Open Palm Technique in Dupuytren's Disease Treatment.

OBJECTIVE: To evaluate the results of the open palm technique for the treatment of Dupuytren's disease.
METHOD: The authors used the technique described by McCash. Twelve patients (13 hands) were surgically treated, between october 2002 and september 2011.
RESULTS: The wounds healed in a medium of 25 days (variation of 17 to 30 days). There were no complications, such as infection, haematoma formation, skin necrosis, residual edema.
CONCLUSION: The open palm technique remains a safe alternative for the treatment of Dupuytren's disease, with satisfactory results and low risk of complications.

Introduction

Palm aponeurosis, also known as Dupuytren's disease, was initially described by Felix Platter in 1614. However, according to Rayan, Dupuytren was responsible for describing the anatomical characteristics of the disease that remains named after him in 1831.

The disease is most common in Caucasian men. It is more prevalent in North America than in South America, and it is rare in China and Africa. Reis and Mota Júnior demonstrated a relationship between Dupuytren's disease and diabetes.

Myofibroblasts, a cell type described by Gabbiani and Majno, have the morphological characteristics of fibroblasts and smooth muscle cells, and they are currently considered the determinant of Dupuytren's disease.

Although recent research has sugg ested the local administration of substances such as collagenase and corticosteroids for the non-surgical treatment of Dupuytren's disease, surgery is still the most used method.

Among the several surgical techniques employed to treat Dupuytren's disease, the one described by McCash is characterized by its simplicity and low rate of complications. This report evaluated the results obtained in patients suffering from Dupuytren's disease who were treated with the open palm technique.

Method

From October 2002 to September 2011, 12 patients (13 hands) suffering from Dupuytren's disease underwent surgery. The patients’ ages ranged from 33 to 81 years old (average 64 years old). Two patients were female (17%), and one was of African descent (8%; the patient considered him/herself a Caucasian). Of the 13 hands that underwent surgery, 6 were (46%) left hands, and 7 were right hands (54%).

A single finger was affected in 69% of the hands (nine cases). Of these cases, 56% were on finger IV (on five hands), and 44% were on finger V (four hands). Two fingers were affected in four cases (31%), including fingers IV and V (two hands), III + IV (25%) and I + V (25%). Patient 5 had finger V involvement on both hands (the only bilateral case in our sample). In general, fingers I and III were affected in 8% of the hands, finger IV in 54%, and finger V in 54%.

Flexion deformity of the metacarpophalangeal joint greater than 30 degrees and/or deformity of the proximal interphalangeal joint greater than 15 degrees were present in all hands that underwent surgery. Chart 1 shows the general data of the patients.

Chart 1

General patient data.

All patients underwent surgery under block anesthesia with member ischemia.

The surgical technique used was previously described by McCash. The affected tissue was removed through a transverse incision in the region of the distal palm crease, which allowed the correction of the flexion deformity of the metacarpophalangeal joint. When necessary, another transverse incision was performed proximally to the first to facilitate the resection of the affected tissue. Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5 illustrate the clinical case of patient number 2. As shown in Fig. 1, Fig. 2, a flexion contracture was present in finger IV with a clearly observable longitudinal cord. Fig. 3 shows the access pathway used in the McCash technique, and the pathological tissue is evident. Fig. 4, Fig. 5 demonstrate the postoperative evolution of the wound, with complete healing 25 days after the surgery and the absence of functional restriction of the patient's hand.

Fig. 1

Patient number 2, preoperative. Finger IV affected, anteroposterior view.

Fig. 2

Patient number 2, preoperative. Finger IV affected, profile view.

Fig. 3

Patient number 2, perioperative, with identification of the longitudinal cord.

Fig. 4

Patient number 2, 25 days postoperative, with complete extension of the finger.

Fig. 5

Patient number 2, 25 days postoperative, with finger in flexion, demonstrating pulp-palm with minimum functional deficit.

In three digitus annularis and three little fingers, the flexion deformity of the proximal interphalangeal joint was due to a disease nodule located at the proximal digital crease. In these cases, the nodule was resected through a transverse incision at the proximal digital crease. After removal of the tourniquet, the hemostasy revision was performed, and the open wounds remained, including those on the digitals, when present; the hand was immobilized with a plaster splint, and the fingers were kept stretched. The splint was removed on the fifth postoperative day and replaced by a dry gauze bandage covered by a crepe bandage. The patients were then advised to actively move their fingers, and the bandage was replaced weekly until the wounds closed.

Results

The wounds closed in an average period of 25 days, with a range of 17 to 30 days (Table 1). Infection, hematoma, skin necrosis, residual edema, and other local complications were not reported. In 12 hands (92% of the patients), the deformities were completely corrected, with no limitation of the arc of movement of the joints involved at the end of treatment.

Table 1

The time required for wound closure for each patient.

Patient	Closure Time (days)
1	17
2	25
3	27
4	23
5	28
5	25
7	25
8	30
9	22
10	26
11	29
12	25
13	27
Mean	25

In one of the patients (8%) with unilateral disease, the flexion deformity of the proximal interphalangeal joint of finger V exceeded 90 degrees and was treated by resection of the fibrous tissue through a skin incision and multiple z-plasty. The palmar wound was left open and healed in 22 days, but the deformity of the proximal interphalangeal joint was not corrected.

Considering the severity of the deformity and the functional aspect of the hand, finger V was amputated after receiving the patient's approval.

Discussion

Dupuytren's disease is associated with the presence and activity of myofibroblasts, which have the features of both fibroblasts and smooth muscle cells following differentiation. They were originally described by Gabbiani and Majno and later studied by Tomasek et al. Myofibroblasts produce the glycoprotein fibronectin, which binds the cells together and to the extracellular matrix of the stroma. This process, which is associated with the contracture capacity of these cells, results in the formation of nodules and cords in the palm and digital aponeuroses and in the development of flexion deformity of the proximal interphalangeal and metacarpophalangeal joints, which together characterize Dupuytren's disease.10, 11

To treat Dupuytren's disease, the literature suggests several methods, including the local injection of agents such as calcium-channel blockers 9 (verapamil and nifedipine) and lytic enzymes (trypsin and hyaluronidase) in combination with the placement of the fingers in forced extension to liberate the adherences. Surgical treatment is the most used method, and it is indicated when the flexion deformities of the proximal interphalangeal and metacarpophalangeal joints exceed 30 and 15 degrees, respectively.

Some authors recommend percutaneous needle fasciotomy as a minimally invasive procedure for treatment of the disease.14, 15, 16, 17 However, these studies have demonstrated a higher rate of recurrence after this type of procedure, which makes it more appropriate for elderly patients or patients who accept a possible early recurrence of the disease and, eventually, the deformity.

All patients included in this study were surgically treated with the open palm technique. In 1984, one of the authors (MCM) published a study of 10 patients (total of 16 hands) with Dupuytren's disease who underwent surgery using the open palm technique; that study demonstrated results similar to those presented herein. As reported by Schneider et al. in a review of 49 patients, the open hand technique results in a less painful postoperative period, better mobility of the fingers, and a lower rate of complications. Lubahnn recommended this technique and reported a complication rate of 8% in the initial postoperative period, without infections. In the long term, Lubahnn reported that 20% of patients experienced residual contracture compared to 42% for patients treated by suturing the operative wounds.20, 21

Galbiatti et al. reported satisfactory results in the treatment of nine patients with the use of a straight incision in the palm of the hand, which was transformed during z-plasty when the wound was closed. All patients were male with a mean age of 54.2 years old, and 77% were Caucasian. In our study, we obtained similar results, without any concern for skin suturing.

Freitas et al. observed ten patients treated with the open palm technique and verified that the average period for wound closure was 25 days, with a range of 15 to 45 days. In a sample of 30 patients, Silva et al. found the same average duration for closure, but they reported a range of 20 to 40 days. Among our patients, the average time to closure was 25 days, with a range of 17 to 30 days, which in is in general accordance with the literature. A similar finding was observed by Skoff, who reported an average of 40 days to wound closure in patients who underwent open palm surgery. In addition, he observed the complete correction of flexion deformities of the proximal interphalangeal and metacarpophalangeal joints.

In an analysis of 100 patients with a mean age of 52 years, including 88 men, Barros et al. found that the digitus annularis (finger IV) and the little finger (finger V) were affected in 60% of cases and that the thumb (finger I) was involved in 25%. We observed a similar distribution, with fingers IV and V being the most commonly involved.

In one of our patients, flexion deformity of the proximal interphalangeal joints exceeded 90 degrees and could not be corrected with z-plasty. After palmar wound closure, the little finger was amputated for functional reasons.

Conclusion

We conclude that the open palm technique is a safe option to treat Dupuytren's disease and that it offers satisfactory results with low complication rates.

Conflict of Interest

The authors have no conflict of interest to declare associated with this paper.