Proximal Interphalangeal Joint Release in Dupuytren’s Disease of the Little Finger

The efficacies and limitations of fasciectomy and collagenase clostridium histolyticum in Dupuytren's contracture management: A meta-analysis

BACKGROUND

We intend to assess the efficacies and limitations of collagenase clostridium histolyticum (CCH) and fasciectomy in treating Dupuytren's contracture, and the associated complications and rate of recurrences aiming to present a treatment algorithm.

METHODS

A literature search within the PubMed, Web of Sciences, Cochrane Library, and EMBASE databases was performed using the combined key words 'Dupuytren, palmar aponeurosis contracture, collagenase clostridium histolyticum and fasciectomy', including all possible studies with a set of predefined inclusion and exclusion criteria.

RESULTS

Thirty studies were assessed for eligibility from 215 identified records. Seventeen publications satisfied the inclusion criteria including 2142 joints in 1784 patients. The mean follow-up time was 18.0 months (3-60).

CONCLUSION

Acceptable contractures release was obtained in both techniques. Severe complications associated with fasciectomy outrank those of CCH, whereas the low rate of recurrence favors the fasciectomy technique.

Fasciectomy for Dupuytren Contracture

This article discusses limited fasciectomy for Dupuytren contracture, reviews the literature to list common complications, addresses the observations that need to be made after surgery, and systematically reviews the literature for 2 clinical questions: (1) regarding leaving wounds open and (2) the use of postoperative splintage.

[Operative treatment of Dupuytren's contracture : Arthrolysis of the proximal interphalangeal finger joint]

BACKGROUND

In the operative treatment of Dupuytren's disease, in certain cases proximal interphalangeal joint flexion contracture remains after fasciectomy due to shrinkage, shortening, and/or adhesion of the periarticular structures.

OBJECTIVES

How can a residual flexion contracture of the proximal interphalangeal joint after partial fasciectomy in Dupuytren's disease be treated surgically and what follow-up results can be expected?

METHODS

Description of anatomy, indication, surgical technique of arthrolysis of the proximal interphalangeal joint, postoperative treatment, and critical analysis of the results reported in the literature.

RESULTS

Arthrolysis of the proximal interphalangeal joint is performed in up to six consecutive steps. An improvement of only about 50% compared to preoperative flexion contracture can be expected.

CONCLUSIONS

Despite alleged unsatisfactory results arthrolysis of the proximal interphalangeal joint can be recommended in surgery of Dupuytren's disease. In certain cases, patient cooperation during lengthy postoperative treatment is necessary.

Supplementary arthrolysis of the proximal interphalangeal finger joint in Dupuytren's contracture: primary operation versus revision

INTRODUCTION

In operative treatment of Dupuytren's disease, in certain cases proximal interphalangeal joint (PIP) flexion contracture remains after fasciectomy which can be corrected by a supplementary arthrolysis, but few data comparing primary and revision surgery are available.

MATERIALS AND METHODS

Fifteen patients who had a fasciectomy and supplementary PIP arthrolysis at the affected finger for the first time were compared to 13 patients who had a revision fasciectomy with a supplementary PIP arthrolysis. Upon follow-up at 22 months, flexion contracture was measured and data were compared to the preoperative values. Patient satisfaction with the outcome of the operation was determined and patients completed the Disabilities of the Arm, Shoulder and Hand outcome measure questionnaire.

RESULTS

Fingers of patients with Dupuytren's disease that had a partial fasciectomy and supplementary arthrolysis of the PIP for the first time had a median residual PIP flexion contracture of 30° compared 39° of fingers that had a partial fasciectomy and supplementary arthrolysis of the PIP as a revision. The patients of both groups were equally satisfied with the outcome of the operation, while their DASH scores were nearly identical.

CONCLUSION

After a mean follow-up of 2 years, the outcome of recurrent PIP contracture is comparable in patients with Dupuytren's disease that were treated by partial fasciectomy and supplementary arthrolysis for the first time and as a revision.

What are we measuring? A critique of range of motion methods currently in use for Dupuytren's disease and recommendations for practice

BACKGROUND

Range of motion is the most frequently reported measure used in practice to evaluate outcomes. A goniometer is the most reliable tool to assess range of motion yet, the lack of consistency in reporting prevents comparison between studies. The aim of this study is to identify how range of motion is currently assessed and reported in Dupuytren's disease literature. Following analysis recommendations for practice will be made to enable consistency in future studies for comparability. This paper highlights the variation in range of motion reporting in Dupuytren's disease.

METHODS

A Participants, Intervention, Comparison, Outcomes and Study design format was used for the search strategy and search terms. Surgery, needle fasciotomy or collagenase injection for primary or recurrent Dupuytren's disease in adults were included if outcomes were monitored using range of motion to record change. A literature search was performed in May 2013 using subject heading and free-text terms to also capture electronic publications ahead of print. In total 638 publications were identified and following screening 90 articles met the inclusion criteria. Data was extracted and entered onto a spreadsheet for analysis. A thematic analysis was carried out to establish any duplication, resulting in the final range of motion measures identified.

RESULTS

Range of motion measurement lacked clarity, with goniometry reportedly used in only 43 of the 90 studies, 16 stated the use of a range of motion protocol. A total of 24 different descriptors were identified describing range of motion in the 90 studies. While some studies reported active range of motion, others reported passive or were unclear. Eight of the 24 categories were identified through thematic analysis as possibly describing the same measure, 'lack of joint extension' and accounted for the most frequently used.

CONCLUSIONS

Published studies lacked clarity in reporting range of motion, preventing data comparison and meta-analysis. Percentage change lacks context and without access to raw data, does not allow direct comparison of baseline characteristics. A clear description of what is being measured within each study was required. It is recommended that range of motion measuring and reporting for Dupuytren's disease requires consistency to address issues that fall into 3 main categories: Definition of terms, Protocol statement, Outcome reporting.

A review of the classification of Dupuytren's disease

Although much has been published about the treatment of Dupuytren's disease, there is no clear consensus regarding the most effective form of treatment. Part of this uncertainty may result from the absence of a universal method of assessing this condition. We undertook a review of the literature in order to summarize the various methods by which Dupuytren's disease has been measured and quantified. We included all articles that offered a classification or assessment system for the disease. We excluded articles that dealt solely with surgical technique (although inevitably there was some overlap). We conclude that there are many methods of assessment, but that none of them is perfect and that further work is needed in the field.

Surgical and therapy update on the management of Dupuytren's disease

Advancements in surgical and therapy management for Dupuytren's disease are highlighted. Indications for treatment and various surgical options for Dupuytren's disease are described. Non-surgical techniques are also presented. Therapy interventions are reviewed. Treatment techniques for the management of secondary problems resulting from prolonged digit flexion are presented. The benefits, limitations and outcomes of treatments are reviewed to assist the reader to link patient specific problems and goals to the most appropriate treatment choice.

Patterns of recontracture after surgical correction of Dupuytren disease

PURPOSE

To study the evolution of deformity of the proximal interphalangeal joint over 5 years after good surgical correction of Dupuytren-induced contracture.

METHODS

We assessed 63 patients (72 fingers; 69 hands) with Dupuytren disease for the degree of contracture, its correction after surgery, and the range of movement at the proximal interphalangeal joints at 3 and 6 months, and 1, 3, and 5 years after fasciectomy with or without the use of a firebreak graft. We investigated associations between the recurrence of contracture and preoperative patient and surgical factors.

RESULTS

There were 4 patterns of evolution of contracture after surgical correction. A total of 31 patients (33 hands) showed good improvement that was maintained for 5 years (minimal recontracture group). Twenty patients (23 hands) showed good initial improvement, which mildly worsened (< 20°) but was then maintained over 5 years (mild early recontracture group). Four patients (5 hands) worsened in first 3 months after surgery (> 20°) but there was no further worsening (severe early recontracture group). Eight patients (8 hands) worsened progressively over 5 years (progressive recontracture group). Worsening of contracture more than 6° between 3 and 6 months after surgery predicted progressive recontracture at 5 years.

CONCLUSIONS

Recurrence of contracture (not disease recurrence) could be predicted as early as 6 months after surgery for Dupuytren disease.

Optimal functional outcome measures for assessing treatment for Dupuytren's disease: a systematic review and recommendations for future practice

BACKGROUND

Dupuytren's disease of the hand is a common condition affecting the palmar fascia, resulting in progressive flexion deformities of the digits and hence limitation of hand function. The optimal treatment remains unclear as outcomes studies have used a variety of measures for assessment.

METHODS

A literature search was performed for all publications describing surgical treatment, percutaneous needle aponeurotomy or collagenase injection for primary or recurrent Dupuytren's disease where outcomes had been monitored using functional measures.

RESULTS

Ninety-one studies met the inclusion criteria. Twenty-two studies reported outcomes using patient reported outcome measures (PROMs) ranging from validated questionnaires to self-reported measures for return to work and self-rated disability. The Disability of Arm, Shoulder and Hand (DASH) score was the most utilised patient-reported function measure (n=11). Patient satisfaction was reported by eighteen studies but no single method was used consistently. Range of movement was the most frequent physical measure and was reported in all 91 studies. However, the methods of measurement and reporting varied, with seventeen different techniques being used. Other physical measures included grip and pinch strength and sensibility, again with variations in measurement protocols. The mean follow-up time ranged from 2 weeks to 17 years.

CONCLUSIONS

There is little consistency in the reporting of outcomes for interventions in patients with Dupuytren's disease, making it impossible to compare the efficacy of different treatment modalities. Although there are limitations to the existing generic patient reported outcomes measures, a combination of these together with a disease-specific questionnaire, and physical measures of active and passive individual joint Range of movement (ROM), grip and sensibility using standardised protocols should be used for future outcomes studies. As Dupuytren's disease tends to recur following treatment as well as extend to involve other areas of the hand, follow-up times should be standardised and designed to capture both short and long term outcomes.

Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: the importance of clear definitions

PURPOSE

To call attention to the wide variety of definitions for recurrence that have been employed in studies of different invasive procedures for the treatment of Dupuytren contracture and how this important limitation has contributed to the wide range of reported results.

METHODS

This study reviewed definitions and rates of contracture correction and recurrence in patients undergoing invasive treatment of Dupuytren contracture. A literature search was carried out in January 2011 using the terms "Dupuytren" AND ("fasciectomy" OR "fasciotomy" OR "dermofasciectomy" OR "aponeurotomy" OR "aponeurectomy") and limited to studies in English.

RESULTS

The search returned 218 studies, of which 21 had definitions, quantitative results for contracture correction and recurrence, and a sample size of at least 20 patients. Definitions for correction of contracture and recurrence varied greatly among articles and were almost always qualitative. Percentages of patients who achieved correction of contracture (ie, responder rate) when evaluated at various times after completion of surgery ranged from 15% to 96% for fasciectomy/aponeurectomy. Responder rates were not reported for fasciotomy/aponeurotomy. Recurrence rates ranged from 12% to 73% for patients treated with fasciectomy/aponeurectomy and from 33% to 100% for fasciotomy/aponeurotomy. Review of these reports underscored the difficulty involved in comparing correction of contracture and recurrence rates for different surgical interventions because of differences in definition and duration of follow-up.

CONCLUSIONS

Clearly defined objective definitions for correction of contracture and for recurrence are needed for more meaningful comparisons of results achieved with different surgical interventions.

CLINICAL RELEVANCE

Recurrence after surgical intervention for Dupuytren contracture is common. This study, which evaluated reported rates of recurrence following surgical treatment of Dupuytren contracture, provides clinicians with practical information regarding expected long-term outcomes of surgical treatment choices.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and decision analysis III.

The prognosis of fasciectomy for abductor digiti minimi and pretendinous cords in Dupuytren's disease of the little finger

Thirty-nine consecutive patients with little finger Dupuytren's contracture underwent open fasciectomy. Diseased abductor digiti minimi (ADM) pretendinous (PT) cords were identified. The mean pre-operative PIPJ contracture was 77 degrees in the PT group and 66 degrees in the ADM group. Mean residual deformity was 12 degrees in the PT group and 9 degrees in the ADM group. At six months, ten out of 27 patients had developed a recurrent deformity in the PT group (mean 24 degrees ) and seven out of 11 in the ADM group (mean 18 degrees ). There was no statistically significant difference between the two groups at any stage. Dupuytren's contracture of the little finger is as a result of an ADM cord in 29% of cases. In this series it led to an isolated contracture of the PIPJ in the majority of cases and rarely affected the MCPJ. Disease of the ADM cord was not associated with a difference in contracture or prognosis compared to a PT cord.

The association between intraoperative correction of Dupuytren's disease and residual postoperative contracture

The purpose of this study was to determine whether preoperative contracture and the amount of intraoperative correction can be used to predict the postoperative outcome of fasciectomy for Dupuytren's disease. A prospective study of 52 patients undergoing primary fasciectomy during an 18 month period was undertaken. The contracture of each joint was measured preoperatively, after fasciectomy during the operation and 6 months after surgery. Forty-two metacarpophalangeal (MCPJ) and 58 proximal interphalangeal (PIPJ) joints were treated surgically. Full intraoperative correction was achieved in 41 MCPJs. Thirty-seven had full correction at follow-up. Full intraoperative correction was obtained in 35 PIPJs and 13 had complete correction at follow-up. The extent of the preoperative deformity was a significant predictor of complete intraoperative correction. The extent of both preoperative deformity and intraoperative correction were significant predictors of loss of surgical correction after operation.

Predicting the outcome of surgery for the proximal interphalangeal joint in Dupuytren's disease

PURPOSE

We prospectively studied the outcome of limited Dupuytren's fasciectomy, in combination with joint release if necessary, for disease involving 49 proximal interphalangeal joints (PIPJs) to identify factors that predispose to recurrent PIPJ contracture.

METHODS

Thirty-seven patients were treated over a 4-year period. The flexion contracture of the PIPJ was measured before surgery, immediately after surgery, and at more than 1 year after surgery.

RESULTS

A mean preoperative flexion contracture of 67 degrees +/- 22 degrees was corrected to 6 degrees +/- 10 degrees at the time of surgery and 25 degrees +/- 25 degrees at the follow-up evaluation. There was a positive correlation between the severity of the preoperative flexion contracture and recurrent deformity, with a preoperative contracture greater than 60 degrees leading to significantly worse outcome. Incomplete correction of PIPJ flexion contracture during surgery and poor postoperative compliance with therapy were also associated with worse recurrent joint contractures. The digit involved and the necessity for joint release did not significantly affect outcome.

CONCLUSIONS

In the absence of recurrent Dupuytren's disease, severe preoperative deformity, incomplete correction at surgery, and noncompliance with therapy predispose patients to worse PIPJ contracture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.