the SemmesWeinstein monofilaments going from thumb to small finger was 6,
5, 5, 5, and 6 on the right, and 5, 5, 6, 6, and 6 on the left.
Radiographic evaluation revealed bilateral basal thumb arthritis
and contracted ring finger, without obvious bony lesion in the
fingers.

Management: Surgical Technique

Patient Information and Preoperative Evaluation
The patient was carefully evaluated before the procedure.
Expectations were explained as possible improvement up to 90 of
MCP and up to 50 % improvement in PIP contracture [1]. After
thorough clinical evaluation, the procedure was explained to the
patient, including the importance of co-operation during surgical
manipulations. The patient should be able to report paresthesias or
numbness and avoid sudden movements. Potential complications

42

V.I. Sakellariou and M. Rizzo

(i.e., skin tear, nerve or tendon injury) and the significance to follow a postoperative care protocol were clearly explained and a
written informed consent was received.
Procedure
The portals of fasciotomy were marked using a sterile marker pen
(Fig. 3.3). Potential portals were considered areas where the skin is
soft and the cord was a discrete linear structure that changed from
soft to firm with joint extension. Firm nodules or deep impalpable
cords were avoided because it is known that the associated risk for
neurovascular damage is increased. Distance between portals was
not closer than 5 mm. Portals were designed in line directly over
the cord, and at its sides especially where its width exceeded 5 mm.
Ultrasound examination for preoperative mapping of spiral cords
was performed prior to fasciotomy. The patients hand was placed
on the evaluation table palm up. Utilizing a Sonosite S-MSK series
ultrasound machine in Doppler mode and 136 MHz hockey stick
transducer, the arterial supply of the palm was evaluated and

Fig. 3.3 Fasciotomy (needle stick sites) portals are planned and marked with
a sterile marker pen

Ultrasound Assisted Needle Aponeurotomy

43

Fig. 3.4 The position of the superficial palmar arch is identified via Doppler
and its position is recorded on the skin with an indelible skin marker

recorded. The position of the superficial palmar arch was identified

via Doppler and its position was marked on the skin using an indelible skin marker (Fig. 3.4). The depth of the vascular supply was
also noted. Via continued use of the Doppler, the common palmar
digital arteries and proper palmar digital arteries were identified and
superficially marked from the arch all the way to the PIP joint of the
respective fingers (Figs. 3.5 and 3.6). Displacement of neurovascular structures associated with spiral cords were noted and marked.
Subsequently the palm and fingers were surgically prepped
using chlorhexidine solution and drapped. Superficial pinpoint
aliquots of 1 % lidocaine were intermittently injected over the premarked portals using a 30-gauge needle (Fig. 3.7). A fraction of
one milliliter was utilized with each injection. The aim was to
anesthetize the skin over the cord only and not the deeper digital
nerves. Then a sterile short (0.75 in.) 19-gauge hollow needle was
inserted perpendicular to the long axis of the cord fibers through
anesthetic puncture sites. As one progresses into the finger a short
(0.75 in.) 22 gauge needle was utilized. Using the digital nerve skin
tracings as a guide, the needle was advanced to a depth of a few
millimeters and carefully swept back and forth in a transverse orientation cutting the fibrotic bands (Fig. 3.8). The fascia was felt
crisp or crunchy when being cut.

44

V.I. Sakellariou and M. Rizzo

Fig. 3.5 Doppler image of digital artery with metacarpal on both sides

Fig. 3.6 Ultrasound image showing the identification of a Dupuytrens nodule

Ultrasound Assisted Needle Aponeurotomy

45

Fig. 3.7 Superficial pinpoint aliquots of 1 % lidocaine are intermittently

injected over the pre-marked portals using a 30-gauge needle

Fig. 3.8 Using the digital nerve skin tracings as a guide, the needle is advanced
to a depth of a few millimeters and carefully swept back and forth in a transverse orientation cutting the fibrotic bands

46

V.I. Sakellariou and M. Rizzo

Simultaneous passive cord tension was applied by holding the

finger in extension during the procedure making the targeted cords
more prominent and confirming contracture release. This process
was repeated along the involved digit until optimal extension was
attained. During the dissection of the fascial fibers flexor tendons
were slack in order to reduce the risk of injury. Pressure on fingertips was avoided and the patient was reminded at that point to be
calm trying to keep all fingers lax. The patient was queried routinely during the procedure to report electrical-shock sensations,
which suggest that the needle was near or on a nerve. Fingertip
sensitivity at both radial and ulnar sides of the digit was repeatedly
checked through the procedure.
Tendon proximity was carefully and sequentially checked
through the procedure. While the needle was inserted, the patient
was asked to lightly flex and extend the PIP and DIP joints.
Presence of needle motion demonstrated tendon penetration and
was withdrawn. Bleeding at each needle site was controlled with
pressure.
Releases were started at distal portals, progressing proximally.
Passive stretching was done after each portal release as well as at
the completion of all portals. During stretching patients wrist was
kept in flexion in order to prevent hyper-tensioning, which could
eventually result in skin tear.
At the end of the procedure, portals and remaining nodules were
injected with corticosteroids, and integrity of digital vessels was
confirmed and documented with a final ultrasound scanning.

Post-procedure and Rehabilitation

Hemostasis was obtained with pressure. Small adhesive bandages
(band-aids) were applied to the needle sites. Ice and elevation were
recommended for the first 2 days while passive and active motions
were allowed immediately (Figs. 3.9 and 3.10). Generally, the
patient had no postoperative restrictions other than to avoid submerging his hands for 48 h.
The patient was instructed to use a daytime dynamic splint to
help release residual contractures of the joints. It was recom-

Ultrasound Assisted Needle Aponeurotomy

47

Fig. 3.9 Palmar view of the hand after the procedure. Note the correction of
deformity and recovery of extension deficit of the ring finger

Fig. 3.10 Postoperative sagittal view of the hand showing all fingers in full
extension

mended to utilize it for 30-min intervals three times per day

(Fig. 3.11). A static extension (night) splints was also recommended and the patient was instructed to utilize it for 3 months
postoperatively.

48

V.I. Sakellariou and M. Rizzo

Fig. 3.11 A daytime dynamic splint is recommended to help release residual

contractures of the joints

Potential Complications
Percutaneous needle fasciotomy is a safe minimally invasive procedure [24]. Recurrence of the disease is the most common complication after this procedure [5]. One should be aware that
recurrence rate is higher compared to open procedures, and this is
the reason that should be better limited to elderly, who want simple
treatment without extensive wounds.
Damage to digital neurovascular structures is another potential
complication [4, 5]. However, careful preoperative ultrasonographic mapping of the cords can diminish the possibilities of
accidental lesions.
Skin tears and subsequent flexor tendon lesions are also possible
[3, 4]. They usually occur in and adjacent to flexion creases at the
PIP and the base of the finger. This is why skin creases should be
better avoided during portal planning because of the proximity of
the flexor sheath and the likelihood of skin tear. Once a tear develops, further attempts at passive extension are likely to propagate and
thus are better avoided. Allowing a skin tear to first heal and then
resuming NA is a reasonable course of action in these cases.

Ultrasound Assisted Needle Aponeurotomy

49

Literature Review
Dupuytrens contracture is a relatively common disorder that is
characterized by a progressive fibrosis and thickening of the palmar fascia, and in long-standing or severe disease can result in
shortening and thickening of the ligaments, as well as joint and
skin contractures [6, 7]. Multiple etiologic factors can induce a
pathognomonic fibroblastic proliferation and disorderly collagen
deposition with fascial thickening and local formation of nodules
and cords [6, 7].
Both conservative and surgical treatment modalities have been
historically presented. Conservative measures include continuous
slow skeletal traction, dimethyl sulfoxide, vitamin E, allopurinol,
physical therapy, ultrasound therapy, glucocorticoid injections,
interferon, and splinting, but are considered unsuccessful [8, 9].
Prophylactic external beam radiation therapy can prevent progression and provide symptomatic benefit in patients with mild to
moderate flexion deformities [10]. Collagenase injection can be
effective but limited to patients with less severe contractures
(<50 % contracture) or early stages of the disease [11]. In addition,
risks of allergic reaction, skin tearing, and immune response and
tendon injury are associated with collagenase.
Surgical options include either fasciotomies (limited open or
percutaneous), in which the cord is simply divided, or fasciectomies, in which the diseased fascia is excised [3, 6, 8, 12]. Selection
of operative procedure is basically related to the severity of the
disease and patient preference. Increasingly, patients express preference to avoid formal surgery for Dupuytrens. Tubiana grading
system [13] encounters the amount of total passive extensive deficit
(TPED) which is the sum of the passive extension deficits (PEDs)
of the metacarpophalangeal (MCP), proximal interphalangeal
(PIP), and distal interphalangeal (DIP) joints.
In general, percutaneous fasciotomies are best indicated for
Tubiana grades I and II, but they are not as effective as limited
open fasciotomies or fasciectomies for moderately severe forms of
the disease (Tubiana stages III and IV). Treatment options include
both surgical and conservative modalities.

50

V.I. Sakellariou and M. Rizzo

Indications and Contraindications

It is generally agreed that percutaneous needle fasciotomy is best
indicated for elderly patients with relatively mild contractures
(Tubiana stages I and II) [4] especially with only a metacarpophalangeal deficit. Patients that need a stick or a palmar support to
walk and those who have associated pathologies (arthrosis, short
life expectancy) could benefit from this technique [4]. Relative
indications could include patients willing to accept a higher risk of
recurrence in the context of lower complication rates, faster recovery times, and minimal invasiveness [12]. Eaton presented four
basic requirements for the procedure: (1) contracture due to a (2)
palpable cord lying beneath (3) redundant skin in a (4) cooperative
patient [1]. Other indications are more controversial; presence of
algodystrophy, or patient who are very active and cannot take a
sick leave are included in this group [2].
In contrary, percutaneous fasciotomies should not be attempted
in the absence of a palpable cord and they should not be expected
to correct longitudinally inadequate skin or scars [4]. While debatable, infiltrating disease, inaccessible multiple cords, postsurgical
digital recurrences in young adults, and severe and long present
digital disease causing the stiffness of the PIP joint are reported as
clear contraindications by Foucher et al. [2]. This technique is also
less effective for contractures not resulting from Dupuytrens disease or for patients with constitutionally treatment resistant disease. Rijssen et al. showed that percutaneous needle fasciotomy is
not effective as limited open fasciotomy for Tubiana stages III and
IV and thus these cases should be considered as relative contraindications [4]. It is debatable if use of anticoagulant drugs is a contraindication [14] or actually a relative indication of the procedure
compared to limited open fasciotomy or fasciectomy [1, 2].
The main advantages of fasciotomies are lower incidence of
nerve injury, flare reaction, and reflex sympathetic dystrophy as
well as decreased time needed for recovery [3, 4]. Needle percutaneous fasciotomies can be performed in the office setting, usually
permit return to normal manual activities within a week after the
procedure. They are gaining popularity due to the growing demand
for fast recovery, low complication rate, and minimal invasiveness,

Ultrasound Assisted Needle Aponeurotomy

51

which allows both hands to be treated on consecutive days when

needed. Chen et al. also showed that this is a cost-effective procedure over open procedures [15].
The main disadvantage is a higher recurrence rate compared to
limited open fasciotomies and fasciectomies that occur more rapidly [4]. Moreover, the procedure may be limited only for contractures that they do not include severe skin shortage or capsular
shrinkage of the proximal interphalangeal (PIP) joint [1].

Clinical Pearls/Pitfalls
It is a straightforward procedure.
Combines the advantages of a minimally invasive procedure
with the increased safety of the ultrasonographic mapping of the
digital neurovascular bundles.
Lowering the small, but significant, risk of postoperative finger
numbness with preoperative ultrasound mapping is reasonable
in our view.
Ultrasound mapping does increase procedure cost but is favorably received by patients, as it likely reduces their surgical risk
without adding discomfort.

References
1. Eaton C. Percutaneous fasciotomy for Dupuytrens contracture. J Hand
Surg. 2011;36(5):910.
2. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy.
Complications and results. Chirurgie de la main. 2001;20(3):206.
3. Rahr L, Sondergaard P, Bisgaard T, Baad-Hansen T. Percutaneous needle
fasciotomy for primary Dupuytrens contracture. J Hand Surg Eur Vol.
2011;36(7):548.
4. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytrens disease: percutaneous needle
fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;
129(2):469.
5. Rayan GM. Dupuytrens disease: anatomy, pathology, presentation, and
treatment. Instr Course Lect. 2007;56:101.

52

V.I. Sakellariou and M. Rizzo

6. Trojian TH, Chu SM. Dupuytrens disease: diagnosis and treatment. Am

Fam Physician. 2007;76(1):86.
7. Townley WA, Baker R, Sheppard N, Grobbelaar AO. Dupuytrens contracture unfolded. BMJ. 2006;332(7538):397.
8. Rayan GM. Dupuytren disease: anatomy, pathology, presentation, and
treatment. J Bone Joint Surg Am. 2007;89(1):189.
9. Hurst LC, Badalamente MA. Nonoperative treatment of Dupuytrens disease. Hand Clin. 1999;15(1):97.
10. Seegenschmiedt MH, Olschewski T, Guntrum F. Radiotherapy optimization in early-stage Dupuytrens contracture: first results of a randomized
clinical study. Int J Radiat Oncol Biol Phys. 2001;49(3):785.
11. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals
RA, Smith TM, Rodzvilla J. Injectable collagenase clostridium histolyticum for Dupuytrens contracture. N Engl J Med. 2009;361(10):968.
12. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. A
comparison of the direct outcomes of percutaneous needle fasciotomy and
limited fasciectomy for Dupuytrens disease: a 6-week follow-up study.
J Hand Surg. 2006;31(5):717.
13. Tubiana R. The cutaneous stage in the surgical treatment of Dupuytrens
disease. Ann Chir Plast. 1963;8:157.
14. Symes T, Stothard J. Two significant complications following percutaneous needle fasciotomy in a patient on anticoagulants. J Hand Surg.
2006;31(6):606.
15. Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial
fasciectomy, needle aponeurotomy, and collagenase injection for dupuytren contracture. J Hand Surg. 1826;36(11):2011.

Chapter 4

Corticosteroid Injections and Needle

Aponeurotomy in the Management
of Dupuytrens Contracture
Paul Binhammer

Case Presentation
A 59-year-old right hand dominant female bookkeeper presented
with concerns about Dupuytrens disease of her right small finger.
She had noticed this for 34 years. She had a family history of
Dupuytrens disease. She was otherwise well. She was on no medications. Clinical examination revealed a right small finger PIP
flexion deformity of 57. She had an ulnar-sided cord. The patient
was informed of the underlying pathophysiology and the variable
progression of Dupuytrens disease. She was informed of her
options for management including surgical excision and percutaneous release. She was informed of average success and failure rates
and warned of the risk of infection and numbness. The requirement
for splinting and therapy was explained. She decided to proceed
with percutaneous release.

P. Binhammer, MD, FRCS(C) ()

Hand Wrist and Microvascular Surgery, Sunnybrook Health Sciences Centre,
2075 Bayview Ave, Toronto, ON, Canada, M4N 3M5
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_4

53

54

P. Binhammer

Management
Under alcohol prep using 1 % lidocaine and 0.5 % bupivacaine with
epinephrine, for local infiltration, she underwent routine release of
her right small finger to complete release using the technique
described below. The release was performed at multiple levels. She
had steroid injection of 0.5 cc of triamcinolone 40. She was
referred to the therapist for a splint to maintain the digit in extension. The splint was to be worn at night. There was no therapy
program.
Six weeks following the procedure she returned to have 0.4 cc of
triamcinolone 40 injected along the length of the prior cord. The
patient was advised to continue splinting for another 6 weeks at night.
At 3 and 6 months post-procedure the patient was measured to
have a straight digit.

Outcome
The patient returned 5 years later with recurrent contracture of the
right small finger. She had a precentral cord with an MP contracture of 50 and PIP of 78. After reviewing the available options
including surgery, needle aponeurotomy and collagenase and their
advantages, disadvantages, risks and benefits, she elected to
undergo needle aponeurotomy. She underwent repeat needle aponeurotomy with steroid injection to achieve a straight digit
(Figs. 4.1, 4.2, and 4.3). She was referred for splinting.

Literature Review
Needle aponeurotomy (NA) has the benefits when treating
Dupuytrens disease of a rapid recovery and low risk of complications, which include tendon rupture and/or laceration, nerve injury,
and infection [1, 2]. Reported recurrence rates range from 33 to
100 % [3, 4].

4 Corticosteroid Injections and Needle Aponeurotomy

55

Fig. 4.1 Patient with right hand small finger Dupuytrens cord with significant contracture

Fig. 4.2 Photo of finger following needle aponeurotomy

Triamcinolone acetonide injections have been used to treat

keloids and hypertrophic scars with success [5]. Triamcinolone
has also been used to alter disease progression of Dupuytrens
nodules [6].

56

P. Binhammer

Fig. 4.3 Photo following injection of triamcinolone

Technique
The combination of NA and triamcinolone can be used together in
the treatment of Dupuytrens disease [7]. Under local anaesthesia
using 1 % lidocaine and alcohol skin preparation, the cord is percutaneously divided using the bevel of a 16-gauge injection needle.
Local anaesthesia is restricted to the skin and a digital nerve block
is avoided so that any contact between the releasing needle and the
neurovascular bundle can be identified. Multiple points of division
are performed along the length of the cord. The procedure is terminated when the finger can be passively straightened to an extended
posture, to a total extension deficit of 0. If the digit can not be
straightened, further points of release are performed until the digit
can be straightened or it is felt there are no more points that can be
released. Supplemental digital block is performed at this point

4 Corticosteroid Injections and Needle Aponeurotomy

57

using a long-acting local anaesthetic to provide the patient with

post-operative anaesthesia. Closed manipulation can be performed
at this point. A 25-gauge needle is used to administer injections of
triamcinolone directly into the cords causing contracture immediately following PNA. The point of injections is between the points
of release. The preparation used is Triamcinolone Acetonide
Injectable Suspension USP (40 mg/ml). The amount injected is
approximately 1 cc per digit divided between the release points.
The triamcinolone suspension leaks out through the holes of the
NA. A bandage or small dressing is applied and usually discontinued within 48 h. No medications are prescribed. Patients are fitted
with a custom thermoplastic orthosis and are directed to wear it at
night for 3 months to maintain digital extension. A daily stretching
program is advised for the first 6 weeks in order to maintain range
of motion. Patients are not followed by a therapist.
Follow-up injections of triamcinolone are given at 6 weeks and
3 months to areas of palpable thickness along previously released
cords. If no area of palpable thickness is present, no injection is
administered. Injections are not administered to newly developed
cords. The triamcinolone dose is split between injection sites.
The amount injected at 6 weeks is less than 1 cc per digit and at
3 months this is approximately 0.5 cc.

Results
A randomized trial was performed following NA-treated patients
with or without a series of triamcinolone injections and compared
total active extension deficit (TAED) [7]. The study involved 47
patients. Correction at 6 months was 87 % of pre-operative TAED
for the TA group versus 64 % for the control group. This difference was statistically significant. The amount of triamcinolone
administered did not correlate with TAED improvement. PIP
joint correction was statistically better for the triamcinolone
group at all time points measured, 6 weeks, 3 months and 6
months. There were no adverse outcomes associated with the
administration of triamcinolone.

58

P. Binhammer

A follow-up study looking at the same group of patients found

that mean TAED was significantly less in the triamcinolone group
between 13 and 24 months but not at 36 months [8]. Kaplan-Meier
survival estimates demonstrated a significantly higher percentage
of NA without triamcinolone patients expected to return for retreatment by 24 but not by 36 months. Younger age, more than one joint
treated at the initial NA, and TAED severity throughout the followup period were associated with earlier retreatment.

References
1. Eaton C. Percutaneous fasciotomy for Dupuytrens contracture. J Hand
Surg Am. 2011;36(5):9105.
2. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br. 2003;28(5):42731.
3. van Rijssen AL, ter Linden H, Werker PMN. Five-year results of a randomized clinical trial on treatment in Dupuytrens disease: percutaneous needle
fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;
129(2):46977.
4. Werker PMN, Pess GM, van Rijssen AL, Denkler K. Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: the importance of clear denitions. J Hand Surg Am. 2012;37(10):
2095105.
5. Ketchum LD, Robinson DW, Masters FW. Follow-up on treatment of
hypertrophic scars and keloids with triamcinolone. Plast Reconstr Surg.
1971;48(3):2569.
6. Ketchum LD, Donahue TK. The injection of nodules of Dupuytrens disease with triamcinolone acetonide. J Hand Surg Am. 2000;25(6):115762.
7. McMillan C, Binhammer P. Steroid injection and needle aponeurotomy for
Dupuytren contracture: a randomized, controlled study. J Hand Surg Am.
2012;37(7):130712.
8. McMillan C, Binhammer P. Steroid injection and needle aponeurotomy for
Dupuytren contracture: long term follow-up of a randomized, controlled
study. J Hand Surg Am. 2014;39(10):19427.

Chapter 5

Clostridial Collagenase Injections

in the Treatment of Dupuytrens
Contracture
Jan-Ragnar Haugstvedt

Case Presentation
An 84-year-old right-hand dominant man, previously engineer,
showed up in the clinic and asked for advice for treatment of his
flexed fingers. He was being treated for hypertension, was on salicylic acid, and had twice been in surgery due to a colon cancer.
Following the last surgery 4 years ago, the follow-ups had shown
no signs of recurrence of his cancer. His current problem was his
right hand. He was no longer able to shake hands with people, he
had problems grasping an object, and the fingers were in the
way. The flexed position of his fingers had gradually progressed
during the last 2 years. He was familiar with the condition as he
had seen several other family members with a somewhat similar
appearance of their hands, and he had been surfing the Internet
looking for different possibilities for treatment.

J.-R. Haugstvedt, MD, PhD ()

Department of Orthopedics, stfold Hospital Trust,
Peer Gynts vei 78, 1575 Moss, Norway
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_5

59

60

J.-R. Haugstvedt

Diagnosis/Assessment
The patient was found to have the following changes in his right
hand: In his ring finger he had a 70 contracture over his metacarpophalangeal (MCP) joint while his proximal interphalangeal
(PIP) joint was in an 80 flexed position (Figs. 5.1 and 5.2). He
demonstrated a cord running from the proximal part of the palm of
the hand to the middle phalanx of his ring finger. There was an
involvement of the little finger as this finger was somewhat
adducted and flexed; however no separate palpable cord was running from the palm of the hand to this finger.
The changes found in his hand were found to be classical for
the changes seen in a patient with a Dupuytrens contracture, and
as already mentioned he was well aware of the diagnosis before his
visit. He was informed about the disease, the different changes that
could be found in the different fascias in different parts of the body,
and he was informed about different forms of treatment. With the
changes described, there was a clear indication for treatment. The
patient being in the mid-80s, and already having had some major

Fig. 5.1 The right hand before collagenase injection showing the flexed fourth
finger with the cord running from the palm of the hand towards the finger itself

5 Clostridial Collagenase Injections in the Treatment

61

Fig. 5.2 A view from the volar side of the hand showing that the fifth finger
also has a flexed position before treatment

surgery for other conditions, was not interested in any kind of surgery. He felt he would have a better quality of life if he only would
be able to straighten his fingers a little more and he asked for injection treatment.

Management
The patient, who was not allergic to any specific drugs and had not
received any Tetracycline antibiotics the last 14 days prior to treatment, had an injection of collagenase (Xiapex) in his hand. The
localization of the injection in the cord was between the distal
crease of the palm of the hand and the proximal phalanx. The
patient did not experience any pain, waited at the office for half an
hour (for a potential allergic reaction), and went home.

62

J.-R. Haugstvedt

Fig. 5.3 The day after collagenase injection the fingers were extended. Notice
the superficial rupture of the skin at the base of the fourth finger as well as the
edema and the bleeding in the soft tissue

The patient returned the next day and reported no pain or discomfort, although some edema of his hand was noted. After local
anesthesia had been given, the fingers were extended. A clear
sound was heard when the cord ruptured. The fingers were passively extended; however it was neither possible to have full extension in either of the affected fingers nor in the different joints of the
fourth finger. There was a rupture of the superficial layer of the
skin; however there was no deep wound that required any specific
form of treatment (Fig. 5.3). A splint was adapted and the patient
was asked to use this as a night splint for the following 3 months
(Fig. 5.4).

Outcome
Ten weeks after treatment the patient reported on a good result
(Figs. 5.5 and 5.6). Even though he was not able to fully extend his
finger, his quality of life had improved; he was able to shake hands

5 Clostridial Collagenase Injections in the Treatment

63

Fig. 5.4 The patient used a splint during nighttime for 3 months following the
injection treatment

Fig. 5.5 Maximum active flexion 10 weeks after treatment with collagenase

with people, to grasp an object, and to wash his face using his
hands. Two years after treatment he was still happy with the result.
Using a Visual Analog Scale he reported 8 (0 being worst outcome, while 10 was perfect). The reason why he was not totally
satisfied was due to the little finger, which, previously was without
any cord and had not been treated, had started to flex. The situation,

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J.-R. Haugstvedt

Fig. 5.6 Maximum active extension 10 weeks after treatment with collagenase

though, was not so bad that he considered another treatment;

however he stated that he would have done the same procedure
over again and would ask for another injection if the situation
evolved and he would need treatment.

Literature Review
In one epidemiologic study from Iceland [1] 19.2 % of men and
4.4 % of women showed signs of Dupuytrens contracture, the
prevalence increasing with age, the highest value found in men
between 70 and 74 years old. Thus for surgeons working in
Scandinavia treatment of the so-called Viking disease is common.
I have performed needle aponeurotomy, open fasciectomy with or
without excision of overlying skin (with skin transplant if necessary), I have performed microvascular free tissue transfer to cover
the defect after resection of the changes, and Ive done arthrodesis
of a joint, or partial or ray amputation of an affected finger. Thus I
had a variety of appliances in my toolbox, and however still could
need yet another one for selected cases.

5 Clostridial Collagenase Injections in the Treatment

65

I heard about collagenase in the late 1990s [2]; however it took

some years before papers describing the effect of the treatment
were published [3, 4]. In the first papers it was reported that contractures of the finger joints were corrected after collagenase injections while patients treated with placebo did not achieve the same
corrections and did not have the same improvements in range of
motion.
In a study based on 11 clinical trials (n = 1082), the investigators
found the incidence of adverse events (nerve injury, neurapraxia,
CRPS, and arterial injury) was lower with collagenase injection
compared with complications from fasciectomy [5]. Tendon injury,
skin injury, and hematoma occurred more often with collagenase.
Other side effects experienced with collagenase included pain at
the injection site, edema, some pain in the extremity, and lymphadenopathy. These changes were all transient.
Even though fasciectomy may still be considered the gold standard for treatment of Dupuytrens disease, needle aponeurotomy or
collagenase injections are widely used. The patients seeking for
advice and help are today better educated than years ago and have
very often been searching the Internet for the kind of treatment
they want [6]. They ask for a specific treatment, and we, as doctors,
have to decide the proper, or best treatment for the patient; however there should be the same indication for treatment whatever
treatment method is being used.
Patients have often specific problems that lead them to the doctor asking for treatment, the most common problems being difficulty washing self, difficulty picking things up, and finger
hooking on things [7]. The authors state that the long-term outcome of treatment may be more important than quick recovery to
patients.
For the first patients treated with collagenase injections, it was
advocated to treat one cord affecting one joint at a time. In the last
years, however, there have been trials on injections into cords
affecting two joints at the same time. The results of one multicenter
study showed effective treatment with 76 % clinical success for
treatment of MCP joints and 33 % for PIP joints. 60 % of the
patients in this multicenter study were very satisfied with treatment, although the patients experienced more pain in the extremity

66

J.-R. Haugstvedt

and local edema, all of the symptoms being transient [8]. Treatment
of more than one joint or two cords at the same time is gaining
popularity.
For a long time Food and Drug Association approved maximum
injections of 0.58 mg of the enzyme into one cord at a time.
However later studies have been performed using 0.78 mg of the
enzyme at one time, the entire bottle, allowing the doctor to give
multiple injections into several cords using the so-called slow
intracord multi-cord (SIMple) technique [9]. The results reported
in this one study were comparable with previously published studies using a lower dose. The author suggests that using this method
there could be healthcare savings compared with other type of
treatments as the patient would not have to return for another later
injection or surgery.
While considering using collagenase injections, one may wonder if its possible to use this technique in patients that had previous surgery for Dupuytrens disease. In one paper, data from 12
clinical trials where collagenase had been used were pooled and
evaluated [10]. Some of the patients included in the study had
injection of collagenase in a previously nonoperated hand, while
other patients had previous surgery in the hand where they now had
injections. The authors did neither find any differences in reduction
of the flexion contractures of the finger joints, nor in the improvements of the range of motion between the two groups, and both
groups of patients were equally satisfied with the treatment. The
adverse events (injection site hemorrhage, blood blister, axillary
peripheral edema, contusion, pain in the extremity, tenderness,
ecchymosis, and lymphadenopathy) varied between the groups;
however none were clinically relevant. The authors conclude that
injection treatment with collagenase is also well tolerated in
patients previously surgically treated for Dupuytrens disease in
the same finger.
If the treatment with collagenase is not successful, there might
be a demand for later surgery. In one study [11], the authors report
on the surgical findings after initial treatment with collagenase.
Nine surgeons reported on a total of 15 patients with surgical treatment following previous collagenase injections. In 9 out of 15
cases the surgery was considered as easier or equivalent to a primary operation, 2 as equivalent to and 4 as harder than a revision

5 Clostridial Collagenase Injections in the Treatment

67

operation. The problems faced were abnormal thickening and

adherence of the cord with changes of the anatomy and troublesome dissection. I have performed surgery in one case myself
without having any problems with the dissection of the anatomical
structures.
It is difficult to have one good outcome measure to evaluate the
results after treatment for Dupuytrens disease. There should probably be a set of validated outcome measures to monitor the natural
history of the disease as well as compare between treatment
modalities [12]. Patient Related Outcome Measure (PROM) has
been used; however the question is if this correlates with the
patients quality of life (QoL) [13]. Tests that have been used
include Disability of Arm, Shoulder and Hand (DASH), the
URAM scale (Unit Rhumatologique des Affections de la Main),
Southampton Dupuytrens Scoring Scheme (SDSS) as well as the
Michigan Hand Questionnaire (MHQ); however even if at least
some of the tests are meant specifically for Dupuytrens disease,
none seem to be working very well. VAS could be used to reflect
change in the symptom of pain over time in an individual; it has
good intra-rater reliability and can be used to distinguish between
any specific treatment satisfaction being used and the treatment
outcome [14].

Clinical Pearls and Pitfalls

The same indications should be used for treatment of Dupuytrens
disease regardless of what treatment modality is being used.
Clostridial Collagenase injections could be used for one cord in
one finger affecting one joint, however have also been shown to
be effective if using multiple injections affecting several cords/
joints.
When injecting the collagenase, the needle should be directed
away from the flexor tendon in order to avoid the risk of flexor
tendon rupture; the needle should come from dorsal to volar or
pass through the skin in an oblique manner with the needle
pointing beside the tendon.

68

J.-R. Haugstvedt

Edema and bleeding are often seen after treatment with collagenase; thus caution is necessary when the patient is taking any
anticoagulants.
Collagenase can be used for recurrences of Dupuytrens disease; however it is not indicated for treatment of scar tissue.

References
1. Gudmundsson KG. Epidemiology of Dupuytrens disease: clinical, serological, and social assessment The Reykjavik Study. J Clin Epidemiol.
2000;53(3):2916.
2. Starkweather KD, Lattuga S, Hurst LC, Badalamente MA, Guilak F,
Sampson SP, Dowd A, Wisch D. Collagenase in the treatment of
Dupuytrens disease: an in vitro study. J Hand Surg Am. 1996;21(3):
4905.
3. Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytrens contracture. J Hand
Surg Am. 2007;32(6):76774.
4. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals
RA, Smith TM, Rodzvilla J, CORD I Study Group. Injectable collagenase
clostridium histolyticum for Dupuytrens contracture. N Engl J Med.
2009;361(10):96879.
5. Peimer CA, Wilbrand S, Gerber RA, Chapman D, Szczypa PP. Safety and
tolerability of collagenase Clostridium histolyticum and fasciectomy for
Dupuytrens contracture. J Hand Surg. 2015;40(2):1419.
6. Hentz VR. Collagenase injections for treatment of Dupuytren disease.
Hand Clin. 2014;30(1):2532.
7. Rodrigues JN, Zhang W, Scammell BD, Davis TR. What patients want
from the treatment of Dupuytrens disease-is the Unit Rhumatologique de
Affections de la Main (URAM) scale relevant? J Hand Surg Eur.
2015;40(2):1504.
8. Coleman S, Gilpin D, Kaplan FT, Houston A, Kaufman GJ, Cohen BM,
Jones N, Tursi JP. Efficacy and safety of concurrent collagenase clostridium histolyticum injections for multiple Dupuytren contractures. J Hand
Surgery Am. 2014;39(1):5764.
9. Verheyden JR. Early outcomes of a sequential series of 144 patients with
Dupuytrens contracture treated by collagenase injection using an increased
dose, multi-cord technique. J Hand Surg Eur. 2015;40(2):13340.
10. Bainbridge C, Gerber RA, Szczypa PP, Smith T, Kushner H, Cohen B,
Hellio Le Graverand-Gastineau MP. Efficacy of collagenase in patients
who did and did not have previous hand surgery for Dupuytrens contracture. J Plast Surg Hand Surg. 2012;46(34):17783.

5 Clostridial Collagenase Injections in the Treatment

69

11. Hay DC, Louie DL, Earp BE, Kaplan FT, Akelman E, Blazar PE. Surgical
findings in the treatment of Dupuytrens disease after initial treatment with
clostridial collagenase. J Hand Surg Eur. 2014;39(5):4635.
12. Ball C, Pratt AL, Nanchahal J. Optimal functional outcome measures for
assessing treatment for Dupuytrens disease: a systematic review and
recommendations for future practice. BMC Musculoskelet Disord.
2013;14:131.
13. Wilburn J, McKenna SP, Perry-Hinsley D, Bayat A. The Impact of
Dupuytren disease on patient activity and quality of life. J Hand Surg.
2013;38(6):120914.
14. Badalamente M, Coffelt L, Elfar J, Gaston G, Hammert W, Huang J,
Lattanza L, Macdermid J, Merrell G, Netscher D, Panthaki Z, Rafijah G,
Trczinski D, Graham B. American Society for Surgery of the Hand
Clinical Trials and Outcomes Committee. Measurement scales in clinical
research of the upper extremity, part 2: outcome measures in studies of the
hand/wrist and shoulder/elbow. J Hand Surg Am. 2013;38(2):40712.

Suggested Readings
Atroshi I, Strandberg E, Lauritzson A, Ahlgren E, Waldn M. Costs for collagenase injections compared with fasciectomy in the treatment of Dupuytrens
contracture: a retrospective cohort study. BMJ Open. 2014;15(4):e004166.
doi:10.1136/bmjopen-2013-004166.
McGrouther DA, Jenkins A, Brown S, Gerber RA, Szczypa P, Cohen B. The
efficacy and safety of collagenase clostridium histolyticum in the treatment
of patients with moderate Dupuytren's contracture. Curr Med Res Opin.
2014;30(4):7339.
Mickelson DT, Noland SS, Watt AJ, Kollitz KM, Vedder NB, Huang JI.
Prospective randomized controlled trial comparing 1. versus 7-day manipulation following collagenase injection for dupuytren contracture. J Hand
Surgery Am. 2014;39(10):193341.
Peimer CA, Blazar P, Coleman S, Kaplan FT, Smith T, Tursi JP, Cohen B,
Kaurman GJ, Lindau T. Dupuytren contracture recurrence following treatment with collagenase clostridium histolyticum (CORDLESS study):
3-year data. J Hand Surg Am. 2013;38(1):1222.

Chapter 6

Minimally Invasive Partial

Fasciectomy
Sidney M. Jacoby and Justin D. Stull

Case Presentation
A 76-year-old man presented to our clinic with complaints of
decreased right hand function resulting from a flexion deformity
to his right fourth digit, with increasing severity over the past
several years. His past medical history was significant for medically controlled hypertension, controlled type II diabetes mellitus, and benign prostatic hypertrophy. His past surgical history
was unremarkable and limited to cataract removal. His review of
systems was noncontributory. The patient was of Irish decent. He
reported one sibling, a brother who died at 67, whose hand also

S.M. Jacoby, MD
Department of Orthopaedic Surgery, Thomas Jefferson University Hospital,
The Philadelphia Hand Center, PC, The Franklin, 834 Chestnut Street,
Suite G114, Philadelphia, PA 19107, USA
e-mail: [email protected]
J.D. Stull, BA ()
Sidney Kimmel Medical College at Thomas Jefferson University,
Thomas Jefferson University Hospital, 1015 Walnut Street,
Philadelphia, PA 19107, USA
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_6

71

72

S.M. Jacoby and J.D. Stull

clawed up as he aged. The patient was a retired construction

worker, married, without children. He was a non-smoker, nondrug user, but enjoyed a drink with dinner. He reported no known
food or drug allergies.

Physical Assessment and Diagnosis

Visual inspection of the patients affected hand revealed obvious
contractures of the right fourth finger at both the MCP and PIP
joints. A stout, pretendinous cord along the ray of the ring finger
with adjacent pitting at the distal palmar crease was observed.
On palpation, the stout cord was easily appreciated from the
medial aspect of the thenar crease to the base of the fourth MCP
joint. There were no palpable nodules. No pain or tenderness
was noted on deep palpation of the cords. Using a handheld
goniometer, the measured MCP joint contracture was 40.
Holding the MCP joint in neutral, the contracture of the PIP joint
was measured to be 80.
Dupuytrens disease most commonly involves the fourth digit,
and the MCP is the most often involved joint [1]. The highest
prevalence of Dupuytrens disease is among 5070-year-old
males of North European decent, including those of Irish heritage, such as the patient in this vignette [1, 2]. Autosomal dominant genetic inheritance has been reported as a major risk factor
for increased predisposition to the disease. Further, it is thought
that microvascular disease and myofibroblast proliferation play
an important role in disease presentation and progression; smoking, diabetes, repetitive trauma, advanced age, male sex, and
alcohol consumption have all been linked as contributors to this
pathogenesis [1, 36].
Histology can be useful to gauge the severity of the disease;
however Dupuytrens contracture remains a clinical diagnosis;
therefore, imaging and biopsies are not routinely conducted to
confirm diagnosis.

6 Minimally Invasive Partial Fasciectomy

73

Management Options
In patients with MCP joint contracture >30, PIP joint contracture
>30, or any patient who presents with functional disability, surgical management is appropriate. Patients without advanced disease
and those patients who demonstrate a normal tabletop test can
be treated with expectant observation.
Nonsurgical options, including percutaneous needle aponeurectomy (PNA), have reported early results comparable to some standard fasciectomy techniques. Lower rates of long-term success and
diminished visualization of critical structures during the procedure
are two potential drawbacks to PNA, which is usually reserved for
those with total contractures of <90 [1, 710]. Another nonsurgical option, collagenase injection, has yielded good preliminary
outcomes, especially in patients with less severe contractures, but
sufficient long-term analysis is pending. One potential drawback to
collagenase is its cost, and in certain circumstances difficulty in
obtaining expedient insurance clearance [1114].
Primary surgical options vary by the invasiveness, and the extent
of excised tissue, which commonly revolves around the pattern of
palmar fascia involvement. At one end of the spectrum exists the
minimally invasive partial fasciectomy, which utilizes multiple
small transverse incisions to remove diseased fascial cords [10, 15, 16],
and at the other end is the open radical fasciectomy, which has generally fallen out of favor due to its increased morbidity and lengthy
recovery time [1, 17, 18]. Between the two ends of the surgical
spectrum exists options that differ in the degree of tissue excision
and the pattern of exposure. For primary surgical procedures in the
absence of diathesis, preference for minimally invasive surgical
management allows for a quick return to activity, less morbidity
than more extensive techniques, and preservation of facial planes
that still allows for future revision procedures if necessary.

Management Chosen
Minimally invasive partial fasciectomy with multiple transverse
incisions was performed.

74

S.M. Jacoby and J.D. Stull

Clinical Course and Outcome

With the patient under general anesthesia, a pneumatic tourniquet
was applied, prior to skin incision. One-centimeter transverse incisions were made along the length of the pretendinous cord beginning at the proximal palmar crease, extending to the PIP joint
(Fig. 6.1). Hemostasis was achieved through the use of bipolar
electrocautery, and special attention was given to identifying and
isolating neurovascular bundles with reverse Hohmann retractors.
With this approach 12 cm longitudinal cord segments were
excised through each transverse incision in a proximal to distal
manner (Fig. 6.2). Even with isolation of the neurovascular bundles, resection of retrovascular cords must be done with great caution as digital neurovascular bundles may be displaced central,
proximal, or superficial, particularly at the level of palmar-digital
crease. If visualization is not possible, the cord release must be
forgone to judicially protect the neurovasculature. One benefit of
this technique is that it allows for extension of the incisions and
conversion to open fasciectomy if necessary. Once cord release is
complete, and the affected digit was able to achieve maximum
extension on passive manipulation, closure was completed with
4-0 nylon sutures, and a soft dressing applied (Fig. 6.3).
At 1-week follow-up our patient had his surgical dressings
removed, with evidence of excellent early healing. He was maintained in an extension splint and instructed to begin active range of
motion exercises for the wrist and digits. Sutures were removed at
the 10-day postoperative marker, with continuation of splinting,
range of motion exercise, and instruction for scar massage.
Strengthening began at postoperative week 4 with return to daily
activity at week 6.

Review of Literature and Discussion

Widely accepted guidelines for treatment of Dupuytrens disease
stipulate that surgical management should be sought for individuals with >30 flexion contracture of the MCP and >1015 flexion

Fig. 6.1 Preoperative incision markings. (a) Frontal plane: 1 cm transverse incision markings are made 23 cm apart moving distally
from the proximal palmar crease, approaching the PIP joint. (b) Oblique plane: Surgical positions demonstrate disease of the MCP joint
and PIP joint of 40 and 80 respectively

6 Minimally Invasive Partial Fasciectomy

75

Fig. 6.2 Intraoperative photograph. Image illustrates the excision of the diseased
Dupuytrens cord from a segment distal to the transverse incision

Fig. 6.3 Intraoperative photograph. Following excision of all diseased

Dupuytrens cord through multiple transverse incisions, complete extension is
achieved at both the MCP and PIP joints

6 Minimally Invasive Partial Fasciectomy

77

contracture of the PIP [1, 8]. The literature, however, is inconclusive

with regard to which technique is the preferred primary treatment
option [19]. Most commonly, the extent of disease and likelihood
for recurrence drives decision making. The patient in this case is
clearly a surgical candidate (MCP flexion of 40 with PIP involvement) with many risk factors for recurrence and mild to moderate
disease, but also presents at a late age without disease diathesis,
therefore allowing for consideration of a wide range of treatment
intervention options.
A variety of dermal incision patterns have been described with
varying degrees of fasciectomies. Transverse incisions have been
proposed to limit tissue disruption through maximally preserved
blood supply, and minimal tension exertion on the dermis as compared to longitudinal incisions [2022]. As a result, transverse
incisions have been incorporated into a number of fasciectomy
techniques to reduce the likelihood of recurrent disease. Minimally
invasive partial fasciectomy utilizes multiple small transverse
incisions, sequentially spaced along pathologic cords, through
which the fasciectomy is subcutaneously performed proximally
and distally to remove the diseased tissue without substantial incision [10]. By avoiding a large incision and associated traumatic
inflammatory response running in parallel with the diseased fascia, minimally invasive partial fasciectomy offers a less invasive
procedure with quick return to activity and good outcomes with
appropriate patient selection [10, 15, 16]. To a great extent, this
procedure also maintains fascial planes, which is of great importance should revision procedures become necessary in the future.
With 2-year follow-up, several studies have reported outcomes on
par with other minimally invasive techniques including sustained
MCP flexion correction at final data collection [10, 16]. One
2-year follow-up reported no recurrences [16], and a second study
with average follow-up of 15 months reported complete resolution
of PIP joint contracture in a small cohort. [15] Another study, with
a starting n = 67 patients and 119 digits, reported an average recurrence and advancement of PIP contracture (39 pre-op and 45
final post-op); however there was 63 % loss to follow-up, possibly
indicating successful outcomes in patients who decided no further
care was necessary [10]. Overall, minimally invasive partial fasciectomy may result in less maintenance of extension compared

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S.M. Jacoby and J.D. Stull

with more extensive fasciectomy techniques, but the minimally

invasive partial fasciectomy cohorts consistently reported lower
rates of complications [10, 15, 16, 21, 23]. At final follow-up,
minimally invasive partial fasciectomy has displayed excellent
success in the MCP joints treated, while correction of affected PIP
joints has resulted in variable rates and degrees of maintained
extension [10, 15, 16].
Two nonsurgical techniques have been proposed, and accepted
with some popularity in the management of Dupuytrens.
Percutaneous needle aponeurectomy sections Dupuytrens cords at
various levels. This technique has yielded good early results and
patient satisfaction, but long-term results and successes in patients
with severe disease have been less than satisfactory [7, 12]. One
drawback to this technique is that PNA forgoes the cord visualization afforded by minimally invasive fasciectomy, theoretically
increasing the risk of neurovascular injury [10]. Another nonoperative technique, collagenase injections, aims to lyse cords and has
been reported to have excellent short-term results with a low side
effect profile [8, 11]. However, due to its relative infancy as an
intervention option, there is a paucity of long-term data. A single
long-term study reports collagenase has high rates of MCP joint
recurrence (67 %) and recurrence with increased severity of PIP
joint disease as compared to pre-injection measures (45 preinjection to 60 at final follow-up) [24]. Collagenase also has a
high cost assumption, often not covered by insurance plans, and is
generally not considered to be a cost-effective therapy [13, 14, 25].
Open fasciectomy and its derivatives, including limited fasciectomy, are commonly used surgical techniques in the management
of Dupuytrens. These fasciectomy procedures incorporate a variety of incisional patterns which can be fairly invasive, involving
extensive dissection [1, 2629]. Compared to minimally invasive
partial fasciectomy, limited fasciectomy has the advantage of
greater visualization of diseased tissue and neurovascular structures; however it may create a greater traumatic inflammatory
response from more extensive dermal disruption. Despite lower
rates of recurrence and disease extension, the variants of open fasciectomy have been associated with high rates of complications,
both intraoperatively and postoperatively [2830]. Neurovascular
injury, infection, flare reaction, and/or hematoma among other

6 Minimally Invasive Partial Fasciectomy

79

complications have been reported in up to 30.8 % those undergoing

primary fasciectomy [30].
For the patient in this vignette, an elderly man with a multitude
of risk factors and mild-moderate disease of the right fourth digit
with PIP involvement, numerous treatment options exist. Due to
MCP contracture of >30 and PIP involvement, nonsurgical
options were ruled out, per standard practice [1, 8]. The decision to
proceed with a minimally invasive technique was made as a result
of the patients advanced age at presentation and relatively limited
distribution of the disease. The only reservation in making the
choice to proceed with minimally invasive partial fasciectomy was
based on PIP involvement of 80. However, given the patients age
and overall health, the prospective of a quick return to activity with
reduced risk of postoperative complication outweighed the potential for disease recurrence or extension. Generally, minimally invasive partial fasciectomy can be considered as a surgical option for
patients presenting with mild-moderate disease with limited or no
PIP involvement, and the desire for a less invasive surgical option
with an expeditious return to daily activities.

Clinical Pearls/Pitfalls
Patient selection for minimally invasive partial fasciectomy
should exclude patients with advanced disease, Dupuytrens
diathesis, or significant PIP joint involvement.
Patient selection should include those with mild-moderate disease, including those with limited PIP involvement, if rapid
return to activity or a less invasive surgical procedure is desired.
Visualization and isolation of neurovascular bundles with
reverse Hohmann retractors is both helpful and necessary to
avoid iatrogenic neurovascular injuries.
If safe visualization is not obtained, the cord release must be
forgone to judicially protect neurovascular structures.
Early range of motion is encouraged, as is a period of extension
splinting, particularly at night over the initial 46 postoperative
period.

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S.M. Jacoby and J.D. Stull

References
1. Black EM, Blazer PE. Dupuytren disease: an evolving understanding of an
age-old disease. J Am Acad Orthop Surg. 2011;19:74657.
2. Coert JH, Barret JP, Meek MF. Results of partial fasciectomy for
Dupuytren disease in 261 consecutive patients. Ann Plast Surg.
2006;57:137.
3. Dolmans GH, Werker PM, Hennies HC, et al. Wnt signaling and
Dupuytrens disease. N Engl J Med. 2011;365:30717.
4. Murrell GA, Francis MJ, Howlett CR. Dupuytrens contracture: fine structure in relation to aetiology. J Bone Joint Surg Br. 1989;71(3):36773.
5. Burke FD, Proud G, Lawson IJ, McGoech KL, Miles JN. An assessment
of the effects of exposure to vibration, smoking, alcohol and diabetes on
the prevalence of Dupuytrens disease in 97,537 miners. J Hand Surg Eur.
2007;32(4):4006.
6. Burge P, Hoy G, Regan P, Milne R. Smoking, alcohol and the risk of
Dupuytrens contracture. J Bone Joint Surg Br. 1997;79(2):20610.
7. Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for
Dupuytren contracture in over 1,000 fingers. J Hand Surg Am. 2012;
37A:3516.
8. Glickel SZ. Update on surgery of the hand. J Am Acad Orthop Surg.
2013;21(4):2023.
9. Eaton C. Percutaneous fasciotomy for Dupuytrens contracture. J Hand
Surg Am. 2011;36:9105.
10. Gelman S, Schlenker R, Bachoura A, Jacoby SM, Lipman J, Shin EK,
Culp RW. Minimally invasive partial fasciectomy for Dupuytrens contractures. Hand. 2012;7:3649.
11. Srinivasan RC, Shah SH, Jebson PJ. New treatment options for Dupuytrens
surgery: collagenase and percutaneous aponeurotomy. J Hand Surg Am.
2010;35:13624.
12. Chen NC, Srinivasan RC, Shauver MJ, Chung KC. A systematic review of
outcomes of fasciotomy, aponeurotomy, and collagenase treatments for
Dupuytrens contracture. Hand. 2011;6:2505.
13. Baltzer H, Binhammer PA. Cost-effectiveness in the management of
Dupuytrens contracture. A Canadian cost-utility analysis of current and
future management strategies. Bone Joint J. 2013;95B(8):1094100.
14. Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial
fasciectomy, needle aponeurotomy, and collagenase injection for
Dupuytren contracture. J Hand Surg Am. 2011;36A:182634.
15. Lee H, Eo S, Cho S, Jones NF. The surgical release of Dupuytrens contracture using multiple transverse incisions. Arch Plast Surg.
2012;39(4):42630.
16. Shin EK, Jones NF. Minimally invasive technique for release of
Dupuytrens contracture: segmental fasciectomy through multiple transverse incisions. Hand. 2011;6:2569.

6 Minimally Invasive Partial Fasciectomy

81

17. Tonkin MA, Burke FD, Varian JP. Dupuytrens contracture: a comparative
study of fasciectomy and dermatofasciectomy. J Hand Surg Br. 1984;9:
15662.
18. Chick LR, Lister GD. Surgical alternatives in Dupuytrens contracture.
Hand Clin. 1991;7(4):7159.
19. Becker GW, Davis TRC. The outcome of surgical treatments for primary
Dupuytrens diseasea systematic review. J Hand Surg Eur. 2010;
35E(8):6236.
20. McCash CR. The open palm technique in Dupuytrens contracture. Br
J Plast Surg. 1964;17:27180.
21. Moermans JP. Long-term results after segmental aponeurectomy for
Dupuytrens disease. J Hand Surg Br. 1996;21:797800.
22. Citron N, Hearnden A. Skin tension in the aetiology of Dupuytrens disease: a prospective trial. J Hand Surg Br. 2003;28:52830.
23. Moermans JP. Segmental aponeurectomy in Dupuytrens disease. J Hand
Surg Br. 1991;16:24354.
24. Watt AJ, Curtin CM, Hentz VR. Collagenase injection as nonsurgical treatment of Dupuytrens disease: 8-year follow-up. J Hand Surg Am. 2010;
35:5349.
25. Canadian Agency for Drugs and Technologies in Health. Needle or open
fasciotomy for Dupuytrens contracture: a review of the comparative efficacy, safety and cost-effectivenessan update. Rapid response report:
summary with critical appraisal. November 11, 2013.
26. Ullah AS, Dias JJ, Bhowal B. Does a firebreak full-thickness skin graft
prevent recurrence after surgery for Dupuytrens contracture?: a prospective, randomized trial. J Bone Joint Surg Br. 2009;91:3748.
27. Freehafer AA, Strong JM. The treatment of Dupuytrens contracture by
partial fasciectomy. J Bone Joint Surg. 1963;45A(6):120716.
28. Anwar MU, Al Ghazal SK, Boome RS. Results of surgical treatment of
Dupuytrens disease in women: a review of 109 consecutive patients.
J Hand Surg Am. 2007;32:14238.
29. Misra A, Jain A, Ghazanfar R, Johnston T, Nanchahal J. Predicting the
outcome of surgery for the proximal interphalangeal joint in Dupuytrens
disease. J Hand Surg. 2007;32A:2405.
30. Denkler K. Surgical complications associated with fasciectomy for
Dupuytrens disease: a 20-year review of the English literature. Eplasty.
2010;10:e15.

Suggested Readings
Gelman S, et al. Minimally invasive partial fasciectomy for Dupuytrens contractures. Hand. 2012;7(4):3649.
Shin EK, Jones NF. Minimally invasive technique for release of Dupuytrens
contracture; segmental fasciectomy through multiple transverse incisions.
Hand. 2011;6:2569.

Chapter 7

Surgical Fasciotomy for Dupuytren

Contracture
Reid W. Draeger and Peter J. Stern

Case Presentation
A 54-year-old right-handed homemaker presented for evaluation of
progressive drawing in of the right middle and ring fingers. She
began to notice skin puckering in her palm approximately 2 years
prior to presentation. She was able to fully straighten the fingers
until approximately 6 months prior to presentation at which time
the fingers became progressively more contracted and daily activities
became more difficult due to loss of finger extension.

R.W. Draeger, MD ()

Department of Orthopaedics, School of Medicine, University of North
Carolina, Campus Box #7055, 3102 Bioinformatics Building, Chapel Hill,
NC 27599-7055, USA
e-mail: [email protected]
P.J. Stern, MD
Department of Orthopaedic Surgery, College of Medicine, University of
Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45207, USA
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_7

83

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R.W. Draeger and P.J. Stern

On physical examination, tight pretendinous cords were

appreciated to the right middle and ring fingers (Fig. 7.1). The
contractures were confined to the MCP joints of both digits, with
the PIP and DIP joints spared. Range of motion was as follows:
right middle finger MCP 30/90, PIP 0/100, DIP 0/70; right
ring finger MCP 40/90, PIP 0/100, DIP 0/70. Sensibility was
normal and there was brisk capillary refill in all digits. No
Garrod nodes or other sites of ectopic disease were present. The
patients family history was unremarkable for Dupuytren
contracture.

Diagnosis/Assessment
The diagnosis of Dupuytren contracture, in most cases, is confirmed with history and physical examination. There is no role
for laboratory evaluation or advanced imaging. Dupuytren nodules alone may be confused with volar retinacular ganglion
cysts or tender A1 pulleys associated with trigger digits.
However, palpation of a cord helps to firm up the diagnosis of
Dupuytren contracture. Though rare, consideration of palmar
fasciitis and contracture secondary to a paraneoplastic syndrome should be considered in all patients, especially female,
non-Caucasian patients, in which Dupuytren contracture is
uncommon, and in those patients with acutely painful hands, as
is associated with polyarthritis and post-traumatic conditions
(i.e., distal radius fracture) [1].
Evaluation of all patients with suspected Dupuytren contracture
should include questions about family history, ectopic sites of
involvement, bilateral involvement, and patient age at original
onset. Positive family history, ectopic lesions (Garrod nodes,
Peyronie disease, and Ledderhose disease), bilateral hand involvement, original onset before age 50, and male gender are all factors
used to determine a diagnosis of Dupuytren diathesis, which portends a much more aggressive course of disease than isolated
Dupuytren contracture.

MD)

Fig. 7.1 (a and b) Preoperative view of the patients hand (a: palmar view, b: oblique view) (Photographs courtesy of Richard Kang,

7
Surgical Fasciotomy for Dupuytren Contracture
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R.W. Draeger and P.J. Stern

Management
The decision of which of the myriad treatments for Dupuytren
contracture to pursue is not only dependent on the characteristics
of the patients disease, but also patient preference. We are strong
believers in shared decision making with the patient on treatment
selection for Dupuytren disease.
In general, we have found limited fasciotomy to be most effective for contractures at the MCP joints. In patients with multiple
involved digits or those whose health status precludes a regional or
general anesthetic, limited fasciotomy provides a reliable, simple,
treatment for the contractures in a single procedure. Limited fasciotomy was chosen to treat this patients moderate contractures of
her long and ring finger MCP joints.
The incision for a limited fasciotomy is transverse and planned
directly over the most prominent and taut portion of the pathologic
cord or cords. For most MCP contractures, this will be around the
level of the distal palmar crease (Fig. 7.2). The skin is incised and
the skin is dissected off of the underlying cord. Dissection is carried both radially and ulnarly around the cord to ensure no inter-

Fig. 7.2 Planned surgical incision (Photograph courtesy of Richard Kang, MD)

Surgical Fasciotomy for Dupuytren Contracture

87

Fig. 7.3 The skin is dissected off of the underlying cord and a hemostat is
placed under the cord, carefully isolating it from the surrounding neurovascular structures. The cord to the ring finger is isolated (Photograph courtesy of
Richard Kang, MD)

vening neurovascular structures are in danger at the planned

fasciotomy site (Figs. 7.3 and 7.4). The isolated cords are then
transversely incised leaving the surrounding palmar fascia intact
(Fig. 7.5). Once the cord has been divided, the patient is asked to
fully extend the fingers to evaluate the success of the fasciotomy
(Fig. 7.6). The wound is left open to heal by secondary intention.
A sterile soft dressing is applied and the patient is encouraged to
flex and extend the fingers immediately postoperatively.

Outcome
The patient underwent limited fasciotomy of her long and ring
finger MCP Dupuytren contractures. Immediate postoperative
range of motion was initiated and at 5 days, a resting night splint

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R.W. Draeger and P.J. Stern

Fig. 7.4 The cord to the long finger has been isolated from surrounding neurovascular structures with a hemostat placed beneath the cord. The cord to the
ring finger has been transversely sectioned (Photograph courtesy of Richard
Kang, MD)

Fig. 7.5 The longitudinal cords to both the long and ring finger have been cut,
and surrounding structures, including the nonpathologic fibers of the palmar
fascia, are left intact (Photograph courtesy of Richard Kang, MD)

joints of either the long or ring fingers (a: palmar view, b: lateral view) (Photographs courtesy of Richard Kang, MD)

Fig. 7.6 (a and b) View of the patients hand with attempted active intraoperative extension shows no residual contracture at the MCP

7
Surgical Fasciotomy for Dupuytren Contracture
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R.W. Draeger and P.J. Stern

was fabricated to maintain digital extension. Immediately following fasciotomy, the long and ring fingers were actively
extended to 0. This was maintained through the early postoperative period at 1 week (Fig. 7.7) and 3 weeks (Fig. 7.8).
Initially, the patient had difficulty with tight grip activities due
to her palmar wound, but this normalized by 3 weeks postoperatively. The patients wound healed secondarily without complications. After the healing of her palmar wound, the patient was
told to follow-up if she noticed recurrence or worsening of the
contractures. She has not returned to our clinic for recurrence or
worsening of her contractures.

Literature Review
Open fasciotomy for Dupuytren contracture was one of the earliest
described treatments for the condition. Both Sir Astley Cooper in
1823 and Dupuytren himself in 1834 described such a treatment
and found that it was successful [2, 3]. Fasciotomy requires much
less extensive dissection than fasciectomy. Also, because the neurovascular structures can be clearly identified and protected during
an open fasciotomy, risk of damage to neurovascular structures is
lower than in procedures in which these structures are not visualized, such as percutaneous needle aponeurotomy [4].
Little has been written on open surgical fasciotomy for the
treatment of Dupuytren contracture and reports are generally
retrospective case series. Patient selection for open fasciotomy is
important. Results from multiple series indicate that patients with
MCP contractures experienced better results with fasciotomy
than patients with contractures at the PIP joint [2, 5]. Rowley
et al. found the correction of digits with predominately MCP
contractures to be fairly well sustained for an average of 15
month follow-up [2]. However, Bryan and Ghorbal found that
these results deteriorated over time and that even amongst those
patients with predominately MCP contractures, only 57 % maintained their correction at 5 years postoperatively [5]. Because of
this relatively high recurrence rate, these authors recommended

fist view and (c) lateral clenched fist view show that the patient has some residual stiffness (Photographs courtesy of Richard Kang,
MD)

Fig. 7.7 (ac) Views of the patients hand at 1 week postoperatively. (a) Palmar view shows healthy wound bed. (b) Palmar clenched

7
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R.W. Draeger and P.J. Stern

fasciotomy for treatment of unhealthy or elderly patients with

contractures predominately at the MCP joint [2, 5].
Some authors have not limited their indications for fasciotomy to contractures of the MCP joint alone. Colville treated
contractures of both the MCP joints and the PIP joints with fasciotomy incisions placed as distally at the PIP flexion crease, but
reported mixed results with this technique with an average 75
total extensor lag between the MCP and PIP joints by 3 years
postoperatively [6]. A more recent report from Stewart, et al.
offers more promising results of open fasciotomy. At 5 years
follow-up, these authors achieved a complete release in 93 %
of digits using a transverse incision in the palm for MCP contractures and at the palmodigital crease and PIP crease for PIP
contractures [4]. According to this report, 9 % of patients
required a revision surgery after undergoing open fasciotomy at
an average of 4 years postoperatively. Patients who underwent
fasciotomy incisions in both the palm and the digit were more
likely to develop more severe recurrent disease than those
patients with isolated releases in the palm [4].
Despite wounds being left open to heal by secondary intention
in most of these series, reports of complications are minimal, with
only one wound complication (treated successfully with oral antibiotics) [4]. Other complications, including neurovascular complications, have been minimal, with reported nerve injuries always
being transient [4, 6].
No studies to our knowledge have directly compared contracture correction, recurrence, or complications of open surgical fasciotomy to percutaneous needle aponeurotomy. Though recurrence
is often not universally defined, series of percutaneous needle
aponeurotomy have shown recurrence rates of around 50 % at 3
years postoperatively [79], which is likely comparable or slightly
higher than recurrence rates following open fasciotomy [2, 4, 5].
Though nerve lacerations are uncommon with both percutaneous
needle aponeurotomy (<1 %) [79] and open fasciotomy (0 %) [2,
4, 5], the direct visualization of the Dupuytren cords and the neurovascular bundles in open fasciotomy may help to minimize the
risk of nerve-related complications.

Surgical Fasciotomy for Dupuytren Contracture

93

Fig. 7.8 (ad) Views of the patients hand at 3 weeks postoperatively. (a)
Palmar view shows the wound nearly healed by secondary intention with no
sign of infection. (b) Lateral view shows no residual contracture at the long or
ring finger MCP joints. (c) Palmar clenched fist view and (d) lateral clenched
fist view show that the patient can easily make a tight composite fist with no
residual stiffness (Photographs courtesy of Richard Kang, MD)

Clinical Pearls/Pitfalls
Fasciotomy is most effective for isolated contractures of the
MCP joint.
A transverse incision is placed over the most prominent/subcutaneous portion of the offending cord(s). This usually is around
the area of the distal palmar crease, but do not hesitate to deviate from the crease if another location seems better suited for
the fasciotomy.

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R.W. Draeger and P.J. Stern

Do not hesitate to extend the surgical incision transversely to

ensure that the cord can be completely isolated from surrounding neurovascular structures prior to sectioning the cord.
Leave the wound open to close by secondary intention. This
lessens tension on the wound site, which may help minimize
recurrence. Local wound care is required initially; however,
most patients are able to successfully heal the transverse incision by secondary intention.
Acknowledgement The authors would like to thank Dr. Richard Kang, MD,
for use of the photos appearing in this case.

References
1. Manger B, Schett G. Palmar fasciitis and polyarthritis syndrome-systematic
literature review of 100 cases. Semin Arthritis Rheum. 2014;44(1):
10511.
2. Rowley DI, Couch M, Chesney RB, Norris SH. Assessment of percutaneous fasciotomy in the management of Dupuytrens contracture. J Hand Surg
(Edinburgh, Scotland). 1984;9(2):1634.
3. Dupuytren G. Permanent retraction of the ngers, produced by an affection
of the palmar fascia. Lancet. 1834;2:2225.
4. Stewart C, Davidson D, Hooper G. Re-operation after open fasciotomy for
Dupuytrens disease in a series of 1077 consecutive operations. J Hand Surg
Eur Vol. 2013;39(5):5534.
5. Bryan AS, Ghorbal MS. The long-term results of closed palmar fasciotomy
in the management of Dupuytrens contracture. J Hand Surg (Edinburgh,
Scotland). 1988;13(3):2546.
6. Colville J. Dupuytrens contracturethe role of fasciotomy. Hand.
1983;15(2):1626.
7. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg (Edinburgh, Scotland). 2003;28(5):
42731.
8. Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for
Dupuytren contracture in over 1,000 ngers. J Hand Surg. 2012;
37(4):6516.
9. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in
Dupuytrens disease. J Hand Surg (Edinburgh, Scotland). 2006;31(5):
498501.

Surgical Fasciotomy for Dupuytren Contracture

95

Suggested Readings
Bryan AS, Ghorbal MS. The long-term results of closed palmar fasciotomy in
the management of Dupuytrens contracture. J Hand Surg (Edinburgh,
Scotland). 1988;13(3):2546.
Colville J. Dupuytrens contracturethe role of fasciotomy. Hand.
1983;15(2):1626.
Dupuytren G. Permanent retraction of the fingers, produced by an affection of
the palmar fascia. Lancet. 1834;2:2225.
Rowley DI, Couch M, Chesney RB, Norris SH. Assessment of percutaneous
fasciotomy in the management of Dupuytrens contracture. J Hand Surg
(Edinburgh, Scotland). 1984;9(2):1634.
Stewart C, Davidson D, Hooper G. Re-operation after open fasciotomy for
Dupuytrens disease in a series of 1077 consecutive operations. J Hand Surg
Eur Vol. 2013;39(5):5534.

Chapter 8

Surgical Fasciectomy for Dupuytrens

Contracture
Nathan Douglass and Jeffrey Yao

Case Presentation
A 54-year-old right-hand dominant woman presented to our clinic
with recurrent contracture of the ulnar side of her left hand consistent with Dupuytrens disease. A partial surgical fasciectomy
involving the small finger had been performed 6 years prior by
another surgeon. Postoperatively she participated in hand therapy
and nighttime splinting, but her disease gradually returned. Her
chief complaint was difficulty with activities of daily living due to
her contractures. Examination demonstrated a 10 contracture of
the long finger MCP, 20 and 80 contractures of the ring finger
MCP and PIP, respectively, and 30 and 30 contractures of the
small finger MCP and PIP, respectively.

N. Douglass, MD () J. Yao, MD

Department of Orthopaedic Surgery, Stanford University Medical Center,
450 Broadway Street, Redwood City, CA 94063, USA
e-mail: [email protected]; [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_8

97

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N. Douglass and J. Yao

Concepts of Surgical Management

Dupuytrens is a chronic disease without a known cure. Although
surgical fasciectomy often produces the appearance of a short-term
cure without recognizable residual disease, there is a permanent
risk of new or recurrent disease. Even with meticulous microdissection of all visible disease, new or recurrent foci of disease may
appear in the long term. Unlike a tumor with margins, Dupuytrens
disease is an underlying disorder of tissue and therefore margins
are unclear or nonexistent during surgery. One must also consider
the potential for worsening of the inflammatory disease process
after surgery. Dupuytrens disease is an abnormal fibroproliferative
reaction to tensile forces and surgical management focuses on
elimination of diseased tissue and shielding the hand from such
tensile forces, including residual skin. Residual mechanical stress
across the diseased areas may increase fibroblast proliferation and
recurrence of contractures [13].

Indications
Surgical treatment of Dupuytrens disease is an elective procedure
and usually undertaken once the hand begins to lose function.
Contractures of the MCP and PIP joints are most common reasons
for surgery, although web space contractures may also interfere
with grasp or pinch. The tabletop hand test is an excellent and easy
metric for both surgeons and patients to follow clinically [4]. As
contractures develop past 30 in the MCP joints or 1520 in the
PCP joints, the hand is unable to be placed flat on a table. This is
the typical severity of contracture that leads to the consideration of
surgery. Contractures of the first web space between thumb and
index finger may affect hand function significantly (Fig. 8.1ad).
Contractures that are borderline for surgical consideration without
progression or functional impact are reasonably treated with observation. On the other hand, worsening contractures reliably progress
and interfere with functional tasks of daily living.

Surgical Fasciectomy for Dupuytrens Contracture

Fig. 8.1 Contracture of the web space between the thumb and index finger is demonstrated preoperatively (a). A Z-plasty incision (b)
was utilized, with a cord identified for excision intraoperatively (c) and closure (d) with concomitant carpal tunnel release

8
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N. Douglass and J. Yao

The decision to pursue treatment must take into consideration

the context of the disease including the severity of the disease,
patient age and comorbidities, and patient expectations. Evaluation
of disease severity includes its rate of progression, degree of contractures, concomitant lower extremity plantar or penile disease,
and functional losses. At the same time, patients with mild but
worsening contractures should be counseled that the surgery
required to correct contractures becomes more complex and the
results less predictable as the contractures worsen. As with other
joints in the body that are immobilized for long periods of time, the
joint capsule, collateral ligaments, and other surrounding tissues of
the digits will contribute to contractures over time and may require
more aggressive treatment to correct.

Setup
Operative procedures for Dupuytrens disease are best performed
with regional peripheral nerve blockade (supra- or infraclavicular
block) with light sedation in an ambulatory surgical center. The
patient is placed in the supine position with the aid of a hand table.
The upper extremity is draped in the usual sterile fashion, and the
limb exsanguinated with an Esmarch elastic bandage and inflatable
tourniquet. Intravenous antibiotics are given prior to incision. We
prefer to use the universal hand holder and retractor set for positioning of hand and digits.

Open Surgical Techniques

Open surgical treatment of Dupuytrens disease is classified as
segmental fasciectomy, limited fasciectomy, dermatofasciectomy,
or radical fasciectomy.
The once popular radical fasciectomy [5] has largely fallen out
of favor owing to its increased morbidity without demonstrable
improvement in recurrence rates. In radical fasciectomy, the entire

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palmar fascia is excised, including fascia that is normal in appearance. In theory radical fasciectomy eliminates active and future
sources of disease. However, evidence has demonstrated significant recurrence rates nonetheless [6].
Limited fasciectomy remains the mainstay for open treatment of
Dupuytrens disease. Surgery focuses on removal of the bulk of
diseased tissue and correction of contractures, with limited dissection otherwise. The goal is to excise enough diseased tissue in
order to obtain functional improvements with the understanding
that recurrence or disease extension may occur in the long term.
Dermatofasciectomy involves a limited fasciectomy with excision of skin intimately involved with the underlying disease
(Fig. 8.2ad). The defect in the volar digit or palm is filled with full
thickness skin grafting. Proponents theorize that the normal skin
graft acts as a barrier to disease recurrence, although recurrence
still may occur [7, 8]. Surgeons typically utilize dermatofasciectomy more often in cases of greater disease burden, including
recurrence or in younger patients with severe disease [79].
Moermans [10] described the use of multiple segmental aponeurectomies or fasciectomies through the use of multiple 11.5 cm
curved incisions, which if joined together would form a lazy S.
The multiple defects create discontinuities in the contractures
allowing correction of the contracture with limited removal of diseased tissue.

Incisions
Many skin incisions have been described for fasciotomy or fasciectomy. The incision chosen should allow for adequate exposure
without threatening skin flap viability, resection of diseased skin
when indicated, and allow tension-free closures after the correction
of contractures. In general, longitudinal incisions may be easily
extended and provide good intraoperative visualization of primarily longitudinal anatomic structures. Transverse incisions are popular in the palm, including Dupuytrens original description for
fasciotomy. The type of incision chosen depends more on the foci

Fig. 8.2 Contractures affecting the small finger PIP and DIP joint preoperatively (a) were treated with dermatofasciectomy and skin
grafting (b). Postoperative images demonstrating appearance and range of motion (c, d)

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of disease and surgeon preference than the superiority of any particular incision type. Often, multiple incisions and combinations of
types are used in a single procedure. For revision surgery, as was
the case with the patient presented here, previous incisions are best
utilized and extended as needed.
Longitudinal incisions including Bruner-type zigzag, V-Y
advancement, Z-plasty (Fig. 8.3ad), and midaxial (Fig. 8.4a, b)
incisions are well suited for exposure of the longitudinal anatomical structures of the hand and digits including contracted cords.
One randomized study found no difference in recurrence rates
amongst two types of longitudinal incisions [11].
In 1964, McCash [12] popularized the open palm technique
(Fig. 8.5ad). McCash made incisions in the transverse palmar
creases similar to Dupuytrens original technique. Unlike
Dupuytren who incised diseased contractures, McCash performed
limited fasciectomies. Upon correction of the contracture and
extension of the digits, the resulting skin deficit in the distal palmar
crease is left open to heal by secondary intention and treated with
a compressive tulle gras dressing and plaster splint. Tulle gras
consists of gauze or other weaved fabric impregnated with soft
paraffin, or paraffin equivalent. It may also be impregnated with
antiseptics or antibiotics. One layer of tulle gras is applied to the
open wound followed by a polyvinyl sponge or dry gauze. Firm
pressure is applied to the entire hand while a volar plaster slab is
placed over the soft dressing with continued pressure until the
plaster sets [12].
Longitudinal incisions in the fingers can be combined with open
palm technique for the so-called open palm closed fingers technique (Fig. 8.6ac).

Dissection
Generally the incision begins proximally and proceeds distally. The
proximal extent of the incision is determined by the proximal extent
of the diseased cord or a natural landmark such as Kaplans cardinal
line. As the diseased pretendinous cord is released proximally, its

Fig. 8.3 Small finger contracture (a) treated with Z-plasty incision (b), after cord excision (c) and resultant closure (d)

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Fig. 8.4 A midaxial incision (a) used to treat a small finger PIP contracture from pretendinous and abductor digiti minimi cords (b)

8
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Fig. 8.5 Preoperative clinical photograph (a) demonstrating fourth and fifth finger contracture from pretendinous cords seen intraoperatively (b). The open palm technique leaves the incision open (c). Postoperatively the wound is treated with tulle gras compressive
dressing and volar plaster splinting with fingers extended. The wound heals by secondary intention (d)

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Fig. 8.6 Extensive disease affecting the ulnar three digits (a) was treated with the open palm closed finger technique. At the end of the
procedure the longitudinal digital incisions were closed and the palmar incision left open (b). Subsequent follow-up demonstrates
wound healing (c)

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effect on the distal joints may change and allow easier planning of
the distal incisions. There is always concern for injury to the neurovascular bundles. It is helpful to begin the dissection in normal tissue in order to aid in its dissection and for identification and
subsequent protection of the neurovascular bundles during mobilization of diseased tissue.
The preoperative exam provides pertinent information about
which pathologic cords to expect upon the surgical exposure and
minimize risk of neurovascular injury. The common cords
resected include the pretendinous, central, spiral, lateral, natatory,
abductor digiti minimi, retrovascular, commissural, and radial
thumb cord.
Spiral cords present a particular threat and potential for neurovascular injury, particularly with the initial skin incision, as the
neurovascular bundle may lie directly underneath the skin on top
of the fascia. The spiral cord, originating from four components
(pretendinous band, spiral band, lateral digital sheet, and Graysons
ligament), displaces the neurovascular bundle centrally, superficially, and proximally. Surgeons should be suspicious of spiral
cords when clinical exam demonstrates a PIP joint contracture with
a palpable interdigital soft tissue mass.

PIP Joint Contracture

Resection of diseased tissue and cords reliably corrects MCP contractures yet PIP joint contractures continue to be difficult to correct completely and permanently. Often a PIP contracture may
improve but not fully resolve with release of the pathologic cords.
Longstanding severe joint contractures potentially affect the joint
capsule, volar plate, collateral ligaments, tendons, and surrounding
soft tissues.
Severe contractures more reliably achieve a significant
degree of improvement whereas less severe contractures, particularly those less than 30, perform more unpredictably in the
long term [13]. If there is residual contracture following standard fasciectomies, tenolysis and tenotomies at varying levels

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have been advocated [14]. Capsulectomy, volar plate release,

and checkrein ligament release have also been proposed [15].
However in one study there was no significant benefit from capsuloligamentous release in addition to fasciectomy alone for
severe PIP contractures [16]. Residual PIP contractures of 30 or
less after fasciectomy are best left alone without further dissection or release.

Closure
At the end of the procedure the tourniquet is released and great
attention is directed towards achieving hemostasis. The vascularity
of all digits must be confirmed prior to closure. Vasospasm may be
treated first with warm sponges at the time of tourniquet deflation,
and then continuous warm irrigation as needed. Finger flexion and
local application of smooth muscle relaxants such as lidocaine may
be helpful subsequently. If the digit is still not perfusing, the digital
arteries should be explored for unrecognized lacerations or rupture.
Avascular skin flaps may be trimmed.
Reexamining the neurovascular bundles prior to closure allows
immediate repair of unrecognized nerve injuries and eliminates the
potential confusion for neuropraxia in the setting of postoperative
numbness.
Postoperative hematoma will threaten the viability of overlying
skin and provide a nidus for infection, particularly if skin grafts are
used. Per surgeon preference, a drain may be placed in the palm
and removed the next day in the office as most procedures now are
performed on an outpatient basis.
Skin closure is performed by direct re-approximation, V-Y or
Z-plasty, skin grafting, or left open (open palm technique). We
prefer closure with interrupted 4-0 nylon sutures, and placement
of a compressive dressing followed by plaster splinting with
extension at MCP, PIP, and DIP joints. Tulle gras is a popular
material for wound bandaging and consists of a weave fabric
impregnated with soft paraffin placed directly onto the closed or
open wound.

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Follow-Up
The patient follows up in clinic 1 week postoperatively for splint
removal and assessment of the incisions. Hand therapy is begun at
that point with aggressive flexion/extension of the digits. The hand
therapist fashions an MCP/PIP/DIP joint extension splint for nighttime use only. The patient returns 2 weeks postoperatively for reassessment of wounds and suture removal. The patient is instructed
in wound care and scar massage.
When performing the open palm technique, the patient begins
opening and closing the hand at 48 h, and the dressing is changed
1 week postoperatively.
Skin grafts require longer immobilization for the graft to take,
and are checked beginning postoperative day 2 for hematoma.

Literature Review
Outcomes of Fasciectomy
Reviewing the literature demonstrates difficulties comparing studies given varying definitions of recurrence and follow-up periods.
Typically reported recurrence rates range from 8 to 54 % [17] and
up to 74 % in the long term [18]. The majority of recurrences occur
in the first few years after surgery [19, 20]. In the long term nearly
all patients should expect some form of recurrence or extension of
disease [17, 21].
Some authors advocate dermatofasciectomy over partial fasciectomy for severe disease with skin involvement or recurrent disease. In some studies dermatofasciectomy has shown lower rates of
recurrence and similar rates of extension compared to partial fasciectomy alone [22, 23]. A randomized trial showed no benefit compared to partial fasciectomy and skin closure with Z-plasty, with
recurrence rates of 12.2 % at 3 years in both groups [7]. Risk factors for recurrence include young age, knuckle pads, and small
finger involvement [19].

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Complications
Complications after surgical treatment are expected in 1520 % of
patients, but complications causing permanent harm or disability
are rare [1]. Surgeons should monitor for hematoma, neurovascular
injury, infection, wound necrosis, skin graft failure, stiffness, and
postoperative flare or complex regional pain syndrome. Prompt
recognition and treatment of complications, particularly neurovascular injuries, will diminish their short- and long-term impacts
[24]. Revision surgery and extensive disease increase the difficulty
of surgery and likelihood of complication.
Case Presentation
In our patients procedure, the previous Bruner incision in the
small finger was utilized and extended all the way to Kaplans
cardinal line (Fig. 8.7ad). The pretendinous cord was released
proximally and as the cord was brought more distally, the neurovascular bundles were protected. An abductor digiti minimi cord
and spiral cord were identified and carefully excised. The MCP
and PIP joint of the small finger achieved full extension.
In the ring finger a pretendinous cord was identified. A Bruner
incision was used, taking great care to avoid narrow skin flaps. At
this point, the cord was identified proximally and released again
protecting the neurovascular bundles. Again a spiral cord was identified and complete excision of the Dupuytrens fascia achieved
correction of the PIP and MCP joint contractures.
Lastly, the incision from the ring finger was extended over to
the long finger and a pretendinous cord was identified and excised
correcting the MCP joint contracture.
At 4-year follow-up the patient was found to have full active
extension of all joints with the exception of the small finger PIP,
which demonstrated a 20 active and 11 passive flexion contracture (Fig. 8.8ac).

Fig. 8.7 The previous Bruner incision over the small finger and a single longitudinal incision over the fourth digit were utilized and
diseased tissue excised (a, b). Full extension of the digits was achieved (c). A typical specimen of excised tissue (d)

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Fig. 8.8 Clinical photographs at 4-year follow-up demonstrate continued improvement of contractures with mild recurrence of the
small finger PIP joint contracture (ac)

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Summary
Dupuytrens disease is a common hand pathology seen in hand and
upper extremity clinics. Surgical intervention should be considered
when functional disability results from joint or web space contractures. Informed consent must include discussion of the considerable risks of recurrence and extension, based on patient-specific
risk factors. Surgery intends to remove clearly diseased tissue with
limited dissection into normal tissues. A number of skin incisions
and techniques including dermatofasciectomy, skin grafting, and
the open palm technique have been described. Each technique or
incision has its pros and cons without one being clearly superior in
all cases. Vigilant practitioners identify and treat neurovascular
injuries and wound complications promptly. Postoperative care
focuses on wound healing and early motion. Even in cases of
severe and recurrent contractures, surgical fasciectomy for
Dupuytrens disease can preserve considerable hand function from
an otherwise debilitating condition.

References
1. Eaton C, Seegenschmiedt H, Bayat A, Gabbiani G, Werker P, Wach
W. Dupuytrens disease and related hyperproliferative disorders: principles, research, and clinical perspectives. New York, NY: Springer; 2012.
2. McGrouther DA. The microanatomy of Dupuytrens contracture. Hand.
1982;14:21536.
3. Citron N, Hearnden A. Skin tension in the aetiology of Dupuytrens disease: a prospective trial. J Hand Surg Am. 2003;28B(6):52830.
4. Hueston JT. The table top test. Hand. 1982;14:1003.
5. McIndoe A, Beare RL. The surgical management of Dupuytrens contracture. Am J Surg. 1958;95:197203.
6. Dickie WR, Hughes NC. Dupuytrens contracture: a review of the late
results of radical fasciectomy. Br J Plast Surg. 1967;20(1958):3114.
7. Ullah AS, Dias JJ, Bhowal B. Does a firebreak full-thickness skin graft
prevent recurrence after surgery for Dupuytrens contracture? A prospective, randomised trial. J Bone Joint Surg Br. 2009;91:3748.
8. Armstrong JR, Hurren JS, Logan AM. Dermofasciectomy in the management of Dupuytrens disease. J Bone Joint Surg Br. 2000;82:904.

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9. Black EM, Blazar PE. Dupuytren disease: an evolving understanding of an

age-old disease. J Am Acad Orthop Surg. 2011;19:74657.
10. Moermans JP. Segmental aponeurectomy in Dupuytrens disease. J Hand
Surg Br. 1991;16:24354.
11. Citron ND, Nunez V. Recurrence after surgery for Dupuytrens disease: a
randomized trial of two skin incisions. J Hand Surg Am. 2005;
30(6):5636.
12. McCash CR. The open palm technique in Dupuytrens contracture. Br
J Plast Surg. 1964;17:27180.
13. Legge JW, McFarlane RM. Prediction of results of treatment of Dupuytrens
disease. J Hand Surg Am. 1980;5:60816.
14. Hueston JT. The extensor apparatus in Dupuytrens disease. Ann Chir
Main. 1985;4:710.
15. Crowley B, Tonkin MA. The proximal interphalangeal joint in Dupuytrens
disease. Hand Clin. 1999;15:13747. viii.
16. Weinzweig N, Culver JE, Fleegler EJ. Severe contractures of the proximal
interphalangeal joint in Dupuytrens disease: combined fasciectomy with
capsuloligamentous release versus fasciectomy alone. Plast Reconstr Surg.
1996;97(3):5607.
17. Hurst L. Dupuytrens contracture. In: Hotchkiss RN, Pederson WC, Kozin
SH, Wolfe SW, editors. Greens operative hand surgery. 6th ed.
Philadelphia: Churchill Livingstone; 2011. p. 14158.
18. Vigroux JP, Valentin P. A natural history of Dupuytrens contracture
treated by surgical fasciectomy: the influence of diathesis (76 hands
reviewed at more than 10 years). Ann Chir Main Memb Super.
1992;11:36774.
19. Hueston JT. Recurrent Dupuytrens contracture. Plast Reconstr Surg.
1963;31(1):669.
20. Rebelo JS, Ferreira JB, Vilo MC, Bolo-Tom J. Dupuytrens disease.
Analysis of a 10 year caseload. Acta Med Port. 1992;5:4636.
21. Hueston JT. Limited fasciectomy for Dupuytrens contracture. Plast
Reconstr Surg Transplant Bull. 1961;27(6):56985.
22. Tonkin MA, Burke FD, Varian JP. Dupuytrens contracture: a comparative
study of fasciectomy and dermofasciectomy in one hundred patients.
J Hand Surg Br. 1984;9(2):15662.
23. Ketchum LD, Hixson FP. Dermofasciectomy and full-thickness grafts in
the treatment of Dupuytrens contracture. J Hand Surg Am.
1987;12:65964.
24. Boyer MI, Gelberman RH. Complications of the operative treatment of
Dupuytrens disease. Hand Clin. 1999;15:1616. viii.

Chapter 9

Wide Awake Dupuytrens

Fasciectomy: A Pathoanatomical
Approach
Quamar M.K. Bismil and M.S.K. Bismil

Copyright The authors and the Worldwide Awake Hand Surgery group
grant copyright to all materials herein to Springer, without restriction,
with the proviso that the authors have relied upon the 13 referenced
articles and works, the 2 anaesthetic review articles for the appendix; and
the original authors and copyright owners are thus respected.
Declarations MSK Bismil and QMK Bismil are founder members of the
Worldwide Awake Hand Surgery group and the founders of one-stop wide
awake hand surgery.
The Worldwide Awake Hand Surgery Group The Worldwide Awake Hand
Surgery group was founded by TH Robbins, MSK Bismil and QMK Bismil
circa 2012 and is delighted to assist hand surgeons in their transition to wide
awake hand surgery.
www.worldwideawake.net
Q.M.K. Bismil, MBChB, MRCS DipSEM MFSEM DMSMed FRCSEd ()
M.S.K. Bismil, MBBS, MS, FRCSEd, DLM
The World Wide Awake Hand Surgery Group, Queen Anne Street
Medical Centre, London W1G 8HU, UK
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_9

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One-Stop Wide Awake Dupuytrens Fasciectomy

A 40-year-old man presented to the Wide Awake Hand Surgery
clinic with a 15-year history of recurrent deformity of the right
dominant ring and little fingers secondary to Dupuytrens contracture. He had previously undergone two operations on the right hand
and ring finger elsewhere: these were both conventional fasciectomies performed under general anaesthesia and with a tourniquet. He
reported that he had never had a straight ring finger post-surgery.
The patients initial request to the treating surgeons (M.S.K.B. and
Q.M.K.B.) was for amputation of both fingers. The patient was fit
and well with no history of allergy, took no regular medications and
had no history of recreational drug use.
On examination, there was Tubiana stage IV Dupuytrens contracture (Table 9.1) of the ring and little fingers with profound
scarring from the previous surgery. There was a fixed proximal
interphalangeal (PIP) contracture of the ring finger. There were mobile
metacarpophalangeal contractures of both fingers and a mobile PIP
contracture of the little finger. Clinically, the ring finger pathoanatomy
comprised ulnar-sided central, pretendinous and lateral cords,
Graysons ligament and a natatory cord traversing to the little finger
(Fig. 9.1). The central and pretendinous cords were associated with
nodular disease. There was no palpable disease in the little finger ray
per se. At informed consent, the full range of treatment options,
including no treatment and deferred treatment, were discussed. The
main treatment options presented were wide awake fasciectomy
(either as a one-stop procedure or deferred) and dermofasciectomy
(with potential onward referral to a general/regional anaesthesia hand
surgeon). The patient was eager to proceed with ring finger wide
awake fasciectomy in one management stop [one-stop wide awake
(OSWA) fasciectomy].
Table 9.1 Tubiana stages
Tubiana stage
Total degree of contracture (MCP + PIP)
I
Less than 45
II

Greater than 45

III

Greater than 90

IV

Greater than 135

Wide Awake Dupuytrens Fasciectomy

Fig. 9.1 One-stop wide awake Dupuytrens fasciectomy pathoanatomical approach

9
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Wide awake minimally invasive anaesthesia (see appendix,

below) for wide awake fasciectomy typically utilises lignocaine 2 %
with low-dose adrenaline 1:200,000; the latter acts as a vasopressor
and offsets vasodilation from the local anaesthetic. In this case we
used 5 ml of lignocaine 2 % with low-dose adrenaline 1:200,000
infiltrated through a 23-gauge needle into the web spaces to anaesthetise the palmar skin. For digits, we prefer plain lignocaine 2 %,
infiltrated through the anaesthetised palmar skin using a 21-gauge
needle into the volar compartment of the finger at the proximal
phalangeal level (in this case, an additional 5 ml of plain lignocaine
was used). Smaller needles, say 2530 gauge, may also be used to
minimise injection pain, but in our experience there is a tendency to
force the anaesthesia through the smaller needles, especially if
there is increased resistance due to the thickened fascia. It should
also be noted, as an alternative, that Lalonde and colleagues [1, 2]
routinely use lignocaine with low-dose adrenaline for digits as well
as for the palm. A key point for all wide awake anaesthesia techniques is that only small pain fibres are blocked and that peripheral
nerves are not targeted. Thus, surgery is performed on a moving,
sensate hand. In Dupuytrens surgery this means that the flexor tendon mechanism can be assessed dynamically during the procedure,
exercises can be demonstrated and understood with full anatomical
visualisation during the procedure and the mode of wound closure
can be optimised to ensure an ideal (usually full) range of motion is
facilitated. The patient is also advised to tell the surgeon immediately if he feels any nerve pain (tingling/numbness/electric shocks)
as this may help the surgeon when dissecting around the digital
nerves. In our experience, the best ways to minimise injection pain
include injecting very slowly, using a smaller gauge needle initially
to anaesthetise through the web space, advancing the needle tip
sequentially through the anaesthetised field and using no larger than
a 5-ml syringe to inject (larger syringes may encourage a more vigorous injection technique, in terms of rate and pressure applied).
Other options during wide awake anaesthesia include buffering the
local anaesthetic (i.e., alkalising it to a more physiological pH) and
using a tumescent technique with diluted anaesthetic solution. In our
own practice, the former has not been required and the latter is not

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used routinely in Dupuytrens cases because we do not feel it is

particularly helpful for wide awake fasciectomy, where we wish to
minimise distortion of the anatomy, especially in relation to the
neurovascular bundles. Simple additional methods to minimise
injection pain include distraction (through either conversation or
audiovisual materials), skin sensory stimulation through gentle
pinching, meditation/mindfulness techniques and the use of a bone
vibrator or similar device on the nearby soft tissues whilst the injections are being delivered. In our experience, all but the most needlephobic patients are happy to endure usually no more than 30 s of
superficial injections for the comfort of tourniquet-free surgery.
In wide awake fasciectomy surgery, as with any fasciectomy
technique, anatomical dissection is key: not only enabling visualisation and removal of all macroscopically abnormal fascia, but also
obviating the need for a tourniquet. Whereas in conventional fasciectomy the surgeon has the luxury of the tourniquet and a bloodless
field, the wide awake hand surgeon must learn to manage bleeding
effectively. However, as with conventional fasciectomy, it is principally anatomical dissection and a complete understanding of the
pathoanatomy that facilitate an optimal procedure and, in particular, avoidance of any trauma to the palmar arch, digital vessels or
their main branches and tributaries. Providing there is no trauma to
the larger (i.e., macroscopically visible) palmar or digital vessels,
bleeding merely needs to be managed by the wide awake hand
surgeon whilst the microvascular bleeding is controlled by primary
haemostasis. That is, the wide awake hand surgeon must learn to
manage bleeding, especially early in the procedure, whilst awaiting
the progression of microvascular constriction and platelet plug
formation. This leads to the wide awake hand surgeons philosophy
of bleeding management as pressure and time (see the section
entitled Discussion). Thus, through meticulous dissection, point
pressure from a rolled swab and primary haemostasis, hand surgeons ensure that as the wide awake fasciectomy proceeds, bleeding becomes progressively less of an issue (as the coagulation
cascade progresses and the low-dose adrenaline augments
vasoconstriction).

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During the wide awake fasciectomy, the diseased cords related

to the ring finger were fully removed using the standard technique
[3]. In this case, this involved sequential visualisation and fasciectomy of the ulnar-sided pathoanatomy (i.e., central, pretendinous,
spiral and lateral cords, Graysons ligament and the natatory cord
traversing to the ring finger). The neurovascular bundles were
visualised in their entirety and were heavily involved with scar tissue and also a spiral cord. The flexor mechanism was also encased
in scar tissue and was sequentially removed. This necessitated
windowing of the flexor sheath, which could be fine-tuned dynamically with active movement. The patient was also asked to move
the digit intermittently to enable the surgeon to delineate scar tissue
from flexor mechanism.
Extensive skin involvement meant that primary Z-plasty was
not feasible since the skin flaps would have been too thin. For the
fixed PIP contracture, we performed volar joint capsulotomy,
released the checkrein ligaments and released accessory collateral
ligaments. During the informed-consent procedure, the standard
discussion about deferred Z-plasty (as required) had been included.
In fact, in this case deferred Z-plasty was not necessary (see the
following section, Discussion). Pre- versus post-operative photographs demonstrate full correction of the ring finger deformity and
a good correction of the little finger without any separate surgery
having been performed on this ray. The patient was followed up for
several months, and there was a significant improvement in all
outcome measures.

Discussion: Literature Review

There have been recent developments in the management of
Dupuytrens contracture. Ultimately, it is likely that basic science
research into the faulty signalling pathways that result in the abnormalities of the palmar fascia in Dupuytrens contractureand targeting the myofibroblastwill result in a cure for the condition
later this century. Until then, advances in wide awake hand surgery
are likely to play a role in the management of this challenging

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condition. Broadly, the wide awake treatment options for the management of Dupuytrens contracture causing functional problems
are fasciotomy (disrupt the diseased tissue with a blind procedure)
or fasciectomy (remove the diseased tissue with an open procedure). Prior to the advent of wide awake hand surgery, fasciectomy
required tourniquets and general/regional anaesthesia/sedation.
The avoidance of rare but potentially catastrophic complications of
general anaesthesia in the Dupuytrens surgical cohort of often
elderly patients is clearly advantageous.
This complex case demonstrates the role of wide awake fasciectomy, with visualisation and removal of the diseased fascia in the
wide awake patient, in complex cases. The scarring from previous
surgery and the complex disease meant that a blind fasciotomy
technique was not appropriate. At informed consent, the patient
clearly wished to avoid (the risks of) general anaesthesia, regional
anaesthesia, sedation and tourniquets and hence was a good candidate for wide-awake fasciectomy. We invariably adopt a staged
approach to Dupuytrens contracture, with each digit assessed and
treated separately. Indeed, this case demonstrates that just because
multiple digits are affected does not mean that multiple rays
require surgery.
Careful consideration of the pathoanatomy enables logical management of Dupuytrens contracture through wide awake fasciectomy. The cause of the little finger involvement in this case was the
natatory cord, and this was evident from the pre-operative examination. There was no palpable disease in the little finger, but it is
likely that the natatory cord that was removed connected to some
occult lateral cord disease in the little finger. It is possible that
further surgery to the little finger would improve the residual PIP
contracture; but without palpable disease in this finger, we elected
with the patient to adopt a watchful waiting approach to this digit.
The origins of wide awake Dupuytrens surgery can be traced
back to 1981 with TH Robbins paper [4] on deferred Dupuytrens
Z-plasty under local anaesthesia. The rationale for using straight
incisions in wide awake Dupuytrens surgery is related to the principles of wide awake hand surgery without tourniquet, as follows.
Whilst the use of low-dose adrenaline minimises bleeding (in addition to prolonging the duration of anaesthesia), it does not provide a

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bloodless field in tourniquet-free wide awake hand surgery. With the

advent of wide awake techniques, the risk of tourniquet complications
(including swelling, muscular weakness, neurapraxia, hematoma and
infection, vascular trauma, necrosis, compartment syndrome and systemic complications) [5] can be avoided. Moreover, there is a limit to
the duration of tourniquet use, in terms of pain and the onset of complications. It has been documented that there is finite amount of tourniquet time that an awake hand surgery patient can withstand from a
physiological perspective [6].
Straight incisions with or without Z-plasty [4] or Brunner incisions [2, 7] may be used for fasciectomy. However, we primarily
utilise straight incisions [3] because bleeding is invariably at its
peak at the beginning of the procedure when the incision is being
made, so we prefer to use a technique which initially avoids the
neurovascular bundle. The wide awake hand surgeons philosophy
of the management of bleeding, pressure and time, hinges upon
meticulous dissection to avoid any trauma to the vascular macroanatomy; primary haemostasis; point pressure by the surgeon to
control any microvascular bleeding whilst the vessels are constricting and the platelet plug is forming; and promoting vasoconstriction with low-dose adrenaline.
We do not use any form of diathermy for wide awake hand surgery, which underlines the efficacy of the pressure and time philosophy, providing the macrovascular integrity is maintained by
the surgeon. By the end of the procedure, the wound should be
quite dry, with only minimal ooze from the skin edge and subcutaneous microvasculature. If this is not the case, then the vascular
tree in the operative zone should be carefully inspected and any
disruption must be dealt with. The logic of wide awake hand surgery in the context of the management of surgical bleeding in fasciectomy is threefold: firstly, it hinges upon a meticulous
fasciectomy technique; secondly, rather than preventing bleeding
with a tourniquet, the wide awake hand surgeon surgeon respects
the coagulation cascade and augments it with the alpha adrenergic
effects of low-dose adrenaline on vascular smooth muscle; and
thirdly, the wide awake hand surgeon can confidently close the
quite dry wound at the end of the procedure, knowing that the vascular tree has not been compromised. Thus, the rather counterintuitive exercise of eliminating all bleeding/blood flow with a

Wide Awake Dupuytrens Fasciectomy

125

tourniquet for the body of the surgical procedure but then deflating
the tourniquet prior to closing the wound in order to finally see and
manage the bleeding, almost as an afterthought, can now be
avoided. By managing the bleeding in a logical, stepwise fashion
(Fig. 9.2), the wide awake hand surgeon can confidently close the
quite dry wound, knowing that the coagulation cascade will continue to control bleeding, especially if augmented with the modified boxing glove dressing we have described in another publication
[3]. We find that inspecting and working around a normal albeit
vasoconstricted vascular tree (with the propensity to bleed) during
the entire procedure invariably facilitates and ensures the meticulous dissection and preservation of the vascular anatomy that fasciectomy requires. And rather than a race against the tourniquet,
the procedure can be conducted at leisure. Moreover, tourniquetfree hand surgery under local anaesthesia empowers the patient to
understand his condition and treatment and to take control of his
rehabilitation from the point of surgery.
In wide awake hand surgery, bleeding is maximal within the first
510 minutes of the procedure given that the onset of the optimal
vasoconstrictive effect from epinephrine is around 5 minutes [8] and
the bleeding time is invariably less than 10 minutes. This means that
the wide awake hand surgeon can reliably predict and manage the
bleeding as the procedure progresses. Moreover, in terms of incisions and closure, it is inevitable that by the end of the procedure
provided that meticulous dissection has respected the
anatomyZ-plasties can be sited with the neurovascular bundles
under direct vision and without any compromise to vision from
bleeding, but the patient has a physiologically normal vascular tree
with the propensity to bleed if traumatised. We also prefer Z-plasties
as necessary over Brunner incisions because of the 30 % lengthening
Z-plasties invariably enable us to achieve. Robbins [4] deferred his
Z-plasties as a second procedure as required; this approach was
indeed utilised in the case described in this chapter. Ultimately, however, this case did not require a deferred Z-plasty since the scar did
not contract and the correction of the deformity was maintained: this
is a lesson in itself. Finally, on the subject of incisions and closure,
and with regards to our own practice, we should make it clear that
our routine method of incision is longitudinal and our routine
method of closure is Z-plasty. However, on a case-by-case basis we

510 MINUTES

Vasoconstriction +
alpha adrenergic
effects of low-dose
adrenaline

Fig. 9.2 The wide awake hand surgeons pressure and time approach to bleeding

Meticulous and
logical dissection of
pathoanatomy and
point pressure to
control bleeding
10 MINUTES

Platelet plug
formation

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Q.M.K. Bismil and M.S.K. Bismil

Wide Awake Dupuytrens Fasciectomy

127

Primary Z-plasty if
possible when
bleeding stopped
and providing skins
flaps not too thin
Longitudinal incision
to avoid
neurovascular
bundle

Deferred Z-plasty as
required

WIDE AWAKE
WOUND
MANAGEMENT

Fig. 9.3 Wide awake wound management within our practice

apply an algorithm as outlined throughout this chapter and as

depicted in Fig. 9.3.
Whilst the alpha adrenergic vasoconstrictor effect of low-dose
adrenaline is helpful in wide awake fasciectomy for bleeding management and prolongation of the anaesthesia, it is not essential. We
have performed many fasciectomies using only plain local anaesthesia and without a vasopressor; invariably, meticulous dissection,
management of ooze with point pressure and the patients coagulation cascade facilitate a technically successful wide awake fasciectomy without bleeding complication. Patients with coagulopathy or
bleeding diathesis should be carefully evaluated in conjunction with
their haematologist before any treatment is offered for their
Dupuytrens condition. If any contraindications to low-dose adrenaline/vasopressor exist, use plain local anaesthesia. As surgeons plan
their transition to wide awake hand surgery, they should carefully
select their patients. The use of plain local anaesthesia should be
reserved only for the more experienced wide awake hand surgeon
since such procedures are inevitably more challenging.

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With wide awake fasciectomy, the patient is involved in an

immediate patient-centred rehabilitative approach with the pathology, surgery and rehabilitation demonstrated on table and with full
visualisation of the (patho-)anatomy. With the wide awake approach,
the patient is shown her post-operative exercises on the table and
accelerated rehabilitation commences immediately (range-of-motion
exercises, mid-range). Further active movement (full, including endrange) commences according to comfort as soon as the modified
boxing glove bandage is removed (i.e., after 1 week). The modified
boxing glove bandage [3] has been used by the senior author
(MSKB) for several decades; along with the pressure and time
approach to the management of bleeding in hand surgery, it has
eliminated significant post-operative haematoma in Dupuytrens
fasciectomy patients [3]. Thus, we have not had any returns to theatre for bleeding or infection since the foundation of the Wide
Awake Hand Surgery service here in the United Kingdom in 1999.
Passive daily stretching commences once the wound is healed. For
patients such as the gentleman described here who opt for a one-stop
pathway, the rehabilitation taught during the procedure is supplemented with web video. Also, patients have uninterrupted access to
the surgeon via a telephone helpline and email. Scar massage and
scar desensitisation techniques are taught as required, often remotely
using web resources (see Fig. 9.4).
The patients perception and approach to the benefits versus
risks of management options are key in logical decision making
during the informed-consent process (Fig. 9.5). Other than wide
awake fasciectomy, options include fasciotomy with a needle or an
enzymatic injection and dermofasciectomy under general or
regional anaesthetic.
We are reluctant to perform blind fasciotomy techniques in
complex disease configurations or revision cases since the proximity of the digital nerves and tendons jeopardises these structures
when normal anatomy is distorted. For a simple pretendinous or
central cord, a fasciotomy procedure would always be offered at
informed consent as an alternative to wide awake fasciectomy.
Now that Dupuytrens fasciectomy with accelerated rehabilitation
can routinely be performed wide awake [1, 9, 10], it is our experience that the majority of patients, like the patient presently discussed, would not wish to consider dermofasciectomy under

Wide Awake Dupuytrens Fasciectomy

129

Awake Patient with

Moving Sensate
Hand
NO SEDATION
One-Stop
Rehabilitation
Surgeon and/or
Therapist
One-Stop Hand
Surgery NO
TOURNIQUET

Fig. 9.4 One-stop wide awake Dupuytrens fasciectomy

Risk of
Recurrence

Complexity of
Procedure and
Rehabilitation
Fig. 9.5 Patient-centric Dupuytrens care decision making

general or regional anaesthesia because of the complexities of the

anaesthesia, surgery and post-operative programme. Nevertheless,
this should be discussed during informed consent. Wide awake
fasciectomy should form part of a logical, risk-stratified and evidence-based approach to Dupuytrens contracture (Fig. 9.6).

Medium recovery

A Wide Awake procedure

High recurrence

Fig. 9.6 Wide awake fasciectomy in context

Can be done one stop

(<1 week)

Can be done one

stop

(68 weeks)

Medium recurrence

Fasciotomy

Fast recovery

Wide Awake Hand

Surgery:

suited to

Fasciectomy

Cannot be done one stop

Slow recovery (months)

Low recurrence

Wide Awake Not Advised

Dermofasciectomy

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Wide Awake Dupuytrens Fasciectomy

131

OSWA Hand Surgery: Summary

Our experience with wide awake hand surgery in the United
Kingdom over the last 15 years has concentrated on utilising the
advantages of the wide awake approach to enable one-stop surgery
and rehabilitation [5, 6]. The patient described here, like all our
patients, was offered an OSWA patient-centric pathway. This
involves an exchange of information pre-operatively, with the surgeon assessing the patients suitability for OSWA and providing all
the relevant information the patient requires to focus the clinical
consultation and informed consent; patient information videos for
informed consent and for rehabilitation instruction, via the Web,
YouTube or via our bespoke patient apps; and online pre- and postoperative scoring to enable audit and governance.
Patient Centricity
Increasingly, the role of the patient-centric approach to healthcare
is recognised as beneficial [11] and through OSWA and wide
awake hand surgery we believe hand surgeons can deliver patientcentric care for Dupuytrens patients. In this context the modern
Dupuytrens pathway as well as surgeon should
Empower the patient by distilling relevant, focussed and impartial patient education materials (video).
Provide such information in a range of multimedia formats and
via the web, mobile applications and social media.
Use the above to promote hand health for Dupuytrens patients.
Utilise modern technology to provide the most efficient, streamlined patient pathway.
Centre the patient in a surgical and rehabilitative experience,
supported by online rehabilitation and monitoring.

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Q.M.K. Bismil and M.S.K. Bismil

Appendix on Wide Awake Anaesthesia:

Key Points to Wide Awake Fasciectomy
Local Anaesthetics
Local anaesthetics disrupt the inflow of sodium through channels in the membranes of neurones.
They work better in smaller and rapidly firing nerves.
This is why in wide awake hand surgery the pain fibres are
invariably blocked whilst motor (movement) fibres are usually
unaffected. Thus, our patients can benefit from pain-free surgery whilst feeling touch and being able to move the fingers and
hand.
This also means the wide awake hand surgeon can re-assess the
hand during the procedure, with active movement.
Dosage Information as a Guide Only
Please see our principal source, http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3403589.
The maximum dose of lignocaine without adrenaline is
3 mg/kg.
The maximum dose of lignocaine with adrenaline is 7 mg/kg.
Thus, in a 70-kg patient, do not use more than

20 ml of 1 % plain lignocaine or
10 ml of 2 % plain lignocaine or
48 ml of 1 % lignocaine with adrenaline or
24 ml of 2 % lignocaine with adrenaline

Patients Not Suitable for Wide Awake Surgery

The only absolute contraindication is local anaesthetic allergy,
which is rare. If there is any doubt that a patient may have a local
anaesthetic allergy, he should be referred to an allergy specialist for
evaluation and surgery should not be performed.

Wide Awake Dupuytrens Fasciectomy

133

Rather than having a true allergy, patients are more likely to

faint or to react to adrenaline (either their own adrenaline or that
administeredadrenaline is a beta-1 adrenergic agonist). In our
experience with wide awake hand surgery over 15 years, we have
not encountered a patient who was confirmed to have a local anaesthetic allergy.
The least allergenic local anaesthesia would be an alternate
amide such as prilocaine; use it without adrenaline and use a single-use vial (with no preservative).
If there are any doubts, postpone the surgery and refer to an
allergy specialist.
Vasopressors
Vasopressors, such as low-dose adrenaline, for instance, at 1:200,000,
are commonly used in wide awake hand surgery to provide constriction of blood vessels and hence minimise bleeding by activating
alpha-1 adrenergic receptors. In addition to minimising bleeding in
the operative field, low-dose adrenaline delays anaesthetic absorption, enabling pain-free surgery for more complex procedures.
Delayed absorption of local anaesthetics reduces the risk for systemic toxicity and prolongs the duration of anaesthesia.
Low-Dose Adrenaline Contraindications Within Our Practice
Absolute

Tricyclic and monoamine oxidase inhibitor antidepressants

Digoxin
Thyroid hormone
Sympathomimetics used for weight control or attention deficit
disorders
Stimulant drug abuse (e.g., cocaine)
Documented prior clinical problems with finger circulation or
vascular supply to hand/upper limb
Allergy (see above)

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Q.M.K. Bismil and M.S.K. Bismil

Patients expression at informed consent he or she wishes to

avoid use of low-dose adrenaline in his or her case for whatever
reason
Relative

Cardiovascular disease
Hypertension
Vascular disease
History of hand/upper limb circulatory problems (e.g.,
Raynauds syndrome, vibration-induced white finger
Beta blockers
Best Advice with Regards to Low-Dose Adrenaline Injection
from Our Practice
If you have any doubt, use plain local anaesthesia. Via anatomical dissection and intermittent firm point pressure with a rolled
swab, any bleeding can be controlled without vasopressor use.
The peak vasoconstrictor action/absorption of adrenaline is
around 5 minutes after the injection and tails off each minute after
this; hence, manage the risk of injury to the neurovascular structures or tendon mechanism accordingly. This is why we advocate
straight incisions (see the section entitled Discussion) with
Z-plasty as required (at the end of the procedure, deferred to a
second stop or not done at all).

References
1. Lalonde D. How the wide awake approach is changing hand surgery and
hand therapy: inaugural AAHS sponsored lecture at the ASHT meeting,
San Diego, 2012. J Hand Ther. 2013;26(2):1758. doi:10.1016/j.
jht.2012.12.002. Epub 2013 Jan 5.
2. Nelson R, Higgins A, Conrad J, Bell M, Lalonde D. The wide-awake
approach to Dupuytrens disease: fasciectomy under local anesthetic with
epinephrine. Hand (N Y). 2010;5(2):11724. doi:10.1007/s11552-0099239-y. Epub 2009 Nov 10.

Wide Awake Dupuytrens Fasciectomy

135

3. Bismil Q, Bismil M, Bismil A, Neathey J, Gadd J, Roberts S, Brewster

J. The development of one-stop wide-awake Dupuytrens fasciectomy
service: a retrospective review. JRSM Short Rep. 2012;3(7):48.
doi:10.1258/shorts.2012.012050. Epub 2012 Jul 23.
4. Robbins TH. Dupuytrens contracture: the deferred Z-plasty. Ann R Coll
Surg Engl. 1981;63(5):3578.
5. Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in
extremity surgery. J Am Acad Orthop Surg. 2001;9(5):34551.
6. Crews JC, Hilgenhurst G, Leavitt B, Denson DD, Bridenbaugh PO,
Stuebing RC. Tourniquet pain: the response to the maintenance of
tourniquet inflation on the upper extremity of volunteers. Reg Anesth.
1991;16(6):3147.
7. Denkler K. Dupuytrens fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet. Plast Reconstr Surg.
2005;115(3):80210.
8. Achar S, Kundu S. Principles of office anesthesia: part I. Infiltrative anesthesia. Am Fam Physician. 2002;66(1):915.
9. Bismil M, Bismil Q, Harding D, Harris P, Lamyman E, Sansby L. Transition
to total one-stop wide-awake hand surgery service-audit: a retrospective
review. JRSM Short Rep. 2012;3(4):23. doi:10.1258/shorts.2012.012019.
Epub 2012 Apr 16.
10. Teo I, Lam W, Muthayya P, Steele K, Alexander S, Miller G. Patients
perspective of wide-awake hand surgery100 consecutive cases. J Hand
Surg Eur Vol. 2013;38(9):9929. doi:10.1177/1753193412475241. Epub
2013 Jan 24.
11. Phaneuf M. The patient-centered approach, a humanistic pathway for care.
Rev Infirm. 2014;201:368.

References for Appendix

Becker DE, Reed KL. Local anesthetics: review of pharmacological considerations. Anesth Prog. 2012;59(2):90101. doi:10.2344/0003-3006-59.2.90.
PMID: 22822998, quiz 1023. Review.
Reed KL, Malamed SF, Fonner AM. Local anesthesia part 2: technical considerations. Anesth Prog. 2012;59(3):12736. doi:10.2344/0003-300659.3.127. PMID: 23050753, quiz 137. Review.

Chapter 10

Surgical Open Palm (McCash)

Technique
Panayotis N. Soucacos, Zinon Kokkalis, Aristides B. Zoubos,
and Elizabeth O. Johnson

Case Presentation
A 44-year-old male presented to the Orthopedic Clinic with skin
pitting and thickening, a rope like swelling in his palm, and an
inability to fully straighten the ring and little fingers of his right
hand. The patient noted that this had progressed over the last 18
months. The patient was a car mechanic with a history of several
previous minor hand injuries attributed to his manual labor. The
patient was a heavy smoker and had no other medical history of
note. Physical examination showed flexion contractures of the
P.N. Soucacos, MD, FACS () A.B. Zoubos, MD
The Panayotis N. Soucacos Orthopaedic Research & Education Center,
Attikon University Hospital, National & Kapodistrian University of Athens,
Rimini 1, 124 62 Haidari, Athens, Greece
e-mail: [email protected]
Z. Kokkalis, MD
Department of Orthopaedics, School of Medicine, University of Patras,
Patras, Greece
E.O. Johnson, PhD
Department of Anatomy, School of Medicine, National & Kapodistrian
University of Athens, 75 Mikras Asias Str. 11572 Goudi, Athens, Greece
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_10

137

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P.N. Soucacos et al.

proximal interphalangeal joints, palpable nodules on the volar

aspect of all proximal phalanges, and palpable cords to his lateral
three digits. The flexion contracture was 42 and 62 at the metacarpophalangeal (MCP) joint and proximal interphalangeal (PIP)
joint, respectively, of the ring finger. The Orthopedic Surgeon
diagnosed Dupuytrens disease and advised surgical treatment with
an open palmar fasciectomy (McCash technique).

Diagnosis/Assessment
The patient demonstrated the typical presentation of Dupuytrens
disease with nodules and pretendinous cords in the palm, which
results in flexion contractures in the metacarpophalangeal and
interphalangeal joints at the base of the ring and small fingers
[1, 2]. Nodules are a pathognomonic sign of early disease and tend
to be located just proximal or distal to the distal palmar crease and
in the proximal segment of the digits, most frequently the ring and/
or small finger. While nodules can present at the base of the thumb,
they were absent in this particular patient. Pits and folds that form
by the attachment of the diseased fascia to the skin are frequently
mistaken for nodules. The cords observed in the patient suggest
that the disease is still in early stages. The cords are palpable proximal and distal to the nodules as the contracture begins.
While a notable contracture is present in ring and little fingers,
the fist of the disease hand appears normal. In addition the digits
tend to lack extension (Fig. 10.1). In general, the digitus annularis
of finger IV and finger V are affected the majority of times.
The disease, which occurs most commonly in middle-age
males, is characterized by fibroblast proliferation and collagen
deposition in the palmar aponeurosis and its digital prolongations
resulting in a contraction. While the patients history did not indicate a family history (compatible with an autosomal dominant pattern of inheritance), he was a heavy smoker. Smoking along with
alcohol intake and diabetes mellitus has been associated with the
disease [13]. The association with smoking is related to microvascular impairment which can be further augmented in combination

Surgical Open Palm (McCash) Technique

Fig. 10.1 Preoperative view showing flexion contracture of the ring and little finger (a). While the fist of the patient appears normal
(b), the patient is unable to fully extend the digit (c). Palpable cords in lateral digits are a common feature (d)

10
139

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P.N. Soucacos et al.

with alcoholism. While trauma has not been considered a primary

cause of Dupuytren, the fact that the patient has had several minor
injuries to his hand related to heavy manual labor may be a contributing factor.

Management
While there are various nonoperative treatment options including
Dimethyl sulfoxide massaging, ultrasonic therapy along with passive stretching exercises, splinting, steroids, enzymatic fasciotomy,
collagenase enzymatic fasciotomy, among others, the surgeon opted
for surgical management because the contracture of the MCP joint
was greater than 30 which negatively affected the patients normal
work routine. While there are no absolute indications for surgery,
surgery is indicated for relief from bothersome contracture, >30
contracture at the MCP joint, any degree of contracture at the PIP
joint, and the presence of painful nodules (relative indication).
There are several surgical options available to the surgeon. Local
excision of the nodule, however, is rarely necessary, as nodules tend
to recur. Fasciotomy to release the MCP flexion by division of the
cord in the palm is often favored since the procedure is minimal
with few complications, and allows for immediate MCP joint
improvement with negligible postoperative disability. On the other
hand, fasciotomy does not remove nodules, is less effective in correcting PIP contractures, and is associated with frequent recurrence
of the disease. The most common surgical procedures are regional
fasciectomy to excise all the diseased fascia and extensive fasciectomy, which excises all of the diseased fascia, as well as the potentially disease fascia. Various fasciectomy procedures have been
devised, including percutaneous needle fasciotomy, open palm
technique, Gonzales interpositional skin grafts, Huestons dermofasciectomy, PIP joint release, among others [46]. While fasciectomy results in a decreased chance of recurrence, it entails excision
of the aponeurosis and all the cords, regardless of their involvement,
resulting in increased postoperative complications.
The patient was surgically managed with an open palmar fasciectomy (McCash technique) under axillary nerve block and high

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Surgical Open Palm (McCash) Technique

141

humeral tourniquet [7]. The rationale of using the method was to

provide the surgeon with a direct view of the pathology and avoid
complications, such as hematoma formation and skin necrosis from
skin suture under tension, therefore ensuring adequate blood supply for the healing process [811]. Moreover, satisfactory results
have been reported with this technique including less pain, better
motion and low complication rate including hematoma, skin necrosis, and infection [813].
With the McCash open palm technique, fascia is excised
through transverse incisions under axillary nerve block and high
humeral tourniquet on an outpatient basis. The cords were
approached using a z-shaped palmar incision followed by a crossing transverse incision (Fig. 10.2). Removal of the affected tissue
through the transverse incision in the region of the distal palmar
crease allows for the correction of the flexion deformity of the PCP
joint. When necessary, another transverse incision can be made
proximally to the first to further facilitate tissue resection. Once the
neurovascular elements are meticulously dissected, then complete
excision of the scar tissue and cords is performed. The palmar incision is left open and allowed to heal by secondary intention, which
may take up to 6 weeks. Note: the palmar incisions are left open,
but the phalangeal incisions are closed. While the transverse incisions are left open and allowed to granulate, occasionally they can
be skin grafted with a full thickness skin graft (Fig. 10.3)
The wound is covered with Vaseline dressing and digits splinted
in extension. Antibiotic prophylaxis with a second generation
cephalosporin and NSAIDs are administered for 24 days, with a
change of dressing after the first week and every 46 days thereafter. Physiotherapy is initiated 7 days postoperatively, and full activity
is allowed 3 weeks postoperatively. Stitches are removed about
2 weeks postoperatively.

Outcome
The patient had excellent results. The wound healed with 8 weeks
and sensory evaluation revealed no permanent numbness
(Fig. 10.4). The average period for wound healing has been
reported to be 40 days following the open hand technique [14].

Fig. 10.2 The transverse palmar incision (a), and extension of incision to involved digits. Intraoperative view (b)

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P.N. Soucacos et al.

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Surgical Open Palm (McCash) Technique

143

Fig. 10.3 Immediate postoperative view. Note the wound is left open

At a follow-up of 2 years, the MCP joint contracture improved

to 1.8, and the PIP joint contracture improved to 7.1. This is
similar to the finding of Lubahn [9, 15] who reported that 20 % of
the patients experience residual contracture compared to 42 %
observed in patients treated by suturing the operative wounds.
No complications were encountered in the present case. The
absence of infection is attributed to the appropriate wound dressing and close patient monitoring. In general, patients treated with
the open hand technique result in a less painful postoperative
period, better mobility of the digits, and a lower rate of complications [10].

Literature Review
Satisfactory results have been reported with the McCash technique,
with less pain, better motion, and a low complication rate, compared to other methods, which include hematomas, skin necrosis,
and infection. The McCash open palm technique is favored for
advanced disease states, especially diabetics, and is preferred for
patients with multiple involvement.

Fig. 10.4 Six weeks postoperative view, showing digit extension (a) and flexion (b)

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P.N. Soucacos et al.

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Surgical Open Palm (McCash) Technique

145

The various options available to treat Dupuytrens disease have

had variable results. In general, final outcome after surgery tends
to be worse in patients who have an early onset of the disease or
severe PIP joint involvement. To date, no medical strategy has
demonstrated effective long-term results in halting or reversing the
progression of the contracture [11, 12, 16].
Hence, despite the relatively favorable outcomes with the
McCash technique, the surgeons must stress to their patients that
surgery is not a cure for the disease, but a means of relieving some
of the disability associated with the disease.

Clinical Pearls/Pitfalls
Open wounds frequently lead to infection, especially in patients
with abnormal healing. This stresses the importance of appropriate wound dressing and close monitoring.
Adherence to strict rehabilitation program is essential.
Postoperative extension splinting is mandatory.
When contractures are corrected, a gap of 34 cm may be
present.
Common intraoperative pitfall, inadvertent division of a digital
nerve (Loupe magnification and patience are essential).
During dissection of neurovascular bundle, note that the nerve usually travels deeper into fascia in the area of the diseased fascia
mass. (Do not excise any tissue until the digital nerve has been
identified on both sides of the excision zone.)

References
1. Hu FZ, Nystrom A, Ahmed A, Palmquist M, Dopico R, Mossberg I,
Gladitz J, Rayner M, Post JC, Ehrlich GD, Preston RA. Mapping of an
autosomal dominant gene for Dupuytrens contracture to chromosome 16q
in a Swedish family. Clin Genet. 2005;68:4249.
2. Renard E, Jacques D, Chammas M, et al. Increased prevalence of soft tissue hand lesions in type 1 and type 2 diabetes mellitus: various entities and
associated significance. Diabete Metab. 1994;20:513.

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3. Burge P, Hoy G, Regan P, Milne R. Smoking, alcohol and the risk of

Dupuytrens contracture. J Bone Joint Surg Br. 1997;79:296310.
4. Roush TF, Stern PJ. Results following surgery for recurrent Dupuytrens
disease. J Hand Surg Am. 2000;25(2):2916.
5. Bainbridge C, Dahlin LB, Szczypu PP, Cappelleri JC, Gurin D, Gerber
RA. Current trends in the surgical management of Dupuytrens disease in
Europe: an analysis of patient charts. Eur Orthop Traumatol. 2012;3:
3141.
6. Boyer MI, Gelberman RH. Complications of the operative treatment of
Dupuytrens disease. Hand Clin. 1999;15:1616.
7. McCash CR. The open palm technique in Dupuytren's contracture. Br
J Plast Surg. 1964;17:27180.
8. Zachariae L. Operation for Dupuytrens contracture by the method of
McCash. Acta Orthop Scand. 1970;41:4338.
9. Lubahn J. Open palm technique and soft tissue coverage in Dupuytrens
Disease. Hand Clin. 1999;15:12736.
10. Schneider L, Hankin F, Eisenberg T. A review of the open palm method.
J Hand Surg Am. 1986;11:237.
11. Gelberman R, Panagis J, Hergenroder P, Zakaib GS. Wound complications
in the surgical management of Dupuytrens contracture: a comparison of
operative incisions. Hand. 1982;14:24853.
12. Mavrogenis AF, Spyridonos SG, Ignatiadis IA, Antonopoulos D,
Papagelopoulos PJ. Partial fasciectomy for Dupuytrens contractures.
J Surg Orthop Adv. 2009;18(2):10610.
13. Zoubos AB, Stavropoulos NA, Babis GC, Mavrogenis AF, Kokkalis ZT,
Soucacos PN. The McCash technique for Dupuytrens disease: our experience. Hand Surg. 2014;19:617.
14. Skoff HD. The surgical treatment of Dupuytren's contracture: a synthesis
of techniques. Plast Reconstr Surg. 2004;113(2):5404.
15. Lubahn JD, Lister GD, Wolfe T. Fasciectomy and Dupuytrens disease: a
comparison between the open-palm technique and wound closure. J Hand
Surg Am. 1984;9A(1):538.
16. Gilpin D, Coleman S, Hall S, Houston A, Karrasch J, Jones N. Injectable
collagenase Clostridium histolyticum: a new nonsurgical treatment for
Dupuytrens disease. J Hand Surg Am. 2010;35:202738.

Suggested Readings
Cools H, Verstreken J. The open palm technique in the treatment of Dupuytrens
Disease. Acta Orthop Belg. 1994;60:41320.
Lubahn JD. Open-palm technique and soft-tissue coverage in Dupuytrens disease. Hand Clin. 1999;15:12736.
Schneider LH, Hankin FM, Eisenberg T. Surgery of Dupuytrens disease: a
review of the open palm method. J Hand Surg Am. 1986;11:237.

Chapter 11

Treatment of Dupuytrens
Contracture with Dermofasciectomy
Nathan A. Monaco, C. Liam Dwyer, and John D. Lubahn

History
A 59-year-old retired right hand dominant male with history of
Dupuytrens contracture was evaluated in our Hand Clinic for
recurrent disease in the left palm (Fig. 11.1). Five years prior to
evaluation, both hands had been treated with limited fasciectomy and primary wound closure at an outside facility. He was
asymptomatic for 4 years when he began to complain of difficulty gripping a golf club. He reported disease in both hands,
but was only symptomatic on the left. Interestingly, recurrent
disease on the right small finger had led to a PIPJ flexion contracture which he believed helped him better grip a golf club
and improved his game.

N.A. Monaco, MD () C.L. Dwyer, MD J.D. Lubahn, MD

Department of Orthopaedic Surgery, UPMC-Hamot,
201 State Street, Erie, PA 16550, USA
e-mail: [email protected]; [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_11

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Fig. 11.1 A 59-year-old right hand dominant male with left ring and small
finger involvement

Physical Exam Findings

On examination, the patient was a thin-statured, otherwise healthy
appearing man in good health. He had a painful cord in the palm
of the left hand overlying the ring finger metacarpal, with extension to the long and small fingers. There was a fixed MPJ contracture of the ring finger measuring 40, with active flexion to 70.
Flexion contractures were measured at 10 and 20 at the long and
small finger MPJs, respectively. A PIP contracture of the right
ring finger was also noted and measured at 20, with active flexion to 90. Neurovascular examination demonstrated distal digital
sensation intact to light touch with two-point discrimination measuring 5 mm in each digit. Grip strength was diminished on the
left compared to the right dominant extremity, although he did
demonstrate normal sensation in both hands on Semmes-Weinstein
filament testing.

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Treatment Options
Various options exist for treatment of recurrent Dupuytrens disease ranging from nonoperative care with collagenase injection to
needle aponeurotomy or segmental aponeurectomy as described by
Moermans [1, 2]. More invasive procedures such as fasciectomy
and wound closure, or leaving the wound open as described by
McCash [3], are also options. Dermofasciectomy, another type of
invasive procedure, involves surgical excision of diseased skin and
palmar fascia down to the level of the flexor tendon sheath. The
defect in the palm is then covered by a full thickness skin graft
harvested from a non-hair bearing area of the skin.
Some authors advocate collagenase clostridium histolyticum
(CCH) injection to treat recurrent Dupuytrens disease, as it can
potentially help lessen both the small joint contractures and the
previous surgical scar [4]. However, no long-term outcome data is
currently available for treatment of recurrent Dupuytrens contracture with CCH. Furthermore, tendon rupture is a risk following
injection with collagenase if appropriate consideration is not given
to needle placement [5]. Injection of CCH even in primary contracture cases has been found to demonstrate joint recurrence rates of
up to 35 % at 3-year follow-up [6]. Cost can be an important consideration for many patients. A significant financial burden can be
placed on the patient with Dupuytrens seeking treatment with
CCH. In one cost-analysis study, a single injection of CCH was
estimated at $1000 [7].
Percutaneous needle fasciotomy (PNF), also known as needle
aponeurotomy, has also been offered as a therapeutic treatment
option for recurrent Dupuytrens. Proponents of this technique
argue that it is minimally invasive, it can potentially hasten recovery time compared to open techniques, and it is associated with an
overall low complication rate [8]. In addition, the procedure may
potentially be advantageous in that it can be performed in the office
or under local anesthesia. Despite several advantages of PNF,
patients can still have difficulty with recurrence. A study by van
Rijssen utilized PNF to manage 40 digital cases of recurrent
Dupuytrens and demonstrated a recurrence rate of up to 50 % at
4-year follow-up [9].

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Segmental aponeurectomy (SA) aims at correcting contracture

deformity by creating multiple areas of discontinuity in the palmar
aponeurosis through small (12 cm) semilunar skin incisions. While
many authors have contributed to the conceptual formation of the
technique, Moermans described it in 1991 [1]. Initially the technique was developed as a less invasive means of correcting deformity while limiting the postoperative discomfort found after
widespread dissection. Other surgeons have subsequently used
segmental releases of the palmar fascia through transverse incisions
to treat Dupuytrens [10]. Follow-up studies for many of these
approaches, however, have demonstrated recurrence rates up to
38 %, while also reporting instances of iatrogenic nerve injury [2].
Partial or limited fasciectomy (LF) has been used for both primary and recurrent disease. Limited is a relative term, though, as
this technique is one of the more invasive approaches to Dupuytrens
contracture management. The procedure is limited in the sense
that only macroscopic disease tissue is surgically excised. This
stands in contrast to the historical approach of totally or completely
removing the entire palmar fascia [11]. Total, or radical fasciectomy, is now often avoided due to morbidity concerns [12]. While
LF has shown to reliably improve deformity, this approach is not
without complication [13]. Nerve injury, hematoma, infection,
worsening of the preoperative deformity, and circulatory compromise have all been reported [14].

Treatment Chosen
The patient being presented was treated in 1990, prior to the release
of collagenase and prior to needle aponeurotomy or segmental
aponeurectomy being widely accepted. Dermofasciectomy at the
time was widely accepted as the state-of-the-art treatment for
recurrent Dupuytrens disease. While dermofasciectomy carries
with it the risk of donor site morbidity and longer healing time for
the skin graft to take, full thickness skin grafting offers the potential advantage of lowering the risk for disease recurrence [15]. It
was primarily to minimize the risk of recurrence that the decision
was made to proceed with dermofasciectomy.

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Fig. 11.2 Proposed preoperative markings for a planned incision and treatment
of skin excision with skin grafting. The previous fasciectomy surgical sites can
also be visualized

With the patient in the supine position, satisfactory general

anesthesia was induced. A sterile tourniquet was applied to the
upper extremity and inflated to 250 mmHg after routine prepping
and draping of the arm. The surgical approach involved placing a
Brunner-style, zig-zag incision over the palm (Fig. 11.2). Excision
of the superficial skin took place in ellipse fashion centered over
the distal palmar crease of the previously marked site (Fig. 11.3).
Careful dissection was carried out with a combination of 15-blade
scalpel and tenotomy scissors in a proximal to distal fashion. The
final objective was removal of all deep palmar fascia with preservation of the neurovascular bundle. Once adequate resection of
diseased tissue was achieved, the long ring and small fingers could
be brought into full extension at the MPJ. The ring finger was then
secured with a lead hand to maintain the PIP and MCP joint in
maximal extension for graft application. A minimal residual PIPJ
contracture was felt to be acceptable. Next, a full thickness skin
graft was harvested from the medial brachium (Fig. 11.4a). The
graft was de-fatted and sutured into place of the defect with 5-0
nylon suture. Tie-over sutures were also used to secure the graft.
Donor site closure was performed using 5-0 nylon suture thrown in
a simple-interrupted manner (Fig. 11.4b). The tourniquet was
deflated prior to final closure and meticulous hemostasis was

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Fig. 11.3 Full thickness skin was excised from the diseased left palmar surface

obtained with bipolar electrocautery to limit potential hematoma

complications. A soft tissue dressing was then applied along with
a static splint maintaining the hand in the safe position. Once the
graft was completely healed, the sutures were removed and the
patient was started in a formal hand therapy program which
included nighttime splinting and gentle active motion.

Clinical Course
This patients postoperative course was free of any complications.
At the 3-month follow-up visit, there were no signs of recurrence
or disease extension. The patient demonstrated full extension and
flexion of the MPJs of the long ring and small fingers after healing
of the skin graft (Fig. 11.5a, b). A 10 PIPJ contracture persisted in
the ring finger. The patient was satisfied with the results of his
dermofasciectomy, specifically in that he was able to return to
being an avid golfer.

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Fig. 11.4 (a) Donor site for full thickness skin graft. This was in an area void
of hair, in the medial brachium. Alternative graft sites include skin inferior to
the iliac crest and inner arm skin, with the key determinant being skin with
similar characteristics between the donor and graft site. (b) Immediate postoperative appearance of left palm after application of full thickness skin graft

Discussion: Literature Review

The definition of recurrence of Dupuytrens disease varies
among authors and short-term follow-up may limit our ability to
accurately compare different treatment options. A systematic
review concluded that at present, the evidence does not support

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Fig. 11.5 (a) Three months postoperative. Patient noted to have healing of skin
graft with improvement and almost full extension. (b) Range of motion with
full flexion, allowing the patient to return to golf

clear superiority of one treatment over another in terms of degree

of initial correction and prevention of recurrent disease [16]. Early
observations reported by Gordon [17] and Hueston [18] that recurrence does not occur under an area of skin grafting led many surgeons to recommend and perform dermofasciectomy. Ketchum and
Hickson noted no recurrence in 36 hands at an average of 4-year
follow-up after dermofasciectomy [19]. Noting similar results,
other authors reported that dermofasciectomy with full thickness

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155

skin graft resulted in lower rates of recurrence of Dupuytrens

contracture [20].
Indications for use of dermofasciectomy often include recurrent
disease as well as aggressive forms associated with diffuse skin
involvement as well as with so-called Dupuytrens diathesis.
Armstrong and colleagues agreed with Huestons indications, utilizing dermofasciectomy in cases of Dupuytrens with widespread
skin association [21]. Abe collaborated to develop a scoring system
for evaluation of disease recurrence and extension [22]. Components
of this scale include bilateral disease (1), previous small finger
surgery (1), early onset (1), ectopic plantar (2) or knuckle fibrosis
(2) and radial sided disease (2). Out of a possible nine total risk
points, patients scoring four or higher according to this classification demonstrate an indication for dermofasciectomy [23]. Anwar,
while championing a local skin flap for mild disease, conceded an
indication for dermofasciectomy to manage either severe involvement or recurrent disease [24]. Heuston noted that surgically devitalized skin and longitudinal skin deformity in the palm following
flexion deformity correction can also be considered indications for
skin grafting [25].
Results of recurrence following dermofasciectomy, while promising, have not always matched Huestons early findings. Armstrong
et al. reported a recurrence rate of 11.6 % in 103 patients managed
with dermofasciectomy over a mean 5.8-year follow-up period
[21]. The authors suggested considering dermofasciectomy as a
subtotal preaxial amputation of the digit, with an emphasis on
removing all tissue that may be responsible for contracture. This
differs from Huestons belief that it is merely the insertion of a full
thickness skin graft that is the key component to Dupuytrens disease control. Brotherston, however, found no evidence of disease
recurrence after dermofasciectomy at an average follow-up of 100
months in 34 patients [26]. Hall reported six cases of recurrence in
a series of 90 digits (7 %) with 48-month follow-up [27], and Roy
found seven recurrences in 100 cases (7 %) followed for 52 months
post dermofasciectomy [28].
Only a few studies have attempted the difficult task of comparing dermofasciectomy to other operative techniques to manage
recurrent Dupuytrens. Tonkin and colleagues compared 100
patients managed with either dermofasciectomy or fasciectomy [29].

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At an average follow-up of 38 months, there were only three cases

of recurrence in the skin graft group, compared to an overall rate
of recurrence of 47 % in the study. The authors argued that skin
grafting , specifically interposition of dermal tissue following
Dupuytrens excision, may limit recurrence in comparison to fasciectomy for recurrent Dupuytrens disease. Rouch and Stern
compared results of 28 digits at median of 4-year follow-up in
three treatment groups for recurrent Dupuytrens: limited fasciectomy, dermofasciectomy, and fasciectomy with local skin flaps
[30]. These authors found that skin grafting did not limit postoperative contracture and the only statistically limited recurrence rate
was found in the treatment group managed with a locally based
flap. A definitive conclusion regarding superiority of the technique
of fasciectomy with local flap coverage versus dermofasciectomy
was unable to be reached due to heterogeneity among the studys
treatment groups. One prospective trial randomized 90 digits in
patients treated with fasciectomy plus skin grafting or fasciectomy
plus local skin z-plasty [31]. At the 3-year follow-up, no difference
was found in the recurrence rate of the skin grafts (13.6 %) and
Z-plasty (10.9 %) group. In general, the available evidence currently suggests that there may still be a role for dermofasciectomy
in the treatment of Dupuytrens disease, with particular utility in
cases of recurrent disease.
Complication after use of dermofasciectomy may be significant.
Reported complications following this technique range from mild
skin irritation or transient digital neuropraxia to major skin necrosis and loss of the graft. Hematoma, skin necrosis, iatrogenic digital nerve, and vascular injury as well as infection have all been
reported following dermofasciectomy [12]. Surgeons may be hesitant to use this technique, considering the risk of the skin graft not
taking over a flexor tendon and/or the neurovascular bundle.
Armstrong notes, however, that graft incorporation is usually successful unless both digital arteries have been damaged [21]. In
addition to operative complications, there are also a number of
associated surgical morbidities which may prove undesirable to the
patient. Skoog noted patients undergoing radical fasciectomy complained of palm sensitivity, particularly when grasping heavy
objects [11]. Because palmar sensitivity was a common complaint
and a problem for Skoogs factory worker patient population, he

11 Treatment of Dupuytrens Contracture with Dermofasciectomy

157

recommended a more limited excision over total fasciectomy.

Unfortunately, the risk for palmar sensitivity under the graft site
remains with dermofasciectomy.
Minor subtleties between donor and recipient skin can lead to
variations in the appearance of the graft, such as difference in color
and/or the potential for hair growth. For this reason, it is important
to harvest donor skin that has characteristics as similar as possible
to the recipient site. Common donor sites include the proximal
forearm (brachium), the inner upper arm, and redundant skin surrounding the iliac crest. The patient must be willing to accept a
residual postoperative surgical scar at whatever donor site is ultimately chosen. In addition, the patient may have a longer recovery
time following a grafting procedure when compared to alternative
less invasive techniques.
Despite the potential for operative morbidity and complication,
dermofasciectomy may offer the advantage of prevention of recurrent disease. If the technique is efficacious in preventing recurrence, the patient also benefits from avoiding additional surgery.
This would be especially useful in an instance where the patient
may be predisposed to recurrence.
The patient presented offers one possible scenario where dermofasciectomy may be a useful treatment option. This particular
individual had already had one previous fasciectomy procedure.
His disease and his contracture recurred, however, along with a
functional deficit impairing his ability to participate in avocational
activities. In such instances, fasciectomy and subsequent full thickness skin grafting is a technique that has been safely used and may
help limit future disease recurrence. In the absence of available
evidence supporting one superior technique, dermofasciectomy
remains a viable surgical option in cases of recurrent Dupuytrens
contracture.

Summary
Dermofasciectomy involves excision of skin that is intimately
associated with underlying diseased palmar fascia in Dupuytrens
contracture. In the void remaining after volar palm tissue excision,

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a full thickness skin graft is placed to limit disease recurrence. The

dermofasciectomy technique may be especially useful in the setting of recurrent Dupuytrens disease or in cases with widespread
contracture. Our patient demonstrates that in an appropriately
selected individual, dermofasciectomy can be safely utilized to
improve range of motion, strength, and overall hand function of an
affected extremity.

References
1. Moermans JP. Segmental aponeurectomy in Dupuytrens disease. J Hand
Surg Br. 1991;16B:24354.
2. Moermans JP. Long-term results after segmental aponeurectomy for
Dupuytrens disease. J Hand Surg Br. 1996;21:797800.
3. McCash CR. The open palm technique in Dupuytrens contracture. J Plast
Surg Br. 1964;17:27180.
4. Denkler KA. Collagenase for recurrent dupuytren contracture with skin
grafts. J Hand Surg Am. 2013;38(6):1264.
5. Zhang AY, Curtin CM, Hentz VR. Flexor tendon rupture after collagenase
injection for Dupuytren contracture: case report. J Hand Surg Am.
2011;36(8):13235.
6. Peimer CA, et al. Dupuytren contracture recurrence following treatment
with collagenase Clostridium histolyticum (CORDLESS Study): 3-year
data. J Hand Surg Am. 2013;38(1):1222.
7. Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial
fasciectomy, needle aponeurotomy, and collagenase injection for
Dupuytrens contracture. J Hand Surg Am. 2011;36A:182634.
8. Eaton C. Percutaneous fasciotomy for Dupuytrens contracture. J Hand
Surg Am. 2011;36A:9105.
9. van Rijssen AL, Werker PMN. Percutaneous needle fasciotomy for recurrent Dupuytren disease. J Hand Surg Am. 2012;37A:18203.
10. Shin EK, Jones NF. Minimally invasive technique for release of
Dupuytrens contracture: segmental fasciectomy through multiple transverse incisions. Hand. 2011;6:2569.
11. Skoog T. Dupuytrens contracture: pathogenesis and surgical treatment.
Surg Clin North Am. 1967;47(2):43344.
12. Henry M. Dupuytrens disease: current state of the art. Hand.
2014;9:18.
13. Denkler K. Surgical complications associated with fasciectomy for
Dupuytrens disease: a 20-year review of the English literature. J Plast
Surg. 2010;10:11633.
14. Dias JJ, Braybrooke J. Dupuytrens contracture: an audit of the outcomes
of surgery. J Hand Surg (Br). 2006;31(5):51421.

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15. Rizzo M, Stern PJ, Benhaim P, Hurst LC. Contemporary management of

Dupuytren contracture. Instr Course Lect. 2014;63:13142.
16. Becker GW, Davis TR. The outcome of surgical treatments for primary
Dupuytrens diseasea systematic review. J Hand Surg Eur.
2010;35(8):6236.
17. Gordon S. Dupuytrens contracture: recurrence and extension following
surgical treatment. Br J Plast Surg. 1957;9:2868.
18. Hueston JT. Digital Wolfe grafts in recurrent Dupuytrens contracture.
Plast Reconstr Surg. 1962;29:3424.
19. Ketchum LD, Hixson FP. Dermofasciectomy and full-thickness grafts in
the treatment of Dupuytrens contracture. J Hand Surg. 1987;12A:
65963.
20. Varian JPW. Full thickness skin grafts in the management of recurrent
Dupuytrens disease. In: Hueston JT, Tubiana R, editors. Dupuytrens
disease. 2nd ed. London: Churchill Livingstone; 1985. p. 1547.
21. Armstrong JR, Jurren JS, Logan AM. Dermofasciectomy in the management of Dupuytrens disease. J Bone Joint Surg [Br]. 2000;82-B:904.
22. Abe Y, Rokkaku T, Ofuchi S, et al. An objective method to evaluate the
risk of recurrence and extension of Dupuytrens disease. J Hand Surg Br.
2004;29B:42730.
23. Tubiana R. Surgical indications. In: Tubiana R, Leclercq C, Hurst LC,
Badalamente MA, Mackin EJ, editors. Dupuytrens disease. London:
Martin Dunitz; 2000. p. 21822.
24. Anwar MU, Al Ghazal SK, Boome RS. The lateral digital flap for
Dupuytren's fasciectomy at the proximal interphalangeal jointa study of
84 consecutive patients. J Hand Surg (Eur). 2009;34E(1):903.
25. Hueston JT. Skin replacement in Dupuytrens contracture. In: Hueston JT,
Tubiana R, editors. Dupuytrens disease. Edinburgh: Churchill Livingstone;
1974. p. 11922.
26. Brotherston TM, Balakrishnan C, Milner RH, Brown HG. Long term follow-up of dermofasciectomy for Dupuytrens contracture. Br J Plast Surg.
1994;47:4403.
27. Hall PN, Fitzgerald A, Sterne GD, Logan AM. Skin replacement in
Dupuytrens disease. J Hand Surg. 1997;22-B:1937.
28. Roy N, Sharma D, Mirza A, Fahmy N. Fasciectomy and full thickness skin
grafting in Dupuytrens contracture. The fish technique. Acta Orthop Belg.
2006;72:67882.
29. Tonkin MA, Burke FD, Varian JPW. Dupuytren's contractures: a comparative study of fasciectomy and dermofasciectomy in one hundred patients.
J Hand Surg Br. 1984;9B:15662.
30. Roush RF, Stern PJ. Results following surgery for recurrent Dupuytrens
disease. J Hand Surg. 2000;25A:2916.
31. Ullah AS, Dias JJ, Bhowal B. Does a firebreak full-thickness skin graft
prevent recurrence after surgery for Dupuytrens contracture? J Bone Joint
Surg Br. 2009;91-B:3748.

Chapter 12

Surgical Fasciectomy for Recurrent

Disease
Ombretta Spingardi and Mario Igor Rosello

Case Presentation
A 72-year-old retired male presented 7 years after a fasciectomy
for Dupuytrens disease involving the fourth and the fifth finger
of his left hand. Four years after surgery, a new nodule appeared
into his left palm while a progressive retraction and joint stiffness
in the site of the previous surgery were already appreciable at
least 1 year after treatment (Fig. 12.1). He complained gradual
impairment of his left hand function and the stiffness of his left
finger.

O. Spingardi, MD () M.I. Rosello, MD

Department of Hand Surgery, San Paolo Hospital, via Genova 30,
Savona 17100, Italy
e-mail: [email protected]; [email protected]

Springer International Publishing Switzerland 2016

M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_12

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Fig. 12.1 Preoperative view of Dupuytrens recurrence with disease extension to palm; a retracting skin scar on the volar surface of
DIP joint of fourth finger and PIP joint contracture of the fifth finger are appreciable

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Physical Examination
Examination findings demonstrated a cord which coerced the PIP
joint of the ring finger at 40 of flexion. Furthermore, the progressive skin retraction on the volar side of the DIP joint of the ring
finger limited the motion of the finger and it was very bothering for
the patient. In addition, he had a significant contracture of the small
finger PIP joint with similar deficit of extension. His prior scars
were nicely healed and he was neurovascularly intact. Given the
severity of contracture, its progression, and the disability of the
patient, intervention was warranted.

Treatment Options
Both operative and nonoperative treatment options can be considered for this condition. Office-based procedures include needle
aponeurotomy and collagenase. In addition, operative interventions are an option. After lengthy deliberation of treatment options,
surgical treatment with fasciectomy was decided upon as it
afforded the opportunity to address both the diseased fascia as well
as prior scar and capsular contracture.
The aims in this secondary surgery were to treat the digital
Dupuytrens recurrence and its palmar extension and to correct the
PIP joint stiffness and the skin scar retraction. These represent the
main and more common problems coexisting in further treatment.

Management
As showed in Figs. 12.2 and 12.3, we used multiple Z-plasties to
correct the scar retraction and to gain the volar opening after a
meticulous dissection of neurovascular bundles at the fourth and
fifth fingers and careful new aponeurotic tissue removal; at the
same time a volar PIP joint arthrolysis by check-reins section has
been done. All these procedures allowed to achieve the complete

Fig. 12.2 Preoperative aspect. The Z-plasties are drawn to increase the skin length for a better wound coverage

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O. Spingardi and M.I. Rosello

Fig. 12.3 Perioperative view. A careful research and dissection of neurovascular bundles is mandatory before treating the articular
contracture

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O. Spingardi and M.I. Rosello

extension of the blocked joints. The patient started the active and
passive motion immediately and 10 days after surgical treatment a
corrective splint was put in place on the small finger to maintain
the PIP extension.

Discussion
Defining the recurrence in Dupuytrens disease is very difficult
because there is no consensus in world literature. Since the first
disease descriptions and observations, many eminent authors made
a lot of efforts to find an effective definition of this common consequence of its treatment.
Tubiana was among the first authors who tried to define the
recurrence [1]. He defined recurrence as the reappearance of
Dupuytren contracture tissue in a zone previously operated.
Hueston felt that reapparition of the smallest nodule constituted
recurrence [2]. Gordon felt that recurrent disease in the same area
defined recurrence [3]. Later, these definitions reappeared in the
literature alternating with new other definitions by Gelberman [4]
who felt that the appearance of new fascial bands, determined by
appearance and palpation, in an area where fasciectomy had been
previously performed was an appropriate definition of recurrence.
Rombouts [5], Foucher [6], Adam [7], and many others [8] also
described recurrence including some of the definitions previously
reported.
The absence of consensus about recurrence definition is accompanied with confusion about rate of recurrence, which ranges from
2 to 86 % in the worldwide literature [4, 9, 10]. Kan et al. reported
recurrence as either the return of nodules or cords in operated hand,
the return of contraction with angular threshold between 1 and
50, or patients self-reporting recurrence. It depends on many factors including intrinsic (the same disease, the patients needs, the
disease degree, and its extension) and extrinsic (surgical technique
used). However, no surgical technique appears to be linked with
more favorable recurrence rates. Open treatment (fasciectomy,
aponeurectomy) has recurrence rates from 12 to 73 % [8], while
Collagenase injection recurrence rates are 10 % for MCP joints
contractures and 20 for PIP joints at 5 years [11]; the rates are

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higher after percutaneous needle fasciotomy: ranging from 58 % at

3 years and up to 100 % in other series [8, 12].
For these reasons in 2012, in Rome, an international consensus
conference formed by 24 hand surgeons from 17 European countries tried to assess a definition of recurrence using the Delphi
method [13, 14], which is a process of anonymous data collection
from experts judgments. The conclusions of the consensus conference have been the following:
The presence of a new nodule cannot be considered a
recurrence.
To assess an extension deficit, the measurement of the passive
extension deficit of the treated joint must be used; the consensus
has not been reached about the total passive extension deficit
(TPED) measurement because it is not considered as precise as
single joint measurement.
The time 0 definition, as the time when treatment results can
be considered stable at follow-up, is the period between 6 weeks
and 3 months after treatment.
Because of the confusion about recurrence in literature, it is
mandatory a quantitative definition of recurrence: the occurrence
of a new nodule can be considered a recurrence only after radical
treatment (fasciectomy), not after fasciotomy, needle aponeurotomy, or CCH (Collagenase Clostridium histolyticum) injection. To
evaluate the results after these treatments, it is better to measure the
return of contracture in angular degrees: the presence of nodules or
cords without finger contracture is not suggestive of recurrence.
The consensus has also been reached about the Tubiana scale system ineffectiveness. It is preferable to measure the goniometric
degrees of passive extension deficit of contracted joint: recurrence
can be appreciated when the angle is greater than 20.
As Tubiana described [15], it is mandatory to distinguish true
recurrence from the so-called pseudo-recurrence such as situations of scar retraction after previous treatment, where bad skin
scars arise after surgical incision or joint stiffness persisting after
treatment. The differential diagnosis is easy whenever the retraction appears late, once good correction of previous deformities can
be appreciated, when associated deformities were already present
before surgery, and they have been only partially corrected by

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treatment. A discerning characteristic is that scar retraction lays in

correspondence to skin scar, arises early (few weeks after treatment), and is usually stable over time. On the other hand, recurrence due to progression of Dupuytrens disease tends to occur
later and doesnt necessarily run along the skin scar.

Literature Review
The papers with longest follow-up periods show that recurrence
belongs to Dupuytrens natural evolution [16]: Tubiana said The
recurrence percentage increases in the time, observing a series of
patients with a long follow-up (814 years) where only 34 % of
them didnt develop any recurrence; the others got different recurrence patterns, with (24 %) or without (42 %) functional impairment. The recurrence rate would increase in cases of multiple rays
involvement (68 % of patients of this series), in a longer follow-up
period and in young patients: all the patients who were less than 45
years old before surgery developed the recurrence. This data supports the relationship between patients young age and disease
aggressiveness. Mantero [17] in 1983 published the longest followup casuistry (30 years) in Dupuytrens recurrence and observed
that in 100 % of patients who were suffering from epilepsy and
chronic alcoholism, while the mean recurrence rate was 97 % in
patients affected by cardiac or respiratory disease, 52 % in diabetic
people, and 47 % in patients with generic bad general conditions.
Particularly, the recurrence rate was higher in the first 35 years
follow-up (43 %); 2030 years after surgery, the mean rate was
77 %. Mc Grouter [18] reached similar conclusions. The longer
patients are followed, the higher the recurrence rate: almost all
patients suffering from Dupuytrens disease will develop a recurrence if their survival time will allow them it.

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Clinical Pearls/Pitfalls
We believe in fasciectomy as the best and most effective treatment
for Dupuytrens recurrences, because this technique allows to
treat also the associated deformities: joint contracture, skin scars.
In accordance with literature we treat only the symptomatic cases
with a significant deformity or impairment. The aim of the treatment is to treat all the anatomical elements involved.
To decrease any skin flap necrosis rate, the surgical approach
consists always in broken incisions on the skin, as Bruners incision; however, we prefer multiple Z-plasties because they will
warrant a better coverage of surgical field during the suture, with
healthy skin, and consequent scar lengthening: it makes gain
more palm and digit opening, facilitating and improving the correction of joint retraction too. When the scar tissue is poor and the
Z-plasties are not enough to cover the underlying tissues, the
full-thickness skin graft harvested from the wrist or the medial face
of the forearm is used (the so-called firebreak graft, even if it
doesnt warrant any other recurrence reapparition [17]).
A subcutaneous careful dissection allows to identify and protect
the neurovascular bundles, often dislocated from their original
position or already damaged during the previous treatment: this is
the most delicate phase of the surgical treatment. Their accidental
section may be one of the most common operative complications.
As already discussed, in recurrence surgery the joint contracture
is one of the problems to solve.
The possible causes of joint stiffness, beyond a new aponeurotic
tissue presence (and which has to be removed), may be: longitudinal retraction of flexor tendon sheath, capsular and ligamentous
PIP joint contracture, interosseous and extensor tendon apparatus
decay (wreaking a boutonnire deformity). The treatment will be
different for each one of these associated deformities: from a simple tenolysis with flexor sheath opening, until check-reins resection (in case of mild and recent joint contracture) or volar plate
detachment associated with glenoid laminae of collateral ligaments
section. The boutonnire deformity is secondary to volar dislocation of lateral extensor tendon bundles due to joint contracture
followed by the elongation of the central bundle of extensor tendon;

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the interosseous muscle is consequently locked at the lateral side of

MCP joint.
After correction of these deformities, a temporary joint fixation
is made by a K-wire that we put in place for about 3 weeks to
maintain the satisfactory joint position.
Before skin closure a careful hemostasis is performed after tourniquet release and a suction drain is put in place. The pulpal refilling is monitored and, when few minutes after tourniquet removal
the fingertip is not well vascularized, the K-wire is removed to
avoid any excessive stretching of the vascular bundles. It will partially compromise the extension recovery of the joint but at least it
will not threaten the finger survival.
Sometimes, whenever the tendon apparatus or neurovascular
bundles cannot be covered by skin flaps of multiple Z plasties,
their coverage is achieved by pedicled local flaps. In all the cases
without deep tissues exposure the firebreak skin grafts are helpful;
in one case where the most of the skin was useless after a wide
debridement we used Integra: in this case a longer and more
intensive wound dressing program has been necessary, but no complication occurred.
The possible complications described in literature [19, 20] are
commonly early, as problems in wound healing (hematoma, skin
flaps partial necrosis), postoperative swelling, nerve injury, and
infection. In addition, one can develop complex regional pain syndrome (CRPS), new recurrence, skin scar retraction, and joint stiffness (until hook finger deformity). Our experience in our hand
surgery department agrees about these literature data. Particularly,
we never observed any case of persisting digital ischemia requiring
partial or total ray amputation.
A bulky dressing for 24 h is held in place and it will be replaced
as soon as possible by a splint.
Although the literature is very limited in hand rehabilitation, a
careful protocol program is very important after Dupuytrens treatment to maintain the surgical results [2123] and in our clinical
current practice we extend the same principles to Dupuytrens
recurrence surgery. The main goals of rehabilitation are to promote
the wound healing and to keep the joint release and to regain the
joint motion at the same time. A too stressing exercise can compro-

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mise the corner flaps and the skin grafts, encourage the development of dystrophic or hypertrophic skin scar, and trigger vascular
crisis (and subsequent sympathetic flare) because of a too aggressive stretch to neurovascular bundles. For these reasons, a too
aggressive manual therapy associated with aggressive use of
extension orthosis should be strongly avoided in the earliest
reeducation program phase. Any tension on neurovascular bundles
and skin repair must be abolished. A dorsal progressive dynamic
splint with MCP joint at 3545 of flexion and IP joints in relaxed
extension is used whenever the preoperative PIP joint contracture
was mild (<30) and a simple release of check-reins allowed its
satisfactory correction; but if the preoperative joint stiffness is
hardly and strictly framed, and a more aggressive procedure on the
joint is necessary to improve the contracture, we prefer a volar
progressive static splint with silicone support, to treat the skin scar
at the same time: a too drastic stretching of the volar surface of the
finger would be too aggressive either for a satisfying quality of
skin healing or the maintained recovery of extension of the joint. A
careful program of skin scar massages is recommended and it starts
as soon as possible, with parallel Cobans wraps use and silicone
gel sheets local applications. This program is followed for at least
46 weeks.

References
1. Tubiana R, Leclerc C, Hurst LC, Badalamente MA, Mackin EJ, editors.
Dupuytrens disease. 1st ed. London: Martin Dunitz Ltd.; 2000.
p. 23949.
2. Hueston JT. Recurrent Dupuytrens contracture. Plast Reconstr Surg.
1963;31:669.
3. Gordon S. Dupuytrens contracture: recurrence and extension following
surgical treatment. Br J Plast Surg. 1957;9:2868.
4. Gelberman RH, Amiel D, Rudolph RM, Vance RM. Dupuytrens contracture. An electron microscopic, biochemical and clinical correlative study.
J Bone Joint Surg. 1980;62A:42532.
5. Rombouts JJ, Noel H, Legrain Y, Munting E. Prediction of recurrence in
the treatment of Dupuytrens disease: evaluation of histologic classification. J Hand Surg. 1989;14A:64452.

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O. Spingardi and M.I. Rosello

6. Foucher G, Cornil C, Lenoble E. Open palm technique for Dupuytrens disease. A five-year follow-up. Ann Chir Main Memb Super. 1992;11:3626.
7. Adam RF, Loynes RD. Prognosis in Dupuytrens disease. J Hand Surg.
1992;17A:3127.
8. Werker PM, Pess GM, van Rijssen AL, Denkler K. Correction of contracture and recurrence rates of Dupuytren contracture following invasive
treatment: the importance of clear definitions. J Hand Surg Am.
2012;37A:2095105.
9. Becker GW, Davis TR. The outcome of surgical treatments for primary
Dupuytrens diseasea systematic review. J Hand Surg Br. 2010;35:6236.
10. Kan HJ, Verrijp FW, Huisstede BMA, Hovius ERS, van Nieuwenhoven
CA, Selles RW. The consequences of different definitions for recurrence of
Dupuytrens disease. J Plast Reconstr Aesthet Surg. 2013;66:95103.
11. Hurst L. Dupuytrens contracture. In: Wolfe SW, Hotchkiss RN, Pederson
WC, Kozin SH, editors. Greens operative hand surgery. 6th ed.
Philadelphia: Elsevier Churchill-Livingstone; 2011. p. 14158.
12. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy:
complications and results. J Hand Surg (Br). 2003;28:42731.
13. Dalkey N, Helmer O. An experimental application of the Delphi method
to the use of experts. Manage Sci. 1963;9:45867.
14. Felici N, Marcoccio I, Giunta R, Haerle M, Leclercq C, Pajardi G,
Wilbrand S, Georgescu AV, Pess G. Dupuytren contracture recurrence
project: reaching consensus on a definition of recurrence. Handchir
Mikrochir Plast Chir. 2014;46:15.
15. Tubiana R. Traitement des rcidives. In: Tubiana R, Hueston JT, editors.
La maladie de Dupuytren, Monographies du Groupe dtudes de la Main.
3rd ed. Paris: Expansion scientifique franaise; 1986. p. 14953.
16. Tubiana R, Leclercq C. Les rcidives dans la maladie de Dupuytren. In:
Tubiana R, Hueston JT, editors. La maladie de Dupuytren, Monographies
du Groupe dtudes de la Main. 3rd ed. Paris: Expansion scientifique franaise; 1986. p. 2037.
17. Mantero R, Ghigliazza GB, Bertolotti P, Bonanno F, Ferrari GL, Grandis
C, Rossello I, Moretti F. Les formes rcidivantes de la maladie de
Dupuytren. In: Tubiana R, Hueston JT, editors. La maladie de Dupuytren,
Monographies du Groupe dtudes de la Main. 3rd ed. Paris: Expansion
scientifique franaise; 1986. p. 2089.
18. Mc Grouter D. Dupuytrens contracture. In: Green D, Hotchkiss RN,
Pederson WC, et al., editors. Greens operative hand surgery. 5th ed.
Edinburgh: Churchill-Livingstone; 1986. p. 15985.
19. Michon J, Merle M. Difficults et complications dans la chirurgie de la
maladie de Dupuytren. In: Tubiana R, Hueston JT, editors. La maladie de
Dupuytren, Monographies du Groupe dtudes de la Main. 3rd ed. Paris:
Expansion scientifique franaise; 1986. p. 18190.
20. Henry M. Dupuytrens disease: current state of the art. Hand.
2014;9:18.

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21. Evans RB. Therapeutic management of Dupuytrens contracture, Chapter

23. In: Skirve TM, Osterman AL, Fedorczyk JM, Amadio PC, editors.
Rehabilitation of hand and upper extremity. 6th ed. Philadelphia: Elsevier
Mosby; 2011. p. 2818.
22. Jerosch-Herold C, Shepstone L, Chojnowski AJ, Larson D, Barrett E,
Vaughan SP. Night-time splinting after fasciectomy or dermo-fasciectomy
for Dupuytrens contracture: a pragmatic, multi-centre, randomized controlled trial. BMC Muscoloskelet Disord. 2011;12:136.
23. Jerosch-Herold C, Shepstone L, Chojnowski AJ, Larson D. Splinting after
contracture release for Dupuytrens contracture (SCoRD): protocol for a
pragmatic, multi-centre, randomized controlled trial. BMC Muscoloskelet
Disord. 2008;9:62.

Chapter 13

Use of Dynamic External Fixator

(Digit Widget) in Dupuytrens
Contracture
Atanu Biswas and Anthony Smith

Introduction
Management of proximal interphalangeal (PIP) joint flexion
contracture is one of the most challenging problems resulting from
Dupuytrens disease. Progressive Dupuytrens disease causes a
shortening of the palmar soft tissues thereby restricting extension
of the PIP joint. This restriction of active extension at the PIP joint
is due to shortening of pretendinous cord(s), checkrein ligament
development, contracture of the collateral ligaments, scar contracture, or a combination of these abnormalities [1, 2]. Therapeutic
interventions are aimed to relieve this restriction of motion caused
by the flexion contracture as well as to maintain gains in active
digit extension [3]. Nonoperative techniques such as serial splinting, casting, and stretching exercises have been used to offer
gradual lengthening and softening of the contracted tissue [49].
These techniques exploit the increase in newly synthesized collagen

A. Biswas, MD, MS A. Smith, MD ()

Mayo Clinic Hospital, 5779 East Mayo Boulevard, Phoenix, AZ 85054, USA
e-mail: [email protected]; [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_13

175

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A. Biswas and A. Smith

due to increases in levels of the degradative enzymes, metalloproteinases, collagenase, and cathepsins B and L observed when
gradual lengthening of the contracted soft tissue occurs [9]. Serial
splinting and casting have limitations consisting of dorsal digital
skin ischemia, pain, and potential ulceration if used on severe contractures [3]. The Digit Widget (Hand Biomechanics Lab, Inc.,
Sacramento, CA) was developed for treatment of severe PIP joint
contractures while avoiding the soft tissue complications associated with serial casting and splinting.
The Digit Widget is a dynamic external fixator designed to provide an extension torque across the PIP joint for lengthening the
palmar soft tissues in cases of severe Dupuytrens disease. The
torque exerted by the Digit Widget is transmitted through the digital skeleton, thereby obviating any forces on the skin. The patient
is able to retain full flexion of the digit while the Digit Widget is in
place by releasing the traction produced by the device and actively
flexing the digit. The patient can also adjust the amount of extension torque to provide the least amount of force needed for gradual
joint extension while avoiding PIP joint inflammation and swelling
from too much applied torque.
The indication for use of the Digit Widget is to restore the
flexion-extension torque imbalance in any PIP joint flexion contractures. Dupuytrens disease is the most common diagnosis for
placement of the Digit Widget; however, other diagnoses causing
flexion contracture of the PIP joint can be considered for use of the
Digit Widget to restore PIP extension. Patients with evidence of
joint destruction such as in arthritis or trauma are not candidates for
placement of the Digit Widget. Patients with unstable or subluxed
PIP joints such as those with collateral ligament injuries are also
not suitable for placement of the Digit Widget. One must also
inquire about previous pulley injuries or release of checkrein ligaments as evidence of these will increase the flexion force along the
moment arms of the PIP joint which could lead to recurrence with
a worse contracture.
Those patients who are appropriate candidates for placement of
the Digit Widget will keep the device on for approximately 6
weeks. During this time, the Digit Widget functions to gradually
lengthen the palmar soft tissues and neurovascular bundle of the
affected finger while simultaneously decreasing the flexion defor-

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mity of the PIP joint. The goal of treatment is to provide the least
amount of torque to allow gradual decrease of the flexion deformity towards full correction by 6 weeks with a target improvement
of up to 15 per week. Once the PIP joint is near full extension and
the volar PIP joint is supple, the Digit Widget is removed. If the
improvement with Digit Widget therapy plateaus before approaching full extension or if the palmar soft tissues of the PIP joint have
evidence of residual symptomatic Dupuytrens nodules or noncompliant hypertrophic scarring, the Digit Widget is removed and
operative fasciectomy is performed [2].
While the Digit Widget has been described as a 1-stage procedure involving excision of the Dupuytrens bands and nodules
followed by placement of the device, a 2-stage approach has produced better results with regard to restoring active PIP joint extension [2, 5, 7, 10, 11]. Accurate Digit Widget application is
performed with fluoroscopic guidance. The dorsal mid-longitudinal
axis of the affected digit is marked (Fig. 13.1).

Fig. 13.1 Marking of the dorsal mid-longitudinal axis of the digit

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A. Biswas and A. Smith

Next, the PIP joint is radiographically identified using fluoroscopic guidance (Fig. 13.2a, b).
Once the PIP joint has been identified and marked, the locating
drill guide placed on the mid-dorsum line just distal to the PIP joint
(Fig. 13.3).
The locating drill guide is used to place a proximal and distal
predrill pin under fluoroscopic guidance (Fig. 13.4a, b).
The distal predrill pin is then removed and replaced with a permanent distal screw followed by removal of the proximal predrill
pin and subsequent replacement with a permanent proximal screw
(Fig. 13.5a). Proper screw depth is confirmed with fluoroscopy
(Fig. 13.5b).
After confirmation of permanent screw depth, the screw shrouds
are cut and the drill guide is removed. The pin block is placed over
the screws approximately 5 mm above the dorsal skin (Fig. 13.6).
The pin block is tightened in place with a hex wrench that is
included in the Digit Widget kit. Also included in the Digit Widget
kit is the connector assembly and rubber bands to set the torque
force (Fig. 13.7). The connector assembly is attached to the Cuff.
If the patient has hyperextension of the metacarpophalangeal (MP)
joint while the Digit Widget is in place, an MP Flexion Strap is
available to provide extension blocking of the MP joint.
As previously mentioned, the goal is to obtain full correction of
the PIP joint flexion deformity by 6 weeks after placement of the
Digit Widget. The patients are followed at weekly intervals and are
monitored by plotting a graph of the change in range of motion as
a function of time. The rubber bands, gauged as light, medium, and
heavy, are changed daily and additional rubber bands are added if
needed. Once five rubber bands of the same gauge are used simultaneously, a switch to a larger rubber band is made.
Frequent patient follow-up is required not only to monitor the
results of distraction but also to monitor for potential complications. Since the Digit Widget is held in place to the middle phalanx
by bone pins, the pins may serve as a tract for developing superficial or deep pin site infection. Thus, the patient should be educated
on proper hygiene care of the device during the postoperative
course. During distraction therapy, the patient should also be
educated on adjusting the ideal torque force with the rubber bands.

Fig. 13.2 (a) Identification of PIP joint with (b) fluoroscopic guidance

13
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A. Biswas and A. Smith

Fig. 13.3 Locating drill guide placement

If one applies too much torque on the PIP joint, the patient may
experience pain, increased edema accompanied with swelling,
inflammation, and possible decreased or loss of flexion in the PIP
joint. Edema causing stiffness across the PIP joint will further
undermine the effectiveness of the Digit Widget. Careful monitoring of the MP joint should also be addressed. The extension torque
on the MP joint caused by PIP joint flexion contractures leads to
MP joint hyperextension which reduces the efficiency of the Digit
Widget [3]. This torque imbalance heavily trends toward MP joint
hyperextension due to a reduced resting tension in the proximally
translocated flexor digitorum superficialis and profundus tendons
as well as an increased moment arm due to the dorsal dislocation
of the extensor tendon off the metacarpal head. The result is a limitation of proximal excursion of the extensor tendon and its central
slip. The net effect is inefficient mechanics required for PIP joint
extension. Therefore, critical to achieving long-term active PIP
joint extension after reversal of the PIP contracture is to restore
central slip tension and excursion. If one identifies excessive
hyperextension in the MP joint, the MP Flexion Strap can be used
to prevent MP joint hyperextension to facilitate rebalancing of
torque forces across the MP joint to allow more efficient PIP joint
extension. Acute complications may occur on device installation

Fig. 13.4 (a) Proximal and distal predrill pins placement with (b) fluoroscopic guidance

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181

Fig. 13.5 (a) Proximal and distal predrill pins replaced with permanent screws and (b) depth confirmed with fluoroscopy

182
A. Biswas and A. Smith

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Fig. 13.6 Pin block seated 5 mm above the dorsal skin

Fig. 13.7 Connector assembly and rubber band placement (Cuff and MP
Flexion Strap not shown)

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A. Biswas and A. Smith

including damage to tendons or the neurovascular bundle upon

insertion of the bone pins, tissue necrosis from excessive heat generated during placement of the bone pins, and breakage of the
device components.
After 6 weeks of Digit Widget distraction, the amount of contracture correction is assessed and operative considerations are
entertained depending on the amount of contracture correction and
evidence of residual Dupuytrens disease [2, 10]. If significant PIP
joint contracture has not been corrected and Dupuytrens disease
has not been operated on previously, the Digit Widget is then
removed and palmar fasciectomy is performed. If the PIP joint is
straight, but significant Dupuytrens nodularity remains, the Digit
Widget is removed and palmar fasciectomy is performed. Lastly, if
the PIP joint is straight and supple with no residual Dupuytrens
disease or excessive scarring, the Digit Widget is removed and no
additional surgery is required.
The Digit Widget offers an adjunct modality for treatment of
flexion contractures of the PIP joint. The ideal management of
severe PIP joint contractures is still debatable, and surgical management of Dupuytrens contractures has largely been disappointing [1214]. Literature regarding the use of the Digit Widget
combined with surgery is limited [2, 3, 10]. Craft et al. showed a
statistically significant average extension improvement in digits
treated with distraction of 53.4 compared to 31.4 in digits treated
with fasciectomy plus ligament release [2]. No studies that compare the effectiveness of the Digit Widget to dynamic extension
splint orthoses exist. Other external fixation devices designed to
apply continuous soft tissue distraction for correction of severe PIP
joint flexion contractures have been reported. Messina et al.
described the continuous extension technique for severe PIP joint
flexion contractures using the Tecnica di Estensione Continua
(TEC) apparatus where passive distraction is applied over a 2-to4-week period [5]. The TEC device is anchored into the fifth metacarpal by two threaded pins and skeletal traction rings are anchored
to the affected digits. Traction to lengthen the contracted soft tissues is accomplished by turning screws on threaded rods that are
attached to the skeletal traction rings. Citron and Messina reported
their experience using the TEC device as well as another skeletal

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185

external fixator device for correction of severe PIP joint flexion

contractures called the Verona apparatus [7]. The Verona apparatus
is anchored to the affected digit by two threaded pins placed on the
phalanges on each side of the PIP joint. An Allen wrench is used
to turn a gear to provide extension torque force. Both devices were
used as progressive static splints before fasciectomy but the sample
size was too small to make comparisons and preliminary results
showed correction of contracture but overall results were worse
than Messinas study. Kasabian et al. described use of a multiplanar distractor that was originally designed for mandibular distraction for correction of PIP joint contracture in one patient but the
results did not show maintenance of finger extension [15].
Houshian et al. described the use of the compass hinge external
fixator yielding an average extension gain of 38 at the end of a
mean of 33 days for chronic flexion contractures of PIP joint
caused by a variety of etiologies [16]. Siow et al. reported use of a
miniature external fixator for treatment of severe flexion contractures of the distal interphalangeal joint as well as the MP and PIP
joints from trauma in three patients [17]. White et al. also reported
use of a miniature external fixator in 27 patients with Dupuytrens
contracture of the PIP joint yielding an average PIP joint improvement of 7537 [18]. Only one patient in their series had recurrence. Beard and Trail described the S-Quattro device for use
post-limited fasciectomy for severe PIP joint contractures in
Dupuytrens disease but observed significant recurrence (55 %) in
their series [19]. Rajesh et al. also used the S-Quattro device for
severe PIP joint flexion contractures but their method involved a
preliminary palmar fasciotomy, followed by 6 weeks of distraction,
and then fasciectomy [20]. Their series showed a mean correction
of 22 in patients treated with PIP joint flexion contractures greater
than 70.
Currently, no long-term data exists on the role of the soft tissue
distraction devices for PIP joint flexion deformities and the Digit
Widget is no exception. However, preliminary data of the Digit
Widget showing superior extension improvement compared to
checkrein ligament release after fasciectomy, as well as no recurrence in the Digit Widget cohort, has shown promise. The current
accepted use of the Digit Widget is preliminary distraction

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A. Biswas and A. Smith

followed by fasciectomy and further studies in larger samples are

needed to characterize the potential for recurrence and other
complications.

References
1. McFarlane R. Patterns of the diseased fascia in the fingers in Dupuytrens
contracture. Plast Reconstr Surg. 1974;54:3144.
2. Craft R, Smith A, Coakley B, Casey III W, Rebecca A, Duncan
S. Preliminary soft-tissue distraction versus checkrein ligament release
after fasciectomy in the treatment of dupuytren proximal interphalangeal
joint contractures. Plast Reconstr Surg. 2011;128(5):110713.
3. Agee J, Goss BC. The use of skeletal extension torque in reversing
Dupuytren contractures of the proximal interphalangeal joint. J Hand Surg.
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4. Ball C, Nanchahal J. The use of splinting as a non-surgical treatment for
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5. Messina A, Messina J. The continuous elongation treatment by the TEC
device for severe Dupuytrens contracture of the fingers. Plast Reconstr
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6. Rives K, Gelberman R, Smith B, Carney K. Severe contractures of the
proximal interphalangeal joint in Dupuytrens disease: results of a prospective trial of operative correction and dynamic extension splinting.
J Hand Surg Am. 1992;17:11539.
7. Citron N, Messina J. The use of skeletal traction in the treatment of severe
primary Dupuytrens disease. J Bone Joint Surg Br. 1998;80:1269.
8. Larocerie-Salgado J, Davidson J. Nonoperative treatment of PIPJ flexion
contractures associated with Dupuytrens disease. J Hand Surg Eur Vol.
2012;37(8):7227.
9. Brandes G, Messina A, Reale E. The palmar fascia after treatment by the
continuous extension technique for Dupuytrens contracture. J Hand Surg
Br. 1994;19(4):52833.
10. Bailey A, Van der Stappen TJJ, Sims T, Messina A. The continuous elongation technique for severe Dupuytrens disease. A biochemical mechanism. J Hand Surg Br. 1994;19(4):5227.
11. Murphy A, Lalonde D, Eaton C, Denkler K, Hovius S, Smith A, Martin A,
Biswas A, Van Nieuwenhoven C. Minimally invasive options in
Dupuytrens contracture: aponeurotomy, enzymes, stretching, and fat
grafting. Plast Reconstr Surg. 2014;134(5):8229.
12. Donaldson O, Pearson D, Reynolds R, Bhatia R. The association between
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13. Misra A, Jain A, Ghazanfar R, Johnston T, Nanchaha l J. Predicting the

outcome of surgery for the proximal interphalangeal joint in Dupuytrens
disease. J Hand Surg Am. 2007;32(2):2405.
14. Van Giffen N, Degreef I, De Smet L. Dupuytrens disease: outcome of the
proximal interphalangeal joint in isolated fifth ray involvement. Acta
Orthop Belg. 2006;72(6):6717.
15. Kasabian A, McCarthy J, Karp N. Use of a multiplanar distracter for the
correction of a proximal interphalangeal joint contracture. Ann Plast Surg.
1998;40(4):37881.
16. Houshian S, Gynning B, Schrder H. Chronic flexion contracture of proximal interphalangeal joint treated with the compass hinge external fixator.
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17. Siow Y, Ahmad T, Goh S. Use of a new external fixator for the correction
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18. White J, Kang S, Nancoo T, Floyd D, Kambhampat IS, McGrouther
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19. Beard A, Trail I. The S Quattro in severe Dupuytrens contracture.
J Hand Surg Br. 1996;21(6):7957966.
20. Rajesh K, Rex C, Mehdi H, Martin C, Fahmy N. Severe Dupuytrens contracture of the proximal interphalangeal joint: treatment by two-stage
technique. J Hand Surg Br. 2000;25(5):4424.

Chapter 14

The Distal Interphalangeal Joint

in Dupuytrens Disease
Michael A. Tonkin and Jonathan P.A. Bellity

Case Report
Presentation
A 25-year-old right hand dominant male bartender and labourer
presented with a flexion contracture of the proximal phalangeal
(PIP) and distal interphalangeal (DIP) joints of the left little
finger. These contractures had been evolving progressively over
7 years when he first noticed a lump on the radial aspect of the
PIP joint.
The patient denied any family or personal history of Dupuytrens
disease, diabetes or epilepsy. He did not recall a specific fracture,
joint dislocation or soft tissue injury, but did recall a number of
small traumatic incidences incurred while playing sport at school.

M.A. Tonkin, MD () J.P.A. Bellity, MD

Department of Hand Surgery & Peripheral Nerve Surgery,
Royal North Shore Hospital, University of Sydney,
St Leonards 2065, NSW, Australia
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_14

189

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Diagnosis/Assessment
The clinical examination revealed a radial cord on the palmar side
of the left little finger, extending from the distal aspect of the proximal phalanx to the proximal aspect of the terminal phalanx. The
metacarpophalangeal (MP) joint range of motion was normal. The
PIP and DIP joints had flexion contractures of 50 and 60 respectively which were not correctable (Fig. 14.1). Active and passive
flexion ranges of motion were normal. There was some thickening
in the fascia of the first web without restriction of movement of the
thumb. He was unable to place his hand flat on the table, demonstrating a positive tabletop test [1]. There was no evidence of
Garrods knuckle pads, Peyronies or Ledderhoses disease. A
presumptive diagnosis of Dupuytrens disease was considered
most likely clinically.
Ultrasound and MRI scans were performed to assist in diagnosis
and to more precisely designate the origins and insertions of the

Fig. 14.1 Case report. Patient with PIP and DIP joint contractures

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191

Fig. 14.2 MRI with white arrow pointing to the cord-like structure

pathological tissue. These found a cord-like structure extending

from the level of the distal aspect of the proximal phalanx to the
mid-aspect of the terminal phalanx on the radial side of the digit
(Fig. 14.2).
Management
The patient described difficulty with daily activities and significant
interference with function. After discussion, he chose to proceed to
open excision of the palpable tissue to confirm the clinical diagnosis and to correct the contractures as best possible. Needle fasciotomy and collagenase injections were considered inappropriate as
a diagnosis had not been absolutely established and the anatomical
position of the tissue was likely to involve neurovascular bundles
and be adherent to the flexor tendon sheath.
A hemi-Brunner incision was fashioned over the tissue along
the radial side of the finger from mid-proximal phalangeal level to
the pulp (Fig. 14.3). After elevation of the flaps, the cord was

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Fig. 14.3 Hemi-Bruner incision

mobilised. Macroscopically it resembled Dupuytrens tissue. It

took origin from the distal third of the proximal phalanx adjacent
to the distal end of the A2 pulley attachment and from the adjacent
flexor tendon sheath, deep to the neurovascular bundle. The neurovascular bundle crossed from lateral to medial sides of the cord,
superficial to the cord which involved retrovascular fascial fibres.
At the level of the DIP joint the cord enveloped the neurovascular
bundle with superficial fibres inserting into the flexor tendon
sheath at and distal to the joint, and deep fibres inserting into the
mid-aspect of the distal phalanx on the radial side of the flexor
digitorum profundus (FDP) insertion and into adjacent skin
(Fig. 14.4).
The dissection protected the neurovascular bundle and its terminal branches. Excision of the cord achieved full correction of PIP
and DIP joints. The skin was closed without tension (Fig. 14.5).
The histological findings were of fibromatosis consistent with
Dupuytrens disease.

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Fig. 14.4 The cord, with superficial connection to flexor tendon sheath at DIP
joint level (white arrow) and neurovascular bundle (black arrow) prior to the
excision of the cord

Post-operative care involved splinting and early range of motion

exercises. Healing was uneventful and at 6 months post-operation
there were no signs of recurrence of deformity. Active motion at
the PIP joint was from 5 to full flexion; and at the DIP joint from
0 to full flexion (Fig. 14.6a, b).

Discussion
Although of a young age and without a family history of
Dupuytrens contracture, the clinical findings in this patient were
suggestive of the presence of an isolated Dupuytrens cord.
Contracture of the DIP joint is uncommon; in fact, Ellis claimed

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M.A. Tonkin and J.P.A. Bellity

Fig. 14.5 Full correction and skin closure

that the DIP joint was not affected by Dupuytrens disease [2].
Millesi (1967) reported an incidence of 4.9 % in 287 patients with
Dupuytrens disease [3]. Anwar found a similar incidence in the
digits of 119 females [4].
A number of clinical circumstances in which the DIP joint is
involved in Dupuytrens disease have been identified. These are
as follows: an isolated primary DIP joint contracture; primary
disease involving PIP and DIP joints but with isolation to the
digit, without MP joint contracture; and a primary DIP joint contracture in association with MP and PIP joint contractures [3, 58].
Two other forms of involvement of the DIP joint by Dupuytrens
disease are recognised: a swan neck deformity with flexion at the
distal phalanx secondary to disease tethering the lateral band and
central slip proximal to the PIP joint, with consequent hyperextension of the PIP joint [9]; and DIP joint hyperextension
(Boutonniere or pseudo-Boutonniere). Each of these deserves
further consideration.

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The Distal Interphalangeal Joint in Dupuytrens Disease

Fig. 14.6 Post-operative extension (a) and flexion (b)

195

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M.A. Tonkin and J.P.A. Bellity

Primary DIPJ Contracture

It is agreed that the most common cords creating a primary DIP
joint contracture are lateral and retrovascular cords [1016]. If the
cord takes origin from the lateral or retrovascular fibres of the lateral digital sheet distal to the PIP joint, then it will result in the relatively uncommon isolated DIP joint contracture. The insertion is to
terminal phalanx and skin and flexor tendon sheath deep to the
neurovascular bundle but also to skin and flexor tendon sheath
superficial to the neurovascular bundle depending upon whether
retrovascular and/or lateral cords are involved. The contracted tissue may cause spiralling of the neurovascular bundle and may
encompass the neurovascular bundle, particularly at the level of the
DIP joint.
Only a small number of isolated DIP joint contractures have
been reported in the literature1 of 16 DIP joint contractures in
Millesis 1967 report, one by Bellonias and Nancarrow in 1991,
one by Rao et al. in 2006, one by Zyluk in 2007, and one by Takase
in 2010 [3, 58]. Of these five cases, four affected the little finger
with the cord lying on the radial side. One affected the ring finger
on its radial side.
In those digits in which the diseased cord is isolated to the digit
but involves both PIP and DIP joints, the origin of the cord is
proximal to the PIP joint, again most commonly involving lateral
and retrovascular fascial fibres. Combined PIP and DIP joint contractures are more common than isolated DIP joint contractures.
The little finger is most commonly affectedin 12 of 16 patients
in Millesis study [3]. Tubiana and Defrenne (1976) and White
(1984) believed that it was the ulnar aspect of the little finger,
rather than the radial aspect, which was most often affected by
Dupuytrens disease, although this was not so for those cases referenced above with isolated DIP joint contractures, nor the case
report of this presentation [17, 18].
A pretendinous palmar cord may connect with the lateral digital
sheet proximal or distal to the PIP joint, either superficially or deep
to the neurovascular bundle. In this instance, an MP joint contracture will accompany PIP and DIP joint contractures.

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McGrouther and McFarlane highlighted the high recurrence of

PIP joint deformities following surgery, the latter believing that
this was due to incomplete excision of diseased fascia at the initial operation, although others have incriminated other factors
including involvement of periarticular structures at the PIP joint
and the loss of an effective extensor mechanism in long-standing
PIP joint contractures [1216]. They have stated that DIP joint
contractures are more common in recurrent disease. However,
there are no specific studies addressing recurrence of deformity
at the DIP joint.

Swan Neck Deformity

Dorsal Dupuytrens disease presents as Garrods knuckle pads,
rarely as nodules overlying the middle phalanx, and as disease
involving the transverse and oblique retinacular ligaments [1922].
Garrods knuckle pads are generally believed not to involve the
extensor mechanism and do not produce contraction [23]. However,
Addison (1984) has shown that, on occasions, Garrods knuckle
pads can involve the extensor mechanism and tether the central slip
and lateral band, limiting PIP joint flexion [24]. This may lead to
swan-necking.
Boyce and Tonkin (2004) have described an unusual case of a
swan neck deformity in which diseased fascia coursed parallel to
the oblique retinacular ligament of Landsmeer, but dorsal to it [9].
The cord inserted proximal to the PIP joint into the central slip and
radial lateral band at the level of the intervening transverse retinacular ligament. Contraction of this cord caused a rigid swan neck
deformity with dorsal subluxation of the lateral bands creating a
secondary DIP joint flexion deformity distally. Excision of the cord
allowed correction of both joint deformities.
A swan neck deformity may also be associated with a primary
DIP joint contracture. The forces of the extrinsic extensor tendon
mechanism, central slip and lateral bands, are concentrated on the
PIP joint in an effort to extend the DIP joint, causing a secondary
hyperextension of the PIP joint.

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DIP Joint Hyperextension Deformity

This is the most common DIP joint deformity. A number of theories have been advanced as to the cause of hyperextension at the
DIP joint and it is probable that differing mechanisms may be
responsible, either occurring in conjunction or separately.
A long-standing PIP joint flexion contracture can lead to attenuation of the central slip of the extensor mechanism and palmar migration of the lateral bands with secondary DIP joint hyperextensiona
true Boutonniere deformity [1315, 25, 26] (Fig. 14.7). An extensor
tenotomy over the mid-aspect of the middle phalanx may be beneficial in diminishing extensor tone to the DIP joint and increasing
extensor tone to the PIP joint [1315, 26] (Figs. 14.8 and 14.9).

Fig. 14.7 Boutonniere deformity

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Fig. 14.8 (a) Pre-operative boutonniere deformity in association with a longstanding PIP joint contracture; (b) Limitation of passive DIP joint flexion; (c)
Extensor tenotomy over middle phalanx; (d) Passive flexion increased following extensor tenotomy

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M.A. Tonkin and J.P.A. Bellity

Fig. 14.9 (a) Post-operative extensionnote that the PIP joint flexion deformity is partially corrected; (b) Post-operative flexionnote some restriction in
active DIP joint flexion

However, even if the central slip is protected for a time, recurrence

of an extension deformity at the DIP joint or at least a restriction in
full flexion may eventuate.
Kuhlmann believed that contraction of the transverse retinacular
ligament may draw the lateral bands palmarwards primarily rather
than this being a secondary phenomenon following central slip
attenuation [21]. Excision of the transverse retinacular ligament
allowed correction of the deformity in his cases.
Direct involvement of the oblique retinacular ligament in the
primary pathological process may create a pseudo-Boutonniere
deformity with hyperextension of the DIP joint, but without primary interference with the central slip. However, McFarlane considered that the oblique retinacular ligament was rarely primarily
involved in disease; rather if there was a long-standing PIP joint
contracture the fascial structures such as the oblique retinacular
ligament and the extensor tendon may be foreshortened [1315].
In this instance, he advised division of the oblique retinacular
ligament.

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201

In addition to these mechanisms leading to DIP joint

hyperextension, Hueston described a plaque of Dupuytrens tissue
tethering to the extensor tendon and the middle phalanx, limiting
DIP joint flexion [20].

Conclusion
The case which is presented demonstrates a primary flexion contracture of the DIP joint, in association with a contracture of the
PIP joint, caused by a retrovascular cord taking origin from midproximal phalangeal level and inserting into the terminal phalanx,
flexor tendon sheath and skin distal to the DIP joint. Excision of
the diseased fascia achieved full correction. However, it is possible
that recurrence is likely, given the age of the patient and the tendency for recurrence in DIP joint contractures secondary to
Dupuytrens disease. The case report is used to provide a review of
the differing ways in which the DIP joint may be involved in
Dupuytrens disease.

References
1. Hueston JT. The table top test. Hand. 1982;14:1003.
2. Ellis H. Baron Guillaume Dupuytren: Dupuytrens contracture. J Perioper
Pract. 2013;23:11920.
3. Millesi H. On the flexion contracture of the distal interphalangeal joint
within the scope of Dupuytrens contracture. Bruns Beitr Klin Chir.
1967;214:4005.
4. Anwar MU, Al Ghazal SK, Boome RS. Results of surgical treatment of
Dupuytrens disease in women: a review of 109 consecutive patients.
J Hand Surg Am. 2007;32:14238.
5. Bellonias EC, Nancarrow JD. Two unusual cases of distal interphalangeal
joint Dupuytrens contracture. Br J Plast Surg. 1991;44:6023.
6. Rao K, Shariff Z, Howcroft AJ. Dupuytrens contracture of the distal interphalangeal joint: a rare presentation. J Hand Surg Br. 2006;31:6945.
7. Zyluk A. Dupuytrens contracture limited to the distal interphalangeal
jointa case report. Chir Narzadow Ruchu Ortop Pol. 2007;72:3634.

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M.A. Tonkin and J.P.A. Bellity

8. Takase K. Dupuytrens contracture limited to the distal interphalangeal

joint: a case report. Joint Bone Spine. 2010;77:4701. doi:10.1016/j.
jbspin.2010.02.036.
9. Boyce DE, Tonkin MA. Dorsal Dupuytrens disease causing a swan-neck
deformity. J Hand Surg Br. 2004;29:6367.
10. Gosset J. Anatomie des Aponeuroses Palmodigitales. In: Tubiana R, editor. La Maladie de Dupuytren. 2nd ed. Paris: Expansion Scientifique
Francaise; 1972. p. 23.
11. Thomine JM. The development and anatomy of the digital fascia. In:
Hueston JT, Tubiana R, editors. Dupuytrens disease. Edinburgh: Churchill
Livingstone; 1974. p. 19.
12. McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytrens
contracture. Displacement of the neurovascular bundle. Plast Reconstr
Surg. 1974;54:3144.
13. McFarlane RM. The anatomy of Dupuytrens disease. In: Hueston JT,
Tubiana R, editors. Dupuytrens disease. 2nd ed. Edinburgh: Churchill
Livingstone; 1985. p. 5572.
14. McFarlane RM. Dupuytrens contracture. In: Green DP, editor. Operative
hand surgery. New York: Churchill Livingstone; 1988. p. 55389.
15. McFarlane RM. Dupuytrens disease. In: McCarthy JG, editor. Plastic
surgery. Philadelphia: WB Saunders; 1990. p. 505386.
16. McGrouther DA. Dupuytrens contracture. In: Green DP, Hotchkiss RN,
Pederson WC, et al., editors. Greens operative hand surgery. Philadelphia:
Elsevier Churchill Livingstone; 2005. p. 15985.
17. Tubiana R, Defrenne H. Localizations of Dupuytrens contracture in the
radial part of the hand. Chirurgie. 1976;102:98993.
18. White S. Anatomy of the palmar fascia on the ulnar border of the hand.
J Hand Surg Br. 1984;9:506.
19. Garrod AE. Concerning pads upon the finger joints and their clinical relationships. Br Med J. 1904;2:8.
20. Hueston JT. Dorsal Dupuytrens disease. J Hand Surg Am. 1982;7:
3847.
21. Kuhlmann JN, Boabighi A, Guero S, Mimoun M, Baux S. Boutonniere
deformity in Dupuytrens disease. J Hand Surg Br. 1988;13:37982.
22. Iselin F, Cardenas-Baron L, Gouget-Audry I, Peze W. Dorsal Dupuytrens
disease. Ann Chir Main. 1988;7:24750.
23. Hueston JT. Some observations on knuckle pads. J Hand Surg Br. 1984;
9:758.
24. Addison A. Knuckle pads causing extensor tendon tethering. J Bone Joint
Surg Br. 1984;66:12830.
25. Smith P, Breed C. Central slip attenuation in Dupuytrens contracture: a
cause of persistent flexion of the proximal interphalangeal joint. J Hand
Surg Am. 1994;19:8403.
26. Crowley B, Tonkin MA. The proximal interphalangeal joint in Dupuytrens
disease. Hand Clin. 1999;15:13747.

Chapter 15

Knuckle Pads (Garrods Nodules)

of the Fingers: Painful Dorsal Nodules
on the PIP Joints of the Fingers
and Concomitant Recurrent
Dupuytrens Contracture
Karsten Knobloch

Case Presentation
A 48-year-old male presented himself in my office with painful
dorsal nodules on his fingers in association with a recurrent
Dupuytrens contracture of his small finger of his right dominant
hand. Prior, he underwent surgery with open selective fasciectomy
4 years ago for his right small finger due to Dupuytrens contracture. However, Dupuytrens contracture recurred within 18 months
following conventional open surgery as limited fasciectomy. He
had a positive family history for Dupuytrens contracture.
Regarding knuckle pads in his family history, the patient was not
quite sure about.

K. Knobloch, MD, PhD, FACS ()

SportPraxis, Heiligerstr. 3, 30159 Hannover, Germany
e-mail: [email protected];
http://www.sportpraxis-knobloch.de
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_15

203

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K. Knobloch

Physical Examination
The patient presented himself with dorsal nodules over his proximal interphalangeal (PIP) joints on his right hand predominantly
on the middle, ring, and small finger (Fig. 15.1) and on his left
hand at the identical fingers (middle, ring, and small fingers,
Fig. 15.2), which limit extension and were associated with pain.
These nodules were palpable. Pain was provoked by palpation on
the largest nodules as well as during manual exercise. In addition,
he had a recurrent small finger Dupuytrens contracture following
open conventional selective fasciectomy 4 years ago with a
MP-joint contracture of 40 and a PIP-joint contracture of 90, so
a total contracture of 130 of his dominant right small finger.

Diagnosis/Assessment
Ultrasound examination of the nodules revealed hypoechogenic
echotexture with minimal blood flow upregulation in Power Doppler
ultrasound. Dupuytrens contracture showed hypoechogenic

Fig. 15.1 (a) Knuckle pads (Garrods nodules) of the PIP joints dominantly at
the ring and small finger of the right hand. (b) Knuckle pads (Garrods nodules) of the PIP joints dominantly at the middle, ring, and small finger of the
left hand

Fig. 15.2 (a, b) Grey-scale ultrasound for knuckle pads (Garrods nodules) of the PIP joint as hypoechogenic mass without flow increment (a) in contrast to the index finger without the hypoechogenic mass

15
Knuckle Pads (Garrods Nodules) of the Fingers
205

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K. Knobloch

superficial texture changed superficial to the superficial flexor

tendon involving the A1-pulley ligament.
Epidemiological data on the incidence of knuckle pads should
be interpreted in a geographical perspective as it is the case for
Dupuytrens contracture with a dominance in Northern Europe. In
a northern Germany cohort of 566 Dupuytrens contracture
patients, knuckle pads were evident in 6.7 % [1]. Mikkelsen from
Norway reported a rate of 9 % in adults Norwegian males and
8.6 % in Norwegian femaleswhen Dupuytrens contracture was
simultaneously evident, the rate was increased fourfold [2]. In the
CORD I collagenase RCT with Dupuytrens contracture of at least
20 at the MP or PIP joint, a knuckle pad rate of 5.2 % was
reported [3]. In epilepsy patients from the United Kingdom,
knuckle pads occurred in 42 % of epileptic males and 40 % of
epileptic females [4].

Management
In 1893, Archibald Garrod, the principal reporting physician of
Garrods nodules from the Hospital for Sick Children at Great
Ormond Street, London, UK, once stated: I know of no plan of
treatment with is of any avail in reducing the size of the pads or in
causing them to disappear. In an evidence-based perspective,
nothing substantial has changed in 2015there is no randomized
controlled trial out yet on any treatment modality in Garrods
nodules [5].
However, given the published data derived from the most prevalent fibromatosis, Dupuytrens contracture, I proposed the combination of focused extracorporeal shockwave therapy (ESWT) as
well as topical antifibrotic treatment with TGF--inhibitor acetylcysteine (ACC) to overcome the pain of the Garrods nodules [6]
(Fig. 15.3). Focused ESWT was performed with a Storz Ultra
device with pain-limited energy flux densities up to 0.3 mJ/mm2
with 1000 impulses for each knuckle pad on a weekly base for
three treatments. Pain was reduced from VAS 6/10 before to 1/10
after 4 weeks.

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Knuckle Pads (Garrods Nodules) of the Fingers

207

Fig. 15.3 Topical antifibrotic treatment using acetyl-cysteine instillation as a

profibrogenic transforming growth factor (TGF)--blocking agent limiting
fibrosis and potentially reducing recurrences with a high-flow water-beam
JetPeel system without pain

As far as the recurrent Dupuytrens contracture in this patient

was concerned, enzymatic fasciotomy using collagenase injection
was performed in combination with focused ESWT as well as topical antifibrotic ACC [7] at his small finger (Fig. 15.4). Focused
ESWT has been shown to reduce pain in plantar Ledderhoses
disease [8]. A randomized controlled trial on focused ESWT in
nodular Dupuytrens disease Tubiana N (DupuyShock) is near to
be published soon with 1-year follow-up data.
A small skin laceration at the small finger following enzymatic
fasciotomy with collagenase injection healed by secondary intention supported by the focused extracorporeal shockwave therapy
(ESWT). To date, the evident flexor tendon lacerations following
collagenase injection therapy in the CORD 1 trial have been found
at the small finger at the PIP joint level. Therefore, we suggest
being aware of the complicated small finger Dupuytrens contracture when treating with collagenase injection [9].

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K. Knobloch

Fig. 15.4 Recurrent Dupuytrens contracture following open conventional

surgery and concomitant bilateral Knuckle pads (Garrods nodules). MP-joint
contracture of 40 and PIP-joint contracture of 90 prior to combined enzymatic fasciotomy with collagenase injection and focused extracorporeal shockwave therapy (ESWT) and topical antifibrotic treatment with acetyl-cysteine

Outcome
Recurrence of both knuckle pads and Dupuytrens contracture is a
potential outcome. Recurrence definition is still an issue of debate
[10]. No controlled long-term recurrence data are published on
knuckle pads. Given the fact that focused ESWT has been shown
to reduce pain and improve function in other fibromatosis like
Ledderhoses disease of the foot or Dupuytrens disease, the complete noninvasive approach focusing on pain reduction with the
ESWT as well as potentially slow down the fibrosis progress using
local antifibrotic ACC therapy are suitable options in terms of
symptom control (Figs. 15.5 and 15.6).

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209

Fig. 15.5 Five days following cord breaking using enzymatic fasciotomy with
collagenase injection combined with focused extracorporeal shockwave therapy (ESWT) and topical antifibrotic treatment with acetyl-cysteine in recurrent
Dupuytrens contracture following open conventional surgery and concomitant
bilateral Knuckle pads (Garrods nodules)

Pearls and Pitfalls

Knuckle pads are benign nodules on the proximal interphalangeal joints often associated with Dupuytrens contracture.
Painful knuckle pads might warrant therapy.
Pain and potential disease modification therapeutic options
include noninvasive focused extracorporeal shockwave therapy
(ESWT) as well as local antifibrotic treatment with
acetyl-cysteine.
Currently, no randomized controlled studies have been published on any treatment in knuckle pads.

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K. Knobloch

Fig. 15.6 Nine days following cord breaking using enzymatic fasciotomy with
collagenase injection combined with focused extracorporeal shockwave therapy (ESWT) and topical antifibrotic treatment with acetyl-cysteine in recurrent
Dupuytrens contracture following open conventional surgery and concomitant
bilateral Knuckle pads (Garrods nodules)

References
1. Brenner P, Krause-Bergmann A, Van VH. Dupuytren contracture in North
Germany. Epidemiological study of 500 cases. Unfallchirurg. 2001;104(4):
30311.
2. Mikkelsen OA. Knuckle pads in Dupuytrens disease. Hand. 1977;9(3):
3015.
3. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals
RA, Smith TM, Rodzvilla J, CORD I. study group. Injectable collagenase
clostridium histolyticum for Dupuytrens contracture. N Engl J Med.
2009;361(10):96879.
4. Critchley EM, Vakil SD, Hayward HW, Owen VM. Dupuytrens disease in
epilepsy: result of prolonged administration of anticonvulsants. J Neurol
Neurosurg Psychiatry. 1976;39(5):498503.
5. Knobloch K. Knuckle pads and therapeutic options. MMW Fortschr Med.
2012;154(19):412.
6. Knobloch K. From nodules to cords in Dupuytrens contracture. MMW
Fortschr Med. 2012;154(19):378.

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211

7. Knobloch K, Redeker J, Vogt PM. Antifibrotic medication using a combination of N-acetyl-L-cysteine (NAC) and ACE inhibitors can prevent the
recurrence of Dupuytrens disease. Med Hypotheses. 2009;73(5):65961.
8. Knobloch K, Vogt PM. High-energy focused extracorporeal shockwave
therapy reduces pain in plantar fibromatosis (Ledderhoses disease). BMC
Res Notes. 2012;5:542.
9. Knobloch K, Vogt PM. Beware of the small finger and/or the proximal
interphalangeal joint? Skin lacerations following collagenase injection in
Dupuytrens contracture. Plast Reconstr Surg. 2012;130(1):202e4e.
10. Felici N, Marcoccio I, Giunta R, Haerle M, Leclercq C, Pajardi G,
Wilbrand S, Georgescu AV, Pess G. Dupuytren contracture recurrence
project. Reaching consensus on a definition of recurrence. Handchir
Mikrochir Plast Chir. 2014;46(6):3504.

Chapter 16

Arthrodesis in Treatment
of Dupuytrens Contracture
Ali Izadpanah and Marco Rizzo

Case Presentation
A 69-year-old female, right-hand dominant, presented with recurrent bilateral Dupuytrens contractures requiring multiple limited
fasciectomy. His last surgery involved a limited fasciectomy of
small and ring finger with application of Digit-widget (Hand
Biomechanics Lab, Sacramento, CA) device for correction of a
long-standing flexion contracture (Fig. 16.1). Her preoperative
radiographs demonstrated some evidence of proximal interphalangeal (PIP) joint arthritic changes; however as per patients request,
an attempt to preserve the joint was elected. Following the surgical
subtotal fasciectomy and application of Digit-widget the flexion
contracture was corrected to 25. Within 2 months, she had a rapid
recurrence of flexion deformity (Fig. 16.2). Thus a decision was
A. Izadpanah, MD, FRCSC
Department of Plastic Surgery, Centre Hospitalie de
lUniversite de Montreal, 1560 Sherbrooke Street East,
Montreal, QC, Canada, H2L 4M1
e-mail: [email protected]
M. Rizzo, MD ()
Deparatment of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic,
200 1st St SW, Rochester, MN 55905, USA
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_16

213

Fig. 16.1 Images demonstrating the Dupuytrens contracture and the articular changes of PIP joint prior to limited fasciectomy and
application of Digit-widget

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Arthrodesis in Treatment of Dupuytrens Contracture

Fig. 16.2 Images demonstrating the rapid recurrence of flexion deformity after initial subtotal digital and palmar fasciectomy

16
215

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A. Izadpanah and M. Rizzo

made to proceed with an attempt of Xiaflex (Auxilium,

Chesterbrook, PA) injection. Minimal improvement was noted
after the release and a decision to proceed with salvage procedure
and PIP joint arthrodesis to address both the Boutonnire deformity
and the flexion contracture recurrence.

Assessment
The patient had rapid recurrence of his flexion deformity after subtotal fasciectomy and application of Digit-widget. Given the preexisting arthritic changes at the PIP joint in the context of failure to
correct the flexion contracture, a decision was made to proceed with
PIP joint arthrodesis to both obtain a more desirable position of the
joint and further prevent progression of the deformity.

Management
The initial aspects of the procedure involved a dorsal approach to
the small finger. A tendon-splitting approach was then utilized;
however given the extent of contracture a volar release seemed to
be necessary. At this point, a small transverse incision was utilized,
centered over the cord just distal to the MP flexion crease. A fasciotomy was then to allow for correction of her deformity to approximately 5560. Attention was turned to dorsum of the joint and
using three 0.035 in. Kirschner wires, a successful arthrodesis of
the PIP joint was performed.

Outcome
Patient had favorable outcome with substantial improvement in the
use of her hand. At 2-year follow-up visit, she had no recurrence of
her flexion contracture with good use of hand. The results were so

16

Arthrodesis in Treatment of Dupuytrens Contracture

217

satisfying to the patient that she had opted for a similar procedure
to address her contralateral ring finger deformity with similar findings 1 year after the surgery.

Literature Review
Recurrent Dupuytrens contracture is seen in up to 71 % of patients
[1,2]. Recurrence can be more often seen in individuals with
Dupuytrens diathesis, originally described by Heuston as bilateral
disease, strong family history, ectopic involvement, and early age
of onset [2]. Occasionally it is necessary in Dupuytrens disease to
modify the basic approach of limited fasciectomy, especially in the
context of recurrent disease. In a study by Roush and Stern, authors
investigated three different alternatives in management of recurrent
Dupuytrens contracture [3]. In their results, they showed that the
final total active range of motion (TAM) was not significantly different from preoperative TAM for patients undergoing fasciectomy
and interphalangeal arthrodesis or dermofasciectomy and fullthickness skin graft. However patients with limited fasciectomy
and local flap coverage had the best final TAM compared to preoperative values. Tonkin in a separate study demonstrated only 4 %
recurrence rate after skin graft versus 42 % outside the grafting [4].
Thus, there is no consensus in the optimal management of recurrent Dupuytrens contracture. Watson and Fong in a review of
salvage procedures for addressing recurrent Dupuytrens contractures discuss some of these procedures such as use of local flaps,
use of skin graft, joint replacement, osteotomy, and arthrodesis [5].
Arthrodesis can provide a stable joint in a more functional position. The position of arthrodesis changes according to the involved
digit and also depends on the patients needs. As a rule of thumb,
given the ability of small and ring fingers hyperextension, the
index is fused at 20, the middle at 30, the middle at 40, and the
small finger at 45 [4]. Thus, a multi-operated fixed PIP joint
arthrodesis can provide a stable joint in a more functional position.
Moberg recommends resecting the PIP joint and using a quadrangular bone peg from the proximal ulna to leave the finger in 25 of

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A. Izadpanah and M. Rizzo

flexion [6]. The flexion at the MP joint makes the loss of PIP flexion
less important. Our preferred method of arthrodesis for PIP joint is
the use of multiple Kirschner wires (K-wires) or the tension band
technique using two K-wire and figure-of-eight interosseous wires
(Fig. 16.3). Other authors have used isolated interosseous wiring, or
miniplate and screws [79]. Moberg also describes a dorsal wedge
osteotomy for flexion contractures up to 90 of dorsal angulation.

Fig. 16.3 Radiographs demonstrating PIP joint arthrodesis using Kirschner

wires technique

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Arthrodesis in Treatment of Dupuytrens Contracture

219

Fig. 16.4 Schematic presentation of dorsal osteotomy [6]

This technique allows the motion to be preserved in the finger with

total arc of motion being transferred dorsally (Fig. 16.4) [6]. Watson
and Fong describe a concave-convex arthrodesis technique in an
attempt to salvage procedure of choice [5]. This technique could be
reserved for when a palmar approach does not provide adequate
release or will compromise the digit due to multiple previous surgeries with a flexion contracture of greater than 70 (Fig. 16.5).
Although previous studies have demonstrated absence of any
correlation between Dupuytrens diathesis and recurrence rate and
only the severity of preoperative condition affecting the recurrence
rate, other studies indicate correlation of higher recurrence rate in
the presence of at least one component of diathesis [3,10]. A lower
total active range of motion (TAM) fowlloing interphalangeal
arthrodesis did not affect the experienced quality of life in these
patients. In general, these patients are usually well educated about
their disease and thankful for merely avoiding amputation [3].

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A. Izadpanah and M. Rizzo

Fig. 16.5 Schematic presentation of concave-convex osteotomy to address

severe long-lasting flexion deformity in chronic Dupuytrens contracture with
arthritic changes at the joint [5]

Clinical Pearls/Pitfalls
PIP joint flexion contracture release can be considered in a stepwise manner with first release of palmar skin after previous
surgical interventions, recurrent cord development, joint capsule, and checkrein ligaments.
The oblique retinacular ligament of Landsmeer may become
tight after a long-lasting Dupuytrens contracture and produce
flexion of the PIP joint and subsequent hyperextension of the
distal interphalangeal joint. Thus, this can result into a
Boutonniere deformity. Transection of the Landsmeer ligament
is recommended in these cases.
The effect of gradual external digit extensor in treatment of
long-lasting PIP joint flexion contracture can be suboptimal.
At times, the long-lasting flexion contracture of the joint can
lead to loss of articular cartilage at the PIP joint, necessitating a
salvage procedure such as arthrodesis.
Arthrodesis can be an effective salvage procedure in patients in
an attempt to prevent amputation.

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Arthrodesis in Treatment of Dupuytrens Contracture

221

References
1. Gordon S. Dupuytrens contracture: recurrence and extension following
surgical treatment. Br J Plast Surg. 1957;9(4):2868.
2. Hueston JT. Digital Wolfe grafts in recurrent Dupuytrens contracture.
Plast Reconstr Surg Transplant Bull. 1962;29:3424.
3. Roush TF, Stern PJ. Results following surgery for recurrent Dupuytrens
disease. J Hand Surg. 2000;25(2):2916.
4. Tonkin MA, Burke FD, Varian JP. Dupuytrens contracture: a comparative
study of fasciectomy and dermofasciectomy in one hundred patients.
J Hand Surg. 1984;9(2):15662.
5. Watson HK, Fong D. Dystrophy, recurrence, and salvage procedures in
Dupuytrens contracture. Hand Clin. 1991;7(4):74555. discussion
7578.
6. Moberg E. Three useful ways to avoid amputation in advanced Dupuytrens
contracture. Orthop Clin North Am. 1973;4(4):10015.
7. Beyermann K, Jacobs C, Lanz U. Severe contractures of the proximal
interphalangeal Joint in Dupuytrens disease: value of capsuloligamentous
release. Hand Surg. 1999;4(1):5761.
8. Rives K, et al. Severe contractures of the proximal interphalangeal joint in
Dupuytrens disease: results of a prospective trial of operative correction
and dynamic extension splinting. J Hand Surg. 1992;17(6):11539.
9. Tonkin MA, Burke FD, Varian JP. The proximal interphalangeal joint in
Dupuytrens disease. J Hand Surg. 1985;10(3):35864.
10. Vigroux JP, Valentin P. A natural history of Dupuytrens contracture
treated by surgical fasciectomy: the influence of diathesis (76 hands
reviewed at more than 10 years). Ann Chir Main Memb Super. 1992;
11(5):36774.

Suggested Readings
Watson HK, Fong D. Dystrophy, recurrence, and salvage procedures in
Dupuytrens contracture. Hand Clin. 1991;7(4):74555. discussion 7578.
Wolfe SW, Pederson WC, Hotchkiss RN, Kozin SH. Greens operative hand
surgery: 2-volume set. 6th ed. Philadelphia: Churchill Livingstone; 2010.

Chapter 17

Amputation in Management
of Severe Dupuytrens Contracture
Ali Izadpanah and Marco Rizzo

Case Presentation
An 82-year-old male presents with severe Dupuytrens contracture
of his small finger involving his metacarpophalangeal joint (MPJ).
He had a substantial flexion contracture of the MPJ up to 80 of
flexion deformity (Fig. 17.1). He had intact neurovascular examination. His past medical history was significant for hypertension,
obstructive sleep apnea, and multiple hand osteoarthritic joints.
Functional limitation urged him to seek a medical consult with
Physical Medicine and Rehabilitation and eventually a surgical
consult with a hand surgeon.

A. Izadpanah, MD, FRCSC

Department of Plastic Surgery, Centre Hospitalie de lUniversite
de Montreal, 1560 Sherbrooke Street East, Montreal, QC,
Canada, H2L 4M1
e-mail: [email protected]
M. Rizzo, MD ()
Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic,
200 1st St SW, Rochester, MN 55905, USA
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_17

223

Fig. 17.1 (a, b) Images demonstrating sever flexion contracture due to severe Dupuytrens contracture mainly involving metacarpophalangeal joint

224
A. Izadpanah and M. Rizzo

17 Amputation in Management of Severe Dupuytrens

225

Assessment
A decision was made to proceed with an attempt to limited fasciectomy. One year after the initial fascietomy, he had a flexion
contracture recurrence requiring a repeat limited fascietomy.
Following his second surgery, he reformed a severe flexion contracture. Subsequently, he opted for another revisional surgery for
this recalcitrant Dupuytrens contracture. Eleven months after his
last surgery, he returned with similar contracture. Having failed
two attempts at correction, a decision was made to proceed with
arthrodesis of proximal interphalangeal joint versus possible
amputation depending on the feasibility of fusion.

Management
The initial aspect of the procedure started as an attempt to manipulation of the joints under anaesthesia which was not successful.
Given the extent of flexion deformity, an isolated dorsal approach
for arthrodesis was not feasible; thus, a Brunner-type incision was
designed volarly (Fig. 17.1). Extensive dissection was required
with identification of the neurovascular bundles. Correction of the
deformity to create a suitable arthrodesis proved to be too difficult.
Despite extensive dissection, the skin and neurovascular structures
limited correction. Therefore a decision was made to proceed with
amputation at the level of metacarpal base, as discussed preoperatively with the patient (Fig. 17.2).

Outcome
Postoperatively, our patient did well with good return of hand function. He had some neuropathic phantom pain for 3 months postprocedure which improved significantly on neuromodulators and he
was able to return to full activities at 4 months post-procedure. His
last follow-up, 3 years after surgery, was uneventful; however, he
had developed a new flexion contracture involving his ring finger.

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A. Izadpanah and M. Rizzo

Fig. 17.2 Plain radiograph of hand post-amputation

Literature Review
Dupuytrens contracture can lead to significant recalcitrant flexion
contracture and disability. Recurrence or progression of disease
can occur in 276 % of patients [1]. Postoperative complications
are also common after Dupuytrens flexion contracture release.
Finger amputation for treatment of severe recurrent Dupuytrens
contracture has been described in the literature [2]. The proximal
interphalangeal joint, being a very unforgiving articulation, can
progress to autofusion after prolonged involvement of the joint
requiring amputation in some recurrent cases [3, 4]. Dupuytrens
contracture being more common in the ulnar sided digits can lead
to significant disability with grip and function. Small and ring fingers have been described as the most affected digits. Small finger

17 Amputation in Management of Severe Dupuytrens

227

has been also described as the most difficult finger to treat [5]. In
a large series by Jensen et al., authors investigated the long-term
outcome of 23 amputations in 19 patients. However, a recurrent
lack of extension was seen in 9 out of 16 patients after amputations
distal to metacarpophalangeal joint necessitating intervention.
Painful phantom pain was seen in five out of seven amputations at
or proximal to metacarpophalangeal joint. Patients undergoing
amputations distal to the metacarpophalangeal joint did not demonstrate any phantom pain. Thus, the authors recommended an
amputation at or proximal to metacarpophalangeal joint in patients
with small finger involvement requiring amputation to decrease
any chance of recurrence [5]. However, in another large series by
De Semet, authors investigate the incidence of elective finger
amputation [6]. Out of 31 elective amputations, 12 were indicated
for Dupuytrens contracture. Eleven amputations (92 %) were performed for recurrent disease. Only one patient had an amputation
at own request due to advanced age and functionally disturbing
small finger deformation.
The ideal level of amputation depends on the patients occupation and functional demands. Some studies indicate that in younger
patients with more active lifestyle metacarpophalangeal disarticulation could be preferred for better grip and pinch force with a
preservation of the palmar breadth [2, 7]. On the other hand,
Peimer et al. demonstrated that even in functionally demanding
patients, a ray amputation can lead to acceptable function with
85 % eventual return to work [8]. Thus, although a proximal amputation carries a risk of neuroma formation, a more distal amputation carries a significant risk of recurrent flexion contracture. There
is no clear indication for the optimal level of amputation and a
patient-specific decision should be made. Other salvage procedures
such as arthrodesis (discussed in chapter 16) for severe palmar
fibromatosis, recurrent contractures, and flexion deformity of over
70 should be considered and discussed with patient. In our institution, the senior author performed a total of 2 amputations out of
101 surgeries (2 %) for Dupuytrens contractures. This is similar to
previous reports of elective amputation for treatment of Dupuytrens
contracture [6].

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Clinical Pearls/Pitfalls
Small finger Dupuytrens contracture is more difficult to manage compared to other fingers.
Elective amputation should be discussed in patients with severe
Dupuytrens contracture, especially in patients with recurrent
contracture. It is recommended to have the discussion preopartively for a possible need for amputation.
Attempt to correction of severe flexion contracture of PIP joint in
patients with recurrent Dupuytrens contracture can lead to neurovascular compromise requiring elective amputation.
Amputation at the level of metacarpophalangeal joint or
proximal to it is recommended to decrease the chance of
recurrence.
Amputations proximal to metacarpophalangeal joint are more
prone to have painful neuroma or phantom pain. This can be
discussed preoperatively with patients.
Painful neuroma in these patients could be managed successfully with neuromodulators.

References
1. Dias JJ, Braybrooke J. Dupuytrens contracture: an audit of the outcomes of
surgery. J Hand Surg. 2006;31(5):51421.
2. Hogh J, Hooper G. Amputation of the little nger. Archives of orthopaedic
and traumatic surgery. Arch Orthop Unfallchir. 1988;107(5):26972.
3. Legge JW, Finlay JB, McFarlane RM. A study of Dupuytrens tissue with
the scanning electron microscope. J Hand Surg. 1981;6(5):48292.
4. Legge JW, McFarlane RM. Prediction of results of treatment of Dupuytrens
disease. J Hand Surg. 1980;5(6):60816.
5. Jensen CM, Haugegaard M, Rasmussen SW. Amputations in the treatment
of Dupuytrens disease. J Hand Surg. 1993;18(6):7812.
6. Degreef I, De Smet L. Dupuytrens disease: a predominant reason for elective nger amputation in adults. Acta Chir Belg. 2009;109(4):4947.
7. Nuzumlali E, et al. Results of ray resection and amputation for ring avulsion
injuries at the proximal interphalangeal joint. J Hand Surg. 2003;28(6):
57881.
8. Peimer CA, et al. Hand function following single ray amputation. J Hand
Surg. 1999;24(6):12458.

17 Amputation in Management of Severe Dupuytrens

229

Suggested Readings
Degreef I, De Smet L. Dupuytrens disease: a predominant reason for elective
finger amputation in adults. Acta Chir Belg. 2009;109(4):4947.
Wolfe SC, Pederson WC, Hotchkiss RN, Kozin SH. Greens operative hand
surgery: 2-volume set. 6th ed. Philadelphia: Churchill Livingstone; 2010.

Chapter 18

Treatment of Dupuytrens
Contracture in the Young
Nathan A. Monaco, Scott W. Rogers, and John D. Lubahn

History
The first patient presented at age 52 complaining of progressively
worsening deformity to the small, ring, and long finger of her
dominant right upper extremity. She denied any associated pain,
but noted that this deformity had been getting worse since it started
sometime when she was in her late 30s or early 40s. The patient
was quick to point out that she remembered some of her family
members had a similar condition. She also complained of difficulty
retrieving objects from her pocket with the involved hand. This
complaint prompted her to finally seek out care for her progressively worsening problem. The patient noted that her contralateral
left hand also seemed to demonstrate similar findings. Her medical
history was significant for hypertension, but she denied taking any
current medications. From a social history standpoint, she did not
smoke and stated she used alcohol occasionally. She denied any

N.A. Monaco, MD () S.W. Rogers, MD J.D. Lubahn, MD

Department of Orthopaedic Surgery, UPMC-Hamot,
201 State Street, Erie, PA 16550, USA
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_18

231

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N.A. Monaco et al.

food or drug allergies. At the time of her presentation, she did not
report any previous treatment for her complaints, aside from trying
a self-directed stretching program that did not appear to help.
The second patient, a right hand dominant medical student,
presented at the age of 23 with complains of inability to extend his
nondominant left ring finger. He denied any associated pain, but
had difficulty with fine motor tasks such as playing the piano.
There was no family history of Dupuytrens. He did not have any
significant medical comorbidities. The patient felt the contracture
began following a minor injury 6 years prior to his presentation.
The third patient with radial-sided palmar disease and associated
index finger small joint contracture presented at age 41. She reported
problems in both the left and right upper extremity, but the right side
was more severe. There was no prior family history of Dupuytrens
or medical comorbidities. Working as a massage therapist, the
patient complained initially that she was unable to place her hand flat
on a tabletop. She had undergone a prior limited fasciectomy at age
33 on the ulnar two digits of her right upper extremity.

Physical Exam Findings

General examination of the first patient revealed an overall healthy
appearing woman appearing as expected for her stated age.
Inspection of the right upper extremity revealed contractures of the
ulnar three digits. The overlying skin was intact without any breakdown and palpation demonstrated a warm-well perfused distal
extremity. Active and passive range of motion demonstrated a
metacarpophalangeal (MCP) deformity that was passively correctible to 10 short of full extension (Fig. 18.1). The right ring
finger proximal interphalangeal (PIP) joint had a fixed deformity
that was unable to be extended passively beyond 30 short of full
extension. Semmes-Weinstein filament testing showed intact sensation compared to the contralateral extremity and two-point discrimination was intact to 5 mm. Capillary refill testing was
consistent with appropriate distal digital flow. Functional testing
revealed that the patient was unable to completely rest her hand flat
on a tabletop.

18 Treatment of Dupuytrens Contracture in the Young

233

Fig. 18.1 Proposed incisions for excision and radical dermofasciectomy

Examination of the second patient demonstrated a fixed deformity about the left ring finger DIP. The patient was unable to actively
or passively extend past 90 of flexion (Fig. 18.2a). A thickened cord
extended from the distal phalanx proximally to the ulnar side of the
left ring finger. Imaging findings were unremarkable for any osseous
or soft tissue abnormality, aside from the fixed contracture posturing
of the ring finger digit (Fig. 18.2b). His exam demonstrated appropriate inspection, sensation, and two-point discrimination.
The third patient had a significant contracture of the PIP joint of
her index finger (Fig. 18.3). There was also partial recurrence of
flexion contractures of her small and ring fingers at the time of her
presentation. She was unable to place her hand flat on the exam
tabletop and noted that this interfered with her ability to work as a
massage therapist.

Treatment Options
Treatments options in young patients are similar to the options of
older patients. At the time of the first patients presentation, the
FDA had not yet approved collagenase clostridium histolyticum
(CCH) injection. Indeed, it was not until 2010 when injection of
CCH for the treatment of Dupuytrens contracture in patients with
a palpable cord was approved [1]. As a result, this option was not

Fig. 18.2 (a) A 23-year-old RHD male with a fixed left long finger DIP contracture. (b) Associated preoperative imaging of the
23-year-old RHD male with fixed DIP long finger contracture

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N.A. Monaco et al.

18 Treatment of Dupuytrens Contracture in the Young

235

Fig. 18.3 Right sided index finger disease. There was an associated PIP index
finger contracture 60 short of full extension

under treatment consideration when the first patient was evaluated.

Methods that were given consideration included needle aponeurotomy, segmental aponeurectomy, fasciectomy, and dermofasciectomy. Currently, although experts may have strong opinions and
advocate for one more appropriate management option in the case
of a young patient with Dupuytrens disease, the evidence does not
convincingly support one modality over another.
Few long-term studies report outcomes of treatment of
Dupuytrens disease using needle aponeurotomy in young patients.
Pess et al. retrospectively examined the results of 1013 digits at a
mean follow-up of 3 years [2]. When patients 55 years and older
were compared to younger patients in the series, a statistically
higher joint contracture correction was achieved in older patients
and a higher recurrence rate was noted in the younger patient population. The authors questioned if multiple needle aponeurotomies
would improve results in young patients and the data presented in
this series indicate that longer-term, comparative studies are
needed to determine the efficacy of this intervention for the young
patient population.

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N.A. Monaco et al.

Segmental aponeurectomy perhaps has even less data with

respect to postoperative follow-up in young Dupuytrens patients.
Moermans series following 175 patients managed with this technique noted an average patient age at time of treatment of
62.1 years, with a range from 29 to 81 [3]. An attempt was made
to analyze the mean age in patients with disease recurrence (62.0)
to the mean age in patients without recurrence (60.0), but no statistically significant difference was demonstrated. Further evaluation of the outcomes using this technique in the young patient is
difficult due to the manner in which the data is reported: outcomes
of the young and old patients are combined. Subsequent longerterm studies have also pooled both young and old patient outcome
data [4, 5]. Despite this method of outcome reporting, Andrew and
Kay suggest segmental aponeurectomy may have particular utility
in the management of Dupuytrens contracture in the elderly
patient [5].
Limited fasciectomy, originally pioneered by Skoog [6], has
also been described in the young patient population. Coert and colleagues retrospectively reviewed 261 consecutive patients managed with limited fasciectomy [7]. From this sample, 62 patients
were younger than 45 at the time of first operation. When followed
over time, patients who received an operation before the age of 45
were found to undergo significantly more operations (3.8) than
those who were operated on after age 45 (2.2). The average number
of operations increased (5.1) if the young patient also had a familial
predisposition to Dupuytrens disease. Unfortunately, other studies
reporting limited fasciectomy techniques have combined data from
young and old patients as well, making it difficult to draw conclusions about the utility of limited fasciectomy specifically in the
young Dupuytrens patient [8, 9].
While currently the above noted interventions may be used to
manage Dupuytrens disease in young patients, at the time of the
first patients presentation, dermofasciectomy as advocated by
Hueston was thought to prevent disease recurrence, at least beneath
the graft, and felt to be the best option for treating a younger patient
with widespread disease. Risks of the dermofasciectomy and skin
graft are similar to other open techniques. These include infection,
neurovascular injury, failure of the graft, and noticeable scaring at

18 Treatment of Dupuytrens Contracture in the Young

237

the donor site. Despite the risks, dermofasciectomy in the younger

Dupuytrens patient with widespread disease offers an advantage
over the aforementioned techniques: there is a potential for
decreased disease recurrence.

Treatment Chosen
The surgical approach for dermofasciectomy in the patient with
widespread disease involved marking a zig-zag incision over the
most involved palmar cord. Skin markings were traced distally into
the three most involved digits (Fig. 18.1). There also was an
ellipse-shaped dotted line marked for skin excision along with the
involved fascia. Gravity exsanguination and tourniquet insufflation
to 100 mmHg above systolic pressure were utilized and are recommended for this procedure. Bipolar electrocautery was used to
maintain meticulous hemostasis. Alice clamps were applied to
grasp and to retract diseased skin for excision. The dissection was
carried out in a proximal to distal fashion. Care was taken to avoid
iatrogenic injury to the neurovascular bundle. Figure 18.5 demonstrates the depth and extent of the dissection. In addition, one can
see in the image that an attempt was made to remove diseased
fascial tissue deep to the neurovascular structures in order to limit
possible disease extension and recurrence. Once all of the grossly
involved tissue was excised, the digital range of motion was
assessed. Occasionally contracture release of the PIP joint may be
required to regain full finger extension. The surgeon should exercise caution to release the check rein and collateral ligaments only
as release of the palmar plate may lead to joint instability and
dorsal PIPJ subluxation.
In order to ensure that the digital nerves were not under excess
tension, the palmar skin incisions were carried distally to the level
of the volar PIP crease (Figs. 18.4 and 18.5). Near complete extension was obtained with only a slight residual PIPJ contracture in
the ring finger. The tourniquet was deflated and good circulation
noted in each digit. A full-thickness skin graft was then harvested
from the proximal medial arm just distal to the tourniquet. The

238

N.A. Monaco et al.

Fig. 18.4 Dissection carried down to the level of the neurovascular bundle.
Care maintained to remove all fascia, even below the NV bundle, to attempt
preventing disease recurrence

Fig. 18.5 Exposed flexor tendon sheath of ring finger. Note that the digital
nerves are not under tension and the underlying tissue has been removed

graft was secured to the recipient site using a 5-0 nylon suture and
the donor site closed with a running subcuticular closure of 4-0
nylon. The inner arm is a good donor site because of lack of hair
and minimal scar (Fig. 18.6). A bulky soft dressing was applied at
the completion of the wound closure. A final dorsal-based plaster
splint was placed to the level of the fingertips to maintain the digital extension immediately postoperatively.

18 Treatment of Dupuytrens Contracture in the Young

239

Fig. 18.6 Immediate postoperative appearance of palm after closure with fullthickness skin graft

Fig. 18.7 Preoperative skin markings for an isolated small joint contracture
release via limited fasciectomy. Note the local anesthetic injection site with a
25 gauge needle

The technique of limited fasciectomy can be performed using a

local anesthetic injected with a 25 gauge needle on the volar radial
and ulnar aspects of the affected digit (Fig. 18.7). Preoperative
markings include a utilitarian Brunner-style incision with an apex
at the midaxial point of the more affected side of the interphalangeal joint. Once the tourniquet has been inflated, dissection can
proceed with a 15 blade to the level of the diseased fascia
(Fig. 18.8). At the level of the DIP joint, Graysons ligament and

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N.A. Monaco et al.

Fig. 18.8 At the level of the distal interphalangeal joint, in the case of isolated
digital contracture, dissection can be carried down to the level of diseased tissue with a scalpel. Clelands ligaments are not involved in the pathologic
process at this level

the lateral digital sheet are typically involved in the pathologic

process and must be excised sharply. The dissection can be carried
proximal to distal or distal to proximal, as long as the digital nerves
and arteries are identified and protected. Once the contractile tissue
is excised, extension can typically be restored to the contracted
joint. Additional soft tissue releases may be necessary to achieve
full extension. Again, care must be maintained to avoid the digital
nerves throughout the procedure. In order to maintain the correction postoperatively, a 2.0 mm k-wire can be placed in retrograde
fashion across the DIP joint (Fig. 18.9). After adequate irrigation
of the surgical site, closure of the skin is carried out using 5-0
nylon suture in simple interrupted fashion. The color and capillary
refill of the digit are noted. A static, short arm splint is applied
immediately postoperatively.
Percutaneous needle aponeurotomy can be done in the outpatient setting under local anesthesia. The patient with radial-sided,
small joint contracture was injected with 2 % lidocaine over the
sites selected for aponeurotomy. Using the technique outlined by
Eaton [10], once adequate anesthesia of the digit was verified, a
25-gauge needle was inserted perpendicular to skin portal sites.
Locations were selected where the skin provided a distinct

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Fig. 18.9 Immediate post-procedure imaging demonstrating correction of the

previously noted DIP flexion contracture

palpable cord with joint extension and were spaced at least 5 mm

apart in longitudinal fashion. While more important in the palm,
care was taken to avoid portal sites over flexion creases in order
to limit flexor tendon irritation and skin tearing. The needle was
first used transversely, to clearly define a border between the dermis and cord. Next, the needle was oriented vertically, to penetrate
the cord and complete the fasciotomy deep to the skin (Fig. 18.10).
The major benefit to having an awake and alert patient is that even
after a block, sensation is often intact to indicate when release is
occurring near a digital nerve. The surgeon can redirect the sterile
needle under such circumstances. A bulky, soft dressing was
placed after the procedure to maintain the joint in extension
(Fig. 18.11).

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Fig. 18.10 Return of digital extension following percutaneous needle aponeurotomy

Fig. 18.11 Post-needle aponeurotomy soft dressing maintains joint extension

Clinical Course
Post-dermofasciectomy, weekly follow-up took place until the
sutures were removed at approximately 2 weeks after the procedure. Once the graft had taken the patient was allowed to initiate
physical therapy. The patient had good incorporation by the 3
month time point (Fig. 18.12). There continued to be marked
improvements in range of motion at the 1-year postoperative time
point (Fig. 18.13a, b). Over time, however, the disease was
observed to extend into the small finger on the ipsilateral upper

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243

Fig. 18.12 Full-thickness skin graft (FTSG) 3 months post-procedure. Graft

obtained from the forearm

extremity. Interesting to note, the area overlying the full-thickness

skin graft appears disease free. Extension was noted to occur over
the small finger ray. This was especially apparent when the patient
returned at a 20-year follow-up for a separate complaint
(Fig. 18.14a, b).
Following limited fasciectomy on the involved isolated ring
finger, weekly follow-up visits took place until suture removal at 2
weeks. The static short arm splint was transitioned to an alumafoam digital splint at the first postoperative check. Once the skin
was healed, the patient began range of motion exercises in a
directed hand therapy program to improve PIP motion. The extension pin was maintained for 12 weeks (Fig. 18.15a, b). The patient
was instructed on twice daily pin care with 3 % hydrogen peroxide
and sterile saline solution. At the 4-year follow-up, there is no
evidence of recurrent disease.
Following the percutaneous needle fasciotomy, blocking exercises were recommended and improvement was maintained compared to pre-intervention status (Figs. 18.16 and 18.17). Short-term
follow-up demonstrated loss of DIP flexion, consistent with FDP
rupture. At 6 months, a 30-degree, fixed PIP flexion contracture
remained (Fig. 18.18). Exploration, release of residual small joint
contracture, and possible staged tendon reconstruction were discussed. There was some concern given her longstanding history of

Fig. 18.13 (a) One-year follow-up, no recurrent disease to this point, almost full extension. (b) Good flexion and range of motion at
the 1-year follow-up

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N.A. Monaco et al.

Fig. 18.14 (a) Same patient with 20-year follow-up. (b) Disease free (no recurrence) area under the skin graft, but extension noted in
the small finger. This case example demonstrates the relentless, progressive nature of Dupuytrens disease, especially with onset at a
young age

18 Treatment of Dupuytrens Contracture in the Young

245

Fig. 18.15 (a) Seven weeks post limited fasciectomy and extension pinning of isolated contracture of a ring finger DIP joint. (b)
Motion following limited fasciectomy and extension pinning 7 weeks post-procedure

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N.A. Monaco et al.

18 Treatment of Dupuytrens Contracture in the Young

247

Fig. 18.16 Three weeks post-needle aponeurotomy. Exam demonstrated 30

lack of extension at the PIP joint, with active flexion to 60

Fig. 18.17 Three weeks post-needle aponeurotomy

fibromatosis that increased scaring could result with minimal

functional improvement. She was able to resume work as a massage therapist with improvement in her ability to place her hand on
a flat surface, but with loss of DIPJ flexion.

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Fig. 18.18 Six months post-percutaneous needle aponeurotomy for index finger PIP contracture. Post-intervention gains noted an improvement of 30 of
extension, with residual numbness and difficulty with active DIP flexion

Discussion
There is a paucity of literature regarding Dupuytrens disease (DD)
in the young patients. While it is rare in the teens and twenties, the
incidence has been found to increase in the following decades of life
[11]. Descriptions of Dupuytrens in the pediatric population are
even less common [12]. A standard definition what age defines
young is lacking. Hueston suggested disease prior to 40 years [13,
14] and later authors have reasoned age 50 is the critical threshold
for young onset [1517]. This distinction becomes relevant considering that DD in the young may suggest Dupuytrens diathesis.
While onset of DD before 50 years of age is not synonymous
with Dupuytrens diathesis, these terms are often related. The
label of Dupuytrens diathesis is important for both prognosis
and patient counseling. Patients with diathesis should expect a
more aggressive course with the possibility for a higher chance of
recurrence following surgical care [14, 18].
From an epidemiologic standpoint, incidence of early onset
Dupuytrens disease is not known. Hindosha and colleagues
reported on a series of 322 DD patients, 152 (47 %) of which had
disease onset prior to age 50 [15]. Degreef and De Smet were able

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249

to follow up with 342 patients following a procedure for

Dupuytrens management between 1983 and 2006 at a single
institution. In their series, they report that 48 % of patients were
younger than age 50 [16]. The study noted an overall recurrence
rate of 56 %, with a higher rate of recurrence in the younger population (66 % vs. 47 %). A study out of the Netherlands reported
5-year follow-up on 93 DD patients randomized to treatment with
percutaneous needle fasciotomy or limited fasciectomy [17]. In
this series, 33 (35 %) patients demonstrated early onset disease.
When all treatment groups were considered together, age less than
50 was predictive of a higher rate of recurrence (p < 0.005). When
considering that some of the above noted series describe study
populations with almost half of the patients being less than 50
years of age, it is evident that not an insignificant portion of DD
patients are younger individuals.
Various treatments of young adult patients and patients with
onset of DD younger than age 50 have been described. Unfortunately,
this data is often found in larger studies combined with management
of more traditional/older DD patients. As such, it can be difficult to
evaluate reported outcomes for thorough evidence-based decision
making. Roush and Stern reviewed a series of 19 patients demonstrating recurrent DD, noting 10 patients with onset of disease prior
to age 50 [14]. Among patients with early onset disease, three were
managed with fasciectomy with local flap coverage, three had fasciectomy with full-thickness skin graft, and four underwent fasciectomy and interphalangeal arthrodesis. Couto-Gonzalez and
colleagues reported the case of a 24-year-old female affected with
aggressive bilateral disease managed with dermofasciectomy [12].
Despite several described techniques to manage DD in the young,
future randomized, prospective studies are still needed to determine
which technique leads to the best long-term functional outcomes.

Summary
Dupuytrens contracture, while commonly affecting Caucasian
males older than 50, can also affect younger individuals. These
instances are often bilateral and associated with a constellation of

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symptoms consistent with what is now referred to as Dupuytrens

diathesis. A number of treatment modalities exist for these complicated patients. Despite management with one of the most
aggressive forms of surgical treatment for widespread disease,
excision with full-thickness skin grafting, progression of the MP,
and PIP flexion contractures can still occur over time. Limited
fasciectomy and primary closure may be helpful in instances of
isolated digital small joint contracture. The cases presented in this
chapter highlight that, at present, the best available options can
only remove diseased tissue. A definitive Dupuytrens disease cure
has yet to be identified. Management can be especially problematic
in the young patient population given the aggressive nature of the
disease and high recurrence rate. Future prospective clinical trials
comparing treatments such as needle aponeurotomy, collagenase
injection, segmental fasciectomy, and limited fasciectomy may
eventually lead to the development of treatment algorithms to treat
individual patients. Such studies would need to be multicentered to
have sufficient patient numbers to extract meaningful data.

References
1. Rizzo M, Stern PJ, Benhaim P, Hurst LC. Contemporary management of
dupuytren contracture. Instr Course Lect. 2014;63:13142.
2. Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for
Dupuytren contracture in over 1,000 fingers. J Hand Surg Am. 2012;37:
6516.
3. Moermans JP. Segmental aponeurectomy in Dupuytrens disease. J Hand
Surg Br. 1991;16:24354.
4. Moermans JP. Long-term results after segmental aponeurectomy for
Dupuytrens disease. J Hand Surg Br. 1996;21:797800.
5. Andrew JG, Kay NR. Segmental aponeurectomy for Dupuytrens disease:
a prospective study. J Hand Surg Br. 1991;16:2557.
6. Skoog T. Dupuytrens contracture: pathogenesis and surgical treatment.
Surg Clin North Am. 1967;47:43344.
7. Coert JH, Nrin JP, Meek MF. Results of partial fasciectomy for Dupuytren
disease in 261 consecutive patients. Ann Plast Surg. 2006;57:137.
8. Gelman S, Schlenker R, Bachoura A, Jacoby SM, Lipman J, Shin EK,
Culp RW. Minimally invasive partial fasciectomy for Dupuytrens contractures. Hand. 2012;7:3649.

18 Treatment of Dupuytrens Contracture in the Young

251

9. Shin EK, Jones NF. Minimally invasive technique for release of

Dupuytrens contracture: segmental fasciectomy through multiple transverse incisions. Hand. 2011;6:2569.
10. Eaton C. Percutaneous fasciotomy for Dupuytrens contracture. J Hand
Surg Am. 2011;36:9105.
11. Mikkelsen OA. The prevalence of Dupuytrens disease in Norway. A study
in a representative population sample of the municipality of Haugesund.
Acta Chir Scand. 1972;138:695700.
12. Couto-Gonzalez I, Brea-Garcia B, Taboada-Surez A, Gonzlez-lvarez
E. Aggressive Dupuytrens diathesis in a young woman. BMJ Case Rep.
2010;20:2010. doi:10.1136/bcr.12.2009.2592.
13. Hueston JT. State of the art: the management of recurrent Dupuytrens
disease. Eur Med Bibliogr. 1991;1:716.
14. Roush TF, Stern PJ. Results following surgery for recurrent Dupuytrens
disease. J Hand Surg Am. 2000;25:2916.
15. Hindocha S, Stanley JK, Watson S, Bayat A. Dupuytrens diathesis revisited: evaluation of prognostic indicators for risk of disease recurrence.
J Hand Surg Am. 2006;31:162634.
16. Degreef I, De Smet L. Risk factors in Dupuytrens diathesis: is recurrence
after surgery predictable? Acta Orthop Belg. 2011;77:2732.
17. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytrens disease: percutaneous needle
fasciotomy versus limited fasciectomy. Plast Reconstr Surg.
2012;129:46977.
18. Bayat A, McGrouther DA. Management of Dupuytrens diseaseclear
advice for an elusive condition. Ann R Coll Surg Engl. 2006;88:38.

Chapter 19

Recurrent Dupuytren Contracture

Treated with Fasciectomy and Skin
Grafting
Reid W. Draeger and Peter J. Stern

Case Presentation
A 60-year-old left-handed man presented for ongoing evaluation of
previously treated bilateral Dupuytren contracture. His right hand
had undergone two prior fasciectomies for contractures of the
small and ring fingers and was no longer problematic. His current
complaint was his left hand. He had undergone a percutaneous
needle aponeurotomy for the left long, ring, and small finger 2
years prior with nearly full correction of all of the contractures.
Over the last 12 months, he complained of worsening of his contractures in the left ring and small fingers that were interfering with
daily activities.

R.W. Draeger, MD ()

Department of Orthopaedics, School of Medicine,
University of North Carolina, Campus Box #7055,
3102 Bioinformatics Building, Chapel Hill, NC 27599-7055, USA
e-mail: [email protected]
P.J. Stern, MD
Department of Orthopaedic Surgery, College of Medicine,
University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45207, USA
e-mail: [email protected]
Springer International Publishing Switzerland 2016
M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_19

253

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R.W. Draeger and P.J. Stern

Examination revealed stout palpable cords to the ring and small

finger with associated skin puckering. The contracture had progressed considerably in both the ring and small fingers with range
of motion as follows: ring finger MCP 55/90, PIP 0/85, DIP
0/70; small finger MCP 75/95, PIP 60/90, DIP 30/65. Twopoint discrimination was 5 mm on the radial and ulnar aspects of
all digits bilaterally. Garrod nodes were present over the dorsum of
the PIP joints of the index, long, ring, and small fingers bilaterally.
Capillary refill was less than 2 s in all digits bilaterally. Clinical
images of the patients left hand are shown in Fig. 19.1.

Diagnosis/Assessment
The diagnosis of Dupuytren contracture is often not difficult.
Typical findings, as illustrated in this case, include palpable nodules and cords, usually first noted in the palm. The disease has
predilection for ulnar-sided digits, but can present with cords or
nodules in any digit(s) leading to contracture. Other findings illustrated in this case consistent with severe diseaseDupuytren diathesisinclude ectopic lesions (Garrod knuckle pads), bilateral
involvement, original onset before the age of 50, male gender, and
positive family history [1]. Other sites of ectopic disease
Peyronie disease and Ledderhose diseasewere absent in this
patient. However, it is important to question the patient regarding
these sites of potential involvement. Presence of all of the abovementioned factors of Dupuytren diathesis increases the risk of
recurrence of contracture by 71 %, compared to a 23 % risk of
recurrence at baseline [1].

Management
In a patient with recurrent Dupuytren disease, treatment should be
tailored to the patients functional goals and the patients willingness and fitness to undergo surgical intervention. We routinely

Fig. 19.1 (a and b). Preoperative view of the patients hand (a: palmar view, b: lateral view)

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Recurrent Dupuytren Contracture Treated
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R.W. Draeger and P.J. Stern

involve the patient in the decision-making process for treatment of

recurrent Dupuytren contracture, as many treatment options exist.
These include: monitoring, fasciectomy with or without skin grafting, dermofasciectomy, surgical fasciotomy, percutaneous needle
aponeurotomy, and collagenase injection.
For patients in whom recurrence is likely, surgical treatment may
be favored over collagenase treatment or percutaneous needle aponeurotomy, though data regarding the effectiveness of certain treatments at preventing recurrence are limited [2]. Dermofasciectomy
has a very low rate of recurrence [3]; however, it is associated with
moderate morbidity as the required dissection is greater and the area
of skin grafting is larger than fasciectomy and fasciectomy with skin
grafting, respectively.
We selected fasciectomy with full-thickness skin grafting from
the hypothenar eminence to treat this patients recurrent left small
finger Dupuytren contracture. Additionally, due to the lesser
severity of the patients ring finger contracture that was localized
to the MCP joint and palpable disease without contracture of the
middle finger, open fasciotomy was chosen to treat palmar disease
of the ring and middle fingers. The discussion will focus on fasciectomy and skin grafting, as fasciotomy is covered in detail in
another chapter.
When designing the incision for fasciectomy for recurrent
disease, we prefer a straight longitudinal incision directly over
the cord. This facilitates dissection down to the cord without
threatening the thin skin flaps that must be raised from subcutaneous disease when a Bruner-type incision is used. Palmar and
lateral views of the proposed skin incision for this patient are
shown in Fig. 19.2. When using a longitudinal incision, if substantial contracture correction is anticipated, skin coverage can
be difficult. Z-plasties may be necessary at the conclusion of the
procedure as well as skin grafting. The patient should be informed
of both of these possibilities preoperatively. Usually, sufficient
full-thickness skin can be obtained from the hypothenar eminence for coverage needed following even severe Dupuytren
contracture release. We favor this donor site because of its local
convenience and because full-thickness hypothenar skin
minimally hyperpigments.

Fig. 19.2 (a and b). Planned surgical incisions (a: palmar view, b: lateral view)

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Recurrent Dupuytren Contracture Treated
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R.W. Draeger and P.J. Stern

Fig. 19.3 Coloring skin with a marking pen helps to prevent buttonholing
when sharply dissecting adherent cords from the overlying skin

The skin is incised and dissection is carried out sharply around

the cord to free the cord from the overlying skin. Attention to placing the tissue to be dissected under tension can facilitate sharp
dissection of the cord from the overlying skin with sharp scalpel.
After raising skin flaps from the underlying cord, the radial and
ulnar neurovascular bundles of the involved digit are identified and
protected. This is best accomplished in the proximal portion of the
wound in the palm. Using tenotomy scissors, the neurovascular
bundles are traced in a proximal-to-distal direction. Care must be
taken to dissect the bundles free from surrounding cord, remembering that the bundles may make abrupt changes in direction due to
the deforming forces of the cord. When dissection is carried along
the border of the digit, care must be taken not to buttonhole through
the skin with sharp dissection. Coloring the overlying skin with the
skin-marking pen allows the surgeon more easily detect thinning
skin flaps (Fig. 19.3).
Once the cord has been circumferentially dissected, it is transected proximally in the wound and dissected sharply off of the
underlying flexor tendon sheath, being careful not to violate the
sheath. The cord is resected en bloc in a proximal-to-distal direction (Fig. 19.4).

Fig. 19.4 (a and b). Cord resection in a proximal-to-distal direction (a: palmar view, b: lateral view)

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Recurrent Dupuytren Contracture Treated
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R.W. Draeger and P.J. Stern

Fig. 19.5 Skin graft being sized with a cut piece of paper from a glove wrapper
placed on the skin defect

Following excision of the cord, extension of the digit is possible.

In cases of severe contracture, such as this case, complete coverage
of the wound will likely not be possible with primary closure.
Z-plasties may be designed in the palm and at any digital crease to
attempt closure with local tissue.
In some cases, such as this case, a skin defect may still be present despite Z-plasties. In this case a full-thickness skin graft can be
planned. We prefer harvesting the graft from the glabrous skin
from the hypothenar eminence. This non-hair-bearing skin graft is
similar in thickness to the resected palmar skin. It is harvested in
an elliptical, football shape and can be as large as 2 cm in width
and 5 cm in length with primary closure still possible. The graft can
be templated with a cut piece of paper (Figs. 19.5 and 19.6). The
graft is harvested in the customary fashion, being careful to defat
the graft as much as possible. Defatting will optimize the chances
of graft take.
The tourniquet is then deflated to ensure that brisk capillary
refill returns to all digits. In severe cases, drastic correction of the
contracture can lead to arterial spasm and digit ischemia. In these
cases, the finger is allowed to bend and arterial inflow is encouraged with application of warm saline. Hemostasis is achieved with

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Fig. 19.6 Skin graft template placed on the hypothenar eminence to plan fullthickness skin graft harvest

bipolar electrocautery to avoid postoperative hematoma formation.

The incision is closed loosely to allow egress of blood and further
prevent hematoma formation. The graft is then sutured to cover
the skin defect and secured with a bolster dressing (Fig. 19.7).
The bolster is left in place for 1 week postoperatively to encourage
graft take and decrease shearing forces at the graft site.

Outcome
The patient underwent limited open fasciotomy of his mild MCP
contracture of the long and ring fingers. For his severe recurrent
contracture of the small finger, he underwent fasciectomy with
Z-plasty and full-thickness skin grafting from the ipsilateral hypothenar eminence. Immediately following fasciectomy and grafting,
the patients small finger passively extended to 0 at the MCP joint,
20 at the PIP joint, and 10 at the DIP joint. Joint contractures were
deemed responsible for the persistent contracture of the PIP and DIP
joints. Hand therapy was initiated 6 days postoperatively and the
intraoperative range of motion was achieved within 3 weeks.

Fig. 19.7 (a and b). The closed wounds with bolster dressing (a: palmar view, b: lateral view)

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Two months following surgery, the patient remained very

satisfied with his range of motion, which measured: MCP 0/95, PIP
25/80, DIP 15/90. At this point he was instructed to follow-up on
an as-needed basis.
Unfortunately, the patient presented 18 months later with recurrent complaints of contracture of the small finger once again with
range of motion as follows: MCP 0/70, PIP 60/90, DIP 45/80.
Though his MCP contracture had not recurred since surgery, his
PIP and DIP contractures had recurred and worsened. He subsequently underwent successful collagenase injections and manipulations of his left small finger PIP and DIP joint contractures. He
initially did well with both of these procedures, but we continue to
follow him with cautious optimism.

Literature Review
Patients with Dupuytren diathesis and aggressive, recurrent disease
have a high risk of recurrence following any treatment for
Dupuytren contracture [1, 3, 4]. Studies on results following surgery for recurrent Dupuytren contracture are limited. One study
showed that though 47 % of patients treated surgically for recurrent
disease experienced functional deficits, 95 % of these patients were
subjectively satisfied with the results of the revision procedure [4].
Histological studies have found myofibroblasts at the dermal/
epidermal junction of skin overlying Dupuytren tissue, which has
been a strong impetus in the recommendation for dermofasciectomy for the treatment of aggressive Dupuytren contracture [5, 6].
A number of retrospective series support the use of dermofasciectomy followed by full-thickness skin grafting (either large grafts or
a smaller firebreak graft) for Dupuytren disease in order to
decrease recurrence [3, 79]. Rates of recurrence in these series
range from 0 to 7 % with dermofasciectomy and full-thickness skin
grafting.
The effectiveness of firebreak skin grafting in preventing recurrence of Dupuytren contracture following dermofasciectomy has
also been called into question. Retrospective series have shown that
dermofasciectomy with full-thickness skin grafting may not decrease

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R.W. Draeger and P.J. Stern

recurrence rate more than other surgical treatment methods [4, 10].
Recently, a prospective trial comparing fasciectomy with Z-plasty
closure to dermofasciectomy with full-thickness firebreak skin
grafting found no significant difference between contracture recurrence between groups (overall average recurrence rate of 12.2 %;
10.9 % for the fasciectomy and Z-plasty group compared to 13.6 %
for the dermofasciectomy and skin grafting group) [11].
Another possible etiology of recurrence of Dupuytren contracture following surgical fasciectomy is the tension of the skin closed
over the excision site. Two clinical studies from Citrons group
support this hypothesis. In one study, patients receiving fasciectomy through a longitudinal incision with Z-plasty employed for
closure had a significantly lower rate of recurrence (15 %) than a
group of patients treated with fasciectomy through a transverse
incision with primary closure (50 %) [12]. Another study found a
trend (not significant) in recurrence following fasciectomy through
a Bruner incision closed with Y-V plasties (18 %) compared to
fasciectomy through a longitudinal incision closed with Z-plasty
(33 %) [13].
Though agreement has yet to be reached on the most appropriate
treatment method to minimize further recurrence in patients with
recurrent Dupuytren contracture, surgical fasciectomy with fullthickness skin is a reliable treatment method for these patients.
Open fasciectomy allows for excision of as much diseased tissue
and deep dermis as is necessary for correction, while full-thickness
skin grafting allows for closure of the surgical wound of the corrected digit with minimal to no tension and conveys the possible
benefits of a firebreak graft at the excision site.

Clinical Pearls/Pitfalls
In cases of revision fasciectomy, the neurovascular bundles
need to be meticulously dissected and protected. They may be
encased in both diseased tissue and scar tissue from previous
surgery.
Full-thickness skin graft from the hypothenar eminence provides glabrous, non-hair-bearing, durable, donor skin that is a

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265

good texture and color match with for grafting to the volar surfaces of digits following Dupuytren fasciectomy.
Dimensions of a hypothenar full-thickness skin graft should be
no wider than 2 cm with a maximum length of 5 cm. Grafts of
this size can usually be closed primarily without difficulty.
Tension can be lessened on the closure site with undermining of
the hypothenar skin to mobilize it before closure.
For cords intimately adherent to the overlying skin, using a
marking pen to tattoo the overlying skin can help to prevent
buttonholing during sharp dissection and cord excision.
Tension on the neurovascular bundles of the digit may compromise the neurovascular status of the digit in cases of severe
contracture and full correction may not be possible.
Despite fasciectomy and full-thickness skin grafting, in aggressive, recurrent cases of Dupuytren contracture, recurrence is
possible.

References
1. Hindocha S, Stanley JK, Watson S, Bayat A. Dupuytrens diathesis revisited: Evaluation of prognostic indicators for risk of disease recurrence.
J Hand Surg. 2006;31(10):162634.
2. Becker GW, Davis TR. The outcome of surgical treatments for primary
Dupuytrens diseasea systematic review. J Hand Surg Eur Vol.
2010;35(8):6236.
3. Roy N, Sharma D, Mirza AH, Fahmy N. Fasciectomy and conservative
full thickness skin grafting in Dupuytrens contracture. The fish technique.
Acta Orthop Belg. 2006;72(6):67882.
4. Roush TF, Stern PJ. Results following surgery for recurrent Dupuytrens
disease. J Hand Surg. 2000;25(2):2916.
5. McCann BG, Logan A, Belcher H, Warn A, Warn RM. The presence of
myofibroblasts in the dermis of patients with Dupuytrens contracture.
A possible source for recurrence. J Hand Surg (Edinburgh, Scotland).
1993;18(5):65661.
6. VandeBerg JS, Rudolph R, Gelberman R, Woodward MR. Ultrastructural
relationship of skin to nodule and cord in Dupuytrens contracture. Plast
Reconstr Surg. 1982;69(5):83544.
7. Tonkin M, Burke F, Varian J. Dupuytrens contracture: a comparative
study of fasciectomy and dermofasciectomy in one hundred patients.
J Hand Surg Br Eur Vol. 1984;9(2):15662.

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R.W. Draeger and P.J. Stern

8. Hall P, Fitzgerald A, Sterne G, Logan A. Skin replacement in Dupuytrens

disease. J Hand Surg Br. 1997;22(2):1937.
9. Brotherston TM, Balakrishnan C, Milner RH, Brown HG. Long term follow-up of dermofasciectomy for Dupuytrens contracture. Br J Plast Surg.
1994;47(6):4403.
10. Norotte G, Apoil A, Travers V. A ten years follow-up of the results of
surgery for Dupuytrens disease. A study of fifty-eight cases. Ann Chir
Main. 1988;7(4):27781.
11. Ullah AS, Dias JJ, Bhowal B. Does a firebreak full-thickness skin graft
prevent recurrence after surgery for Dupuytrens contracture?: a prospective, randomised trial. J Bone Joint Surg. 2009;91(3):3748.
12. Citron N, Hearnden A. Skin tension in the aetiology of Dupuytrens
disease; a prospective trial. J Hand Surg (Edinburgh, Scotland). 2003;
28(6):52830.
13. Citron ND, Nunez V. Recurrence after surgery for Dupuytrens disease: a
randomized trial of two skin incisions. J Hand Surg (Edinburgh, Scotland).
2005;30(6):5636.

Suggested Readings
Becker GW, Davis TR. The outcome of surgical treatments for primary
Dupuytrens diseasea systematic review. J Hand Surg Eur Vol.
2010;35(8):6236.
Hindocha S, Stanley JK, Watson S, Bayat A. Dupuytrens diathesis revisited:
evaluation of prognostic indicators for risk of disease recurrence. J Hand
Surg. 2006;31(10):162634.
Roush TF, Stern PJ. Results following surgery for recurrent Dupuytrens disease. J Hand Surg. 2000;25(2):2916.
Roy N, Sharma D, Mirza AH, Fahmy N. Fasciectomy and conservative full
thickness skin grafting in Dupuytrens contracture. The fish technique. Acta
Orthop Belg. 2006;72(6):67882.
Tonkin M, Burke F, Varian J. Dupuytrens contracture: a comparative study of
fasciectomy and dermofasciectomy in one hundred patients. J Hand Surg Br
Eur Vol. 1984;9(2):15662.
Ullah AS, Dias JJ, Bhowal B. Does a firebreak full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture?: a prospective,
randomised trial. J Bone Joint Surg. 2009;91(3):3748.

ERRATUM

Dupuytrens Contracture
Marco Rizzo

Springer International Publishing Switzerland 2016

M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8

DOI 10.1007/978-3-319-23841-8_20

The original version of the book contained an error which have

been corrected. The correction is given below:
Preface was not included in the original version of the book.

The updated online version of the original book can be found at

http://dx.doi.org/10.1007/978-3-319-23841-8

Springer International Publishing Switzerland 2016

M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8_20

E1

Index

A
Alpha adrenergic effects of
low-dose adrenaline,
124, 127
Amputation, Dupuytrens
contracture
Brunner-type incision, 225
elective amputations, 227
metacarpal base, 225
metacarpophalangeal
disarticulation, 227
metacarpophalangeal joint,
223, 227
neuropathic phantom pain, 225
ray amputation, 227
Anaesthesia
dosage information, 132
local anaesthetics, 132
low-dose adrenaline
contraindications,
133134
low-dose adrenaline injection, 134
patients not suitable for wide
awake surgery, 132133
vasopressors, 133
Aponeurectomies, 101
Arthrodesis
advantages and disadvantages, 220
concave-convex arthrodesis
technique, 219

contralateral ring nger

deformity, 217
dorsal osteotomy, 219
multiple Kirschner wires, 218
PIP joint, 216218
tendon-splitting approach, 216

B
Bruner incision, 111
Bruner-type zigzag, 103
Brunner incisions, 124
Buttonholing, 265

C
Clostridial collagenase injections
arthrodesis of a joint, 64
collagenase injection, 60, 62, 65
diagnosis, 6061
hypertension, 59
lymphadenopathy, 65
management, 6162
treatment, 64, 66
Visual Analog Scale, 63
Collagenase clostridium
histolyticum (CCH)
injection, 149, 233
Complex regional pain syndrome
(CRPS), 170

Springer International Publishing Switzerland 2016

M. Rizzo (ed.), Dupuytrens Contracture,
DOI 10.1007/978-3-319-23841-8

267

268

Index

D
Dermatofasciectomy, 100, 101, 110
Dermofasciectomy, 256, 263
complications, 156
disease recurrence, 236
excision and radical, 233
excision, supercial skin,
151, 152
full thickness skin graft,
151, 153
postoperative course, 152
surgical approach, 151, 237
younger Dupuytrens patient, 237
Diathermy, 124
Digit Widget, 214, 216
compass hinge external
xator, 185
connector assembly and rubber
band placement, 183
description, 176
distraction, 178, 184
dorsal mid-longitudinal axis, 177
Dupuytrens disease, 176
exion contractures, PIP
joint, 184
exion deformity decrease, 177
locating drill guide, 178, 180
MP Flexion Strap, 178
PIP joint exion deformity
correction, 178
proximal and distal predrill pin,
178, 181, 182
TEC device, 184
Verona apparatus, 185
Distal interphalangeal joint
hyperextension deformity, 198,
200, 201
lateral and retrovascular
cords, 196
needle fasciotomy and
collagenase injections, 191
neurovascular bundle, supercial
bres, 192
swan neck deformity, 194, 197
Dupuytren diathesis, 155, 248,
254, 263

Dupuytrens contracture (DC), 54,

85, 147, 175, 213
articular changes, PIP joint, 214
assessment, 17
closure, 109
concave-convex osteotomy, 220
diagnosis, 17
distal rst web space
commissural cord, 15
dynamic external xator
(see Digit Widget)
fasciectomy, 13, 110
fasciotomy, 13
French and Belgian lineage, 14
Huestons denition, 30
indications, 98100
limited fasciectomies, 103
logical, risk-stratied and
evidence-based approach,
129, 130
management, 1720, 122, 123
MCP, 97
mobilization, 108
multiple limited fasciectomy, 213
NA (see Needle aponeurotomy
(NA))
nighttime splinting, 97
open surgical treatment, 100
palmar fascia, 122
pretendinous cords, 15
right hand small nger
Dupuytrens cord, 55
setup, 100
skin incisions, 101
skin puckering, 83
spiral cords, 108
surgical fasciotomy (see Surgical
fasciotomy, Dupuytrens
contracture)
surgical management, 98
triamcinolone acetonide
injections, 56, 57
Tubiana Class I/II Dupuytrens
contracture, 29
Tubiana stage IV, 118
ulnar sided digits, 226

Index
young
bipolar electrocautery, 237
CCH injection, 233
dermofasciectomy, 236
limited fasciectomy, 236
needle aponeurotomy, 235
palmar skin incisions, 237
percutaneous needle
aponeurotomy, 240
post-dermofasciectomy, 242
segmental aponeurectomy, 236
Dupuytrens disease, 74, 138, 189
cords, 138
diagnosis/assessment, 24
distal interphalangeal joint
(see Distal interphalangeal
joint)
broblast proliferation
and collagen
deposition, 138
brous adhesions, 9
intervention protocol, 2
management, 45
nodules, 138
palpable nodules, 2
PIP joint exion contracture, 175
primary static stretch, 9
progressive exion
contractures, 2
recurrence, 153, 166
skeletal traction devices, 9
and smoking, 138
surgical/medical/enzymatic
management, 1
surgical treatment
(see McCash technique)
total active extension, 5
ulnar aspect, little nger, 196
Dupuytrens fasciectomy, OSWA
anaesthesia, 120
anatomical dissection, 121
dermofasciectomy, 118
exor mechanism, 122
exor tendon mechanism, 120
general anaesthesia, 118
MCP contractures, 118

269

minimise injection pain,

120, 121
neurovascular bundles, 122
one-stop procedure/deferred, 118
pathoanatomical approach,
118, 119
PIP contracture, 118
pressure and time, 121
tourniquet, 118
Tubiana stages, 118
tumescent technique, 120
ulnar-sided pathoanatomy, 122
Z-plasty, 122
Dupuytrens recurrence
fasciectomy, 168
preoperative view, 162 (see also
Surgical fasciectomy,
recurrent disease)
Dynamic external xator.
See Digit Widget

E
Extension orthosis, 2, 4
Extracorporeal shockwave therapy
(ESWT), 206, 209

F
Fascietomy, 86, 138
Dupuytren contracture
(see Surgical fasciotomy,
Dupuytrens contracture)
MCP exion release, 140
Finger exion contracture, 7
in Dupuytrens disease
(see Dupuytrens disease)
Firebreak grafting, 263, 264
Flexion contracture
DIP joint, 189, 190, 201
dorsal wedge osteotomy, 218
PIP joint, 189, 190, 198
recalcitrant, 226
Food and Drug Association, 66
Full-thickness skin graft (FTSG),
243, 256

270

Index

H
Hohmann retractors, 74
Hyperextension
deformity, DIP joint, 198, 200
PIP joint, 194, 197
Hypothenar eminence, 256
Hypothenar full-thickness skin
graft, 265

I
Intraoperative photograph, 76

postoperative view, 141, 144

transverse palmar incision,
141, 142
Metacarpophalangeal (MCP)
contractures, 118
deformity, 232
disarticulation, 227
exion contracture, 138
joint contracture, 72
pretendinous cord, 72
Microvascular disease, 72

L
Ledderhose disease, 14, 208
Limited fasciectomy (LF), 150, 225,
236, 246
Low-dose adrenaline
contraindications, 133134
Low-dose adrenaline minimises
bleeding, 123

N
Needle aponeurotomy (NA), 55,
149, 163, 235
advantages, 31
Clostridium histolyticum
species, 32
collagenase injection, 32
CORD I study, 32
disadvantages, 31
distal-to-proximal technique, 26
fasciotomy portals, 25
local anesthetic eld block, 23, 25
nighttime splinting, 28, 33
palmar and digital blocks, 27
percutaneous fasciotomy, 25
perforation and sweeping
maneuvers, 25
PIP joint volar capsular
contractures, 27
post-procedure, 28
preoperative preparation, 20
and triamcinolone
combination, 56
recurrence rate, 54
Neurovascular dissection, 145

M
McCash technique
advantages and
disadvantages, 145
antibiotic prophylaxis, 141
diabetics, 143

O
One-stop wide awake (OSWA) hand
surgery
advantages, 131
Dupuytrens fasciectomy, 118122
patient centricity, 131

K
Knuckle Pads (Garrods Nodules)
antibrotic treatment, acetylcysteine instillation, 207
diagnosis, 204
hypoechogenic mass, 205
local antibrotic ACC
therapy, 208
management, 206207
open selective fasciectomy, 203
physical examination, 204
randomized controlled trial, 207
recurrent Dupuytrens
contracture, 208

Index
Open fasciectomy, 264
Open fasciotomy, Dupuytren
contracture
neurovascular bundles, 92
patient selection, 90
revision surgery, 92
Open palm technique, 103, 109

P
Partial fasciectomy
clinical course and outcome, 74
decreased right hand
function, 71
literature and discussion, 7479
management options, 73
multiple transverse incisions, 73
physical assessment and
diagnosis, 72
Patient Related Outcome Measure
(PROM), 67
Patient-centric approach, 131
Patient-centric Dupuytrens care
decision making,
128, 129
Patient-centric hand surgery, 131
Percutaneous needle aponeurotomy,
90, 92, 240, 242
Percutaneous needle fasciotomy
(PNF), 29, 149
Peyronies disease, 14
Power Doppler ultrasound.
Dupuytrens
contracture, 204
Preoperative incision markings, 75
Prophylactic external beam
radiation therapy, 49
Proximal interphalangeal (PIP)
contracture, 118
joints, 72, 74
joint contracture, 108109
joint exion contracture, 175
S-Quattro device, 185
management
(see Digit Widget)
Pseudo-recurrence, 167

271

R
Radical fasciectomy, 100, 101
Ray amputation, 227
Recurrence
denition, 166, 167
Dupuytrens diathesis, 217
MCP contractures, 92
and pseudo-recurrence, 167
Recurrent Dupuytren contracture,
149, 150, 254, 256262
advantages and disadvantages,
264265
CCH injection, 149
dermofasciectomy
(see Dermofasciectomy)
diagnosis/assessment, Dupuytren
diathesis, 254
exion contractures, 148
ipsilateral hypothenar
eminence, 261
left ring and small nger
involvement, 148
limited fasciectomy (LF), 150
management
closed wounds, bolster
dressing, 261, 262
cord resection, proximal-todistal direction, 258, 259
dermofasciectomy, 256
planned surgical incisions,
256, 257
skin graft, 260
skin marking, 258
PIP and DIP contractures,
148, 263
PNF, 149
preoperative view, patients
hand, 254, 255
SA, 150
segmental apeuronectomy, 150
Revision fasciectomy, 264

S
Scar retraction, 167
Secondary intention, 87, 9294

272

Index

Segmental apeuronectomy (SA),

101, 150, 236
Semmes-Weinstein lament
testing, 232
Skeletal extension torque, 176
Skin grafting, 150, 151, 154157
Skin-marking, 258
Slow intracord multi-cord (SIMple)
technique, 66
Soft tissue distraction, 184
Digit Widget (see Digit Widget)
TEC apparatus, 184
Splinting, 140, 145
S-Quattro device, fasciectomy, 185
Surgical fasciectomy, Dupuytren
contracture, 264
Surgical fasciectomy, recurrent
disease
CRPS, 170
dorsal progressive dynamic
splint, 171
hemostasis, 170
joint contracture, 169
pedicled local aps, 170
temporary joint xation, 169
Z-plasties, 163, 164
Surgical fasciotomy, Dupuytrens
contracture, 8691, 93
advantages and disadvantages,
9394
diagnosis/assessment, 84
management
active intraoperative
extension attempt, 87, 89
hemostat placement, 87, 88
isolated cords, 87, 88
planned surgical incision, 86
postoperative view, patients
hand, 90, 91, 93
MCP joints, 92
percutaneous needle
aponeurotomy, 90
preoperative view, patients
hand, 84, 85

Surgical Open Palm (McCash)

technique. See McCash
technique
Sutures, 74

T
Tecnica di Estensione Continua
(TEC) apparatus, 184
Tissue mobilization techniques
friction massage, 2
joint deformation, 2
prolonged extension stretches, 2
tissue remodeling, 7
Tourniquet-free sedation-free local
anaesthesia, 121, 123
Triamcinolone acetonide injections,
5557

U
Ulnar-sided pathoanatomy, 122
Ultrasound assisted needle
aponeurotomy
advantages, 50
anticoagulant drugs, 50
bilateral basal thumb
arthritis, 41
complications, 48
conservative and surgical
treatment modalities, 49
diagnosis, 4041
disadvantage, 51
hemostasis, 46
hypertension and ankle
osteoarthritis, 39
indications and
contraindications,
5051
patient information and
preoperative evaluation, 41
peripheral vascular
examination, 41
postoperative care protocol, 42

Index
post-procedure and
rehabilitation, 4648
procedure, 42
Sonosite S-MSK series
ultrasound machine, 42
tendon proximity, 46
Ultrasound elastography, 4, 7, 10

V
Vasopressors, 133
Viking disease, 64
V-Y advancement, 103

W
Wide awake Dupuytrens
fasciectomy, 118122
alpha adrenergic effects of
low-dose adrenaline, 124
anaesthesia, 132134
bleeding/infection, 125, 128
Brunner incisions, 124
coagulopathy, 127
contracture (see Dupuytrens
contracture (DC))
diathermy, 124
Dupuytrens contracture, 123
informed-consent process, 128
logical, risk-stratied and
evidence-based
approach, 129
low-dose adrenaline minimises
bleeding, 123
macrovascular integrity, 124
management of surgical
bleeding, 124

273

OSWA (see One-Stop Wide

Awake (OSWA) hand
surgery)
pathoanatomy, 123
patient-centric Dupuytrens care
decision making, 128, 129
patient-centred rehabilitative
approach, 128
post-operative exercises, 128
pre-operative examination, 123
pressure and time approach, 128
pressure and time approach to
bleeding, 124126
scar massage and scar
desensitisation
techniques, 128
tourniquet complications, 124
tourniquet-free hand
surgery, 125
treatment options, 118
visualisation and removal, 123
wound management, 127
Z-plasty, 123, 124, 127
Wide awake Dupuytrens surgery,
Z-plasty, 123
Wide awake hand surgery,
118122
diathermy, 124
One-Stop (see One-Stop Wide
Awake (OSWA) hand
surgery)
principles, 123
in United Kingdom, 128, 131

Z
Z-plasty, 122, 261, 264