Dupuytren Contracture Treatment & Management

A variety of non-surgical and surgical options are available for management of Dupuytren disease (DD). The choice largely depends on the severity of disease, degree of deformity, limitations in function, and provider preference. Although there is no consensus, it is generally accepted that surgical procedures are reserved for patients with contractures > 30-40º or with significant disability. ^[16] In advanced cases a variety of techniques may be used to prevent recurrence (eg, skin grafting, external fixator application, radiation). ^[17]

A study by Stepic et al found that the degree of contracture may influence surgical outcomes with proximal interphalangeal (PIP) joint Dupuytren disease, but not metacarpophalangeal (MCP) joint Dupuytren disease. These researchers followed 60 patients (85 affected fingers) undergoing partial palmar fasciectomy with either PIP or MCP joint contracture of varying degrees (group 1: < 15º, group 2: 15-30º;  group 3: > 30º). Surgical success rates were the same across all MCP joint groups, with complete contracture resolution at 6 months. However, for PIP joint involvement, contractures of > 30º had a statistically lower contracture reduction index compared with groups 1 and 2. This study suggests that optimal results for PIP joints are achieved when contractures are 15-30º. ^[69]

Observation

Observation is appropriate for patients with unchanging, painless Dupuytren disease who have minimal contracture and no functional impairment. ^[70] Patients with mild Dupuytren disease can be monitored on an infrequent basis via a brief follow-up visit every 6-12 months. In addition to accurate measurement of the progression of the contractures, the follow-up also provides an opportunity to elicit a history of any functional deficits. Further, these visits allow assessment and discussion of the need for surgical referral.

Physical and occupational therapy

Stretching with the application of heat and ultrasonographic waves may be helpful in the early stages of Dupuytren contracture. The physical therapist also may recommend that the patient wear a custom splint or brace to stretch the fingers further. Range of motion (ROM) exercises should be performed several times a day. If the patient undergoes surgical correction of the contracture, physical therapy often is involved following the procedure. The postsurgical program consists of the following:

• Wound care
• Massage
• Passive stretching
• Active ROM exercises
• Splinting

Through a course of occupational therapy, the patient may learn adaptive techniques and begin to use assistive devices that enhance functional abilities. For example, adaptive equipment can help a patient to open jars, despite contractures.

Collagenase injection

Prior to 2010, surgical intervention was the mainstay of treatment for Dupuytren disease despite a high rate of recurrence and complications. ^[71] In 2010, the US Food and Drug Administration (FDA) approved collagenase Clostridium histolyticum (CCH; Xiaflex) at a dose of 0.58 mg per injection for the treatment of Dupuytren contracture in a single digit during a 30-day treatment cycle. Injected collagenase extracted from C histolyticum weakens and dissolves the Dupuytren cord. ^{[72, 73]}  This is a minimally invasive procedure, done in office, in which collagenase is injected locally into the cord, then the following day the pathologic cord is ruptured through passive extension. Over the years, this has become a first-line treatment for Dupuytren contractures. ^{[16, 15]}

Surgical therapy

The goal of surgical care is to excise the diseased fascia to help prevent progression of the disease. ^[74] A patient should be referred to a hand surgeon if the MCP contracture is more than 30º or if any contracture of the PIP is present. Functional disability may be an indication for surgery if the patient accepts the associated morbidity and understands that surgery may not be curative. As with all elective surgeries, the patient's age, comorbid conditions, and ability to comply with postoperative care and rehabilitation also determine whether surgery is appropriate.

Surgical interventions consist mostly of fasciectomy. ^[75] Complete extension of affected joints may be possible with earlier intervention. However, any degree of PIP contracture carries a poor prognosis, and excising the involved fascia may not correct the joint contracture, especially if it has been long standing. MCP involvement is more amenable to surgical correction than PIP involvement, even in more advanced or long-standing cases. Subsequently, surgery is recommended as soon as a PIP contracture is detected.

A study found that improvement in the PIP joint contracture has a greater correlation with hand function at 6 and 12 months after surgery than does improvement in the MCP joint contracture.The results of another study revealed the severity of contracture preoperatively had a significantly negative effect on hand power, and older patients experienced less functional benefit from selective fasciectomy. ^[76] In bilateral cases, the initial operation is on the worst or dominant hand. If indicated, the other hand can be operated on 6-8 weeks after healing of the first hand.

If a patient needs to undergo surgical fasciectomy for Dupuytren disease and also requires a carpal tunnel release for carpal tunnel syndrome, a study recommends that both procedures be done concomitantly, as the complication rate is not significantly increased. ^[77]

For more information, see Surgery for Dupuytren Contracture.

Surgery versus percutaneous needle fasciotomy versus collagenase injection

In a study that compared CCH injection with limited fasciectomy in 132 patients with Dupuytren contracture, Zhou and colleagues reported no significant difference in the degree of residual contracture of the MCP joint (13° with CCH versus 6° with surgery; P = 0.095). With PIP joint treatment, residual contracture was significantly worse with CCH (25° versus 15° with surgery; P = 0.010). However, patients treated with CCH had more rapid recovery of hand function and experienced fewer serious adverse events than did those treated with fasciectomy. ^[78]

A prospective, single-blinded, randomized study in patients with an MCP contracture of 20° or more in a single finger found no significant differences in outcome after 1 year between the 69 patients randomized to CCH treatment and the 71 patients randomized to needle fasciotomy. In both groups, 90% of patients had full extension of the treated MCP joint. ^[79]

A meta-analysis by Sanjuan-Cervero et al looked at the safety and efficacy of CCH compared with fasciectomy and percutaneous needle fasciotomy (PNF) in Dupuytren disease. This study found that short- and medium-term improvement to joint movement achieved with CCH were similar to those achieved with fasciectomy, although fasciectomy did outperform CCH with regard to treatment of PIP joint contractures. CCH was associated with higher odds of mild, moderate, or serious complications, but these effects disappeared when mild adverse effects were removed from the equation. Further, these complications were mild, self-limited and resolved without sequelae. ^[80]

A meta-analysis of eleven comparative studies looked at outcome differences between CCH and limited fasciectomy (LF).  The analysis reported that residual contracture at three months was higher in the CCH group than in the LF group. CCH injection also had a significantly higher recurrence rate ((25.8 vs. 9.3%, OR 5.2, 95% CI [1.5, 18.8], p = 0.01).  However, severe complications were significantly higher in the LF group (0.3 vs. 7.3%, OR 0.12, 95% CI [0.03, 0.42], p = 0.001). ^[81]

Another meta-analysis sought to synthesize data on contracture correction and functional outcomes from four randomized clinical controlled trials comparing needle fasciotomy and collagenase treatment for single-digit Dupuytren contractures. Needle fasciotomy and collagenase treatment were found to have similar outcomes with regards to contracture recurrence, final fixed flexion contracture (FFC), Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores, and Unité Rhumatologique des Affections de la Main (URAM) scores at three-year follow-up. ^[82]

Toftgaard et al compared treatment of Dupuytren contractures in PIP joints with CCH versus PNF in an open-label, randomized, controlled trial. After 30 days, all patients treated with PNF and 89% of those treated with CCH had clinical improvement. However, at 2 years, 32% of PNF patients maintained clinical improvement compared with only 8% of CCH patients. In contrast, a study by Nydick et al of patients with mixed PIP and MCP joint contractures reported clinical success in 50% of PNF patients and 42% of CCH patients after 3 to 28 months. It is well established that PIP joint involvement appears more resistant to treatment compared with, MCP joint disease, which may explain the lower maintenace rates found by Toftgaard. ^[83]

Although treatment outcomes with CCH are comparable to surgery and PNF in the short term, CCH is less expensive but associated with higher rates of recurrence. Leafblad et al found in a retrospective review that CCH treatment had the greatest rate of repeat intervention with the highest cumulative cost over time, particularly for large PIP contractures and younger age at time of initial intervention. Fasciectomy had the highest initial cost but long-term costs were significantly less. ^[84]  However, a cost-utility analysis by Chen et al, based on quality-adjusted life years, found that an open partial fasciectomy was not cost effective compared with CCH. ^[85]

Recurrrence of disease is problematic across all treatment options. CCH and PNF have higher recurrence rates than fasciectomy, but the recurrence rate after 5 years with limited fasciectomy was 20.9%. ^[86]  Thus, even surgery is not a definitive cure for the disease. With recurrence, re-treatment after CCH or PNF with CCH or PNF is possible and satisfactory, and surgery after CCH is usually not considered to be more challenging than primary surgery (although there is some debate about this). ^[87]  However, with recurrence following surgery, surgical revision is much more difficult than the primary surgery. ^{[88, 87]}

A study by Leafblad et al that compared outcomes and costs of three Dupuytren contracture treatments concluded the following ^[89] :

• CCH treatment resulted in the highest rate of reintervention at 2 years, comparable reintervention rates to PNF at 5 years, and the highest cumulative costs.
• PNF was the least expensive intervention and resulted in longer duration before reintervention compared with CCH.
• More severe PIP joint contractures and younger age at time of initial intervention were predictive of reintervention after CCH and PNF.
• Fasciectomy has a high initial cost but the lowest reintervention rate.

There is no general agreement on treatment recommendations regarding the choice between PNF, surgery, and CCH at this time among hand surgeons. McMillan et al surveyed 36 hand surgeons from 9 countries including North America based on case scenarios and found little agreement on treatment recommendations. Those in practice longer were significantly less likely to recommend surgery and more likely to recommend collagenase injections rather than multiple treatments, and those with more experience in collagenase injections recommended CCH more frequently. ^[90]

Corticosteroid injection

Intralesional triamcinolone acetonide (Kenalog-40) injections of 40 mg/mL have yielded subjective improvement in the size of Dupuytren nodules in some patients. In one study by Ketchum et al, patients received 60-120 mg injections of triamcinolone acetonide directly into the nodule, resulting in nodule regression in 97% of the hands after an average of 3 injections. However, 50% of patients experienced recurrence of nodules 1 to 3 years after their last injection, and those with mild MCP contractures (< 15º) did not have improvement in their contractures. ^[91]  Ketchum argues that early treatment of a nodule with an intralesional steroid injection, before the development of joint contracture (particularly PIP joint involvement), can interrupt the inflammatory process and thus the progression of disease. ^[92]

However, corticosteroid injections are associated with a high risk of complications, including fat atrophy and skin discoloration, ^[70] although in Ketchum et al's study nearly all patients saw resolution of atrophy and depigmentation by 6 months after the last injection.  ^[91]  In addition, intralesional injection of corticosteroids can result in tendon rupture.

Radiotherapy

Radiotherapy can be effective in slowing disease progression in the early stages of Dupuytren contracture, and may even provide long-term relief of symptoms. In a study of radiotherapy—two courses, 6 to 8 weeks apart, of five daily fractions of 3.0 Gy to a total dose of 30 Gy—in 135 patients (208 hands) with early-stage Dupuytren contracture, 87% of Tubiana stage N cases and 70% of stage N/I cases remained stable or regressed, over mean follow-up of 13 years. However, disease progressed in 62% of those with stage I disease and 86% of those with stage II disease. ^[93]

A systematic review of six studies of radiotherapy in Dupuytren contracture found that salvage surgery was successful in all cases of disease progression after radiotherapy, with no reports of adverse wound healing problems or radiotherapy-associated malignancy. However, the authors concluded that on balance, radiotherapy should be considered an unproven treatment for early Dupuytren contracture, in view of the limited evidence base and unknown long-term adverse effects. ^[94]

Consultations

Surgical intervention may be appropriate in more severe cases. Consider surgical consultation with one of the following specialists:

• Plastic surgeon
• Orthopedic hand surgeon

Investigational pharmacologic therapies

Tumor necrosis factor (TNF) promotes the development of myofibroblasts, the cells responsible for the fibrosing process that lead to the contractures seen in Dupuytren disease. Anti-TNF agents inhibit myofibroblasts in vitro. An ongoing phase II trial is studying the intra-noduar injection of the TNF inhibitor adalimumab in early Dupuytren disease. This is a two-part study, with the first part looking on a molecular level at tissue excised from patients injected with varying doses of adalimumab prior to surgery. The second part is a  multi-center, prospective study following patients receiving adalimumab at 3-month intervals and measuring nodule size, hardness, and disease progression compared with placebo, over a 1-year period. ^[95]

Other approaches

Other pharmacologic treatments for Dupuytren contracture have been proposed but failed to gain traction (eg, 5-fluorouracil, ^[96]  imiquimod, ^[97]  botulinum toxin ^[98] ). For example, high-dose tamoxifen, given before and after surgery for Dupuytren contracture, produced favorable short-term results, but this effect was lost within 2 years, with worsening of contractures after the medication was discontinued.  ^[99]

Physical therapy

Stretching with the application of heat and ultrasonographic waves may be helpful in the early stages of Dupuytren contracture. The physical therapist also may recommend that the patient wear a custom splint or brace to stretch the fingers further. ROM exercises should be performed several times a day. If the patient undergoes surgical correction of the contracture, physical therapy often is involved following the procedure. The postsurgical program consists of the following:

• Wound care
• Massage
• Passive stretching
• Active ROM exercises
• Splinting

Occupational therapy

Through a course of occupational therapy, the patient may learn adaptive techniques and begin to use assistive devices that enhance functional abilities. For example, adaptive equipment can help a patient to open jars, despite contractures.

Prior to 2010, surgical intervention was the mainstay of treatment for Dupuytren disease despite a high rate of recurrence and complications. ^[71] In 2010, the US Food and Drug Administration (FDA) approved collagenase Clostridium histolyticum (CCH; Xiaflex) at a dose of 0.58 mg per injection for the treatment of Dupuytren contracture in a single digit during a 30-day treatment cycle. Injected collagenase extracted from C histolyticum weakens and dissolves the Dupuytren cord. ^{[72, 73]}  This is a minimally invasive procedure, done in office, in which collagenase is injected locally into the cord, then the following day the pathologic cord is ruptured through passive extension.

Over the years, this has become a first-line treatment for Dupuytren contractures. ^[16] Although this procedure is typically done without local anesthesia, Nordenskjold et al found that a nerve block using local injection of 10 mL of mepivacaine 20 minutes prior to CCH injection significantly reduced pain levels. ^[100]

FDA approval of CCH for the management of Dupuytren contracture was based on the results of CORD I and CORD I Extension, which were prospective, randomized, double-blind, placebo-controlled trials by Hurst et al in 308 patients with contractures greater than 20º. Findings included a reduction in contractures to less than 5º in 64% of collagenase-injected patients compared with 6.8% of patients treated with placebo. Patients with MCP involvement tended to improve to a greater extent, as did those patients with less severe flexion contractures. ^[5]

Glipin et al performed a 90-day double-blind placebo-controlled study with a 9-month open label extension evaluating the efficacy of CCH in Dupuytren disease in Australia, termed CORD II. Sixty six patients were enrolled: 45 in the treatment group and 21 in the placebo arm. The primary end-point was reduction of the contracture to 0-5º of normal, 30 days after the last injection. A statistically significant reduction in contracture was reported in the treatment group, with 44% of patients meeting the primary endpoint with treatment versus 4.8% of controls. ^[73]

Witthaut et al reported on the efficacy and safety of CCH in 2 open-label trials (JOINT I in the United States and JOINT II in Australian and Europe). Patients with fixed-flexion contractures of the MCP or PIP could receive up to three 0.58-mg CCH injections per cord, with finger extension procedures 24 hours later. Dupuytren cords affecting 879 joints in 587 patients were injected. Clinical success was achieved in 57% of joints (MCP 70% success rate, PIP 37% success rate). The mean change in contracture was 55º for MCP joints and 25º for PIP joints. ^[101]

Peimer et al evaluated the long-term safety and efficacy of CCH in the CORDLESS study, which enrolled 1080 patients from the original 5 clinical trials (JOINT I, JOINT II, CORD I, CORD I extension, and CORD II). Patients were evaluated beginning 2 years after their first injection and then annually for a total of 4 years. Recurrence rate was 35% (MCP, 27%; PIP, 56%). In the original studies 301 joints were partially corrected; 50% of these had a nondurable response (MCP, 38%; PIP, 62%). ^[102]

Two additional studies of efficacy with CCH 2 years after treatment found results comparable to the CORDLESS study (although the doses used and definition of recurrence were slightly different). Beeck et al evaluated 87 patients (88 joints) treated with CCH and found a recurrence (as defined as increase in passive extension deficit of > 20º) in 28.2% of MCP and 62.1% of PIP joints after 2 years. ^[103] Lauritzson et al found that in 57 patients (59 hands), at 2 years following their CCH injection, 28% of the treated hands had recurrence (defined as active extension deficit > 20º), in MCP and PIPs joints equally. ^[104] In both studies, the rate of complete correction was much higher with contractures of MCP joints (> 80%) than of PIP joints (48-61%). ^{[103, 104]}

Anticlostridial type I collagenase and/or anti-clostridial type II collagenase antibodies were reported in 96% or more of patients who had received 2 or more CCH injections and in 82% who received one injection. No correlation of antibody titer to adverse events was reported. No new or long-term serious adverse events were noted, although the recurrence rate was noted to be lower in fully corrected joints than in partially corrected ones. ^[102]

Coleman et al studied the efficacy of concurrent injection injection of CCH into two Dupuytren cords. The study treated 12 subjects with more than three joint contractures. During the first treatment session, all subjects were injected with single dose of CCH (0.58 mg) into a single cord. Thirty days later, the same patients were injected at two different cords concurrently in the same hand. A mean reduction in joint contracture of 30º was obtained. All patients were satisfied with the outcome, and the rate of adverse events was similar to a single injection. This study suggested that two cords can be treated concurrently with safety profile similar to that of sequential treatment of the individual cords. ^[105]

In 2014, the FDA approved an expanded indication for CCH for the treatment of up to two Dupuytren contracture joints in the same hand during a single treatment visit. ^[106] A finger extension procedure can be performed at 24, 48, or 72 hours after injection. A successful cord rupture with delayed manipulation at 28 days has been reported. ^[107]

Complications associated with CCH are common. In the Hurst et al study, an adverse event occurred in 96% of patients, although only 3 serious reactions were reported. The most common complications included injection site reactions, peripheral edema, bruising, bleeding, and pain. More serious reactions included tendon rupture and complex regional pain syndrome. To date, tendon rupture has been described in 0.3% of 1080 patients. ^[72] There has also been one case report of a proximal phalanx fracture that occurred during attempted release of the contracture following CCH injection. ^[108] Although the incidence of mild adverse affects with CCH can be high, with reports of between 46%-100% of patients experiencing one; these complications tend to be self-limiting and resolve quickly without sequelae. ^[80]

A systematic review of CCH treatment for Dupuytren contracture that included 3753 joints in 2675 patients documented the following ^[109] :

• Initial contracture reduction was more successful with MCP than PIP joints (77% versus 36%, respectively).
• Contracture recurred in 23% of successfully treated joints, typically within 12 to 24 months but sometimes as early as 6 months.
• Although 94% of patients experienced one or more treatment-related adverse effects, most were minor and self-resolving (eg, peripheral edema, extremity pain, contusion); major surgical complications occurred in only 1% of patients, and only two patients experienced major nonsurgical complications (nonrupture tendon injury and anaphylaxis).

Bear et al reported that patients with recurrent contractures in joints previously successfully treated with CCH may be effectively re-treated with up to 3 injections of CCH. In their study, 43 (86%) of 50 patients had a 20° or greater increase in range of motion after re-treatment, and the adverse event profile was consistent with that in previous studies. ^[110]

A study by Bronier et al demonstrated the safety and efficacy of CCH injections in the treatment of palmar Dupuytren nodules. These authors compared three different doses (0.25, 0.40, and 0.60 mg) versus placebo in an 8-week, double-blinded study. Their results showed a significant reduction in nodule size at 8 weeks with the 0.40-mg and 0.60-mg single injection compared with placebo and reduction in nodular consistency and hardness at weeks 4 and 8. The most common adverse events included bruising, extremity pain, and local swelling, but no trends for increased events were noted with using the higher dose; most patients expressed a high degree of satisfaction with CCH treatment. ^[111]

Percutaneous needle fasciotomy/closed fasciotomy

Percutaneous needle fasciotomy (PNF), or needle aponeurotomy, is a minimally invasive treatment that is usually performed as an office procedure under local anesthesia. It involves multiple puncture sites and sectioning of the Dupuytren cord using the bevel of a needle. ^{[112, 113, 114, 115]}

PNF may be an effective initial intervention in the treatment of Dupuytren contracture, either alone or as a first step to subsequent procedures such as repeated fasciotomy, fasciectomy, or CCH injection. ^[116]  

A study by Skov et al found that CCH is not superior to PNF for the treatment of isolated PIP joint Dupuytren contracture. At 2 years, clinical improvement was maintained in 29% of PNF patients (6 of 21), versus 7% of CCH patients (2 of 29). Complications (mostly transient) occurred in in 93% of the patients treated with CCH, versus 24% of the patients treated with PNF. ^[117]

A Danish registry cohort study of PNF reported a low rate of severe complications with the procedure. The study included 3331 treated finger rays in 2257 patients, with median follow-up of 7.2 years.  In the cohort, 4 patients sustained flexor tendon rupture, 1 patient had digital nerve damage, 2 patients had an infection treated in hospital, and 31 patients later received antibiotics for an infection or suspected infection. None of the infections required surgical intervention, and no finger amputations or ipsilateral upper limb reflex dystrophy cases were registered in relation to the procedure. ^[118]

In a study of 211 older patients (average age 65 y), investigators found a single digital nerve injury, no infections, and no tendon injuries with needle aponeurotomy, although damage to the neurovascular bundle is a concern. Recurrence rates (58%) and disease activity (69%) were high at 3-year follow-up. ^[119]

Foucher et al believed this technique was ideal for the elderly patient with a bowing cord and a predominant MCP joint contracture. Needle fasciotomy may also facilitate hygiene in a debilitated elderly patient. Limitations of fasciotomy in treating PIP joint contracture were noted. ^[119]

More recently, fat grafting in conjunction with PNF/percutaneous aponeurotomy has been studied, with promising short-term results. In Dupuytren disease, subdermal fat is lost as it is displaced by fibrosis, often leading to adherence of the fibrosed tissue to the skin.  Further, lipoaspirate containing stem cells may have an inhibitory effect on myofibroblasts (key cells in the process of fibrosis). Kan et al used lipofilling together with percutaneous aponeurotomy and had similar contracture correction results at 12 months compared with selective fasciectomy, but shorter recovery times and lower complication rates. ^{[120, 121]}  

Contraindications to PNF include the following ^[119] :

• Infiltrating disease
• Rapid recurrence in a young patient
• Inaccessible, multiple cords
• Chronic digital disease
• Postsurgical recurrence in the digits

Open fasciotomy

An open fasciotomy is sometimes used to manage more severe cases of Dupuytren contracture, and is more effective in the long term when compared with needle aponeurotomy. Open fasciotomy is still an outpatient procedure performed under local anesthesia. An incision is made over the diseased cord and direct visualization of the cord and neurovascular structures is possible. The offending cord is divided at a point immediately underlying the skin incision.

Fasciotomy is usually most successful for MCP flexion contracture. The recovery is rapid, but the recurrence rate is high. Open fasciotomy is usually reserved for patients who cannot tolerate a more extensive procedure.

Segmental aponeurectomy/fasciotomy

Segmental aponeurectomy of Moermans is a procedure that is intermediate between simple fasciotomy and limited fasciectomy. Segments (1 cm in length) of fascia are excised through C-shaped incisions. ^{[122, 123]}

Regional (or selective) fasciectomy

This involves excising only the fascia that is grossly affected (eg. in the palm, pretendinous cords and involved natatory ligaments; in the fingers, only those structures that are visibly affected). Although the disease process clearly extends into clinically normal palmar fascia, this approach has proven successful in correcting MCP joint contractures and some PIP contractures and carries an acceptably low morbidity rate.

Areas not treated may develop disease. This method is commonly used to treat primary and recurrent disease. Skin incisions may be transverse, longitudinal, or diagonal/zigzag (eg, Z-plasty, Y-V-plasty, Bruner-type zigzag incision). Local advancement flaps, including an ulnar-based skin flap ^[124] and palmar inter-metacarpal flap ^[125] have been described.

In a study of selective fasciectomy, Hueston concluded that this procedure does not prevent recurrence of Dupuytren disease but does allow correction of deformity with more rapid recovery of hand function. ^[126]

Extensive or radical fasciectomy

This involves excision of the entire palmar fascia, including tissue that appears grossly healthy (in an effort to prevent recurrence). Although this procedure is not commonly performed today, it results in a relatively low recurrence rate of about 11%. ^[127] It does have an increased risk of morbidity postoperatively, including hematoma in 14% of cases and nerve irritation or damage in 6%. Patients are also prone to prolonged postoperative edema and stiffness. One study concluded that total aponeurectomy was most appropriate for stage 2 disease. ^[127]

Dermofasciectomy

This removes the diseased fascia and the overlying skin. The wound is then resurfaced and a full thickness skin graft is applied. Recurrence rates are low, being similar to those of extensive fasciectomy. ^[127] Because of the radical nature of this procedure, it is usually reserved for patients with recurrent or severe disease.

In dermofasciectomy, two incisions are made, one from the distal interphalangeal joint of the affected digit to the distal palmar flexion crease, and a transverse palmar incision, to form an L shape. A selective fasciectomy is performed, with partial closure of the incision site. A full-thickness skin graft is harvested from the hypothenar eminence during this surgery. A portion of the palm is left open, and an extension splint is applied. After 4 days, the splint is removed, the wound is cleaned, and the skin graft is applied to the palm. The palm is splinted again for 1 week.

General recommendations for surgical intervention

A fasciotomy or regional fasciectomy is usually sufficient to establish normal function in the MCP joint. The procedure of choice for PIP joint involvement is either dermofasciectomy or extensive fasciectomy.

Amputation may be recommended if digital contracture is greater than 90º or if vascular compromise has developed. Some patients may prefer amputation to the postoperative care required for fascial surgery.

Surgical Considerations

The surgeon and the patient may choose general or regional anesthesia during the procedure. Loupe magnification is used to aid visualization and detection of the delicate structures, specifically the neurovascular bundle.

A pneumatic tourniquet is typically used on the operative extremity to control blood loss and assist with visualization.

Incisions vary and may be transverse, zigzag, or longitudinal, depending on the region involved. The skin is separated from the underlying diseased palmar fascia and all neurovascular bundles that may be jeopardized during dissection are identified. The neurovascular bundles are often displaced or distorted by the contraction of the components of the palmar fascia.

After each neurovascular bundle has been identified and dissected away from the diseased palmar fascia, the diseased fascia is excised. The MCP joint is often fully corrected with this maneuver. PIP joints may have residual flexion at this stage and may require release of the flexor tendon sheath, which can become shortened with chronic contracture.

The skin is closed with running or interrupted absorbable or non-absorbable suture material. A modified skin closure with Z-plasty or V-Y advancement can provide additional length without undue tension. If skin grafting is necessary to close the wound, use a full-thickness graft to minimize wound contracture during healing. Postoperatively, bandage the hand and place it in a splint. 

Alternative techniques

The open-palm technique (McCash technique) involves a transverse skin incision and division of the aponeurosis; healing is by secondary intention. A modification of the McCash technique, called the Jacobsen flap, uses the L-shaped incision of dermofasciectomy, but healing is by secondary intention. ^[128]

The synthesis technique is a method of wound closure that incorporates the advantages of tissue rearrangement, the open-palm technique, and full-thickness skin grafting. One study showed a decreased healing time and recurrence rate with the synthesis technique versus the traditional open-palm technique. ^{[129, 130, 131]}

Postoperative Care

Routine postoperative care is essential for an optimal outcome. Immediately following the procedure, a splint should be applied dorsally to avoid excess pressure on the incision site. The hand should be placed in extension with flexion of the MCPs and extension of the PIPs. Initially, the splint is worn continuously, with removal only for dressing changes and exercise. ^[132] Patients who undergo PIP surgery should wear the brace for 6 weeks on a continual basis and may require 3 months of bracing to minimize scar contractures.

The overall goal of splinting is to provide a prolonged stretch to the tissues and prevent flexion contractures. Splinting is modified over the next 8-10 weeks to accommodate range of motion, with the splint worn primarily at night. However, studies investigating orthoses after surgery have not been high quality and are vulnerable to various sources of bias. Further, orthosis use is associated with potential adverse effects such as pain, slower return of function, joint stiffness and edema. A systematic review by Samargandi et al of night orthosis after surgery, which examined 3 randomized control trials and 4 observational trials, did not find a significant difference in total active extension or Disabilities of the Arm, Shoulder, and Hand (DASH) scores regardless of whether night orthotics were used or not. Nonrandomized studies showed contrasting results; ^[133] thus, further research is needed to clarify the utility of post-surgical splinting.

A specific exercise regimen with an occupational therapist should be instituted with range-of-motion exercises 1 week postoperatively. A rehabilitation program is critical for successful management of these patients; it helps to reduce swelling, improve wound healing, and restore finger mobility and function. ^[134]

Rehabilitation following surgery is a gradual process of increasing activity and decreasing splinting to achieve increased range of motion. According to one study, therapy that avoids applied mechanical tension in the early postoperative phase results in fewer complications, with no digital motion lost to extension. ^[135]

The occupational therapist regularly records the patient’s degree of extension to assist in monitoring the patient’s progress. Maximal results are evident 6 weeks postoperatively. Return to normal activity is expected in 2-3 months.