Place of Segmental Aponeurectomy in the Treatment of Dupuytren's disease

PhD Thesis presented on May, 15 1997 at the Université Libre de Bruxelles

by J.P. Moermans, M.D.

Introduction - Table of Content

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Table of content


  1. Introduction

    1. The difficulties
    2. The solution ?
    3. Goals of the present work
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  2. History

    1. The Middle Ages
    2. The beginnings
    3. Baron Dupuytren
    4. Evolution of surgical management
      1. Fasciotomy
      2. Radical palmar fasciectomy
      3. Limited fasciectomy
      4. Dermofasciectomy
    5. Conclusion
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  3. Anatomy

    1. The development of the palmar fascia
      1. In the presence of a palmaris longus tendon
      2. In the absence of a palmaris longus tendon
      3. The natatory ligament and Cleland's and Grayson's ligaments
      4. The fascial layers in the palm
      5. Conclusion
    2. The palm
      1. The transverse fibres
      2. The longitudinal fibres
      3. The vertical fibres
    3. The finger
      1. The palmar digital area
      2. The finger fascia
    4. The radial border of the hand
      1. The pretendinous band
      2. The transverse fibres
      3. The natatory ligament
    5. The ulnar border of the hand
      1. Conclusion
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  4. Anatomy of the pathological aponeurosis

    1. The palmar localisation
      1. The palmar aponeurosis
      2. The transverse fibres
      3. The natatory ligament
      4. The hypothenar fascia
    2. The digital localisations
      1. The central cord
      2. The spiral cord
      3. The lateral cord
      4. The retrovascular cord
    3. Peculiar characteristics of each finger
      1. The index finger
      2. The little finger
    4. The dorsal localisations and knuckle pads
    5. Conclusions
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  5. Normal connective tissue biology

    1. Introduction
    2. Classification of connective tissue
      1. Connective tissue proper
    3. Connective tissue fibres
      1. Collagen fibres
      2. Reticular fibres
      3. Elastic fibres
    4. Ground substance
      1. Introduction
      2. Glycosaminoglycans
      3. Proteoglycans
    5. Plasticity of the connective tissue
    6. Conclusions
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  6. Histopathology

    1. The normal palmar skin
    2. Histopathology of Dupuytren's disease
    3. The myofibroblast
    4. Myofibroblasts and Dupuytren's disease
    5. Contraction and contracture
    6. Dorsal knucke pads
    7. Initiation and propagational factors of Dupuytren's disease
    8. Conclusion
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  7. Connective tissue biology in Dupuytren's disease

    1. Introduction
    2. Collagen in Dupuytren's disease
      1. Structural changes
      2. Biochemical changes
      3. Discussion of the biochemical and structural changes
    3. Proteoglycans and glycosaminoglycans in Dupuytren's disease
    4. Biology of connective tissue and Dupuytren's disease
    5. Conclusions
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  8. Dupuytren diathesis

    1. Introduction
    2. Race
      1. A Nordic Origin?
      2. Other isolated genetic events?
    3. Involvement of other areas and bilateral disease
    4. Early onset of the disease
    5. Family history
    6. Conclusion
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  9. Epidemiology of surgical patients

    1. The patients
    2. Age and sex differences
      1. Length of evolution
      2. Age of onset
      3. Discussion
    3. Hand dominance and first affected side
      1. Discussion
    4. Manual labour
      1. Manual labour and age of onset
      2. Discussion
    5. Family history of Dupuytren's disease
      1. Family history and sex of the patient
      2. Family history and age of onset of the disease
      3. Discussion
    6. Ectopic sites of the disease
      1. Ectopic sites, sex of the patient and age of onset
      2. Ectopic sites and family history
      3. Discussion
    7. Involvement of both hands
      1. Involvement of both hands and ectopic lesions
      2. Involvement of both hands and family history
      3. Involvement of both hands and sex of the patient
      4. Involvement of both hands and age of onset
      5. Discussion
    8. Associated diseases
      1. Local trauma
      2. Alcoholism
      3. Diabetes
      4. Epilepsy
    9. Previous operation
    10. The hands
    11. Tubiana's grade
      1. Tubiana's grade and sex of the patient
      2. Tubiana's grade and family history, involvement of both hands or ectopic localisations
      3. Tubiana's grade and associated diseases
      4. Discussion
    12. Impairment of function
    13. Total loss of extension
    14. Number of involved rays
      1. Number of rays and sex of the patients
      2. Number of rays and family history, involvement of both hands or ectopic localisations
      3. Number of rays and associated disease
      4. Number of rays and age of the patient or length of evolution of the disease
    15. Involvement of the radial rays
      1. Involvement of the radial rays and sex of the patients
      2. Involvement of radial rays and family history
      3. Involvement of radial rays and ectopic sites
      4. Involvement of radial rays and bilateral disease
      5. Involvement of radial rays and associated disease
      6. Involvement of radial rays and age of the patient
      7. Involvement of radial rays and length of evolution
      8. Discussion
    16. Age of onset, length of evolution and severity of the disease
      1. Discussion
    17. Summary
    18. Conclusions
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  10. Segmental aponeurectomy: surgical technique

    1. Introduction
    2. Surgical technique
      1. Anaesthesia and haemostasis
      2. Incisions
      3. Dissection
      4. Skin closure
      5. After-care
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  11. Segmental aponeurectomy: illustrations

  12. Segmental aponeurectomy: early results

    1. The patients
    2. Preoperative evaluation
    3. Postoperative evaluation
      1. Complications
      2. Results
    4. Factors determining the outcome
      1. General factors
      2. Local factors
    5. Discussion
      1. Operative results: comparison with other studies
      2. Factors determining the outcome
    6. Conclusion
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  13. Segmental aponeurectomy: exceptions

    1. The patients
    2. Hand condition
    3. Discussion
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  14. Segmental aponeurectomy: late results

    1. Recurrence
    2. Extension
    3. Residual pathological tissue
    4. Long term evaluation
      1. Material
      2. Interval between operation and follow-up examination
      3. Continuing activity of the disease
      4. Contracture and functional evaluation
      5. Secondary operations
    5. Conclusions
    6. Study of the interval between operation and recurrence
      1. Introduction
      2. Follow-up life table
    7. Life table analysis applied to recurrences
      1. A mathematical model for the proportion of recurrences
      2. Risk factors
      3. Discussion
    8. Conclusion
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  15. Dermofasciectomy

    1. Introduction
    2. Surgical technique
      1. Full thickness skin grafts
      2. Operation
      3. Postoperative treatment
    3. Indications
    4. Results
      1. The patients
      2. Preoperative evaluation
      3. Postoperative evaluation
      4. Complications
      5. Recurrences
    5. Discussion
    6. Conclusion
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  16. Conclusions

    1. Review of the literature
      1. Pathological anatomy
      2. Connective tissue biology
      3. Histopathology
      4. Dupuytren diathesis
    2. Personal data
      1. Epidemiology of surgical patients
      2. Segmental aponeurectomy: early results
      3. Segmental aponeurectomy: late results
      4. Segmental aponeurectomy: summary
      5. Dermofasciectomy
      6. Proposed sequence of treatment
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  17. Bibliography

  18. Figures

  19. Tables





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Introduction


Since its detailed description in 1831 by Dupuytren, the contracture of the palmar aponeurosis has been the subject of numerous discussions. Its origin, its evolution and the patho-physiological mechanisms involved in its development remain obscure despite the many progresses made during the last years. Without a good understanding of the causative factors, the therapeutic options are still uncertain as attested by the multiplicity of surgical techniques and palliative treatments that have been proposed. For the clinician, the choice of the most appropriate treatment is further complicated by the extreme variability of the disease among patients but also for the same patient with the passing time. Significant geographical variations probably exist (Hueston, 1990) that make a simple transposition of the published results illusory.

1. The difficulties

The first surgical procedures for Dupuytren's disease were simple aponeurotomies. Without anesthesia, at a time when infection was a major risk, there were certainly not many candidates for elective surgery for a painless condition. Those limited procedures were followed by numerous recurrences. Progressively, with improving anesthesia techniques, the operations became more aggressive. The surgeons began to perform extensive fasciectomies in an attempt to reduce the risk of recurrences or extensions. Their attempts were only partially successful but the price to pay was high in term of complications leading sometimes to unacceptable functional losses. On this matter, we cannot forget that the most important function of the hand is prehension what implies a good flexion of the fingers. This flexion is often compromised after surgical complications. The functional losses can then exceed, by far, the impairment induced by the retraction of the aponeurosis and the secondary extension deficit.

The radical fasciectomies once recommended (McIndoe et al., 1958), have since been condemned (Clarkson, 1963) because of the numerous postoperative complications that they engendered. Limited resections of the aponeurosis through volar zigzag or straight longitudinal incisions converted to Z-plasties have been advised instead.

However a comparative study of wound complications (Gelberman et al., 1982) confirmed previous reports (Hueston, 1961; Tubiana et al., 1967) showing an average 10 % of flap necrosis with these procedures and demonstrated the superiority of the presently popular open-palm technique of McCash (1964), though this does not solve the difficult problems of the finger deformities and requires dressings of the wound for four or six weeks.

The survey of 990 operations by McFarlane (1983) in a multi-centric study, best illustrates the frequency of serious complications following today's most popular operations: an overall complication rate of 19% and loss of flexion and algo-neuro-dystrophy occurring alone or together in 10% of patients.

These problems, the almost direct relationship between the extent of the surgical procedure and the postoperative morbidity (Zachariae 1967, 1990; Gonzales, 1985) and the frequency of recurrence after all types of fasciectomies (Tubiana et al., 1985) really pose the practical problems bound to the surgery of Dupuytren's disease:


2. The solution ?

At the Belgian Hand Group (Société Belge de Chirurgie de la Main) congress held in 1982, R. Vilain suggests that it is possible to conciliate a low rate of complications and better long term results than achieved by simple fasciotomies. He proposes to carry out segmental resections of the pathological fascia, thus creating discontinuities in the retracted bands, without wide dissection of the fascia itself. He mostly gives examples for palmar cords and his communication which is not backed up by statistics is received with scepticism.

A short while later, we were confronted with a severe Dupuytren's disease in an elderly patient in bad general condition who was barely able to hold his crutch in the affected hand. A simple surgical solution was needed. The risks of complications being almost the same than after a simple fasciotomy, we tried to apply Vilain's proposals. The end result, much better than expected, led us to repeat the experience with other cases and with other favourable results.

In 1983, we began a prospective study of the possibilities of a new technique, later called segmental aponeurectomy, based on principles stated by R. Vilain (Moermans et al. 1984, Moermans, 1991). The basic postulate of this operation is that, if we can create a permanent discontinuity in the retracted aponeurotic band without wide dissection of the fascia itself, then the retracted band, from which tension has been eliminated, will disappear or at least cease to act as a contracture. The same principle is regularly applied in the treatment of hypertrophic scars. It is thus much more than a simple fasciotomy since we create a gap in the retracted aponeurosis.

3. Goals of the present work

After a brief summary of today's knowledge of the histo-pathology of Dupuytren's disease, we will try:



Introduction - Table of Content