Rev. bras. ortop. vol.48 número6

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w w w . r b o . o r g . b r

Original

article

Dupuytren

contracture:

comparative

study

between

partial

fasciectomy

and

percutaneous

fasciectomy

夽

Samuel

Ribak

a,b,∗

,

Ronaldo

Borkowski

Jr.

a

,

Rodrigo

Pereira

do

Amaral

b

,

Alfred

Massato

b

_,

_Ilíada

_Ávila

a

_,

_Dirceu

_de

_Andrade

a

a_Orthopedics_Service,_Hospital_Nossa_Senhora_do_Pari,_São_Paulo,_SP,_Brazil

b_Hand_Surgery_Service,_Pontifícia_Universidade_Católica_de_Campinas,_Campinas,_SP,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received2May2013 Accepted1August2013

Keywords:

Dupuytrencontracture Surgicalprocedures,operative Comparativestudy

a

b

s

t

r

a

c

t

Objectives: Tocomparetheclinicalresultsobtainedbyusingthetechniquesofopenlimited fasciectomy(FP)andpercutaneousneedlefasciectomy(FPC)inpatientswithDupuytren’s contractureafteroneyearfollowup.

Methods:Thirty-threepatientsandatotalof50fingerswithDupuytren’scontracturewere divided non-randomlyand evaluated afterundergoingprocedures withFPor FPC. The resultswereevaluatedbasedontheTubianaclassification,DASHscore(Disabilitiesofthe Arm,Shoulder,andHand),timeuntilreturntoprofessionalactivities,totalpassive exten-siondeficit(DTEP),therelationshipbetweentheextensiondeficitandDASH,recurrenceand complications.

Results:Twenty-sixfingersweretreatedwithFPCtechniqueand24fingerswithFP.The DTEPwassignificantlylower inFPgroup(10.23◦₎_when_compared_to_FPC_group_(23.46◦₎ at12monthspostoperatively(p=0.038).Theremainingitemsassesseddidnotshowany statisticallysignificantdifferences.

Conclusion: Totalpassiveextensiondeficitat12monthsislowerinthegroupofopenlimited fasciectomy.TherearenosignificantdifferencesbetweengroupsFPandFPCoverthe clas-sificationofTubiana,theDASHscore,timeuntilreturntoprofessionalactivitiesandthe incidenceofrecurrence.

Contratura

de

Dupuytren:

estudo

comparativo

entre

fasciectomia

parcial

e

fasciotomia

percutânea

Palavraschave:

ContraturadeDupuytren Procedimentoscirúrgicos

r

e

s

u

m

o

Objetivos:Compararosresultadosclínicosdastécnicasdefasciectomiaparcial(FP)e fas-ciotomia percutânea(FPC) empacientesacometidospelacontraturadeDupuytrencom seguimentodeumano.

夽

Pleasecitethisarticleas: RibakS,etal.ContraturadeDupuytren:estudo comparativoentrefasciectomiaparciale fasciotomia percutânea.RevBrasOrtop.2013;48:545–553.

∗ _{Corresponding}_author_.

E-mail:[email protected](S.Ribak).

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operatórios Estudocomparativo

Métodos: Trintaetrêspacientese50dedoscomacontraturadeDupuytrenforamdivididos deformanãorandomizadaeavaliadosapósseremsubmetidosàFPouàFPC.Asavaliações incluíramaclassificaçãodeTubiana,oescorefuncionalDASH(DisabilitiesoftheArm, Shoul-der,andHand),otempoderetornoàsatividadesprofissionais,odéficittotaldeextensão passiva(DTEP),arelaçãoentreoDTEPeoescoreDASH,arecidivaeascomplicações.

Resultados: Nototal,26dedosforamtratadospelatécnicadeFPCe24peladeFP.ODTEP apresentou-sesignificativamentemenornogrupodaFP(10,23◦₎_em_relac¸ão_ao_grupo_da_FPC (23,46◦_),_aos₁₂_meses₍_p₌_0,038)._Os_demais_itens_avaliados_não_apresentaram_diferenc¸as estatisticamentesignificativas.

Conclusão: Odéficittotal deextensãopassiva,aos12 meses,émenor nogrupoda FP. Nãoexistemdiferenc¸assignificativasentreosgruposFPeFPCquantoàclassificac¸ãode Tubiana,aoescoreDASH,aotempoderetornoàsatividadesprofissionaiseàincidênciade recidiva.

Introduction

Dupuytren’scontractureisabenignfibromatosisthataffects the palmar and digital fasciae, with formation of nodules and cords. Itmay progressto contractureof the interdigi-talspacesandflexiondeformityofthemetacarpophalangeal (MCP),proximalinterphalangeal(PIP)and,morerarely,distal interphalangeal(DIP)joints.1,2

Surgeryisindicatedinthepresenceofcontracturesofthe MCPjointgreaterthan30◦_,_any_degree_of_contracture_of_the_PIP

orDIPjointsandalsointhepresenceofpainfulnodules.1,2

Onealternativetosurgical treatmentisinjectionof col-lagenase,anenzymederivedfromthebacteriumClostridium histolyticum.Inothercases,thetreatmentconsistsof observa-tionofthedegreeofprogressionofthediseaseuntilthereisa needforintervention.1,2

Thefollowingtechniqueshavebeendescribedforsurgical treatmentofDupuytren’scontracture:totalfasciectomy(TF), partialfasciectomy(PF),dermofasciectomy(DF)and percuta-neousfasciectomy(PCF).

TF3_consists_of_complete_excision_of_the_palmar_and_digital

fasciaeandisaproscribedtreatmentbecauseofthehigh inci-denceofcomplications(skinnecrosis)and,notwithstanding this,withoutdiminishingtherecurrencerates.2

PF, which was described by McGrouther,2 _consists _of

resectiononlyofthepalmaranddigitalfasciaethathavebeen affected.2,4

InDF,inadditiontothefascia,thethinadherentoverlying skinthatdoesnothavesubcutaneouscellulartissueisalso removed.Thedefectiscoveredusingatotalskingraftwhen necessary.DFisindicatedmoreforcasesofgreaterseverityin youngerpatients.5,6

PCFwasdescribedbyAstley-Cooperin1822andwas rein-troducedinthe1970s.Itconsistsofsectioningthecordsusing aneedle,withoutanyformalincisionintheskin.2,7–9

ThesurgicaltechniqueindicatedfortreatingDupuytren’s contracturedepends on the experience and preferencesof eachsurgeon,sincethereareadvantagesanddisadvantages foreachofthem.Amongthetechniques,twoofthemstand outbecauseoftheirfrequencyofuse:PFandPCF.

PFmakesitpossibletoviewthetissuesaffectedandthe neurovascularbundles,andalsotoperformcapsulotomyin

casesofjointcontracture.PFpresentsmoreextensive dissec-tion,greaterdurationofsurgeryandrisksofinfectionandskin necrosis.3,10,11

PCFhastheadvantageofbeingfasterandlessinvasive,and canevenbedoneasanoutpatientprocedure,usinglocal anes-thesia.However,itpresentsgreaterrecurrencerates.12–15_The

literaturemostlycomprisesstudiesonseriesofcasesofthese techniquesseparately.Theidealwouldbetohavecontrolled studiesinordertocomparethedifferentsurgicaltechniques andtheirbestindications.

The aim of the present study was to conduct a con-trolledandcomparativestudyontheclinicalresultsobtained throughusingthePFandPCFtechniques,inaseriesofcases ofpatientswithDupuytren’scontracture.

Methods

Thepresentstudywassubmittedtoourinstitution’sethics committeeandwasapproved.

Itconsistedofanon-randomizedcontrolledclinicalstudy withtwoparallelgroupsofpatientswithDupuytren’s contrac-ture.

Theinclusioncriteriawere:indicationofsurgicaltreatment inskeletallymaturepatientswho,afterreceivingexplanations aboutthestudy,agreedtoparticipateandsignedafreeand informedconsentstatement.

Patients who had previously undergone some form of surgical treatment for the same pathological condition, or whopresentedotherdiseasesaffectingtheupperlimbunder examinationthatmightprejudicetheresultsfromthe evalu-ations,wereexcluded.

Thefollowingpersonaldetailswerenoteddown:sex, later-ality,sideaffected,typeofactivity(light,moderateorheavy) andfingersaffected.

For each finger affected, the preoperative assessment consisted of measuring the total passive extension deficit (TPED),whichwas thesumofthe extensiondeficitsofthe MCPandinterphalangealjoints.

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Table1–Tubianaclassification.

Grade TPED InvolvementofPIP

I 0–45◦ ₊

II 46–90◦ ₊

III 91–135◦ ₊

IV >135◦ ₊

Source:HospitalNossaSenhoradoPari.

Thepatientsweredividedintotwointerventiongroups(PF andPCF),accordingtoeachsurgeon’spersonalcriteria, inde-pendentoftheseveritytowhichthefingerwasaffected.

Toevaluatethefunctionalresultsfromtheaffectedupper limb,the DASHprotocol wasused.Thiswasappliedinthe sixthpostoperativemonth.Afinalscoreofzerorepresented absence offunctional incapacity and ascore of100 repre-sentedcompleteincapacity.16

Thelengthoffollow-upforallthepatientswas12months.

Surgicaltechnique

Partialfasciectomy

Allthepatientsunderwentthisprocedureinasurgical envi-ronment,underanesthesiaconsistingofbrachialplexusblock. Theywerepositionedinhorizontaldorsaldecubituswiththe upperlimbinasupineposition,underexsanguination(Fig.1). Onthepalmofthehand,aBrunerincisionorzetaplasty longitudinallytothecordwasused,andthiswasextendedto thefingerswhennecessary(Fig.2).Aftermobilizationofthe skinflaps,allthepathologicalcordswereidentifiedwiththe aidofmagnification(Fig.3).

Carewastakentopreservetheneurovascularbundlesand flexortendonsforsubsequentexcisionofthecordandrelease ofallofthecontractureofthefinger(Figs.4and5).

In casesin which contractureof the PIP joint was also present,capsulotomywasperformedthroughthesame inci-sion.

Aftertheprocedure,asteriledressingandavolar plaster-castsplintwereapplied,withthefingerskeptextended.

Percutaneousfasciectomy

PCFwasalsoperformedinasurgicalenvironment,butunder localanesthesiausing2%lidocaine.

Figure1–Preoperativeappearancewithcontractureofthe MCPoftheringfingerandtheMCPandPIPofthelittle finger.

Figure2–PlanningforBrunerincisionextendingtothe ringandlittlefingers.

Figure3–Identificationofthecords(blackarrows)withthe neurovascularbundlesdisplayed(redarrows).

Figure4–Elevationofthecord(blackarrow),showingthe proximityoftheneurovascularbundle(redarrow)and flexortendons(*).

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Figure6–Preoperativeappearanceshowingcontractureof theMCPoftheringfinger.

Allthecordsresponsibleforthecontracturewerepalpated andsectionedatvariouslevels,inthepalmofthehandand inthefingers,whenpresent.

Sectioningofthecordswasdone byintroducinga non-mounted 40×12 needle, with oscillatory movements in a directionperpendiculartothecords.Throughoutthe proce-dure,carewastakentosubjectthefingertogentleextension force,soastobetteridentifythecordthatwastobesectioned, andtoavoidneedlepenetrationintoaninappropriatelocation andpreventvesselandnerveinjuries.

Carewasalsotakennottomakeanincisionbeyondthe depthofthebezelitself,soastoavoidinjurytothetendons.

Ateachsectioningofthecord,treatedproximallyto dis-tally,progressiveextensionofallthejointswasachieved.The cordwassectionedasmanytimesasnecessary.

Incasesinwhichsmallresidualareasremainedafter max-imumextensionofthefingershadbeenachieved,theseareas wereleftopenforsecond-intentionhealing.

Theprocedurewasconsideredtohavefinishedwhenitwas nolongerpossibletopalpateanytensionalongthepathofthe cord(Figs.6and7).

Afterapplyingasteriledressing,thehand was immobi-lizedusingavolarplaster-cast splint,withthe fingerskept extended.

Figure7–Extensionofthefingerobtainedbymeansofthe PCFtechnique.Theyellowarrowshowsthedirectionofthe oscillatorymovementsoftheneedleforsectioningthecord atseverallevels.

Figure8–UseofbracewithextensionoftheMCPand interphalangealjoints,inordertomaintainthecorrection achieved.

Postoperativeperiod

In bothtechniques,the firstchange ofdressingswas done afterfivedays.Allthepatientsusedastaticbracethatwas constructedbyahandtherapist,withextensionoftheMCP andinterphalangealjoints(Fig.8).

Useofthebracewasstartedaftertheoperativewoundshad healedandwasmaintainedforfourmonths.Itwasremoved afewtimesperdayforactiveexercisestobeperformed,soas toavoidcontractures.Afterthisperiod,thebracewasusedat nightforanotherfourmonths.

Evaluationcriteria

Evaluations weremadeinthefirst,third,sixthand twelfth monthsaftertheoperation.

Inthepatientswithmorethanonefingeraffected,each fingerwasconsideredseparatelyforthepurposesofstatistical calculations.Asingletherapistperformedalltheevaluations, basedonthefollowingcriteria:

• ClassificationofthecontracturesasdescribedbyTubiana.

• DASHfunctionalquestionnaire.

• Timetakentoreturntoprofessionalactivities.

• Totalpassiveextensiondeficit(TPED).

• Recurrenceofthepathologicalcondition–definedasloss ofthecorrectionachievedthatwasgreaterthan20◦_.17

• CorrelationofTPEDwiththeDASHscore.

• Correlationofthetypes(+)oftheTubianaclassificationwith recurrences.

Dataanalysis

Datafromtheclinicaltrialweregatheredonastandardized formandweretransferredtoaspreadsheetintheMicrosoft Office2010software.

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Table2–DistributionofpreoperativedataonthePFandPCFgroupsinrelationtothenumberofpatients,numberof fingersoperated,sex,activity,laterality(R,right;L,left),sideaffectedandfingersaffected(II,index;III,middle;IV,ring; V,little).

PF PCF pvalue

Numberofpatients 17 16

Numberoffingers 24 26

Malesex(%) 94% 88%

Activity(light/moderate/heavy) 8/3/13 9/10/7 0.062

Laterality(R/L) 24/0 25/1 1

Sideaffected(R/L/bilateral) 12/8/4 5/18/3 0.033 Fingersaffected(II/III/IV/V) 1/1/10/12 2/6/9/9 0.230

Thedatawereanalyzedthroughcomparisonsbetweenthe PFandPCFgroups.

Continuous data were subjected to the Kolmogorov–Smirnovtestofnormalityofdistribution.

Thedatathatpresentednormaldistributionwereanalyzed bymeansofStudent’sttestand,whenthiswasnotpossible, thenonparametricMann–WhitneyUtestforcomparisonof independentpairswasused.

Forthecategoricaldata,thechi-squaretestwasusedto investigatethedifferencesintheproportionsofoccurrenceof theeventstudied.

Somesubanalysespresentedsmallsamplesandwere sub-jectedtotheFishertest.

pvalues<0.05wereacceptedastypeIerrors.SPSS20.0for Windowswasthesoftwareusedfortheanalyses.

Results

Thestudypopulation wascomposed of33 patientsand 50 fingerswereanalyzed.

Malesexpredominated(94%inthePFgroupand88%inthe PCFgroup)andtheulnarfingerswereaffectedmoreoften.

ThePCFtechniquewasusedtotreat26fingers,and15of thempresentedcontractureofthePIPjoint(+).

INthePFgroup,therewere24fingers,ofwhich21werePIP (+).

Theonlysignificantdifferencebetweenthetwogroupswas thattherightsidewaspredominantlyaffectedinthePFgroup andtheleftsideinthePCFgroup(Table2).

RegardingthedistributionaccordingtotheTubiana clas-sification,thepatientsinthePFgrouppresentedsignificant improvementsincontracture.

Overthe12 monthsoftheevaluation,itwasnotedthat gradesIV,IIIandIIconvergedtogradeI(23fingersofgradeI andonlyoneofgradeII[Fig.9]).

InthePCFgroup,therewasamoresignificantimprovement incontractureofthefingers,and88%ofthefingersreached gradeI(23)inthefirstpostoperativemonth.

Aftersixmonths,96%ofthefingershadreachedgradeI (25),withsubsequentworseningto85%(22fingers)after12 months.

No fingers of grades III and IV were observed after 12 months(Fig.10).

25

20

15

10

5

0 4

7 11

15

18

21

23

3

1 0 0 0 0

4

0 0 6

1 0 2

Before 1 month 3 months 6 months 12 months

Grade I Grade II Grade III Grade IV

Figure9–DistributionofthenumberoffingersinthePF group,accordingtotheTubianaclassificationbeforethe operationandone,three,sixandtwelvemonthsafterthe operation.

25

20

15

10

5

0 5

11

23 23

25

22

1

4

0 0 0 0

3

0 0 3

0 0 4

6

Grade I Grade II Grade III Grade IV

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Table3–NumberofpatientswithcontractureofthePIPoverthecourseofthestudyinthePFandPCFgroups.

Beforeoperation 1month 3months 6months 12months

PF 21 16 13 13 10

PCF 15 10 11 9 10

pvalue 0.529 0.709 0721 1 0.320

Inrelationtothenumberofpatientswhopresented con-tractureofthePIPjoint(+),therewasnosignificantdifference betweenthePFandPCFgroups.

CompletecorrectionofthePIPcontracturewasachievedin 23.8%ofthePFgroupandin33.3%ofthePCFgroupinthefirst monthaftertheoperation.

Afteroneyear,52.4% ofthe (+)patients inthe PFgroup werefreefromcontracturesinthePIPjoints,whilethenumber remainedunalteredinthePCFgroup(Table3).

InrelationtoDASH,thePFgrouppresentedameanscore of21.92,witharangeof20.3.

ThePCFgroup presentedamean of29.12 witharange of20.65,withoutanysignificantdifferencebetweenthetwo group(p=0.102).

INrelationtothetimetakentoreturntoprofessional activ-ities,thePFgroupreturnedafterameantimeof32.92days (±19.8)andthePCFgroupafter38.35dias(±31.3).This differ-encewasnotstatisticallysignificant(p=0.484).

After12months,therewasasignificantimprovementin TPEDinbothgroups,withevolutionfrom91.96◦_to_10.23◦ _in

thePFgroupandfrom87.77◦_to_23.46◦_in_the_PCF_group.The

resultwasstatisticallysuperiorinthePFgroup(Table4and

Fig.11).There wasgreaterrecurrenceofcontracturesinthe PCRgroup(fourgroupsinthreepatients).

InthePFgroup,thereweretwofingersinonepatient, with-outastatisticallysignificantdifference(p>0.05).

Amongthefingerswithrecurrence,onlythreebelongingto thePCFgrouppresentedPIPcontracturebeforetheprocedure. There wasno statistical correlation betweenrecurrence andthepresenceofPIPcontracture.

There was no correlation between TPED and the DASH score(p>0.05).

Inthisstudy,nocomplicationswereconsideredtobesevere (i.e.injuriestonerves,tendonsorvesselsthatwouldrequire subsequentinterventions).

InthePFgroup,therewasonecaseofpartialnecrosisof thebordersoftheoperativeincision.

Inthe PCFgroup, therewasonecaseoftypeIcomplex regionalpainsyndromeandonecaseoftransitory paresthe-siaofthefingers.Thesecaseswereresolvedsatisfactorilywith conservativetreatment.

PF PCF

100

90

80

70

60

50

40

30

20

10

0

Figure11–Totalpassiveextensiondeficit(TPED)in degrees,inthePFandPCFgroupsbeforetheoperationand one,three,sixandtwelvemonthsaftertheoperation.

Discussion

Surgical treatment of Dupuytren’s contracture still lacks preciseindicationsaccordingtothegradeoftheclinical pre-sentationandeachpatient’sindividualneeds.

Comparativestudiesandstudieswithahighlevelof evi-dencearescarceintheliterature.15

Thecaseseriesthathavebeendescribedonlyanalyzedone typeoftechnique12–14,17_and_there_has_not_been_any

standard-izationfortheevaluations.Thesefactorsmakeitdifficultto choosethebesttreatmentoption.

Theepidemiologicaldatacontainedinthesampleofthis studywerehomogenousinthetwogroupsevaluatedandwere equivalenttothedataintheliterature.18–21

Theonlydifference betweenthe groups wasinrelation totheinvolvementofthelefthand,whichwassignificantly greater inthePFgroup,whiletheinvolvementofthe right handwassignificantlygreaterinthePCFgroup.

The PF technique has been described in the liter-ature as effective in relation to initial correction of contractures.2,15,22,23 _One _week _after _performing _PF, _van

Table4–Totalpassiveextensiondeficit(TPED)indegrees,inthePFandPCFgroupsbeforetheoperationandone,three, sixandtwelvemonthsaftertheoperation.

Before(±SD) 1m(±SD) 3m(±SD) 6m(±SD) 12m(±SD)

PF 91.96±42.3 30.32±26.6 21.91±19.9 16.59±18 10.23±14.2 PCF 87.77±44.2 24.23±21.5 24.04±19.8 17.5±16.4 23.46±19.3

pvalue 0.734 0.386 0.713 0.833 0.038

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Rijssenetal.23_obtained_a_correction_of_TPED_of_73%,_and_they

reached15◦_.

StudieshaveshownthatPCFalsoachievesagooddegree ofcorrectioninitially.10,14,17,22_In_a_review_on₁₀₀₀_cases_of_PCF,

Pessetal.17_found_that_almost_total_correction_was_achieved_in

theimmediatepostoperativeperiod,with99%correctionfor theMCPjointand89%forthePIP.

Inarandomizedcomparativestudy,vanRijssenreported PF achieved a significantly greater degree of correction in the immediate postoperative period (73% versus 58% for PCF).Inourcomparativestudy,thetechniqueswereequally effective.

Inrelation to TPED,both techniquesproduced a signif-icant progressive improvementover the months. However, aftercompletionof12monthsoffollow-up,theresultswere significantlybetterwiththePFtechnique.

Progressive improvement after the procedure was also observedbyvanRijssenetal.23

ThehigherTPEDvalueforPCFthanforPFafter12months, asfoundinthepresentstudy,isalsoinagreementwithwhat hasbeen describedinthe literature,inwhichthe percuta-neous technique has presented greater contracture values withlongerfollow-ups.15

Thereisnoconsensusintheliteratureregardingwhat char-acterizesrecurrenceofthedisease.24

Someauthorshaveconsideredthistobethereturnof pal-pablecordsatasitethathadpreviouslybeentreated,while othershaveascribedthistodegreesofworseningofTPED.17,23

Thepresenceofapalpablecordisnotagoodcriterionfor determiningrecurrenceincasesofPCF,sincethecordsarenot excisedandmaybepalpableevenaftertheprocedure.15

Inthepresentstudy,thedefinitionusedwasaworsening ofTPEDby20◦_or_more_in_relation_to_what_was_obtained_one

monthaftertheoperation.Thiswassimilartothecriterion usedbyPessetal.17

Inastudyoverafive-yearperiod,vanRijssenetal.15_used

asimilarcriterion,butwithavalueof30◦_.

Wechosethevalueof20◦_because_this_was_more_sensitive

andmoreappropriateforastudywithafollow-upofonlyone year.

Accordingtothiscriterion,arecurrencerateof8.3%was observedforthePFgroupand15.4%forPCF,after12months. Thisdifferencewasnotsignificant(p>0.05).

AccordingtovanRijssenetal.,15_recurrence_was_seen

ear-lierandmoreincisivelyinthePCFgroup(30.19%inthefirst year),butnorecurrencewasseeninthePFgroupinthefirst year.Inthesamestudy,afterfiveyears,therecurrenceratein thePCFgroupwas84.9%versus20.9%inthePFgroup.15

Althoughweusedrecurrencecriteriathatweremore rigor-ousthanthoseoftheabovementionedstudy,ourrecurrence rateinthePCFgroupwasconsiderablylowerafteroneyear: 15.4%versus30.19%over thefirstyear ofthe studybyvan Rijssenetal.15

Badoisetal.15_found_a_five-year_recurrence_rate_of_50.4%,

whichwasalsoconsiderablylowerthanthe84.9%obtained byvanRijssen,albeitwithcorticosteroiduse.

Inasystematicreview,Chenetal.22 _found_recurrence_of

50–58%forPCFoverathree-tofive-yearperiod.Inthesame review,therecurrencerateforPFwas12–39%overaperiodof 1.5–7.3years.

Some authors havealsodescribed repetitionofthe PCF techniqueafterrecurrenceandhaveobtainedgoodresults.25

WhencontractureofthePIPjointwaspresent,therewas nosignificantdifferenceinthecorrectionobtainedusingthe two techniques. These data demonstrate that despite the impossibilityofperformingcapsulotomyinthepercutaneous technique,itwaspossibletoachievecorrectionofthe contrac-tureofthePIPjointinagoodproportionofthecases.

Wedidnotobservethereturnofcontractureinthisjoint witheitherofthetechniques,overtheperiodevaluated.

ThestudybyPessetetal.,17_with_a_sample_of₁₀₀₀_cases_of

PCF,alsodemonstratedagoodcorrectionrateforcontracture ofthePIPjoint(89%),butwithahighrecurrencerateinthis joint(65%versusonly20%intheMCP).

InthestudybyvanRijssen,thecorrectionobtainedforthe PIPwasnotsoefficient,withameancorrectionofonly40%, onemonthaftertheoperation,andtherecurrencerateforthe PIPwasalsohigh(74%).15

TheusefulnessoftheDASHprotocolforDupuytren’s con-tracturehasbeencontestedbysomeauthors26_and_validated

byothers.27

In the present study, no direct statistical correlation betweenDASHandTPEDwasobserved(p=0.045).

The DASH score was lower in the PCF group after six months(29.12versus21.92forPF),butwithoutstatistical sig-nificance.

Inashortstudylastingsixweeks,vanRijssenetal.23_found

significantlyhigherDASHresultsforPCF.23_This_difference_can

beattributedtoearlierapplicationoftheDASHprotocol(six weeksversussixmonths),giventhatPCFhasanadvantage overthisperiodbecauseitisalessinvasiveprocedure.

Inthisstudy,itwasdecidedtoperformtheDASHprotocol onlyaftersixmonths,becauseitisdifficulttoapplyanditsuse inallevaluationswouldbeunviableinthehospitalservicein question.

Thus, itwas consideredtobesufficientfordetermining thefunctionalresult,sincetherehabilitationhadalreadybeen concludedinallcases.

Differentlengthsoftimeoffworkhavebeenshowninthe literatureforthePFandPCFtechniques.5,23,28

Althoughtherewasnostatisticallysignificantdifference, therewasagreatermeanlengthoftimeoffworkinthePCF group(38.35daysversus32.92forPF).

Afasterreturntoprofessionalactivitieswouldbeexpected amongpatientsundergoingPCFbecausethisisaless inva-siveprocedurewithfasterhealing.29_The_short_time_and_low

samplingmayhaveinfluencedthis.

Notendonorneurovascularinjurieswerefoundinusing either of the techniques. The most serious complication occurredinthePCFgroup,consistingofacaseoftypeI com-plexregionalpainsyndrome.

ThePFgrouppresentedonlyonecaseofnecrosisofthe incisionborders,andthisdidnotrequireanewsurgical pro-cedure.

Skin tears after percutaneous release were common. However,becauseoftheirrapidresolution,theywerenot con-sideredtobecomplications.

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Althoughnot evaluatedin this study,it isimportant to emphasize that PCF is a considerably less expensive and notablyfasterprocedure,andhastheadvantagethatitcan bedoneinanoutpatientsetting,underlocalanesthesia.

Overthe 12-monthperiod, weobservedthat both tech-niquespresentedagooddegreeofcorrectionofthedeformity, withfewcomplications.

BothtechniquesareadequatetreatmentsforDupuytren’s contracture,althoughPFpresentedbetterTPEDattheendof theevaluationperiod.

Dependingoneachpatient’sneedsand preferences,and thoseofthesurgeon,aparticulartechniquecanbeindicated. Forpatientswhorequirealessinvasivetechniqueanddo notdemandamorelong-lastingtechnique,PCFisaprocedure withlowercostthatisfasterandeasytoperform.Ontheother hand,forpatientswhorequirealongertimefreefrom contrac-turesandwhodonotwishtoundergomultipleprocedures,PF isabetterindication.

Longer-term studies with larger samples are needed in ordertodeterminetheincidenceandrecurrencetimemore precisely,andtodeterminetheneedfornewprocedures.In thismanner,itwillbepossibletobetterdefinetheindications foreachtechnique.

Conclusion

The PF and PCF techniques are effective for treating Dupuytren’scontracture.

Twelvemonthsaftertheoperation,thetotalpassive exten-siondeficitinthegrouptreatedwithPFwassignificantlylower, andtherewerenosignificantdifferencesbetweenthe tech-niquesregardingthefunctionalresults,timetakentoreturn toprofessionalactivitiesandrecurrenceofthepathological condition,inrelationtotheparametersofthisstudy.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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