Open Fasciectomy Research Articles

Collagenase Clostridium histolyticum in Dupuytren’s contracture: a guide to its use in the EU

Collagenase Clostridium histolyticum (CCH; Xiapex®) is an injectable enzymatic collagenase approved for the treatment of Dupuytren’s contracture (DC). In two double-blind studies, up to three injections (mean of 1.5) of CCH per cord at monthly intervals were significantly more effective than placebo in reducing contractures, achieving clinical success in 64 % of treated joints affected by DC. CCH is generally well tolerated, with most adverse effects being local, transient injection-site reactions, such as oedema, pain and bruising. There is some evidence suggesting that CCH is associated with fewer major complications than open fasciectomy among selected patients. Estimated costs associated with CCH are generally lower than those associated with fasciectomy, but cost-effectiveness based on accepted willingness-to-pay thresholds is dependent on injection price.

Pearls and pitfalls of needle aponeurotomy in Dupuytren's disease.

Dupuytren's disease is a benign, progressive, fibroproliferative disease, and despite advances in basic science and technology, there remains no cure. To date, open fasciectomy procedures remain the criterion standard for the treatment of Dupuytren's disease despite a significant complication rate and recovery time. Needle aponeurotomy, a less invasive treatment, is associated with reduced complications and quicker recovery. A literature review and a compilation of over 700 procedures was performed to highlight the clinical relevance of needle aponeurotomy. A step-by-step description of the author's technique for needle aponeurotomy is presented, emphasizing the pearls and pitfalls of the procedure. Recurrence rates for open fasciectomy are 5 to 10 percent per year compared with rates for needle aponeurotomy, which are 10 to 20 percent per year. Overall complication rates are much less frequent with needle aponeurotomy, with skin tears being the most common (3 percent). Needle aponeurotomy is cost effective compared with open fasciectomy. Recurrent proximal interphalangeal joint flexion contractures remain the most problematic in terms of correction. Needle aponeurotomy has been shown to be an extremely useful adjunct available to the surgeon in the treatment of Dupuytren's disease. This procedure can be performed easily in an outpatient setting or office and carries with it dramatic results. Needle aponeurotomy has a lower complication rate and quicker recovery when compared with open fasciectomy and is therefore offered to patients as a first-line treatment.

Hueston Revisited

Various surgical treatment modalities have been advocated for the treatment of Dupuytren's disease. However, recurrence following surgical treatment of Dupuytren's disease remains a common problem. Previous studies have demonstrated lower recurrence rates with use of a full-thickness skin graft. We therefore postulated that use of acellular dermal matrix may be associated with a similar outcome, based on the common inhibitory effect on underlying myofibroblasts. We performed a retrospective cohort study of 43 patients undergoing open fasciectomy for Dupuytren's disease from years 2005 to 2012 at our academic institution. Standard fasciectomies of the affected palmar and digital fascia were performed via Brunner incisions on all patients. Patients in the experimental group had a sheet of acellular dermal matrix (Alloderm; LifeCell, Bridgewater, NJ) sutured into the surgical bed with interrupted absorbable sutures before closure, whereas patients in the control group were not closed with acellular dermal matrix. Patients were then evaluated at follow-up for disease recurrence, defined as presence of Dupuytren's tissue in an area previously operated on with a contracture greater than that recorded following the surgical fasciectomy, or presence of contracture requiring surgery. Among our cohort of 43 patients, 23 (53.5%) were treated with acellular dermal matrix while 20 (46.5%) were not. The median age of our cohort was 66.5 years (range 54-91 years). The median follow-up was 1.8 years. During this follow-up period, recurrence of contracture was observed in 1 of 23 patients in the group receiving acellular dermal matrix, compared to 5 of 20 in the control group (P = 0.045). No differences in the incidence of minor wound complications were observed. Our novel technique of placement of acellular dermal matrix into the wound bed following fasciectomy for Dupuytren's disease may be an important surgical strategy to reduce recurrence rates in patients with Dupuytren's disease.

The incidence of postoperative flare reaction and tissue complications in Dupuytren's disease using tension-free immobilization.

Open fasciectomy represents a standard treatment of Dupuytren's disease. Although patients are commonly immobilized in extension to prevent postoperative contracture formation, immobilizing the extremity under tension may precipitate a flare reaction and scar-related complications. This study explores the incidence of flare reaction and other complications with postoperative tension-free splinting after fasciectomy for Dupuytren's contracture. We retrospectively reviewed patients' charts that consisted of 228 procedures in 191 patients who underwent surgery by the senior author between 2000 and 2010. Postoperative notes were reviewed for wound healing problems, scar appearance, flare reaction, and complications. The grading system defined by Evans et al. was used to standardize flare reaction and scar complications. Using tension-free splinting, the incidence of flare reaction was 3.5% (8/228). The eight patients that had flare reactions had mild involvement, and no severe reaction was observed. Fifteen patients had hypertrophic scars, eight had hypersensitive scars, and six had recurrent contractures. The incidence of flare reaction using tension-free immobilization postoperatively was low in our study. According to our findings, wound healing problems are rare when tensionless splinting is utilized. Type of study/level of evidence Case series, Level IV, Therapeutic study.

Dupuytren's contracture: an analysis of outcomes of percutaneous needle fasciotomy versus open fasciectomy

Percutaneous needle fasciotomy (PNF) is a minimally invasive technique used to manage Dupuytren's contracture. We compared outcomes of PNF versus open fasciectomy (OF) to examine the suitability of PNF in Australia. A retrospective cohort study using two questionnaires regarding Dupuytren's treatment was used to assess patients with uncomplicated primary disease. The primary outcomes were immediate and medium-term correction of contracture (2-year mean follow-up to time of survey). Secondary outcomes were patient satisfaction and complications including tendon/nerve injury, infection, skin necrosis and vascular damage. One hundred fifty-five out of 191 surveys were returned (81%). The final analysis included 125 cases (65%), 73 PNF and 52 OF. No significant differences were observed between both groups with regards to follow-up time, gender, smoking status, co-morbidities or preoperative deformity grade. No significant differences were observed in terms of immediate or medium-term deformity correction, tendon/nerve injury or circulatory complications. The postoperative infection rate was higher with OF, with these patients 7.57 (95% confidence interval 1.56, 36.77; P = 0.01) times as likely to have a postoperative infection as patients undergoing PNF. A higher number of patients who underwent PNF were told that they would require another operation (30% versus 12%; P = 0.02). Satisfaction scores were similar (OF 33.2 versus PNF 32.6; P = 0.82). The OF and PNF procedures provide comparable deformity correction for uncomplicated primary Dupuytren's disease in the immediate perioperative period. The reduced side effect profile of PNF should prompt surgeons to consider incorporating it in their practice for the first-line management of uncomplicated primary Dupuytren's disease.

Cost Comparison of Open Fasciectomy Versus Percutaneous Needle Aponeurotomy for Treatment of Dupuytren Contracture

Many surgical options exist for the treatment of Dupuytren contracture. Little has been written regarding their financial implications. The purpose of this study was to compare the immediate direct costs of open fasciectomy to percutaneous needle aponeurotomy (NA) for the surgical treatment of Dupuytren contracture. A retrospective review was performed comparing patients treated with open fasciectomy (group 1) to patients treated with percutaneous NA (group 2) for the treatment of Dupuytren disease from 2008 to 2010. Financial and medical records were reviewed. Direct cost of treatment was calculated from hospital billing records, including surgical, anesthesia, and facility fees. Statistical analysis was performed using unpaired t test. Twenty-four patients received open segmental palmar and/or digital fasciectomy (group 1). Average preoperative metacarpophalangeal joint flexion contracture was 30 degrees, and proximal interphalangeal joint flexion contracture was 42 degrees. Group 2 consisted of 24 patients. Average preoperative metacarpophalangeal flexion contracture was 31 degrees, and proximal interphalangeal flexion contracture was 27 degrees. Mean cost for group 1 was $11,240 and mean cost for group 2 was $4657 (P < 0.0001). Immediate postoperative contracture correction was similar between both. Two complications occurred in group 1 (wound dehiscence and nerve injury); no complications in group 2. Percutaneous NA is associated with decreased direct costs in the short-term compared to traditional open fasciectomy with comparable deformity correction.

Dupuytren’s Disease

Dupuytren's disease is a benign contractile disorder of the hand. The condition commonly affects older men of Celtic descent. Although fibroproliferation and collagen alteration play a role in its etiology, defining a cause remains elusive. Nonoperative intervention for advanced disease has shown only short-term benefit. Therefore, open fasciectomy has become the mainstay of treatment. Associated morbidity and recurrence have prompted investigation into less invasive techniques, including needle aponeurotomy and enzymatic fasciotomy. Data from phase III studies using injectable collagenase are changing treatment algorithms. Postoperative rehabilitation includes nighttime splinting and immediate active range of motion exercises to facilitate return to function.

Dupuytren Disease: An Evolving Understanding of an Age-old Disease

Dupuytren disease, a clinical entity originally described more than 400 years ago, is a progressive disease of genetic origin. Excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia; the resultant digital flexion contractures may severely limit function. The pathophysiology is multifactorial and remains a topic of research and debate. Genetic predisposition, trauma, inflammatory response, ischemia, and environment, as well as variable expression of proteins and growth factors within the local tissue, all play a role in the disease process. Common treatments of severe disease include open fasciectomy or fasciotomy. These procedures may be complicated by the complex anatomic relationships between cords (pathologic contracted fascia) and adjacent neurovascular structures. Recent advances in the management of Dupuytren disease involve less invasive treatments, such as percutaneous needle fasciotomy and injectable collagenase Clostridium histolyticum. Postoperative management focuses on minimizing the cellular response of cord disruption and maximizing range of motion through static or dynamic extension splinting.

Percutaneous Fasciotomy for Dupuytren's Contracture

Needle aponeurotomy (percutaneous needle fasciotomy) for Dupuytren's contracture can be performed in the office setting with local anesthesia. It is simple and inexpensive and has a low complication rate and rapid recovery compared with open fasciectomy. It can usually be repeated safely and effectively for recurrent disease.

THE PROGNOSIS OF FASCIECTOMY FOR ABDUCTOR DIGITI MINIMI AND PRETENDINOUS CORDS IN DUPUYTREN'S DISEASE OF THE LITTLE FINGER

Thirty-nine consecutive patients with little finger Dupuytren's contracture underwent open fasciectomy. Diseased abductor digiti minimi (ADM) pretendinous (PT) cords were identified. The mean pre-operative PIPJ contracture was 77 degrees in the PT group and 66 degrees in the ADM group. Mean residual deformity was 12 degrees in the PT group and 9 degrees in the ADM group. At six months, ten out of 27 patients had developed a recurrent deformity in the PT group (mean 24 degrees ) and seven out of 11 in the ADM group (mean 18 degrees ). There was no statistically significant difference between the two groups at any stage. Dupuytren's contracture of the little finger is as a result of an ADM cord in 29% of cases. In this series it led to an isolated contracture of the PIPJ in the majority of cases and rarely affected the MCPJ. Disease of the ADM cord was not associated with a difference in contracture or prognosis compared to a PT cord.

Diagnosis and management of chronic compartment syndrome

Background. This article describes the diagnosis and management of chronic compartment syndrome and functional popliteal entrapment syndrome, unusual causes for claudication in young adults. Methods. A total of 276 patients (<50 years old) with isolated muscle cramping, swelling, and plantar paresthesia were routinely evaluated with compartment pressures (normal < 15 mm Hg), stress plethysmography, and selectively evaluated with pulse volume recordings and arteriography. Results. Patients were young (mean 28.4 years) with long-standing symptoms (mean 24 months), affecting 1 or both lower extremities (32% vs 68%, respectively). Of the patients, 84 were male (30%) and 192 were female (70%). Common symptoms were isolated muscle cramping (100%) or swelling (40%), and plantar paresthesia (20%). Of 436 treated compartments, 316 were anterolateral, 70 deep-posterior, and 50 superficial-posterior. Mean compartment pressure was 28 mm Hg. Resting pulse volume recordings were abnormal in 6 patients (2.5%); 82 had positive popliteal entrapment tests (30%), but symptoms were present in only 21 (9.7%). Open fasciectomy was performed in all patients with chronic compartment syndrome or functional entrapment. Local anesthesia was used in 243 (88%) and general in 33 patients (12%). Mean follow-up was 60 months. Of the 276 patients, 92% had full relief of symptoms and returned to normal daily or athletic activity. Eight percent obtained symptomatic relief, but activity was limited because of new compartment symptoms or other orthopedic injury. Conclusions. Open fasciectomy for chronic compartment and functional entrapment syndromes is effective therapy. (Surgery 2002;132:613-9.)

Chronic compartment syndrome. An unusual cause for claudication.

Chronic Compartment Syndrome (CCS) is usually caused by overuse injury in well-conditioned athletes (particularly runners). Less common causes of CCS include blunt trauma, venous insufficiency, and tumor. CCS is clinically manifested as claudication, tightness, and occasional paresthesia. Unlike other forms of overuse injury (tendonitis, stress fracture), CCS does not respond to rest, anti-inflammatory medications, or physical therapy. The diagnosis of this condition is confirmed by elevated compartment pressures (normal less than 15 mmHg; CCS greater than 20 mmHg). The only effective treatment is surgical compartment release. Two hundred nine patients have been surgically treated for CCS, 100 by subcutaneous fasciotomy (group I) and 109 by open fasciectomy (group II). These procedures were usually performed in ambulatory surgery using local anesthesia. Patients treated by open faciectomy instead of subcutaneous fasciotomy had fewer early postoperative wound complications (6% vs. 11%) and fewer late recurrences (2% vs. 11%).