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Dupuytren’s Contracture: Subtotal Palmar Fascietomy

 



                                                                     Case Example by James R. Urbaniak MD.
- Discussion:
    - regional fasciectomy is the most commonly performed procedure for Dupuytren's contracture;
    - current trend is for limited palmar and digital fasciectomy confined to contracted rays;
    - in the report by Armstrong JR, et al (2000), the authors reviewed 143 rays in 103 patients undergoing dermofasciectomy for diffuse disease with involvement of the skin;
           - there was recurrence in 12 rays (8.4% of rays; 11.6% of patients) during a mean follow-up of 5.8 years;
           - ref: Dermofasciectomy in the management of Dupuytren's disease  



- Surgical Technique:
    - surgical incision:
           - Urbaniak (personal communication) uses a Brunner incision and recommends that the little finger incision cross the phalangeal crease
                   on the ulnar border (as is seen in the diagram);
           - incision is carried down thru the skin, but care is taken to avoid incising too deeply over the MCP joints (since the N/V structures
                   may lie especially superficial at this location);
           - always consider the quality of the skin and position of the cords before making incisions;
                   - obviously it would not be wise to have the base of a flap underneath a thickened cord which is densely adherent to the skin since this
                          could potentially devascularize the entire flap when the cord is removed;
    - pre-tendinous cords
           - proximal to the metacarpal heads, the knife can be used to elevate the skin and the subcutaneous tissues off the palmar fascia and pretendinous cords;
                   
    - identification of nerves and vessels:
           - over the metacarpal heads, tenotomy scissors are used to spread thru the subcutaneous tissues until both digital nerves and arteries are identified on each side of the cord;
                   

    - spiral cord:
           - recognize that the sprial cord may pass underneath the N/V structures, which causes them to shift centrally and superficially;

             

    - regional fasciectomy:
           - once the digital nerves and vessels have been identified, a beaver blade is used to fashion a distally based trap door of diseased palmar fascia;
                   - the proximal edge of the flap is grapsed w/ a clamp and is elevated inorder to provide tension;
                   - this thickend fascia is progressively elevated and dissected distally;

           

           - once the dissection reaches the metacarpal heads great care is taken to carefully dissect the digital nerves and vessels off the diseased palmar fascia;
                   - as Urbaniak points out, usually one digital vessel will be more encased in thickened fascia than the other;
                   - if possible attempt to leave one vessel undisturbed in its bed of areolar tissue (which avoids possibility of arterial spasm);
           - once the digital nerve and vessel are freed, the fascial cord is excised;

             

    - PIP joint:  


- Post Op:
      - carefully fashioned bulky hand dressing is manditory;
      - some advocate several days of immobilization of hand w/ slight wrist extension along w/ MP flexion and slight PIP flexion before early mobilization is started;
            - it is essential to avoid postoperative stiffness;
      - pain in the post operative period must alert the surgeon of possible post operative hematoma;

- Complications:
     - post operative complications include recurrence hematoma, skin loss, infection (treated with early debridment), joint stiffness, and occassionally RSD;
     - use of K wires is thought to promote infection



Treatment of Dupuytren's contracture. Long-term results after fasciotomy and fascial excision.

Segmental aponeurectomy for Dupuytren's disease: a prospective study

Segmental aponeurectomy in Dupuytren's disease.

Treatment of Dupuytren's contracture. Long-term results after fasciotomy and fascial excision.

Fasciotomy and Z-plasty in the management of Dupuytren's contracture.