Instituto Jundiaiense de Ortopedia e Traumatologia, Jundiaí, SP, Brazil
Dupuytren's disease was named after Baron Guillaume Dupuytren,1 a celebrated French surgeon, whose complete monograph guided the current knowledge of this pathology. In 1831, Dupuytren described the disease as an anatomopathological change, with thickening and retraction of the palmar fascia with flexion deformity of the fingers. This monograph associated the disease to local chronic trauma on the palm, usually related to heavy duty. But Dupuytren cautioned that not all cases could be explained this way.
The condition is due to metaplasia of the palmar fascia fibrous framework, which basically compromise the pretendinous band, superficial transverse ligament, spiral band, natatory ligament, lateral sagittal ligament, and Grayson's ligament.
The Dupuytren's contracture follows a progressive evolution, and its initial manifestations are an invagination of the skin and the appearance of nodules that unite among them, forming hard consistency cords in the palm and advancing longitudinally to the finger. The condition is usually painless, and after its maturation may suffer retractions, which cause a flexion deformity of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The condition affects more men than women (ranging from 7:1 to 10:1), from the fourth to sixth decade of life; and the fourth and fifth fingers are the most commonly affected. Additionally, there may be an association with the formation of fibrous strands in the plantar fascia (Lederhose's disease, 5%) and in the penile fascia (Peyronie's disease, 3%).2
Its etiology is still unknown, but the importance of heredity was proved, because of the high incidence in the descendents 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 association with epilepsy, 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 a large number of cells and mitoses. The basic cell present is the myofibroblast (similar to fibroblast), usually found in the palmar fascia, but with significant ability to generate contractile forces. The transforming growth factor (TGF-) is an abundant cytokine present in the tissue, being largely responsible for the proliferation and differentiation of fibroblasts into myofibroblasts. Moreover, it improves the contractile behavior of myofibroblasts and causes rapid and stronger contractions in response to mechanical stimuli.2,5
Other factors influencing the differentiation, growth, and contractility of myofibroblasts include platelet-derived protein, fibroblast growth factor, epidermal growth factor, and interleukin-1, as well as cells that synthesize the proteins periostin and tenascin.5
The diagnosis is clinical, being established by inspection and palpation. The differential diagnosis includes acamptodactilia, rheumatoid arthritis, retraction of the scar caused by burn or injury, palmar callus of effort, and ulnar nerve deficit.5 Compared to conservative treatment, the most promising therapy is the application of intrafocal clostridium collagenase in the cord, now in an advanced clinical trial phase.5
Nowadays, the surgical option is the most acceptable. In the development of the therapeutic plan, it is important to determine the stage at which the disease is, as this knowledge influences the intraoperative technical difficulty and in the post-operative complications, as well as the recurrence of the disease. The need for more extensive dissection, the devitalized skin and the excessive tension on the suture are predisposing factors for post-operative complications, such as hematomata, skin necrosis, infection and pain.5,6
The original surgical treatment was the removal of the contracted fascia; since then, various techniques and modifications have been described: fasciotomy, dermofasciotomy with skin graft, regional fasciotomy, radical fasciotomy, open palm technique, partial fasciotomy with preservation of the skin, limited fasciotomy, segmental aponeurectomy, and percutaneous fasciotomy.1,4,6-10
In the open palm technique, originally described by Dupuytren1 and popularized by McCash,7 a regional fasciotomy in the palm of the hand is done, allowing the extension of the fingers. This procedure results in a large skin defect. The wound is left open to heal by secondary intention, to avoid stress and hematomai formation; this reduces the incidence of necrosis and the possibility of infection and scar adhesions.6
Objective
The objective of this study is to evaluate the results of surgical treatment of patients with Dupuytren's disease grades III and IV operated in our department with the use of the open palm technique (McCash) modified with the association of proximal and distal longitudinal incisional extensions on the palm, besides Brunner incisions in the fingers.11
Materials and methods
From March 2004 to December 2007, 16 patients with clinical diagnosis of Dupuytren's disease underwent surgical treatment. The mean age was 65 years (range, 54-75), with postoperative follow-up of 5-8 years. Six patients were affected only in the fifth finger, five were bilateral and five
unilateral, with involvement of the fourth and fifth fingers.Thirteen patients were male Caucasians, including the threewomen.
In our study, we used the classification proposed by Tubianaet al.,12which consists of the sum of the extension deficitsof the metacarpophalangeal (MCP), proximal interphalangeal(PIP), and distal interphalangeal (DIP) joints, measured witha goniometer. This classification is divided into four stages:grade I (0-45?), grade II (46-90?), grade III (91-135?), and grade IV(>135?). In this study, were included only patients with GradesIII and IV, and it was taken into account only the finger withgreater involvement.11,12
In all patients, the surgical technique used was that rec-ommended by McCash, with transverse incision in the distalpalmar crease, associated with a modification with proximaland distal longitudinal incisional extensions on the palm. Inthe fingers, Brunner incisions were made. We made a partialfasciotomy, which left open only the transverse incision.4
Post-operative care consisted of daily dressing changes dur-ing the first 48 h, daily changes in the next two weeks, andevery three days in subsequent weeks. The fingers were immo-bilized in extension for the first five days and the patient wasreferred for early chirotherapy rehabilitation.
The extension deficits for MCP, PIP, and DIP joints weregauged in preoperative, post-operative (three months) and latepost-operative periods (5-8 years). Extension deficits exceed-ing 30?in MCP, 15?in PIP, and 10?in DIP joints were consideredas surgical recurrences.11,12
Results
Table 1 lists the measurements of the extension deficit, indegrees, of the three joints (MCP, PIP, and DIP) obtained with agoniometer.
Fig. 1 displays the results of measurements of the extensiondeficits in each joint in the pre-, post-, and late post-operativeperiod.To compare the angle of the MCP, PIP, and DIP joints ofpatients with respect to preoperative, post-operative (threemonths) and late post-operative period (5-8 years), we appliedthe non-parametric statistical test of Mann-Whitney forpaired samples, and the p values were corrected by Bonferronimethod for multiple comparisons. Table 2 shows the resultsof the tests.
For the three joints, a statistically significant decrease wasobserved for the average angle of the pre- to post-operativeperiod, at the level of 5% (p < 0.05). For the MCP and DIP joints,no significant difference between the post-operative period(three months) and late post-operative period (5-8 years) wasnoted. However, for the PIP joint a significant mean increasebetween the post-operative and late post-operative periodsvas noted (p = 0.0025), but still at a lower value than thatobserved preoperatively.
Fig. 2 displays the scatter plot and the Spearman's cor-relation coefficient among the joints for the angulationsmeasured. A strong positive correlation among measures ofdifferent joints, with coefficients between 0.75 and 0.85 (allstatistically significant, p > 0.0001) was noted.
Fig. 1 - Boxes for the joint angulation, according to the joint and by period. In this figure the results of measurements of theextension deficits in each joint in the preoperative, post-operative, and late post-operative period are depicted.
Fig. 2 - Dispersion for angulation measures among different joints.
Discussion
The literature is controversial as to the advantages and dis-advantages of the open palm technique, which determinesmore skin stretching, besides preventing complications suchas hematoma, necrosis, skin ischemia, tension and pain. Adisadvantage would be an increased risk of infection and thepatient discomfort by having an "open" injury and by thenecessity of more frequent dressings. Lubahn et al.13con-ducted a comparative study between the two techniques andconcluded that patients operated by techniques in which thepalm was completely closed came to suffer greater residualcontracture.8,13,14
In the present study, 13 (81.25%) males and three (18.75%)females were recruited, all Caucasians, which is consis-tent with the literature, which reports 80% of male anddominance of Caucasians. In this study, the mean age ofpatients was 65 years (range, 54-75), similar to that of moststudies.15,16
In our study we found 37.5% of surgical recurrence. Theserates vary widely (28-50%), regardless of the technique used.However, to obtain good results the patient must have an ade-quate post-operative care, and an stimulus for early activemobilization after removal of immobilization, under orienta-tion of a chiropractor. McGrouther is most emphatic that, in along-term post-operative period, the recurrence rate reaches100% for some degree of contracture. This fact occurs becausethere is a residual pathological fascia, or what is called theextent of the disease, in which there is the formation of newfascia in a place near the surgical site.12,17,18
Recurrence in MCP joint is very low. On the other hand,in PIP joint the incidence of recurrence is higher. Our studydescribed six cases of surgical recurrence, all in the PIP joint,because of an angulation > 15?in the late postoperative period(5-8 years), which agrees with the literature.9,19
Concerning MCP and DIP joints, no significant differ-ences in the angulations between the post-operative period(three months) and late post-operative period (5-8 years)were observed. However, for the PIP joint there was a signifi-cant mean increase in angulation between the post-operative(mean, 2.2?) and late post-operative (mean, 13.8?) periods,which shows a higher rate of recurrence in the PIP joint-alsoobserved in other works.9,19
An extension deficit decrease for all patients in the twopostoperative periods compared to the preoperative periodwas observed, which is shown in the boxes (Fig. 1). Thisdemonstrates the effectiveness of the open palm technique(modified), provided there is an appropriate therapeutic plan,which is consistent with the literature.5,6
In comparing the three joints in the three periods (Table 3),only the PIP joint showed significant mean increase betweenthe post-operative and late post-operative periods, whichdemonstrate a higher recurrence in PIP, also evident in theliterature.9,19
Conclusion
The modified McCash technique is an effective option forsevere cases (stages III and IV) of Dupuytren's disease.Conflicts of interestThe authors declare no conflicts of interest.
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