Severe Contractures of the Proximal Interphalangeal Joint in Dupuytrenʼs Disease: Combined Fasciectomy with Capsuloligamentous Release Versus Fasciectomy Alone

Abstract

Severe proximal interphalangeal joint contracture in Dupuytren's disease presents a frustrating problem for hand surgeon. Some surgeons argue for fasciectomy alone, avoiding violation of the proximal interphalangeal joint, which may prolong morbidity and result in permanent limitation of flexion; this loss of flexion can be more disabling than a mild flexion contracture. Others favor capsulotomy in addition to fasciectomy, especially for severe contractures, to obtain additional release, arguing that one cannot completely correct secondary contracture by fasciectomy alone. We performed a retrospective review of severe flexion contractures (60 degrees or greater) involving 42 proximal interphalangeal joints in 28 patients with Dupuytren's disease. Twenty-seven joints in 18 patients underwent fasciectomy alone, and 15 joints in 10 demographically similar patients underwent capsulotomy in addition to fasciectomy. In the noncapsulotomy group, preoperative contracture averaged 78.4 degrees. Postoperative contracture averaged 36.6 degrees, with a 53 percent improvement. In the capsulotomy group, preoperative joint contracture averaged 82.5 degrees. Postoperative contracture averaged 36.8 degrees, with a 55 percent improvement. Intraoperative residual contracture for 21 of the 27 joints in the noncapsulotomy group averaged 7 degrees compared with 8 degrees for 9 of the 15 joints in the capsulotomy group. Preoperative proximal interphalangeal joint flexion averaged 100.6 degrees in the noncapsulotomy group and 98.6 degrees in the capsulotomy group. Postoperative flexion averaged 92.2 degrees in the noncapsulotomy group, which was 91.7 percent of preoperative flexion, and 82.7 degrees, which was 83.9 percent of preoperative flexion, in the capsulotomy group. No statistically significant difference was seen in the percentage of contracture correction in the capsulotomy group compared with the noncapsulotomy group at follow-up. The degree of correction initially obtained at surgery using either method was not maintained during the short follow-up period. There was a significant decrease in postoperative proximal interphalangeal joint flexion compared with preoperative flexion following either surgical approach; however, there was no significant difference between the two groups with respect to the percentage of flexion lost. Complications developed in both groups but tended to occur more commonly in the capsulotomy group. This study failed to show any advantage to capsuloligamentous release in addition to fasciectomy in treating severe proximal interphalangeal joint contracture due to Dupuytren's disease.

Predicting the Outcome of Surgery for the Proximal Interphalangeal Joint in Dupuytren’s Disease

“…Some researchers 11 have suggested that joint release is not useful, but in that study the patients were not randomized and may have been subject to selection bias. More recently, when studying patients with PIPJ flexion deformity of at least 60°, patients who achieved full correction at the time of surgery had an almost identical final residual deformity (15°) at 6 months when compared with those requiring joint release (16°) to improve residual preoperative deformity after fasciectomy.…”

Severe Contracture of the Proximal Interphalangeal Joint in Dupuytren’s Disease: Does Capsuloligamentous Release Improve Outcome?

“…This study failed to report proximal interphalangeal joint extension after excision of the diseased fascia and after capsuloligamentous release. Weinzweig et al (1996) performed a retrospective review of flexion contractures (601 or greater) involving 42 proximal interphalangeal joints in 28 patients with Dupuytren's disease. Twenty-seven joints in 18 patients underwent fasciectomy alone, and 15 joints in 10 similar patients underwent capsulotomy in addition to fasciectomy.…”

“…This is as secondary contracture of the joint capsule and ligaments can prevent complete correction of the deformity. Some surgeons feel that at least partial division of the capsuloligamentous structures should be done to correct the joint contracture (Rives et al, 1992;Watson et al, 1979;Weinzweig et al, 1996), while others advice against capsulotomy, arguing that any benefit will be short-lived, and that the surgical assault will cause further scarring and contracture (Hueston, 1991;McFarlane, 1974). This prospective study assesses whether patients with severe proximal interphalangeal joint contractures due to Dupuytren's disease which does not correct with fasciectomy alone benefit from an additional capsuloligamentous release.…”

Simultaneous Regional Fasciectomy, Skin Grafting, and Distraction Arthrolysis of the Proximal Interphalangeal Joint for Dupuytren’s Contracture of the Little Finger

“…1,2) We have generally performed regional fasciectomy because needle fasciotomy alone is associated with a higher recurrence rate, together with primary wound closure (or skin grafting) because it causes less soft tissue contracture, gentle passive manipulation of the PIP joint to avoid complications, and immobilization of the PIP joint with Kirschner wire to restore the extensor tone. [1][2][3][4] Despite these measures, we do not always achieve satisfactory maximum active extension and painless postoperative PIP joint motion, especially when the little finger is severely affected.…”