Rev. bras. ortop. vol.49 número1

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

Original

Article

Evaluation

of

surgical

treatment

of

Dupuytren’s

disease

by

modified

open

palm

technique

夽

,

夽夽

Thiago

Almeida

Guilhen

∗

_,

_Ana

_Beatriz

_Macedo

_Vieira,

_Marcelo

_Claudiano

_de

_Castro,

Helton

Hiroshi

Hirata,

Itibagi

Rocha

Machado

InstitutoJundiaiensedeOrtopediaeTraumatologia,Jundiaí,SP,Brazil

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t

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e

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n

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o

Articlehistory:

Received11March2013 Accepted20May2013

Keywords:

Dupuytrencontracture Hand

Surgicalproceduresoperative

a

b

s

t

r

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c

t

Objective:toassessthesurgicaltechniqueusingthemodifiedpalmopentechniqueforthe treatmentofseverecontractionsofDupuytren’sdisease.

Methods:overaperiodoffouryears,16patientsunderwentsurgicaltreatment,andinits entiretybelongedtostagesIIIandIVoftheclassificationproposedbyTubianaetal.We per-formedmeasurementsoftheextensiondeficitofthemetacarpophalangealjoints,proximal anddistalinterphalangealinpreoperative,postoperative(3months)andlatepostoperative period(5–8years).Anglesgreaterthan30◦_{metacarpophalangeal}_joints_and₁₅◦_proximal

interphalangealtheresultswereconsideredsurgicalrecurrence.

Results:therewasobtainedanaverageof6.3◦_at_the_{metacarpophalangeal}_joint,_13.8◦_in_the

proximalinterphalangealanddistalinterphalangealat1.9◦_.

Conclusion: themodifiedopenpalmtechniqueisaneffectivemethodinthesurgical treat-mentofseverecontracturesinDupuytren’sdisease.

Avaliac¸ão

do

tratamento

cirúrgico

da

doenc¸a

de

Dupuytren

pela

técnica

da

palma

aberta

modificada

Palavras-chave:

ContraturadeDupuytren Mãos

Procedimentoscirúrgicos operatórios

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e

s

u

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o

Objetivo:avaliarotratamentocirúrgicocomousodatécnicadapalmaabertamodificada paraotratamentodascontraturasgravesdadoenc¸adeDupuytren.

Métodos:emquatroanos,foramsubmetidosaotratamentocirúrgico16pacientes,que per-tenciamaosestágiosIIIeIVdaclassificaçãopropostaporTubianaetal.Foramfeitasaferições dodéficitdeextensãodasarticulaçõesmetacarpofalangeanaseinferfalangeanaproximale distalnosperíodospré-operatório,pós-operatório(trêsmeses)epós-operatóriotardio(cinco aoitoanos).Angulaçõesmaioresdoque30◦_nas_{articulações}_{metacarpofalangeanas}_e₁₅◦

nasinterfalangeanasproximaisforamconsideradascomorecidivacirúrgica.

夽

Pleasecitethisarticleas:GuilhenTA,VieiraABM,deCastroMC,HirataHH,MachadoIR.Avaliac¸ãodotratamentocirúrgicodadoenc¸a deDupuytrenpelatécnicadapalmaabertamodificada.RevBrasOrtop.2014;49:31–36.

夽夽

StudyconductedatInstitutoJundiaiensedeOrtopediaeTraumatologia,Jundiaí,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:tguilhen@hotmail.com(T.A.Guilhen).

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Resultados: obtivemosumamédiadedéficitdeextensãode6,3◦ _ao_nível_da_{articulac¸ão}

metacarpofalangeana,13,8◦_na_{interfalangeana}_proximal_e_1,9◦_na_{interfalangeana}_distal.

Conclusão:atécnicadapalmaabertamodificadaéummétodoeficaznotratamentocirúrgico dascontraturasgravesnadoenc¸adeDupuytren.

Introduction

Dupuytren’s disease was named after Baron Guillaume Dupuytren,1 _a _celebrated _French _surgeon, _whose _complete

monographguidedthecurrentknowledgeofthispathology.In 1831,Dupuytrendescribedthediseaseasan anatomopatho-logicalchange,withthickeningandretractionofthepalmar fasciawithflexiondeformityofthefingers.Thismonograph associatedthediseasetolocalchronictraumaonthepalm, usuallyrelatedtoheavyduty.ButDupuytrencautionedthat notallcasescouldbeexplainedthisway.

Theconditionisduetometaplasiaofthepalmarfascia fibrous framework, which basically compromise the pre-tendinousband,superficialtransverseligament,spiralband, natatoryligament,lateralsagittalligament,andGrayson’s lig-ament.

TheDupuytren’scontracturefollowsaprogressive evolu-tion,anditsinitialmanifestationsareaninvaginationofthe skinandtheappearanceofnodulesthatuniteamongthem, forminghardconsistencycordsinthe palmandadvancing longitudinallytothefinger.Theconditionisusuallypainless, andafteritsmaturationmaysufferretractions,whichcausea flexiondeformityofthemetacarpophalangeal(MCP)and prox-imalinterphalangeal(PIP)joints.Theconditionaffectsmore menthanwomen(rangingfrom7:1to10:1),fromthefourth tosixth decadeoflife;and the fourthand fifthfingersare themostcommonlyaffected.Additionally,theremaybean associationwiththeformationoffibrousstrandsinthe plan-tarfascia(Lederhose’s disease,5%) andinthepenilefascia (Peyronie’sdisease,3%).2

Itsetiologyisstillunknown,buttheimportanceofheredity was proved,because ofthe high incidence inthe descen-dents of northern Europe. The condition is even known as “disease of the Vikings”. Its inheritance is autosomal dominant with reduced penetrance in women. There is a significant associationwithepilepsy, diabetes,trauma, and alcohol intake, and no evidence that it is an occupational disease.2–4

The anatomopathologic aspect is that of an aggressive lesion,displaying alargenumberofcellsandmitoses. The basiccellpresentisthemyofibroblast(similartofibroblast), usuallyfoundinthepalmarfascia,butwithsignificantability togeneratecontractileforces.Thetransforminggrowthfactor

␤(TGF-␤)isanabundantcytokinepresentinthetissue,being largely responsible for the proliferation and differentiation offibroblastsintomyofibroblasts.Moreover,itimprovesthe contractilebehaviorofmyofibroblastsandcausesrapidand strongercontractionsinresponsetomechanicalstimuli.2,5

Otherfactorsinfluencingthedifferentiation,growth,and contractility ofmyofibroblasts includeplatelet-derived pro-tein, fibroblastgrowth factor,epidermal growth factor,and

interleukin-1, as well as cells that synthesize the proteins periostinandtenascin.5

Thediagnosisisclinical,beingestablishedbyinspection andpalpation.Thedifferentialdiagnosisincludes acampto-dactilia,rheumatoidarthritis,retractionofthescarcausedby burnorinjury,palmarcallusofeffort,andulnarnervedeficit.5

Comparedtoconservativetreatment,themostpromising therapyistheapplicationofintrafocalclostridiumcollagenase inthecord,nowinanadvancedclinicaltrialphase.5

Nowadays,thesurgicaloptionisthemostacceptable.In the developmentofthetherapeuticplan,it isimportantto determinethestageatwhichthediseaseis,asthis knowl-edgeinfluencestheintraoperativetechnicaldifficultyandin the post-operativecomplications,aswell astherecurrence ofthedisease.Theneedformoreextensivedissection,the devitalizedskinandtheexcessivetensiononthesutureare predisposingfactorsforpost-operativecomplications,suchas hematomata,skinnecrosis,infectionandpain.5,6

The original surgical treatment was the removalof the contractedfascia;sincethen,varioustechniquesand modi-ficationshavebeendescribed:fasciotomy,dermofasciotomy withskingraft,regionalfasciotomy,radicalfasciotomy,open palmtechnique,partialfasciotomywithpreservationofthe skin,limitedfasciotomy,segmentalaponeurectomy,and per-cutaneousfasciotomy.1,4,6–10

In the open palm technique, originally described by Dupuytren1 _and _popularized _by _McCash,7 _a _regional

fas-ciotomy in the palm of the hand is done, allowing the extensionofthefingers.Thisprocedureresultsinalargeskin defect.Thewoundisleftopentohealbysecondaryintention, toavoidstressand hematomaiformation;this reducesthe incidenceofnecrosisandthepossibilityofinfectionandscar adhesions.6

Objective

Theobjectiveofthisstudyistoevaluatetheresultsofsurgical treatmentofpatientswithDupuytren’sdiseasegradesIIIand IVoperatedinourdepartmentwiththeuseoftheopenpalm technique(McCash)modifiedwiththeassociationof proxi-malanddistallongitudinalincisionalextensionsonthepalm, besidesBrunnerincisionsinthefingers.11

Materials

and

methods

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Table1–Preoperatory,post-operatory(threemonths)andlatepost-operatory(5–8years)angulation.

Preoperatory Post-operatory Latepost-operatory

MCP PIP DIP MCP PIP DIP MCP PIP DIP

Patient1 45 35 20 05 00 00 15 20 00

Patient2 50 30 20 05 05 00 05 20 00

Patient3 40 30 15 00 00 00 00 10 00

Patient4 50 40 20 00 05 05 10 30 05

Patient5 45 30 15 05 10 00 25 20 00

Patient6 40 30 20 00 05 00 00 05 00

Patient7 50 35 10 00 05 00 00 05 00

Patient8 45 30 10 05 00 00 05 05 05

Patient9 50 35 20 05 00 00 05 10 05

Patient10 45 30 20 00 00 00 00 10 00

Patient11 50 40 10 00 00 00 15 20 00

Patient12 40 30 20 00 00 00 00 10 00

Patient13 45 35 20 05 00 05 05 10 05

Patient14 55 40 25 00 00 05 10 20 05

Patient15 50 45 25 00 05 05 05 15 05

Patient16 45 30 25 00 00 00 00 10 00

MCP,metacarpophalangeal;PIP,proximalinterphalangeal;DIP,distalinterphalangeal.

unilateral,withinvolvementofthefourthandfifthfingers. ThirteenpatientsweremaleCaucasians,includingthethree women.

Inourstudy,weusedtheclassificationproposedbyTubiana etal.,12 _which_consists_of_the _sum_of_the_extension_deficits

ofthemetacarpophalangeal(MCP),proximalinterphalangeal (PIP),anddistalinterphalangeal(DIP)joints,measuredwith agoniometer.Thisclassificationisdividedintofourstages: gradeI(0–45◦_),_grade_II_(46–90◦_),_grade_III_(91–135◦_),_and_grade_IV

(>135◦_)._In_this_study,_were_included_only_patients_with_Grades

IIIandIV,anditwastakenintoaccountonlythefingerwith greaterinvolvement.11,12

Inallpatients,thesurgicaltechniqueusedwasthat rec-ommendedbyMcCash,withtransverseincisioninthedistal palmarcrease,associatedwithamodificationwithproximal anddistallongitudinalincisionalextensionsonthepalm.In thefingers,Brunnerincisionsweremade.Wemadeapartial fasciotomy,whichleftopenonlythetransverseincision.4

Post-operativecareconsistedofdailydressingchanges dur-ingthefirst48h,dailychangesinthenext twoweeks,and everythreedaysinsubsequentweeks.Thefingerswere immo-bilizedinextensionforthefirstfivedaysandthepatientwas referredforearlychirotherapyrehabilitation.

Theextensiondeficits forMCP, PIP, and DIPjoints were gaugedinpreoperative,post-operative(threemonths)andlate post-operativeperiods(5–8years).Extensiondeficits exceed-ing30◦_in_MCP,₁₅◦_in_PIP,_and₁₀◦_in_DIP_joints_were_considered

assurgicalrecurrences.11,12

Results

Table1lists the measurementsofthe extensiondeficit, in

degrees,ofthethreejoints(MCP,PIP,andDIP)obtainedwitha goniometer.

Fig.1displaystheresultsofmeasurementsoftheextension deficitsineachjointinthepre-,post-,andlatepost-operative period.

Tocompare the angleofthe MCP,PIP, andDIP jointsof patients withrespectto preoperative,post-operative(three months)andlatepost-operativeperiod(5–8years),weapplied the non-parametric statistical test of Mann–Whitney for pairedsamples,andthepvalueswerecorrectedbyBonferroni methodformultiplecomparisons.Table2showstheresults ofthetests.

Forthethreejoints,astatisticallysignificantdecreasewas observedfortheaverageangleofthepre-topost-operative period,atthelevelof5%(p<0.05).FortheMCPandDIPjoints, no significantdifference betweenthepost-operativeperiod (threemonths)andlatepost-operativeperiod(5–8years)was noted.However,forthePIPjointasignificantmeanincrease betweenthe post-operativeand latepost-operativeperiods vas noted (p=0.0025), but still ata lower value than that observedpreoperatively.

Fig. 2displays the scatter plotand the Spearman’s cor-relation coefficient among the joints for the angulations measured.Astrongpositivecorrelationamongmeasuresof differentjoints,withcoefficientsbetween0.75and0.85 (all statisticallysignificant,p>0.0001)wasnoted.

Table2–ResultsoftheMann–Whitneytestfor comparisonofmeasurementsofthejointsbetween periods.

Comparisons pa

MCP-FL PIP DIP

Pre×post 0.0012 0.0013 0.0012

Pre-×post-late 0.0012 0.0013 0.0012

Post-×post-late 0.1020 0.0025 1.0000

PIP,proximalinterphalangeal;DIP,distalinterphalangeal.

pvalueslessthan0.05indicatesignificantdifferenceatthe5%level. a _p_values_corrected_by_the_Bonferroni_method_for_multiple

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PIP MCP-FL

DIP Period Preoperative

50

40

30

20

10

0 40

30

20

10

0

Post-operative Late post-operative

Periodo

Preoperative Post-operative Late post-operative

Period

Preoperative Post-operative Late post-operative Mean value

Mean value

Grades

Fig.1–Boxesforthejointangulation,accordingtothejointandbyperiod.Inthisfiguretheresultsofmeasurementsofthe extensiondeficitsineachjointinthepreoperative,post-operative,andlatepost-operativeperiodaredepicted.

Spearman correlation =0,8586

40

25

20

15

10

5

0

25

20

15

10

5

0

10 20 30 40 50 0 10 20 30 40 50 0 10 20 30 40

30

20

10

0

MCP-FL

MCP-FL DIP

PIP DIP DIP

Spearman correlation =0,7844 Spearman correlation =0,7558

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Table3–Valuesofminimum,median,mean,maximumandstandarddeviation(SD)fortheangulationofthejoints, accordingtojointandperiod.

Joint Period Minimum Median Mean Maximum SD

MCP Preoperatory 40.0 45.0 46.6 55.0 4.4

Post-operatory 0.0 0.0 1.9 5.0 2.5

Latepost-operatory 0.0 5.0 6.3 25.0 7.2

PIP Preoperatory 30.0 32.5 34.1 45.0 4.9

Post-operatory 0.0 0.0 2.2 10.0 3.1

DIP Preoperatory 10.0 20.0 18.4 25.0 5.1

Post-operatory 0.0 0.0 1.3 5.0 2.2

MCP,metacarpophalangeal,PIP,proximalinterphalangeal,DIP,distalinterphalangeal.

Thistablepresentsdescriptivemeasuresofdeficits.Clearlyoccursadecreaseintheangleofthejointsinallpatientsaftersurgery.

Discussion

Theliteratureiscontroversialastotheadvantagesand dis-advantagesofthe openpalm technique,whichdetermines moreskinstretching,besidespreventingcomplicationssuch ashematoma,necrosis,skinischemia,tensionand pain. A disadvantagewouldbeanincreasedriskofinfectionandthe patient discomfort byhaving an “open” injury and by the necessityofmore frequentdressings. Lubahn et al.13

con-ductedacomparativestudybetweenthetwotechniquesand concludedthatpatientsoperatedbytechniquesinwhichthe palmwascompletelyclosedcametosuffergreaterresidual contracture.8,13,14

Inthepresentstudy,13(81.25%)malesandthree(18.75%) females were recruited, all Caucasians, which is consis-tent with the literature, which reports 80% of male and dominance of Caucasians. In this study, the mean age of patientswas65years(range,54–75),similartothatofmost studies.15,16

Inourstudywefound37.5%ofsurgicalrecurrence.These ratesvarywidely(28–50%),regardlessofthetechniqueused. However,toobtaingoodresultsthepatientmusthavean ade-quate post-operativecare,and anstimulus forearly active mobilizationafterremovalofimmobilization,under orienta-tionofachiropractor.McGroutherismostemphaticthat,ina long-termpost-operativeperiod,therecurrenceratereaches 100%forsomedegreeofcontracture.Thisfactoccursbecause thereisaresidualpathologicalfascia,orwhatiscalledthe extentofthedisease,inwhichthereistheformationofnew fasciainaplacenearthesurgicalsite.12,17,18

RecurrenceinMCPjoint isvery low.Ontheother hand, inPIPjointtheincidenceofrecurrenceishigher.Ourstudy describedsixcasesofsurgicalrecurrence,allinthePIPjoint, becauseofanangulation>15◦_in_the_late_{postoperative}_period

(5–8years),whichagreeswiththeliterature.9,19

Concerning MCP and DIP joints, no significant differ-encesintheangulations betweenthepost-operativeperiod (three months) and late post-operative period (5–8 years) wereobserved.However,forthePIPjointtherewasa signifi-cantmeanincreaseinangulationbetweenthepost-operative (mean,2.2◦₎ _and _late _{post-operative} _(mean, _13.8◦₎ _periods,

whichshowsahigherrateofrecurrenceinthePIPjoint–also observedinotherworks.9,19

Anextensiondeficit decreaseforallpatients inthetwo postoperative periodscompared tothe preoperativeperiod was observed, which is shown in the boxes (Fig. 1). This demonstratestheeffectivenessoftheopenpalmtechnique (modified),providedthereisanappropriatetherapeuticplan, whichisconsistentwiththeliterature.5,6

Incomparingthethreejointsinthethreeperiods(Table3), onlythePIPjointshowedsignificantmeanincreasebetween the post-operative and late post-operative periods, which demonstrateahigherrecurrence inPIP,alsoevidentinthe literature.9,19

Conclusion

The modified McCash technique is an effective option for severecases(stagesIIIandIV)ofDupuytren’sdisease.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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