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Proximal Interphalangeal Joint Release in Dupuytren's Disease of the Little Finger
PROXIMAL INTERPHALANGEAL JOINT RELEASE IN DUPUYTREN’S DISEASE OF THE LITTLE FINGER J. F. S. RITCHIE, K. M. VENU, K. PILLAI and D. H. YANNI From the Orthopaedic Department, Bromley Hospitals NHS Trust, Bromley, Kent, UK
We present a prospective study, with 3-year follow-up, of the role and outcome of fasciectomy plus sequential surgical release of structures of the proximal interphalangeal joint in Dupuytren’s contracture of the little finger. Our treatment programme involves fasciectomy for all patients followed by sequential release of the accessory collateral ligament and volar plate as necessary. Of the 19 fingers in the study, eight achieved a full correction by fasciectomy alone, and in these cases there was a fixed flexion deformity of 61 at 3 months and 81 at 3 years. The remaining 11 fingers (initial mean deformity 701 flexion) were left with a fixed flexion deformity of 421 after fasciectomy which reduced to 71 with capsulo-ligamentous release. This increased to 261 at 3 months but then remained relatively stable, increasing only to 291 at 3 years. In our experience sequential proximal interphalangeal joint release has led to consistently good results with few complications in the correction of severe Dupuytren’s disease of the little finger. Journal of Hand Surgery (British and European Volume, 2004) 29B: 1: 15–17 Keywords: proximal interphalangeal joint, Dupuytren’s disease
constitute. Neither has it been shown how much additional correction may be obtained in these living subjects, how much correction is maintained in the long term and what the complications of the procedure might be. We aimed to address these questions with our study.
INTRODUCTION AND AIMS Dupuytren’s contracture of the proximal interphalangeal joint of the little finger may prove refractory to surgical correction as significant deformity often remains despite release of the fascial cords. The concept of surgical correction of proximal interphalangeal joint contracture by release of the capsuloligamentous structures of the joint was described by Watson et al. (1979) and subsequently addressed by other authors over the last 20 years (Abbiati et al., 1995; Diao and Eaton, 1993; Rajesh et al., 2000; Tonkin et al., 1985). Andrew (1991), in a cadaveric study, demonstrated not only that full correction of proximal interphalangeal joint contracture in Dupuytren’s disease could be attained by surgical means but identified the accessory collateral ligaments and volar plate as the important structures involved. Since that time the technique has gained general acceptance but several authors have raised the concern that the surgical violation of the joint would result in excessive scar tissue formation and stiffness, thus proving counterproductive in the long term. Others have worried that the approach to the joint might lead to instability or increase the risk of damage to the neurovascular bundles. While it is clear that surgical release of the proximal interphalangeal joint is by no means universally appropriate in Dupuytren’s contracture, there are to date no published prospective series to address which patients are likely to benefit from the technique or what proportion of the Dupuytren’s population they
PATIENTS AND METHODS We designed a prospective study into which we recruited all patients presenting over a 6 month period for primary Dupuytren’s surgery with a little finger contracture greater than 201. There were 19 fingers in 12 men and two women who had a mean age of 68 (range 30–81) years. The mean duration of symptoms prior to surgery was 3.6 years. Range of motion and fixed flexion deformity of the affected joints were measured with a goniometer prior to surgery. All patients underwent surgery following a standard protocol. The incision was mixed linear and Bruner with z-plasties as necessary. A standard full resection of the central, pre-tendinous, spiral and abductor cords was carried out in all cases. The residual contracture of the proximal interphalangeal joint was then measured with a goniometer: if it was greater than 201 sequential release of the accessory collateral ligaments and palmar plate was carried out as necessary. The surgical procedures carried out were as follows: fasciectomy alone in eight cases; fasciectomy plus accessory collateral release in five cases; fasciectomy 15
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THE JOURNAL OF HAND SURGERY VOL. 29B. No.1 FEBRUARY 2004
plus accessory collateral and palmar plate release in six cases. Rehabilitation was with aggressive mobilization by our hand therapist from the third post operative day. A thermoplastic splint was used at night and for short periods by day for the first month only. Measurements of residual deformity and range of motion were carried out in all patients in the immediate postoperative period and at a mean final follow-up of 36 (range 35–39) months. No patients were lost to followup during this period.
obtain correction of the deformity. These were without exception those patients with initial deformities of less than 451. This accords with the widely held belief that joint release is unnecessary in many patients with a proximal interphalangeal joint contracture, but also suggests that approximately half of such patients might benefit from the technique. In all patients with a severe initial deformity (more than 451), some form of proximal interphalangeal joint release proved necessary. In almost half of the group (five out of 11 fingers) division of the accessory collaterals alone proved sufficient to obtain full correction, but in the others release of the palmar plate was required. In all patients, significant loss of correction, probably due to postoperative scar tissue, occurred during the first 3 months. This was slightly more marked in those in whom proximal interphalangeal joint release had been carried out (mean residual deformity increased from 71 to 261) than in the others (deformity increased from 11 to 61). Over the next 33 months there was little further loss of correction: a mean of only another 31 in the proximal interphalangeal joint release group and 21 in the non-released group. At 831 mean maximum flexion was slightly reduced in those who had undergone proximal interphalangeal joint release than the mean of 881 in those who had not but this was not statistically significant. Most of the loss of correction, therefore, occurred during the first 3 months and thereafter the situation remained relatively stable. There appeared to be little increase in postoperative scar tissue formation and no significant loss of flexion following proximal interphalangeal joint release. We suggest that those fingers which did stiffen probably did so for a variety of reasons. This would accord with the findings of Weinzwieg et al. (1996) that the loss of correction in those who had had a proximal interphalangeal joint capsulotomy (39%) was the same as in those who had not (35%) at 6 months. Better correction of severe deformity was obtained at 3 years with fasciectomy and proximal interphalangeal joint release (mean residual deformity of 291) than intraoperatively with fasciectomy alone (mean residual deformity of 421). It is of course impossible to say how those fingers would have fared in the long term if treated by fasciectomy alone. We found no problems of neurovascular injury in our series. No patient developed lateral instability because the main collateral ligaments were preserved. One patient out of the 11 who underwent proximal interphalangeal joint release developed a hyperextension deformity but this reduced as the usual postoperative loss of correction took its course, although the finger remained stiff. Several other authors have described surgical release of the contracted proximal interphalangeal joint, though seldom for Dupuytren’s disease. Diao and Eaton (1993)
RESULTS Eight fingers required only fasciectomy for full correction. These patients started with a mean fixed flexion deformity of only 281 (range 20–451). The mean postfasciectomy residual deformity was 11 (range 0–51), and this increased to 61 (range 0–131) at 3 months. The mean deformity at 36 months was 81 (range 0–151). The range of flexion was well preserved with mean maximum flexion of 881 (range 84–951) at 3 years. The only significant difference between this group and those requiring a proximal interphalangeal joint release was in the severity of the contracture: no finger with an initial deformity of less than 451 needed proximal interphalangeal joint release while all with initial fixed flexion of more than 451 did require it. The remaining patients started with a mean fixed flexion deformity of 701 (range 45–941). After fasciectomy this was reduced to 421 (range 30–801). Sequential proximal interphalangeal joint release further reduced the deformity to 71 (range 0–271). The mean fixed flexion deformity increased to 261 (range 0–581) at 3 months and 291 (range 0–881) at 36 months. Range of motion of the proximal interphalangeal joint was also well preserved in all but one of this group with mean maximum flexion of 831 (range 40–941) at 3 years.
COMPLICATIONS One patient developed a wound infection that settled with oral antibiotics. One developed a swan neck deformity following complete proximal interphalangeal joint release. This initially gave a hyperextension deformity of 101 but at 3 years range of motion was 0 to 401. One patient suffered a recurrence of deformity. No patient sustained a neurovascular injury.
DISCUSSION In our study just under half the patients did not require release of the proximal interphalangeal joint in order to
PIPJ CONTRACTURE IN DUPUYTREN’S DISEASE
obtained good results for primary flexion contracture of the proximal interphalangeal joint through the release of the entire collateral ligament, often bilaterally, a technique which we have not found necessary. Abbiati et al. (1995) used a technique involving release of the accessory collateral ligaments and palmar plate, also obtaining good results, but again excluded Dupuytren’s disease from their series. Rajesh et al. (2000) did focus upon proximal interphalangeal joint contracture in Dupuytren’s disease and used a technique involving joint release with application of a tissue distractor for 6 weeks. The results of their series were broadly comparable with ours. Our study has its limitations, principally small numbers and the lack of a control group. These are, however, to a great extent products of the relative scarcity of severe contractures of the proximal interphalangeal joint in Dupuytren’s disease. Most studies of proximal interphalangeal joint contracture are either small in numbers or large, uncontrolled and retrospective.
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References Abbiati G, Delaria G, Saporiti E, Petrolati M, Tremolada C, (1995). The treatment of chronic flexion contractures of the proximal interphalangeal joint. Journal of Hand Surgery, 20B: 385–389. Andrew J G (1991). Contracture of the proximal interphalangeal joint in Dupuytren’s disease. Journal of Hand Surgery, 16B: 446–448. Diao E, Eaton R G (1993). Total collateral ligament excision for contractures of the proximal interphalangeal joint. Journal of Hand Surgery, 18A: 395–402. Rajesh K R, Rex C, Mehdi H, Martin C, Fahmy N R M (2000). Severe Dupuytren’s contracture of the proximal interphalangeal joint: treatment by two-stage technique. Journal of Hand Surgery, 25B: 442–444. Tonkin M A, Burke F D, Varian J P W (1985). The interphalangeal joint in Dupuytren’s disease. Journal of Hand Surgery, 10B: 358–364. Watson H K, Light T R, Johnson T R (1979). Checkrein resection for flexion contracture of the middle joint. Journal of Hand Surgery, 4A: 67–71. Weinzweig N, Culver J E, Fleegler E J, (1996). Severe contractures of the proximal interphalangeal joint in Dupuytren’s disease: combined fasciectomy with capsuloligamentous release versus fasciectomy alone. Plastic and Reconstructive Surgery, 97: 560–566.
Mr J. Ritchie, 1 Fairmount Briar, Croft Road, Crowborough, East Sussex TN6 1NQ, UK. Tel.: +44-1892-610013; E-mail: [email protected] r 2003 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2003.08.005 available online at http://www.sciencedirect.com
We present a prospective study, with 3-year follow-up, of the role and outcome of fasciectomy plus sequential surgical release of structures of the proximal interphalangeal joint in Dupuytren’s contracture of the little finger. Our treatment programme involves fasciectomy for all patients followed by sequential release of the accessory collateral ligament and volar plate as necessary. Of the 19 fingers in the study, eight achieved a full correction by fasciectomy alone, and in these cases there was a fixed flexion deformity of 61 at 3 months and 81 at 3 years. The remaining 11 fingers (initial mean deformity 701 flexion) were left with a fixed flexion deformity of 421 after fasciectomy which reduced to 71 with capsulo-ligamentous release. This increased to 261 at 3 months but then remained relatively stable, increasing only to 291 at 3 years. In our experience sequential proximal interphalangeal joint release has led to consistently good results with few complications in the correction of severe Dupuytren’s disease of the little finger. Journal of Hand Surgery (British and European Volume, 2004) 29B: 1: 15–17 Keywords: proximal interphalangeal joint, Dupuytren’s disease
constitute. Neither has it been shown how much additional correction may be obtained in these living subjects, how much correction is maintained in the long term and what the complications of the procedure might be. We aimed to address these questions with our study.
INTRODUCTION AND AIMS Dupuytren’s contracture of the proximal interphalangeal joint of the little finger may prove refractory to surgical correction as significant deformity often remains despite release of the fascial cords. The concept of surgical correction of proximal interphalangeal joint contracture by release of the capsuloligamentous structures of the joint was described by Watson et al. (1979) and subsequently addressed by other authors over the last 20 years (Abbiati et al., 1995; Diao and Eaton, 1993; Rajesh et al., 2000; Tonkin et al., 1985). Andrew (1991), in a cadaveric study, demonstrated not only that full correction of proximal interphalangeal joint contracture in Dupuytren’s disease could be attained by surgical means but identified the accessory collateral ligaments and volar plate as the important structures involved. Since that time the technique has gained general acceptance but several authors have raised the concern that the surgical violation of the joint would result in excessive scar tissue formation and stiffness, thus proving counterproductive in the long term. Others have worried that the approach to the joint might lead to instability or increase the risk of damage to the neurovascular bundles. While it is clear that surgical release of the proximal interphalangeal joint is by no means universally appropriate in Dupuytren’s contracture, there are to date no published prospective series to address which patients are likely to benefit from the technique or what proportion of the Dupuytren’s population they
PATIENTS AND METHODS We designed a prospective study into which we recruited all patients presenting over a 6 month period for primary Dupuytren’s surgery with a little finger contracture greater than 201. There were 19 fingers in 12 men and two women who had a mean age of 68 (range 30–81) years. The mean duration of symptoms prior to surgery was 3.6 years. Range of motion and fixed flexion deformity of the affected joints were measured with a goniometer prior to surgery. All patients underwent surgery following a standard protocol. The incision was mixed linear and Bruner with z-plasties as necessary. A standard full resection of the central, pre-tendinous, spiral and abductor cords was carried out in all cases. The residual contracture of the proximal interphalangeal joint was then measured with a goniometer: if it was greater than 201 sequential release of the accessory collateral ligaments and palmar plate was carried out as necessary. The surgical procedures carried out were as follows: fasciectomy alone in eight cases; fasciectomy plus accessory collateral release in five cases; fasciectomy 15
16
THE JOURNAL OF HAND SURGERY VOL. 29B. No.1 FEBRUARY 2004
plus accessory collateral and palmar plate release in six cases. Rehabilitation was with aggressive mobilization by our hand therapist from the third post operative day. A thermoplastic splint was used at night and for short periods by day for the first month only. Measurements of residual deformity and range of motion were carried out in all patients in the immediate postoperative period and at a mean final follow-up of 36 (range 35–39) months. No patients were lost to followup during this period.
obtain correction of the deformity. These were without exception those patients with initial deformities of less than 451. This accords with the widely held belief that joint release is unnecessary in many patients with a proximal interphalangeal joint contracture, but also suggests that approximately half of such patients might benefit from the technique. In all patients with a severe initial deformity (more than 451), some form of proximal interphalangeal joint release proved necessary. In almost half of the group (five out of 11 fingers) division of the accessory collaterals alone proved sufficient to obtain full correction, but in the others release of the palmar plate was required. In all patients, significant loss of correction, probably due to postoperative scar tissue, occurred during the first 3 months. This was slightly more marked in those in whom proximal interphalangeal joint release had been carried out (mean residual deformity increased from 71 to 261) than in the others (deformity increased from 11 to 61). Over the next 33 months there was little further loss of correction: a mean of only another 31 in the proximal interphalangeal joint release group and 21 in the non-released group. At 831 mean maximum flexion was slightly reduced in those who had undergone proximal interphalangeal joint release than the mean of 881 in those who had not but this was not statistically significant. Most of the loss of correction, therefore, occurred during the first 3 months and thereafter the situation remained relatively stable. There appeared to be little increase in postoperative scar tissue formation and no significant loss of flexion following proximal interphalangeal joint release. We suggest that those fingers which did stiffen probably did so for a variety of reasons. This would accord with the findings of Weinzwieg et al. (1996) that the loss of correction in those who had had a proximal interphalangeal joint capsulotomy (39%) was the same as in those who had not (35%) at 6 months. Better correction of severe deformity was obtained at 3 years with fasciectomy and proximal interphalangeal joint release (mean residual deformity of 291) than intraoperatively with fasciectomy alone (mean residual deformity of 421). It is of course impossible to say how those fingers would have fared in the long term if treated by fasciectomy alone. We found no problems of neurovascular injury in our series. No patient developed lateral instability because the main collateral ligaments were preserved. One patient out of the 11 who underwent proximal interphalangeal joint release developed a hyperextension deformity but this reduced as the usual postoperative loss of correction took its course, although the finger remained stiff. Several other authors have described surgical release of the contracted proximal interphalangeal joint, though seldom for Dupuytren’s disease. Diao and Eaton (1993)
RESULTS Eight fingers required only fasciectomy for full correction. These patients started with a mean fixed flexion deformity of only 281 (range 20–451). The mean postfasciectomy residual deformity was 11 (range 0–51), and this increased to 61 (range 0–131) at 3 months. The mean deformity at 36 months was 81 (range 0–151). The range of flexion was well preserved with mean maximum flexion of 881 (range 84–951) at 3 years. The only significant difference between this group and those requiring a proximal interphalangeal joint release was in the severity of the contracture: no finger with an initial deformity of less than 451 needed proximal interphalangeal joint release while all with initial fixed flexion of more than 451 did require it. The remaining patients started with a mean fixed flexion deformity of 701 (range 45–941). After fasciectomy this was reduced to 421 (range 30–801). Sequential proximal interphalangeal joint release further reduced the deformity to 71 (range 0–271). The mean fixed flexion deformity increased to 261 (range 0–581) at 3 months and 291 (range 0–881) at 36 months. Range of motion of the proximal interphalangeal joint was also well preserved in all but one of this group with mean maximum flexion of 831 (range 40–941) at 3 years.
COMPLICATIONS One patient developed a wound infection that settled with oral antibiotics. One developed a swan neck deformity following complete proximal interphalangeal joint release. This initially gave a hyperextension deformity of 101 but at 3 years range of motion was 0 to 401. One patient suffered a recurrence of deformity. No patient sustained a neurovascular injury.
DISCUSSION In our study just under half the patients did not require release of the proximal interphalangeal joint in order to
PIPJ CONTRACTURE IN DUPUYTREN’S DISEASE
obtained good results for primary flexion contracture of the proximal interphalangeal joint through the release of the entire collateral ligament, often bilaterally, a technique which we have not found necessary. Abbiati et al. (1995) used a technique involving release of the accessory collateral ligaments and palmar plate, also obtaining good results, but again excluded Dupuytren’s disease from their series. Rajesh et al. (2000) did focus upon proximal interphalangeal joint contracture in Dupuytren’s disease and used a technique involving joint release with application of a tissue distractor for 6 weeks. The results of their series were broadly comparable with ours. Our study has its limitations, principally small numbers and the lack of a control group. These are, however, to a great extent products of the relative scarcity of severe contractures of the proximal interphalangeal joint in Dupuytren’s disease. Most studies of proximal interphalangeal joint contracture are either small in numbers or large, uncontrolled and retrospective.
17
References Abbiati G, Delaria G, Saporiti E, Petrolati M, Tremolada C, (1995). The treatment of chronic flexion contractures of the proximal interphalangeal joint. Journal of Hand Surgery, 20B: 385–389. Andrew J G (1991). Contracture of the proximal interphalangeal joint in Dupuytren’s disease. Journal of Hand Surgery, 16B: 446–448. Diao E, Eaton R G (1993). Total collateral ligament excision for contractures of the proximal interphalangeal joint. Journal of Hand Surgery, 18A: 395–402. Rajesh K R, Rex C, Mehdi H, Martin C, Fahmy N R M (2000). Severe Dupuytren’s contracture of the proximal interphalangeal joint: treatment by two-stage technique. Journal of Hand Surgery, 25B: 442–444. Tonkin M A, Burke F D, Varian J P W (1985). The interphalangeal joint in Dupuytren’s disease. Journal of Hand Surgery, 10B: 358–364. Watson H K, Light T R, Johnson T R (1979). Checkrein resection for flexion contracture of the middle joint. Journal of Hand Surgery, 4A: 67–71. Weinzweig N, Culver J E, Fleegler E J, (1996). Severe contractures of the proximal interphalangeal joint in Dupuytren’s disease: combined fasciectomy with capsuloligamentous release versus fasciectomy alone. Plastic and Reconstructive Surgery, 97: 560–566.
Mr J. Ritchie, 1 Fairmount Briar, Croft Road, Crowborough, East Sussex TN6 1NQ, UK. Tel.: +44-1892-610013; E-mail: [email protected] r 2003 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2003.08.005 available online at http://www.sciencedirect.com