Advancing Treatment

Dupuytren’s disease is a fibroproliferative disorder primarily affecting the palmar fascia, affecting Caucasian men predominantly, and exhibiting varying prevalence across different regions.1 The contracture caused by this disorder ultimately leads to decreased hand function. Especially at the metacarpophalangeal joint (MCP), a patient with severe contracture in the MCP joint cannot extend the finger(s) effectively, making it difficult to engage in activities of daily living. There is no consensus on the best approach to the treatment of Dupuytrens. There are various open surgical approaches, including limited fasciectomy, subtotal fasciectomy, and dermofasciectomy. Limited fasciectomy is the least invasive, as it only requires excision of pathologic Dupuytren cords. This technique resembles the closed needle aponeurotomy technique but is much easier to learn, with less risk of nerve injury and by removing a segment of the cord, possibly lower recurrence rates. In subtotal fasciectomy, both diseased cords and adjacent palmar fascia within the region are removed to decrease recurrence risk. Dermofasciectomy is the most extensive procedure, as it requires excision of diseased fascia and overlying skin and skin grafting. This technique is typically reserved for recurrent or more aggressive cases. Wound closure techniques have also been investigated, ranging from straight incisions followed by “Z” plasty, Brunner’s incisions, excision with skin grafting, and the McCash “open palm” technique.2 Limited palmar segmental fasciectomy has been used in managing Dupuytren’s disease due to its ability to remove affected tissue segments selectively and less invasively, preserving functional hand mobility.3 In this context, the primary anatomic structure that is addressed is the superficial palmar fascia. The pretendinous bands, key structures affected by the contracture, undergo transformation into the pretendinous cords. This transformation contributes to the contracture observed at the MCP joint. At the distal palmar crease level, the central bands are transversely bridged by the superficial transverse palmar ligament, a structure unaffected by Dupuytren’s disease. During surgical intervention, the primary target is the pretendinous cord. The surgeon isolates this structure and transects the diseased tissue while preserving the superficial transverse palmar ligament. In our case series study, we introduce an improved approach to Dupuytren’s disease affecting the MCP joint combining a less than 1 cm incision limited palmar segmental fasciectomy and the McCash techniques as a surgical intervention for Dupuytren’s contracture. TECHNIQUE A total of 18 patients and 27 procedures were identified through chart review. There were 16 male and two female patients with a mean age of 66. The surgical technique: the patient is placed on the table in a supine position and given IV sedation. The affected arm is prepped and draped in the usual sterile fashion, and a regional block is given at the wrist or more proximal level. A high-arm tourniquet is placed and inflated at the onset of adequate analgesia. A transverse incision of less than 1 cm (Fig. 1) is made over the palm just proximal to the MCP crease following the Langer lines to limit scarring. This location is proximal to the spiral cord phenomenon and therefore a very safe and easy dissection. Subsequently, the skin and subcutaneous tissues are sharply incised. Then, under loupe magnification, full-thickness skin flaps are elevated distally and proximally superficial to the pretendinous cord. A beaver blade and a blunt hemostat are used to isolate the cord and expose a 1 cm segment. Care is taken to avoid any injury to the adjacent neurovascular bundles. While protecting the neurovascular bundles, the cord is incised, initially distally, and at this point, the finger is extended, and a correction is obtained. To decrease the possibility of recurrence and healing of the cord, the proximal fragment is then pulled into the wound, and a short segment, usually 1 cm, is excised. The flexor tendon sheath is not disturbed. Immediate correction of the MCP is assessed by positioning the affected digit in full extension. If a continuous fixed flexion deformity is present, an examination is conducted to identify any remaining disease or other causes of tightness such as skin scarring, intrinsic tightness, or inflammation.3 If adequate correction is not obtained, the incision can be extended distally using Brunner’s lines. This has not been necessary in our experience. The patients understand that a limited approach may not give a complete correction, but enough to restore function. Once adequate extension of the MCP joint is restored, the incision is left open to close by secondary intention (Fig. 2B) in a McCash-type technique. The tourniquet is deflated, hemostasis is achieved, and the wound is irrigated. The wound is covered with Xeroform and sterile dressings, and the wrist and fingers are splinted in extension for a week. At 1-week follow-up, the splint is removed and dressings changed, betadine is applied to the skin to dry out any maceration, a new Xeroform and gauze dressing is used, and a removable thermoplastic orthosis is made to keep the MCP and PIP in extension at night and allow daytime active flexion. Hand therapy, including composite and hook grip, passive and active finger flexion, extension, abduction, and adduction of the wrist and fingers, is initiated immediately after their first follow-up visit. Showering and daily dressing changes by the patient are started at two weeks and continued until healing (Fig. 2C). Night-time splinting is carried out for 4 to 6 weeks.FIGURE 1: Schematic representation of the surgical planning technique. Depicted is the incision site.FIGURE 2: A, Representation of MP contracture of 40 degrees at the 5th and 30 degrees at the 4th MCP. B, One-week follow-up showing the open palm technique with some maceration. C, Two-week follow-up showing the healed wounds and correction of flexion contracture.EXPECTED OUTCOMES The average follow-up time between surgery and final follow-up appointment was about 30 days. Mild issues with wound healing occurred in 18.52% of the procedures, or 4 of our patients. However, they were appropriately managed and resolved over time. The combination of limited palmar segmental fasciectomy and the McCash technique is a viable and effective approach for managing MCP joint contractures in Dupuytren’s disease. Our findings support the use of this less invasive technique, which offers excellent contracture correction, minimal complications, and a favorable recovery profile. Limited segmental fasciectomy and the McCash technique are attractive treatment options for several reasons. As reported in various case series, these methods are associated with earlier return to hand exercises, mild postoperative pain, excellent contracture correction, and decreased incidence of hematoma and infection.2,4,5 Successful correction of contraction angles and low recurrence rates are achieved when adequately indicated. Furthermore, it has been observed that the open palm technique leads to excellent results, low pain, and better motion for patients when adequately monitored. Future studies with larger sample sizes and longer follow-up periods are warranted to validate these results and further refine the surgical approach. COMPLICATIONS The resolved complications included two cases of wound maceration, one instance of finger swelling, and one patient with a pyogenic granuloma. The most common clinical problems often observed include stiffness, granuloma, skin dimple on the incision site, and superficial wound maceration (treated with dry dressing and betadine application). None of the patients showed evidence of nerve or vascular damage, infection, contracture recurrence, hematoma, joint instability, or need for revision surgeries. No patients required return to the operating room for their wound issues. Additional potential complications associated with this technique could be infection, nerve damage, bleeding, and wound problems. However, none of our patients experience these issues. The minor wound healing issues that we encountered are to be expected with a secondary healing technique. Nerve injury can be avoided through careful dissection, and if it does occur, it can be addressed immediately with either repair or a nerve graft.