Surgical Treatment of Dupuytren Disease

The surgeries listed here are for the Dupuytren carpal tunnel syndrome as well as for reconstructive surgeries for hand and fingers. Except these, we also perform soft tissues tumor (synovial cysts) and foreign objects removal surgeries. Also, we take in small trauma as emergencies during the work week.

The surgical treatment of Dupuytren Disease

There are several symptoms in the Dupuytren disease: apparition of a palm nodule, palm strings, the affected finger cannot be stretched or the finger is bent in the palm. The treatment consists of palm and finger incisions and then immobilization of the palm/finger in a gypsum splint for 2-3 weeks.

The symptoms can be:

Stage I – apparition of a palm nodule (frequently phase V or I)

Stage II – apparition of palm strings as well as nodules

Stage III – the affected finger cannot be stretched – it is fixed with an AMF flexion

Stage IV – the affected finger is bent in the palm, little palm skin holes appear + ulcerations

Treatment

With the help of some palm and finger incisions (aponeurotomy; aponevrotomy – total or subtotal) the callous skin areas are relaxed or removed. The surgery is not painful. The palm/fingers are immobilized in a gypsum splint for 2-3 weeks and the recovery period is 3-4 weeks.

There has been discovered the treatment without incisions and with personal fat transplant (which contains regenerative cells with an anti-inflammatory role) or the enzyme extract injections made locally. Another utilized technique is based on incisions in the affected area with a special needle, ecographically supervised.

The plastic regenerative surgery in Dupuytren disease

The plastic regenerative surgery, with its new valences and therapeutical possibilities promises to play an important part in the treatment of the Dupuytren disease too.

That’s why the plastic surgeons can have a new surgical approach in the Dupuytren contracture. This technique, minimally invasive, combines multiple, percutaneous, punctiform sectionings of the fiber strings with personal fat transfer, a diminished or disappeared tissue due to this affection.

On the one hand, this technique solves the impossibly to function because of the contractions and, on the other hand, it leads to the decrease of relapses. Also, the adipose palm tissue is regenerated. In this way, the classical surgical treatment is avoided which consists of meticulously dissecting the affected areas and which does not prevent the physio-patological process of fibrosis. Also, the risk of post operatory scars is avoided.

The Dupuytren disease – generalities, etiology, morphopathology

The Dupuytren Disease is characterized by a thickening and retraction of the palm fascia which leads to functional impotence, meaning a deficit in stretching the fingers. The disease appears frequently in the 5^th decade of life at men and in the 6^th decade of life at women.

The disease is more present in the North Europe. A more aggressive development of the disease was registered for men under 50. Among the risk factors: alcohol, smoking, DZ, physical work and sports that imply hand movements.

The Dupuytren contracture is a fibromatosis which also includes plantar fibromatosis (Ledderhose), penian fibromatosis (Peyronie) and dorsal fibromatosis AIFP (Garrod). The disease develops in 3 stages:

The proliferation phase – myofibroblasts start to proliferate developing painful or touch sensitive nodules.
The involutory phase – the disease spreads across the fingers fascia which leads to the developing of strings. The most present type of cell is the myofibroblast.
The residual phase – the process continues to develop to the tip of the fingers, the strings appear which leads to the contracture.

At the molecular level, the contraction of the myofibroblasts determines the transformation of collagen type I in scar collagen type II. In this time, the atrophy of the adipose local tissue appears and transforms itself in fibrosis tissue. The strings continue to grow in the fingers in 3 layers. The first layer is superficial and is attached to the tegument. The second layer is deep and is connected with the vascular-nervous package. The third layer goes parallel with the covering of the flexors on the dorsal side. The strings can be spiral-shaped, surrounding the vascular-nervous package and making it more superficial.

The disease is usually bilateral but with different levels of affection, the fingers IV and V are the most affected.

There are more classifications regarding the levels of the disease. One of the most utilized is Tubiana and De Frenne’s staging, 1976, which measures and calculates in grades the existing contracture of each articulation (AMF, AIFP, AIFD).

Stage 0 – no injury

N- palm nodule, without contracture

Contracture with a 0-450 flexion
Contracture with a 450-900 flexion
Contracture with a 900-1350 flexion
Contracture with a 1350+ flexion

The treatment of the Dupuytren Disease

The conservatory treatment consists of using splints, topic drugs or local anti-inflammatory injectables (cortisone), collagenase injections (Xiaflex), warm physiotherapy, ultrasounds and radiotherapy. Most of these treatments have little efficiency and do not stop the development of the disease.

The surgical treatment varies from invasive surgery to radical surgery which is recommended when the nodules are painful, when there is functional impotence and when the conservatory therapy has failed.

Intervention types utilized in the treatment of Dupuytren Disease:

Needle fasciotomy
Open fasciotomy
Partial or segmental fasciectomy
Dermofasciectomy

Although the excision surgery is the standard treatment, the procedure is followed by aprox 17% complications. These can include injuries of the vascular-nervous package, articular rigidity, cutaneous necrosis, infections, hematomas, hypertrophic scars, reflex sympathetic dystrophy etc. Among these, the needle fasciotomy has the least complications (under 1%).

The relapses are between 27% and 46,5% at 3 years.

Because the needle aponevrotomy has little complications and enables the adipose palm tissue disparition, Hovius, Smit and Khouri proposed an alternative surgical treatment. This consists of needle aponevrotomy followed by personal fat transfer.

The selection of the patients for this technique is important because this procedure is for the people who want minimum recovery time, for the people who have many fingers affected by the disease and for those who would normally have a recommendation for extensive surgery.

The result of the procedure is limited in the case of old and severe contractures and of the relapses of contracture AIFP.

Also, the procedure is not recommended to smokers and to people who had surgical interventions with grafts.

The surgical technique

The surgery is performed with a local sedative anesthesia. After the exsanguination with the Esmarch band, the fingers are fixed on a plumb hand retractor which holds the fingers stretched so that the contracted bands may be tensioned.

Steps:

Small incisions are made with the transcutaneous needle. 20-30 incisions for each area in order to cut the previous portion of the cords. The sectioning movement oscillates transversally at the point of every needle sting. The little holes and folds of the skin are released through a tangential cut of the cords attachments to the derma. As the cords get released it is important to hold the tension constant and to use the retractor to extend the fingers. The most important side concerning the safety of the packages is the depth of the needle sting, which should be 2 mm deep close to the palm transversal fold and between 1-1,5 mm away from it.
The harvested adipose tissue is injected with a 14 g cannula with a blunt tip on 2 or 3 holes. The technique is to inject the tissue when the cannula is withdrawn. It is done in multiplan and 20-300 cc are injected in the fingers area.

We present you 2 of the cases we solved in the ProEstetica clinic through this revolutionary technique.

The carpal tunnel syndrome

This affection is also called the neuropathy of the median nerve at the wrist of the hand and is characterized by compressing the median nerve, a very important nerve for the hand. The traits are: pain, anesthesia, weak muscle of the hand and wrist, numbness and hand pains.

The symptoms that alert the patient are:

numbness sensations in the affected hand
hand and wrist pains, especially at night.
in severe phases, there can be an anesthesia of the median nerve (the person cannot feel the touch with the thumb, middle finger and index)
intermittent blockage of the fingers (thumb, middle finger and index)
muscular atrophy of the thumb and a weak hand
elbow and shoulder pains (which makes people to confuse them with the rheumatic pains).