Abstract
Purpose:
The aim of this study was to analyze long-term results after limited fasciectomy for Dupuytren’s contracture.
Methods:
The study included 34 patients (52 rays), with an average follow-up of 9.5 years (range: 7–13 years). Range of motion, functional status, recurrence, and complications were recorded.
Results:
Preoperative metacarpophalangeal joint (MCPJ) contracture (median: 35°, range: 0–90°) improved postoperatively to full extension in all but one patient, with no recurrence at the most recent follow-up. Preoperative proximal interphalangeal joint (PIPJ) contractures (median: 52°, range: 5–100°) were initially corrected, but recurred with time (median: 25°, range 0°–80°). Hand function was assessed using the Disabilities of the Arm, Shoulder and Hand questionnaire. Postoperative hand function improved (median: 0, range: 0–27), compared to preoperative function (median: 20, range: 0–51). Hand function worsened with time (at most recent follow-up: median: 3, range: 0–40), mainly due to PIPJ contracture recurrence, but function remained better than before surgery.
Conclusion:
Limited fasciectomy is an effective treatment method for MCPJ, with full correction achievable in both the short and long term. Regarding the PIPJ, treatment outcomes seem to be multifactorial. Further clarification is required to distinguish between local recurrence and remaining contracture of the PIPJ.
Introduction
Dupuytren’s contracture (DC) is a condition in which cords (or contractures) of diseased palmar fascia extend to the digits, resulting in limited function and range of motion of the affected hand and fingers. Release or removal of the diseased cord with consequent finger extension can be achieved by surgical and invasive nonsurgical modalities. 1,2 Limited fasciectomy (LF) has proven to be effective and most commonly performed of the surgical interventions. 3 In the last decade, less invasive treatment methods have gained popularity. 1 Limited and generalized fasciectomies could be considered as curative procedures, in which affected tissue is partially or completely removed. In the absence of palmar fascia, the possibility of local recurrence should theoretically equal zero, since there is no tissue in which relapse could occur. Still, defining recurrence in each treatment option remains controversial. 1,4,5
Published studies have analyzed postoperative DC results mostly from the perspective of local finger status. To our knowledge, only a few studies focused on functional status, with a follow-up of 3.5 years maximally. 6 –9 No studies performed analyses of long-term clinical performance or patient satisfaction. The aim of our mid- to long-term study is to evaluate functional results, recurrence rates, and complications after LF.
Patients and methods
In this single-institution and single-technique study, we included a total of 34 patients (27 males and 7 females), who underwent procedures between 2000 and 2006 and were followed for an average of 9.5 years (ranging from 7 to 13 years).
Patients included in the study reside in the city of Zagreb and Zagreb County. This study was approved by the Ethical Committee of the University of Zagreb School of Medicine (registration number: 380-59/12-302/81, class 641-01/12-02). Patient consent and authorization for publication of personal information related to the study was obtained. At the time of treatment, the average age of patients was 58 years (range 40–70) and at the time of follow-up, the average age was 68 years (range 52–79). A total of 52 rays and 65 joints (41 metacarpophalangeal joints (MCPJs) and 24 proximal interphalangeal joints (PIPJs)) were treated ; 15 cases with the involvement of only the MCPJ, 11 with both MCPJ and PIPJ, and 8 with only the PIPJ involved. Nineteen patients had involvement of one ray, two rays in 12 patients, and three rays in 3 patients.
Finger and joint distribution is presented in Table 1.
Finger and joint distribution.
MCPJ: metacarpophalangeal joint; PIPJ: proximal interphalangeal joint.
All patients underwent procedures utilizing the same surgical technique—LF in axillary block anesthesia. Two different senior orthopedic surgeons performed the procedures, as available. All patients had postoperative static volar extension splinting for 10–14 days, followed by physical therapy for 2–4 weeks. All patients had their first follow-up at 6–8 weeks postoperatively and at 3 months postoperatively. Decisions for further follow-ups were made for each patient individually; we did not have a clear follow-up protocol after 3 months. The patients were called in for a checkup which we will refer to as “the most recent follow-up.”
Two patients were found to have a history of Ledderhose’s disease and one was found to have Peyronie’s disease. Thyroid disease was reported in six patients and diabetes mellitus in two. One patient had a history of liver cirrhosis due to alcohol abuse. No other significant comorbidities were recorded.
The clinical status of the hand was examined and noted preoperatively (time point titled TP1), 6–8 weeks after surgery (TP2), and at the most recent follow-up (TP3). The degree of contracture, involved finger, joint, and dominant hand were marked. The degree of contracture was measured with a protractor. Hand function was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. 6
Statistical analysis
The variables were compared using the Wilcoxon non-parametric test (for two groups; TP1 versus TP2, TP1 versus TP3, etc.) and the Friedman test (TP1 versus TP2 versus TP3). Multiple comparisons were corrected using the Bonferroni method post hoc. The correlations between variables are Spearman’s rank correlations. All values were deemed significant if p < 0.05, except with the Friedman test (p < 0.17, after Bonferroni adjustment). A necessary sample size of 29 subjects was calculated a priori using α = 0.05 and β = 0.80.
Results
The average duration of the patients’ clinical symptoms prior to the operation was 12 years (range: 9 months to 16 years).
Hand function
The hand function of patients preoperatively (TP1), postoperatively 6–8 weeks after the surgery (TP2), and at the time of the most recent follow-up (TP3) is shown in Figure 1. Postoperative hand function improved (median: 0, range: 0–27), compared to the function before the surgery (median: 20, range: 0–51). Hand function worsened with time (at last follow-up: median 3, range: 0–40). A statistically significant improvement in hand function was noted postoperatively.
DASH value of patients preoperatively at TP1, 6–8 weeks postoperatively at TP2, and at the most recent follow-up at TP3. A box-and-whisker plot. DASH: disabilities of the arm, shoulder and hand; TP: time point.
Only three patients had a statistically significant impairment of function at the follow-up visit, but function was still better than preoperatively in all three cases. In all three patients, only one finger with PIPJ involvement was affected. The number of affected fingers does not correlate with hand function in any of the three cases (Spearman’s test, p > 0.05). There was no statistically significant correlation between age and function in any of the three cases.
Hand function was better in cases with a single affected MCPJ (n = 15), versus both MCPJ and PIPJ involvement (n = 11), preoperatively (Spearman’s test, r = 0.57, p < 0.05), and at follow-up with the level of p < 0.01 (Spearman’s test, r = 0.35). Postoperatively, there was no statistically significant correlation.
Local recurrence
The median value of finger contracture preoperatively was 41° (range 0–100°) and 10° at the most recent follow-up (average 0–80°). The values of MCPJ and PIPJ contracture are shown in Table 2. No reoperations were performed in this cohort.
Median values of MCPJ and PIPJ contractures, preoperatively at TP1, and at the follow-up control TP3.
MCPJ: metacarpophalangeal joint; PIPJ: proximal interphalangeal joint; TP: time point.
All but one MCPJs were completely corrected by the surgical procedure. In one patient, the degree of contracture was reduced from 90° to 10° and it remained at 10° at follow-up. Skin on the palmar side showed no signs of thickening or recurrent nodules. Sixteen of 24 PIPJs were completely corrected. At follow-up, only five joints had full range of motion. The eight joints that were not fully corrected had continued to worsen. Functional results were not influenced by the patients’ age.
Complications
There was one intraoperative and one early postoperative complication: one patient sustained digital nerve injury, and wound dehiscence was found in one patient.
Discussion
A very good clinical function of the hand was found in long-term clinical results after LF. We found the LF technique to be a clinically successful treatment option, with a mean reduction of contracture and no reoperations required in our cohort.
To our knowledge, no long-term studies have been conducted to review other treatment modalities for DC, such as needle aponeurotomy and collagenase injections.
Postoperatively, all but one MCPJ contracture was completely corrected with no further recurrence. Even though PIPJs were initially corrected, on the most recent follow-up, the median of recurrence contractures was 25° (range 0–80°). Due to PIPJ recurrence, the DASH values deteriorated slightly from 0 postoperatively to 3 at the most recent follow-up. Clinically, hand function was preserved due to full mobility of the MCPJ, with no deterioration.
In his review, Denkler concluded that LF has a high number of complications (3.9–39.1%), where major complications occurred in 15.7%. 10 In comparison to the review data, our patients had a small number of complications, only two. One possible reason could be the surgeons’ level of experience, along with similar surgical outcomes between them. In general, it is difficult to establish the complication rate after surgery for DC, since only a small proportion of reports provide exact details on complication rates.
To date, we found only a few Dupuytren’s disease papers pertaining to hand function. 7 –9 Our results are compatible with those of Zyluk and Jagielski, who concluded that the function was significantly improved and that the number of fingers operated on did not correlate with hand function. 9 Regarding age and hand function, they concluded that younger patients have better postoperative outcomes, which is the exact opposite of our results. This discrepancy is probably due to their younger cohort at the time of follow-up; they reported an average age of 60 versus our median age of 68 at the time of follow-up.
Sinha et al. report contradictory findings: a significant negative correlation between the total loss of extension and hand function. 7 The opposing results could be explained by the theory of patient adaptation during the course of slow contracture progression. Skoff compared the outcome of two surgical techniques (the new “synthesis” technique and the open palm technique after Mansfield/McCash) and reported no statistically significant correlations between the two groups. 8
van Rijssen et al. directly compared LF with percutaneus needle fasciotomy (PNF) at 6 weeks postoperatively. Prior to surgery, the mean DASH score in the LF group was 14. One week postoperatively, it reached 49 and returned to the preoperative level after 5 weeks (DASH = 16). Among the LF cases, a better outcome was found after 6 weeks (79% reduction in total passive extension deficit versus 63% in the PNF group) and hand function was better in the PNF group. 9 This was probably due to a complication rate of 5% in the LF group versus 0% in the PNF group. 11 The patients in our cohort had a median DASH value of 0 (0–26) at 6–8 weeks postoperatively, in comparison to a preoperative 20 (0–51), with a complication rate of 6%.
Local recurrence was analyzed, mainly within a short follow-up period. Denkler et al. reported that the LF technique has the lowest recurrence rate out of all surgical and nonsurgical methods and is currently the most popular technique used. 3 Donaldson et al. reported a recurrence of contractures in 100 joints (MCPJ = 42, PIPJ = 58) at 6 months after LF. All but one MCPJs were fully corrected. Of 58 PIPJs, 35 were completely corrected and at the time of follow-up, only 13 maintained a full range of motion. 12 Concurrently with our results, it appears that recurrences in the PIPJ progress rapidly in the first few months. Even so, the patients from our cohort were very satisfied. The exact dynamics of the postoperative deterioration of function, patient satisfaction, and causes of recurrence are yet to be investigated.
The LF technique is an effective treatment method for MCPJ, with full correction achievable in both the short and long term. Hypothetically, after removal of the palmar fascia, recurrence of the disease should not be possible since the tissue in which the disease relapses is removed. The anatomical differences in the shape of the metacarpal head, volar plate, and collateral ligament between the MCPJ and PIPJ also affect the different recurrence outcomes in these two joints. Though the MCPJ is in flexion in DC, this position remains the anatomical position of the joint. Therefore, recovery is complete, whereas the anatomical position of the PIPJ is in extension (as seen in the intrinsic-plus hand position). 13 The prolonged flexion position of the PIPJ induced by Dupuytren’s disease leads to shortening of the PIPJ soft tissue anatomical structures, such as the collateral bands, intrinsic muscles, and axis of rotation. 14 Removal of Dupuytren’s cord will, as shown in our study, only temporarily correct the PIPJ flexion contracture but in most cases, with time, recurrence of the flexion contracture is expected. It seems that the most probable cause for the consequent recurrence of the PIP flexion contracture is shortening of the intrinsic soft tissue of the PIPJ, and not the recurrence of Dupuytren’s disease. Further clarification is needed to differentiate between local recurrences and remaining contractures of the PIPJ.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.