The isolated digital cord in Dupuytren's contracture: anatomy and clinical significance

Skin extension with a digito-lateral flap and early active finger extension training for Dupuytren contracture: A retrospective study

In the surgical management of Dupuytren contracture (DC), Y-V plasty (YV) and Z-plasty (ZP) are techniques often used for skin extension. However, achieving sufficient skin extension with these procedures alone is often difficult. Therefore, we addressed this issue with an adjunctive digito-lateral flap (DLF) and report the clinical results of the surgery using a DLF in addition to YV and ZP. Fifteen patients with DC (15 affected fingers) underwent partial fasciectomy using a DLF in addition to YV or ZP, and early active finger extension training was performed immediately after the operation. The flap survival rate, preoperative and postoperative extension angle, Tonkin contracture improvement (TCI) rate, and Tubiana staging grades were evaluated. The contracture sites were at 4 proximal interphalangeal (PIP) and 3 metacarpophalangeal (MP) joints of the little finger and 4 PIP and MP joints each of the ring and little fingers. All the flaps survived, and the extension angle improved at the final observation from a preoperative mean of -45° to -3° and -55° to 5° for the PIP and MP joints, respectively. One patient with PIP joint contracture treated in the early stage of the study experienced a persistent 5° limitation of extension, even though the TCI rate was satisfactory (91.9%) and the outcome was "good." Full extension of the joints was achieved in 15 patients, in whom the TCI rate was 100% and the outcome was "very good." This technique was able to solve 3 important steps to achieve full extension: intraoperatively, wound closure, and rehabilitation. We attained and maintained long-term full extension intraoperatively and immediately after surgery and obtained very good treatment results, as shown in this study. In conclusion, highly favorable clinical outcomes were achieved through the combination of a DLF with YV and ZP. Skin extension with a DLF is a useful surgical technique for DC.

The "Y" Double Spiral Cord: An Anatomic Variant of Dupuytren Disease: A Report of 2 Cases

CASE

We report 2 cases of a spiral nerve variant that has only 1 previously reported description in the literature. A pretendinous cord was found to branch into a "Y" configuration, extending distally on both the radial and ulnar sides of the same digit, with the radial and ulnar digital nerves spiraling around each limb of the "Y cord".

CONCLUSION

Rare spiral nerve variants exist which place the digital neurovascular bundles (NVBs) at risk. Awareness of these variants and adherence to conservative surgical principles allow the surgeon to identify these scenarios intraoperatively and safely dissect the digital NVBs free of pathologic tissue.

Double Spiral Dupuytren's Disease: Case of Ulnar and Radial Spiral Cords in Shared Digit

Dupuytren’s disease is a benign fibroproliferative disorder resulting in progressive contraction of palmar and digital fascia. Diseased fascia of the hand condenses into tensile cords, manifesting in various anatomical combinations. The spiral cord variant is especially troublesome, as the cord travels under the digital neurovascular bundle and places it at risk during surgical resection. In severe cases, limited fasciectomy is required to release contracture and restore finger extension. Here, we present the case of a 79-year-old right-handed man with a history of severe Dupuytren’s disease of both hands, who was found to have ulnar and radial spiral cords in his right ring finger. Diseased tissue was removed en bloc, restoring extension and function. To our knowledge, this is the first case of a digit with two spiral cords affecting both neurovascular bundles. It is important to be aware of the anatomical variations possible in Dupuytren’s disease to avoid iatrogenic injury.

Outcomes at 7 and 21 years after surgical treatment of Dupuytren's disease by fasciectomy and open-palm technique

The goal of this study was to assess the recurrence of Dupuytren's disease and the stability of the functional result after fasciectomy combined with the McCash open-palm technique. From 1989 to 1999, 56 consecutive patients were surgically treated for Dupuytren's disease. In 2003, 40 of these operated patients were reviewed by an independent evaluator; 12 patients were Tubiana stage 1, 16 stage 2, 9 stage 3 and 3 stage 4. Twenty-one of them were reviewed again in 2016 by a second evaluator who was unaware of the clinical results in 2003. The mean follow-up was 7.32 years (range, 4.26 to 12.5 years) at the first review. Recurrence occurred in 7 patients (17.5%) and extension of the disease in 15 (37.5%). Three patients had developed complex regional pain syndrome (CRPS). Mean residual contracture was 19.3°. Average improvement in finger extension was 53°. At the second review, 21 patients were assessed with a mean follow-up of 21.5 years (range, 18.7 to 26.3 years). None of them were re-operated and no extension of the disease was observed. There was no recurrence in patients who had no recurrence in 2003. However, the contracture had worsened in five patients (23.8%), three of whom had a recurrence of the disease in 2003. Mean residual contracture was 31.8°. Recurrence occurs most often in the first few years after surgery. The functional result is stable over time. CRPS and the number of rays operated are the main factors negatively affecting overall improvement of mobility.

Normal and Pathologic Anatomy of Dupuytren Disease

Dupuytren disease causes nodules and thickened fascial cords in the hands of affected individuals. In this article, the author explains normal fascial anatomy of the hand and describes how it relates to the pathologic anatomy found in Dupuytren disease. Anatomic findings in diseased cords are described, with particular reference to dangers encountered in treatment of this condition.

The quantitative role of flexor sheath incision in correcting Dupuytren proximal interphalangeal joint contractures

Controversy exists regarding intra-operative treatment of residual proximal interphalangeal joint contractures after Dupuytren's fasciectomy. We test the hypothesis that a simple release of the digital flexor sheath can correct residual fixed flexion contracture after subtotal fasciectomy. We prospectively enrolled 19 patients (22 digits) with Dupuytren's contracture of the proximal interphalangeal joint. The average pre-operative extension deficit of the proximal interphalangeal joints was 58° (range 30-90). The flexion contracture of the joint was corrected to an average of 28° after fasciectomy. In most digits (20 of 21), subsequent incision of the flexor sheath further corrected the contracture by an average of 23°, resulting in correction to an average flexion contracture of 4.7° (range 0-40). Our results support that contracture of the tendon sheath is a contributor to Dupuytren's contracture of the joint and that sheath release is a simple, low morbidity addition to correct Dupuytren's contractures of the proximal interphalangeal joint. Additional release of the proximal interphalangeal joint after fasciectomy, after release of the flexor sheath, is not necessary in many patients.

LEVEL OF EVIDENCE

IV (Case Series, Therapeutic).

Efficacy and safety of collagenase clostridium histolyticum in the treatment of proximal interphalangeal joints in dupuytren contracture: combined analysis of 4 phase 3 clinical trials

PURPOSE

To examine the results of proximal interphalangeal (PIP) joint contractures from 4 phase 3 clinical trials of collagenase clostridium histolyticum (CCH) injection for Dupuytren contracture.

METHODS

Patients enrolled in Collagenase Option for Reduction of Dupuytren I/II and JOINT I/II with one or more PIP joint contractures (20° to 80°) received CCH 0.58 mg/0.20 mL or placebo (Collagenase Option for Reduction of Dupuytren I/II only) injected directly into a palpable cord. The percentage of PIP joints achieving clinical success (0° to 5° of full extension), clinical improvement (50% or more reduction in baseline contracture), and range of motion improvement at 30 days after the first and last CCH injections was assessed. The PIP joint contractures were classified into low (40° or less) and high (more than 40°) baseline severity. Adverse events were recorded.

RESULTS

A total of 506 adults (mean age, 63 ± 10 y; 80% male) received 1,165 CCH injections in 644 PIP joint cords (mean, 1.6 injections/cord). Most patients (60%) received 1 injection, with 24%, 16%, and 1% receiving 2, 3, and 4 injections, respectively. Clinical success and clinical improvement occurred in 27% and 49% of PIP joints after one injection and in 34% and 58% after the last injection. Patients with lower baseline severity showed greater improvement and response was comparable between fingers, as were improvements in range of motion. Adverse events occurring in more than 10% of patients were peripheral edema (58%), contusion (38%), injection site hemorrhage (23%), injection site pain (21%), injection site swelling (16%), and tenderness (13%). This incidence was consistent with data reported in phase 3 trials. Two tendon ruptures occurred. No further ruptures occurred after a modified injection technique was adopted.

CONCLUSIONS

Collagenase clostridium histolyticum was effective and well tolerated in the short term in patients with Dupuytren PIP joint contractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Spiralling of the neurovascular bundle in Dupuytren's disease

Displacement of the neurovascular bundle within a digit affected by Dupuytren's disease can occur when disease superficial to the neurovascular bundle is connected to disease deep to it. Contraction of such cords results in spiralling of the neurovascular bundle, classically when a pretendinous cord connects with the lateral digital sheet and Grayson's ligament via the oblique cord, but also in association with an isolated digital cord. We describe six cases in which cord formation and contraction resulted in a distal spiral, which may occur in isolation or in combination with a classical proximal spiral, creating a double spiral or corkscrew neurovascular bundle.

Severe Contractures of the Proximal Interphalangeal Joint in Dupuytren's Disease:Value of Capsuloligamentous Release

A retrospective review of severe flexion contractures (60 degrees or more), involving 51 proximal interphalangeal joints in 40 patients with Dupuytren's disease, was performed. Thirty-two joints underwent aponeurectomy alone, 19 joints additional capsuloligamentous release. Mean follow-up was 12 months. No statistically significant difference was seen in the percentage of contracture correction in the capsulotomy group compared with the noncapsulotomy group.

Severe contractures of the proximal interphalangeal joint in Dupuytren's disease: combined fasciectomy with capsuloligamentous release versus fasciectomy alone

Severe proximal interphalangeal joint contracture in Dupuytren's disease presents a frustrating problem for hand surgeon. Some surgeons argue for fasciectomy alone, avoiding violation of the proximal interphalangeal joint, which may prolong morbidity and result in permanent limitation of flexion; this loss of flexion can be more disabling than a mild flexion contracture. Others favor capsulotomy in addition to fasciectomy, especially for severe contractures, to obtain additional release, arguing that one cannot completely correct secondary contracture by fasciectomy alone. We performed a retrospective review of severe flexion contractures (60 degrees or greater) involving 42 proximal interphalangeal joints in 28 patients with Dupuytren's disease. Twenty-seven joints in 18 patients underwent fasciectomy alone, and 15 joints in 10 demographically similar patients underwent capsulotomy in addition to fasciectomy. In the noncapsulotomy group, preoperative contracture averaged 78.4 degrees. Postoperative contracture averaged 36.6 degrees, with a 53 percent improvement. In the capsulotomy group, preoperative joint contracture averaged 82.5 degrees. Postoperative contracture averaged 36.8 degrees, with a 55 percent improvement. Intraoperative residual contracture for 21 of the 27 joints in the noncapsulotomy group averaged 7 degrees compared with 8 degrees for 9 of the 15 joints in the capsulotomy group. Preoperative proximal interphalangeal joint flexion averaged 100.6 degrees in the noncapsulotomy group and 98.6 degrees in the capsulotomy group. Postoperative flexion averaged 92.2 degrees in the noncapsulotomy group, which was 91.7 percent of preoperative flexion, and 82.7 degrees, which was 83.9 percent of preoperative flexion, in the capsulotomy group. No statistically significant difference was seen in the percentage of contracture correction in the capsulotomy group compared with the noncapsulotomy group at follow-up. The degree of correction initially obtained at surgery using either method was not maintained during the short follow-up period. There was a significant decrease in postoperative proximal interphalangeal joint flexion compared with preoperative flexion following either surgical approach; however, there was no significant difference between the two groups with respect to the percentage of flexion lost. Complications developed in both groups but tended to occur more commonly in the capsulotomy group. This study failed to show any advantage to capsuloligamentous release in addition to fasciectomy in treating severe proximal interphalangeal joint contracture due to Dupuytren's disease.

A mid-term review of the results of dermofasciectomy for Dupuytren's disease

Clinical involvement of the palmar and digital skin by Dupuytren's disease occurs frequently. A review of 40 rays in 32 patients who had consecutively undergone dermofasciectomy is presented. The average follow-up period was 38 months, with a minimum of 24 months. Four out of the 40 rays developed recurrent nodule formation limited to the proximal or distal graft insets but there was no recurrent cord formation, suggesting better disease control than by fasciectomy alone. Full thickness graft to resurface the defect has been surprisingly complication-free.

The proximal interphalangeal joint in Dupuytren's disease

In one hundred patients with Dupuytren's disease, one hundred and fifty-four operations were performed. The average pre-operative proximal interphalangeal joint contracture was 42 degrees and the average percentage improvement in proximal interphalangeal joint extension at post-operative review was 41%. Fourteen amputations were performed (9.1%). The primary deformity is caused by disease involvement of the palmar fascial structures. Secondary changes may prevent correction of the deformity despite excision of the contracted fascia. The anatomy of the joint is reviewed together with the primary and secondary mechanisms of joint contracture in Dupuytren's disease. Arthrodesis, osteotomy of the proximal phalanx and joint replacement are considered as alternatives to amputation when a systematic surgical approach fails to correct the flexion contracture.