Dupuytren’s Disease

Video

Definition

Fibroproliferative disorder of palmar aponeurosis

Aetiology

Murrell’s Theory of Pathogenesis

• Initiating event is microvascular ischaemia
• Ischaemia itself leads to conversion of
  • ATP toHypoxanthine
  • Endothelial Xanthine Hydrogenase to Xanthine Oxidase
• Xanthine Oxidase catalyses reaction
  • Hypoxanthine to Uric Acid
  • Which gives off OH- (hydroxyl free radicals)
• OH- stimulate fibroblast proliferation
  • Increasing Type III Collagen
• Fibroblasts strangle microvessels
  • Vicious Cycle
• ATP : Hypoxanthine : Uric acid + OH- : fibroblast proliferation : microvascular strangulation

Epidemiology

• 5% Caucasians
• Especially Vikings
• Rare Blacks & Asians
• M:F – 5:1
• 20% Male > 65 years

R>Risk factors

• Local ischaemia
  • DM
  • Smoking
  • Trauma (including fractures of the wrist)
  • Occupation? (weight of evidence against it)
  • Alcoholic cirrhosis
  • Anti-epileptic medication (phenobarbitone)
  • HIV
• Genetic
  • Vikings – Anglo-Saxon/ Celtic origin
  • AD with variable penetrance

Ana>Anatomy

• Key to dissection
• Normal structures (bands) become cords & nodules
• Pneumonic “bland bands become crazy cords”

Pretend>Pretendinous Bands

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Volar & midline to neurovascular bundle

Form from palmar aponeurosis as it travels to digits

Splits at MCPJ

Some into skin

Rest deep to neurovascular bundle as spiral band

Natator>Natatory Ligament

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Transverse & superficial to neurovascular bundle at web space

Attached to flexor sheath/ skin

Almost always involved

Spiral >Spiral Bands

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Termination of pretendinous band

Pass deep then lateral to neurovascular bundle

Lateral>Lateral Digital Sheet

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Lateral condensation superficial fascia

Grayson>Grayson’s Ligament

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Volar to neurovascular bundle

Arises tendon sheath

Inserts to lateral digital sheet

Cleland>Cleland’s ligament

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Dorsal to nv structures & same origins as Grayson’s ligaments

Not involved

Transvers>Transverse fibres of the palmar aponeurosis

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“Skoogs fibres”

Superficial to nv bundles at level MC heads

Never involved

Where you should look to trace nv bundles

Cords

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Central, Spiral, Lateral, Natatory

Form along normal fascial pathways

Tighten up

Follows three dimensional anatomy

Neurovascular bundle spirals around spiral cord

Between distal palm crease & proximal crease finger

Coalesce into one

Spiral CordSpiral Cord

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Formed by

• Pretendinous band (medial to nv bundle)
• Spiral Band (deep)
• Lateral Digital Sheet (lateral)
• Grayson’s ligament (superficial)

Pathology

Pathology"wp-block-heading">Myofibroblast>Myofibroblasts"wp-block-list">

Contractile cell

Occur elsewhere (GUT)

But not normally in palmar fascia

• Originate as Perivascular Fibroblasts

Convert secondary to local hypoxia

• Mainly in nodules

None in cords

Responds to cell growth factors

• PDGF/ FGF/ TGF B

Type III Coll>Type III Collagen

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Increased secondary to ↑ cell density

Controversial role

Abundant Fibrob>Abundant Fibroblasts

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Cords only

Peri-arterial

Organized along stress lines

Occluded microvessels

Classification<>Classification

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M>F – 7:1

Right > Left

RF > LF > MF > thumb > IF

Tender nodules beyond distal palmar crease

Painless fixed flexion deformity with disability

Nodules, cords, pits

Dupuytren’s Diath>Dupuytren’s Diathesis

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Aggressive Disease : rapid progression & marked contractures

• Young males
• Significant family history
• Multiple digits
• Bilateral
• Garrod’s Nodes (dorsal thickening of knuckle pads at PIPJ vs carpet layers at MCPJ)
• Lederhose Disease
• Peyronie’s Disease

Examination

<>Examinationk-heading">Investigations >Investigationsk-heading">Differential Diagnosi>Differential Diagnosisk-heading">Treatment

Treatment

k-heading">Don’t operate if negative Table Top Test

• Don’t operate if nodule is painful – can trigger surrounding tissue & ↑ proliferation
• On occasion may need to operate if deep skin folds & pits cause repeated maceration & infection

Nonoperative

• No proven benefit
  • Corticosteroids (to nodules & Garrod’s pads – Ketchum 1991)
  • Occupational Therapy
  • Allopurinol
  • 5-FU
  • Vitamin E
• Patient Education

Operative

Hueston̵>Operativee Top” Test

• Palm unable to touch table when trying to place hand flat on table
• If FFD of PIPJ & MCPJ able to hyperextend & allows palm to touch table then this is a –ve test
• Positive when MCPJ fixed flexion deformity > 40° ?

MCPJ fixed flexion deformity

• easily correctable (see below)
• Often becomes troublesome with FFD > 30°
• Generally correctable at any degree of FFD

PIPJ fixed flexion deformity

• difficult to correct
• 30° fixed flexion deformity usual end result
• Hence McFarlane (1990) advocates
  • Release of PIPJ only if fixed flexion deformity > 30°
• Preoperative splint?

Three technical considerations

>Three technical considerationson

Fasciotomy/ fasciectomy

• Fasciotomy
• Segmental fasciectomy
• Selective fasciectomy
• Radical fasciectomy

Wound closure

“Operation is dissection of the neurovascular bundles”

Skin Options

• Direct Closure ± Flaps
  • Longitudinal with Z-plasty
    • Midline longitudinal
    • Points at creases in midlateral line passing to midline
    • Angle 60° to longitudinal axis
    • Allows dissection from palm to finger
    • Does not allow wide dissection in palm : ↓ postoperative haematoma
  • Transverse
    • Used in palm when 2-3 rays involved
    • Can be combined with longitudinal incisions
    • Simple, good exposure & rapid healing
    • Skin necrosis & ↑ postop haematoma
  • Brunner ± VY plasty
    • Popular
    • Can do lazy Brunner (lazy “S”)
    • Zig-zag prevents scar contracture
    • However difficult to design flaps with finger contracted & flap difficult to construct with intimate proximity of diseased fascia
• Dermofasciectomy
  • Skin excision
  • Full thickness flaps
  • Less recurrence
  • Graft failure
• McCash Open Technique
  • Transverse mid palm wound at distal palmar crease
  • Leave open but review regularly
  • Allows haematoma to drain
  • Closes by contraction (takes 3-5/52)

Fascia Options

• Fasciotomy/ Segmental Fasciectomy
  • Limited procedure with cord divided or short portion of fascia excised
  • Partial or complete correction
  • Elderly or mild disease
  • Can be performed as outpatient procedure
• Selective Fasciectomy
  • Only Dupuytren’s tissue excised – leave normal looking tissue
  • Most popular technique
  • Mainstay
  • Subclinical disease may progress but often does not warrant further surgery
• Radical Fasciectomy
  • Excision of normal & diseased fascia
  • Less popular now
  • Still get recurrence
  • For those with Dupuytren’s diasthesis?

Wound closure

• Options
  • Suture
  • Graft
  • Leave open
• Principle is closure without tension as this predisposes haematoma & wound breakdown

Release of PIPJ FFD

• Volar capsule/ volar plate released proximally at pars flaccida
• Checkrein Ligament (at proximal end of volar plate) released
• Accessory Collateral Ligaments (“sides of the wheelbarrow”) released
• Then pass along volar portion of collateral ligaments (ie “remove the arms off the wheelbarrow”)
• Then can release one collateral ligament if still tight

Management of Recurrence

• Revis>Management of Recurrence
• Test Sensation
• High risk neurovascular bundle injury
• Selective fasciectomy & graft
• PIPJ fusion if severe

Amputation of finger if

• PIPJ fixed flexion deformity > 90°
• Insensate
• Pain
• Dysvascular

Complications

• 20%
• Class>Complicationsmatoma
• Infection
• Skin loss

Neurovascular bundle injury

• Start dissection of nerve proximally

Recurrence 50%

• Dupuytren’s in a surgically treated field

15% need repeat operation

RSD

Prognosis

References

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