Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Nonmicrosurgical Techniques
Osteoplastic Reconstruction
Osteoplastic thumb reconstruction is the combination of a bone graft and a skin flap to provide soft tissue
coverage over the bone graft. The classic description is an iliac crest bone graft and a pedicled groin flap
either in separate (flap followed by graft) or in the same operation. 29,30 These techniques require
immobilization for several weeks prior to flap division at the groin. Pedicled flaps from the forearm
including the posterior interosseous osteocutaneous and radial forearm osteocutaneous flaps are
alternative single stage options. However, this approach does not provide sensibility to the reconstructed
thumb and is often augmented with a heterodigital neurovascular island flap at a later operation. Though
good functioning of these reconstructions is reported, 31,32 the bulky appearance, bone graft resorption,
need for multiple stages, and issues with double sensitivity limit the use of this procedure. One stage
sensate osteoplastic reconstruction has been reported 33,34 (Figure 84.3). Though these operations do not
require microvascular anastomosis, the complexity of the dissection is significant and provides inferior
results compared to microsurgical techniques. 35
FIGURE 84.3 A. Delayed presentation of a ring avulsion of thumb with necrosis of underlying phalanges. B, C. Sensate,
osteocutaneous radial forearm flap to reconstruct a thumb post.
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Distraction Lengthening
Matev described distraction lengthening to reconstruct proximal thumb amputations. 36 The technique
involves an osteotomy in the metacarpal and placement of an external distractor to lengthen the
metacarpal up to 3 cm. The residual defect is left to undergo spontaneous osteogenesis and consolidation
or an autologous bone graft can be placed into the defect. A good soft tissue envelope is required at the
tip of the thumb to withstand the stress of the process. This technique requires significant patient
compliance and can take more than 6 months until a stable construct is complete. Additional soft tissue
procedures may be required to provide a durable tip or to deepen the effective webspace.
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Microsurgical Reconstruction
Numerous microsurgical options exist for proximal phalanx amputations. Sensate osteocutaneous free
flaps such as the radial forearm, lateral arm, or superficial circumflex iliac artery flaps can reconstruct the
thumb but may require secondary debulking. As with distal thumb injuries, toe-to-thumb transfers have
the advantage of a single-stage reconstruction and can be tailored to optimally restore a functional and
aesthetic thumb. Options from the great and second toe are acceptable. Details of flap options, anatomy,
dissection, and donor site considerations are discussed later.
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Amputation Through the Metacarpal but With a Preserved TM Joint
These injuries represent a complete loss of the thumb post and require a significant amount of bone and
soft tissue. The preserved basilar joint provides stability to the thumb and may provide some degree of
abduction and opposition; however, secondary opposition transfers may be required to optimize its
function. Additionally, secondary regional flaps or free tissue transfer may be required in injuries that
compromise the first webspace.
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Nonmicrosurgical Techniques
Osteoplastic reconstruction and distraction lengthening may be options for distal metacarpal
amputations, though they will lack an MP joint and serve mostly as a post. Distraction lengthening
requires that the majority of the metacarpal remains for placement of the external fixator. Additionally, as
the maximum amount of length gained is only 3 cm, it is not likely to adequately create a functional
thumb except in the most distal injuries. In proximal metacarpal amputations, osteoplastic reconstruction
and distraction lengthening are most successful in combination with other methods such as transfer of an
injured index finger ray or microsurgical toe-transfer.
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Index Finger On-Top-Plasty
The transfer of an adjacent finger to the thumb position on its intact neurovascular pedicle is called a
pollicization (see discussion later). When transferring a partial digit to add length to the reconstructed
thumb, the term on-top-plasty may be more appropriate. Transfer of an already injured index finger can
provide length and sensate soft tissue to reconstruct distal transmetacarpal thumb injuries without the
need for microsurgical techniques. With a preexisting injury to the index finger, there may be minimal
morbidity to overall hand function; with a fully functioning index finger, loss of grip strength and the
resulting three-finger hand provide inferior results when compared to toe-transfer. 37 On-top-plasty may
be a suitable option in patients for whom toe-transfer is contraindicated due to comorbidities or the
patient’s wishes. It may also be a useful adjunct to add length to the proximal thumb in combination with
toe-transfer techniques.
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Microsurgical Techniques
Toe-to-thumb transfer represents the standard of reconstruction for complete thumb amputations
proximal to the MP joint. In distal transmetacarpal injuries, great toe and second toe transfers can provide
adequate length and function. However, in more proximal injuries, transfer of the great toe is not an
option due to the need to preserve the entire first metatarsal. Transfer of the great toe in these cases will
require adjunctive procedures to add metacarpal length in combination with toe-transfer. Details of flap
options, anatomy, dissection, and donor site considerations are discussed later.
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Amputation With Destruction of the TM Joint
Amputation of the entire thumb metacarpal with loss of the TM joint is a difficult problem with limited
reconstructive options. In these cases, special attention to the creation of a stable post with appropriate
position relative to the remaining fingers is crucial. These injuries also involve the first webspace and may
require regional or free tissue transfer procedures to provide adequate soft tissue for thumb
reconstruction and the first webspace.
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Pollicization
Pollicization of the index finger (or rarely the long finger) is the best option for reconstruction of these
proximal injuries 38 (Figure 84.4). The finger metacarpal is fixed to the scaphoid or the proximal index
finger metacarpal base with the MP joint hyperextended to create a TM joint analog. Care to properly
position the finger is paramount so it can oppose the remaining fingers. With traumatic thumb
amputations, the radial aspect of the index finger is often involved and special consideration must be
taken to ensure adequate vascularity to the ulnar aspect of the digit and dorsal veins if microsurgical
techniques are to be avoided. 39 Vascularized soft tissue augmentation at the base of the thumb or in the
first webspace may be required. Children accommodate extremely well to pollicization in congenital and
traumatic cases; however, adults may require a prolonged period of retraining and secondary procedures
to optimize the function.
FIGURE 84.4 A, B. Amputation of the thumb just distal to the TM joint, with some stiffness of the index finger. C, D. Patient
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elected to undergo pollicization. E, F. Postoperative results were excellent.
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Second-Toe Transfer
Second-toe transfer has been used as an alternative to reconstruct these proximal thumb amputations
when pollicization is not an option due to injury to the index finger. 40,41 As much as 5 cm of the second
metatarsal may be required to provide adequate length but this has limited donor site morbidity. Motion
of the reconstructed thumb will be limited to the MTP and IP joints of the thumb, and so special care is
needed to properly orient the thumb to oppose the remaining digits. Fixation can be performed to the
distal scaphoid or remaining trapezium. Staged reconstruction with a soft tissue flap prior to toe-transfer
is usually required to provide coverage for the toe-transfer and new thumb ray.
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Toe-to-Thumb Reconstruction
The great and second toes provide a multitude of flap options to reconstruct thumb injuries. As discussed
previously, this includes isolated thumb pulp soft tissue defects all the way to reconstruction of the entire
thumb. All of these flaps are based on the blood supply to the first webspace of the foot, usually from the
first dorsal metatarsal artery (FDMtA). There is significant variability in the arterial supply to the first and
second toes from the FDMtA and detailed knowledge of this anatomy is crucial to successful transfer. 42
The dominant vascular pedicle can be identified in the first webspace and dissected retrograde without
the need for preoperative imaging. 43 One or both of the proper digital nerves and the dorsal nerves are
included for neurorrhaphy depending on the flap design. The venous drainage of these flaps is most
often the terminal branches of the saphenous vein harvested from the dorsal foot.
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Great-Toe Transfer
Great-toe transfer involves isolating the great toe on the FDMtA. Flap harvest is limited to the proximal
phalanx of the hallux, preserving at least the entire head of the first metatarsal to avoid uneven plantar
weight distribution and unsteady gait. With sacrifice of the great toe, there will be some decrease in push-
off strength during ambulation but this is generally well-tolerated. The great toe will appear as a short
and broad thumb but has excellent functional outcomes.
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Wrap-Around Great-Toe Transfer
The wrap-around toe-transfer is a modification of the great toe flap to preserve all or most of the hallux to
avoid donor site morbidity and create a more normal size and contour to the reconstructed thumb. The
flap is harvested as an onychocutaneous flap and can include a portion of the distal phalanx. The majority
of the toe phalanges and a strip of plantar skin and soft tissue are left behind and the donor site defect
reconstructed with a skin graft. The flap is then wrapped around a degloved thumb or a bone graft as in
traditional osteoplastic techniques.
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Trimmed Great-Toe Transfer
The trimmed great-toe transfer is another modification of the standard great-toe transfer designed to
improve the appearance of the reconstructed thumb. In this case, the medial skin and dissected off the
trimmed-toe flap and a longitudinal osteotomy were performed to remove 2 to 4 mm of the medial
phalanges and 4 to 6 mm of the medial prominence at the IP joint. The remaining skin flap is then
trimmed and draped over the remaining bone prior to transfer. 44 This technique allows the surgeon to
most closely replicate the natural size of the thumb (Figure 84.5). However, due to the longitudinal
osteotomy through the IP joint there is some loss of range of motion.
FIGURE 84.5 A. Amputation of the thumb distal to the MP joint. B, C. The patient underwent trimmed toe-transfer for
reconstruction. D, E. Postoperative appearance and function were excellent.
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Second-Toe Transfer
The second-toe transfer is an alternative to the great-toe transfer with several advantages. The second toe
donor site decreases morbidity to the foot relative to sacrifice of the hallux. The second-toe transfer can
also include the majority of the second metatarsal allowing for reconstruction of transmetacarpal thumb
amputations. However, the second toe will least resemble a normal thumb in terms of its size and shape.
Additionally, the second toe is prone to clawing with hyperextension of the MP joint and flexion of the IP
joint and may require capsular procedures to maximize function. 26
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Twisted-Toe Transfer
The twisted-toe transfer is a flap combining tissue from both the great and second toes based on the
common FDMtA pedicle. An osteoonychocutaneous flap similar to a trimmed toe is harvested from the
lateral great toe and a cutaneous flap is harvested from the medial second toe. The second toe flap is then
twisted on its pedicle to cover the exposed medial aspect of the great toe flap. 45,46 The advantages of this
flap are the creation of a more normal sized thumb and the donor site closure can recreate a neo-hallux to
minimize donor site morbidity.
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Toe Pulp and Distal Trimmed Toe-Transfer
Sensate cutaneous flaps can be harvested from the great and second toes to reconstruct isolated thumb
pulp defects. Most often the lateral great toe pulp and medial second toe are selected. 27 These flaps can
include portions of the distal phalanx and or nail matrix in a customized fashion to directly reconstruct
partial tip amputations, providing optimal aesthetic and functional results. 28,45 Donor sites can be closed
primarily, with a skin graft, or amputation of the distal phalanx of the toe. Because of the preservation of
most of the donor toes, morbidity is minimal (Figure 84.6).
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FIGURE 84.6 A, B. Partial thumb fingertip amputation with loss of the ulnar pulp. C–E. The patient underwent reconstruction
with toe-pulp transfer from the ipsilateral great toe. F, G. The postoperative appearance is satisfactory at 3 months with slight
contracture of the IP joint but return of protective sensation. H, I. Minimal donor site morbidity after delayed healing of first
webspace incision.
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Toe-Transfer Donor Site Morbidity and Outcomes
Donor site complications from toe transfers are common. As much as 35% of patients will have some
degree of incisional dehiscence or delayed wound healing. Preservation of the head of the first metatarsal
is mandatory to avoid irregular plantar pressure and wear. When the MP joint of the hallux is preserved,
both great and second toe transfers have some degree of gait changes, though this is well tolerated in the
majority of patients. Additionally, patients with great-toe wrap around transfers have demonstrable
changes in gait. 47 Considering this, the major disadvantage of the great-toe transfer relative to the
second-toe transfer, with regards to the donor site morbidity, is the change in appearance of the foot and
the effect on future footwear (e.g., inability to wear sandals). The twisted-toe technique may minimize
these donor site issues.
The survival of toe-transfer techniques is greater than 95% in most series. However, patients must accept
the potential loss of the toe-transfer prior to proceeding with this invasive surgery. Functional outcomes
of toe-transfer techniques are excellent with good ROM, 70% to 85% grip strength relative to the
contralateral side and static 2PD averaging 10 mm. The standard teaching is that the great-toe transfer
will result in a stronger and more stable thumb relative to second toe. However, when amputations distal
to the MP joint are compared, there are no statistically significant differences between techniques. 48 The
decrease in strength seen in some series of second toe transfers may be due to the loss of thenar
musculature in proximal amputations where the second toe is required.
In selecting the best option for toe-transfer in thumb amputations, there are several important factors for
the surgeon to consider. For injuries in the proximal metacarpal, the second toe is the best option due to
the need for additional bony length. The second toe is also preferred in the middle and distal metacarpal
amputations; however, these may be salvaged with a great-toe transfer in combination with another
method to lengthen the metacarpal. The second important factor is the surgeon’s comfort level with the
various techniques. The great-toe wrap around, trimmed, and twisted-toe techniques add another layer of
complexity onto an already difficult operation. Finally, the surgeon should discuss the donor site
morbidity, foot appearance, and the appearance of the reconstructed thumb (Figure 84.7) with the patient
and help the patient decide on the best option.
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FIGURE 84.7 Diagram depicting the thumb and donor site appearance after great and second toe transfers.
(From Lin, PY, Sebastin, SJ, Ono, S, et al. A systematic review of outcomes of toe-to-thumb transfers for isolated traumatic thumb amputation. Hand.
2011;6(3):235-243. Copyright © American Association for Hand Surgery.)
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Conclusion
Thumb reconstruction is a challenging area of hand surgery due to the functional and aesthetic
requirements. However, the rewards for both the patient and surgeon after restoring function to an
injured hand are far greater. The evolution of thumb reconstruction since the 19th century demonstrates
the ingenuity of surgeons who advanced medical knowledge and technology in hand and plastic surgery,
all with the goal to make a thumb. 30 Many of the early techniques are still relevant today. However, with
increasing experience in microsurgical reconstruction, toe-to-thumb transfer is now the gold-standard as
it provides optimal aesthetic and functional outcomes.
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Questions
1. A 34-year-old right hand dominant mechanic presents to clinic to discuss options for hand
reconstruction. One year earlier he had a significant injury to his right hand from fireworks that
resulted in the amputation of his thumb and index finger. On examination, he has functional thenar
musculature and approximately 2 cm of thumb metacarpal remaining and a mobile
trapeziometacarpal joint. What is the best option to reconstruct his thumb?
a. Distraction lengthening
b. Great-toe transfer
c. Second-toe transfer
d. Wrap-around toe-transfer
2. A 65-year-old right hand dominant man presents with a volar oblique amputation of the distal
thumb pulp. The distal phalanx and FPL insertion are exposed within a 2 × 2 cm wound. A Moberg
flap is planned. What is the most likely outcome of this reconstructive technique?
a. Interphalangeal joint flexion contracture
b. Lack of functional sensibility
c. Unaesthetic appearance of the reconstructed thumb
d. Flap failure
3. A 32-year-old left hand dominant pianist presents to clinic 3 months after a distal thumb
amputation that was treated with a composite graft from the amputated part during the initial ER
visit. In clinic, she is noted to be missing 1 cm of the distal phalanx with the proximal portion
covered by 2 cm of glabrous skin graft adherent to bone. There is 4 mm of an intact nail and nail
plate dorsally with a hook nail deformity. She would like thumb reconstruction to restore the
appearance and function of her thumb. What is the best reconstructive option to achieve these goals?
a. Moberg advancement flap
b. Germinal matrix ablation and first dorsal metacarpal artery flap
c. Onychoosteocutaneous trimmed toe flap
d. Second toe pulp flap
4. A 48-year-old right hand dominant construction worker presents to the ER 1 hour after a saw
injury to his left hand. The thumb and index finger were amputated through the proximal phalanges,
and the amputated parts were not found. The middle finger is devascularized and has a complex
intra-articular fracture through the PIP joint with significant proximal phalanx comminution and
only a 4 mm dorsal skin bridge remaining intact. The ring and small finger are devascularized with
volar lacerations at the level of the PIP joint but no fractures. What is the best acute operative plan?
a. Revascularization of the middle finger, ring, and small fingers; revision amputation of the
index and thumb
b. Revascularization of the middle, ring, and small fingers; revision amputation of the index and
FDMA flap to cover the remaining thumb
c. Revascularization of the ring and small fingers; revision amputation of the index and middle
fingers, and a skin graft from amputated parts to cover the thumb tip.
d. Revascularization of the ring and small fingers; amputation and heterotopic replantation of
the middle finger to the thumb; revision amputation of the index finger.
5. A 40-year-old right-hand-dominant postal worker suffered a severe crush injury to his right hand
2 years earlier. He required amputation of the thumb and index finger and closure of the wound
with a groin flap. He now presents for thumb reconstruction. He has normal motion of remaining
fingers and a soft, redundant soft tissue flap on the radial aspect of the hand. He has 1.5 cm of the
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thumb metacarpal remaining and some motion with attempted abduction. The patient elects to
undergo second-toe transfer for reconstruction. What secondary procedure will the patient most
likely require to maximize hand function after toe-transfer?
a. First webspace deepening
b. Debulking of the thumb
c. Opponensplasty
d. Distraction lengthening of the reconstructed thumb
1. Answer: c. Due to the significant loss of length in the patient’s thumb, adequate reconstruction will
require significant bone and soft tissue. Distraction lengthening will not be able to achieve this. Out
of the remaining microsurgical options, the second-toe transfer is the only option that can provide
the necessary bony length. During harvest of the second toe, a significant portion of the metatarsal
can be taken without increased donor site morbidity. However, with great toe transfers, the first
metatarsal head must be preserved to prevent destabilization of the foot and gait. Wrap-around toe-
transfer would not provide the necessary bone required for optimal reconstruction.
2. Answer: a. The Moberg flap is a bipedicle advancement flap of the proximal volar thumb skin. It is
very reliable, and because it uses native thumb tissue, it provides near normal sensibility and
appearance to the thumb. However, the maximum distance that it can be advanced is 2 cm and this
often requires IP joint flexion during inset and may result in a flexion contracture.
3. Answer: c. A trimmed great toe flap including portions of the distal phalanx, nail matrix, and skin
with its neurovascular pedicle can restore this patient’s thumb to near normal appearance and
function. The Moberg flap will require significant advancement and result in possible IP joint
contracture. The FDMA flap and germinal matrix ablation will provide soft tissue to the tip of the
thumb and correct the hook nail deformity but result in an abnormal appearing thumb without a
nail. A second toe pulp flap would create durable and sensate soft tissue to the tip but would not
restore length to the thumb or the nail.
4. Answer: d. In multiple digit amputation and mangled hand injuries involving the thumb,
reconstruction of the thumb takes top priority. In this case, the amputated thumb and index finger
are not available for replantation. The thumb is amputated through the proximal phalanx which will
require a reconstructive procedure to restore function. Revision amputation should not be
considered for the thumb. An FDMA flap is not an option given the amputation of the index finger,
and a skin graft will provide an inadequate reconstruction. The middle finger has a severe injury
with a destroyed proximal phalanx and PIP joint. Revascularization of this finger will not result in a
functional digit. However, the finger can be amputated and the distal portion heterotopically
replanted onto the remaining thumb to restore a normal length and near normal function.
5. Answer: c. In thumb amputations in the mid-to-proximal metacarpal, there is loss of the thenar
muscle insertions and function most importantly the abductor pollicis brevis. The opponens pollicis
may provide some motion to proximal metacarpal amputations but will not likely provide adequate
strength and abduction. Opponensplasty may be required to maximize this. The first webspace will
not likely require deepening given the loss of the index finger and presence of durable soft tissue
from a prior groin flap. The second toe does not require debulking to improve appearance or
function. The second-toe transfer provides adequate length even in proximal amputations and would
not require distraction lengthening.
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 1028e-1039e.A detailed discussion of the FDMtA anatomy including important clinical variations. Knowledge of this anatomy is
essential prior to undertaking any toe transfer.
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Foucher, G, Merle, M, Maneaud, M, Michon, J. Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases. Plast
Reconstr Surg. 1980;65(5):616-626.
Kempny, T, Paroulek, J, Marik, V, et al. Further developments in the twisted-toe technique for isolated thumb reconstruction. Plast Reconstr
Surg. 2013;131(6):
 871e-879e.
Sosin, M, Lin, C-H, Steinberg, J, et al. Functional donor site morbidity after vascularized toe transfer procedures. Ann Plast Surg.
2016;76(6):735-742.This systematic review compares donor site morbidity after various toe-transfer procedures. The outcomes are important for the
physician to understand and discuss with patients prior to choosing the best toe-transfer technique for that patient.
Lin, P-Y, Sebastin, SJ, Ono, S, et al. A systematic review of outcomes of toe-to-thumb transfers for isolated traumatic thumb amputation.
Hand. 2011;6(3):235-243.This systematic review compares outcomes of toe-transfer procedures for amputations distal to the MP joint. In general,
outcomes for all toe-transfer techniques are excellent. The surgeon must be aware of these outcomes when discussing options with patients.
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C H A P T E R 8 5
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Dupuytren Disease
Steven C. Haase
Key Points
Dupuytren disease is a chronic condition without a cure.
Disease aggressiveness can be predicted by defined risk factors.
Treatment is indicated for significant contractures and/or disability.
A detailed knowledge of the disease anatomy can mitigate the risk of surgery.
Multiple treatment options are available—treatment decisions should be based on available
evidence, individual patient characteristics, and the surgeon’s clinical experience.
More aggressive (invasive) treatment options may reduce rate of recurrence, but may be
accompanied by increased risk.
Dupuytren disease (DD) is a fibroproliferative disorder affecting the palmar fascia of the hand. In this
disease, new tissue is deposited that deforms normal fascial structures (bands) into pathologic cords. These
cords may contract, causing variable contractures of the fingers and/or palm. Many interventions have
been described to alleviate the disability associated with these contractures, but there is no cure for this
chronic disorder.
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Historical Perspective
Medical history enthusiasts continue to discuss who might have been the first to describe the entity we
commonly refer to as Dupuytren disease. In 1641, Felix Plater of Basel described the case of a stone mason
with ridging of the palmar skin that drew the ring and small fingers down into the palm. Whether Plater
correctly identified the pathologic cause of the condition is still debated—his exact thoughts may be lost
in translation. 1,2
Many credit Henry Cline, Sr., with first describing this condition in 1777; when in the course of lecturing
on anatomy, he dissected two hands to reveal contractures of the palmar fascia. Shortly thereafter, around
1787, he proposed an operative cure by means of palmar fasciotomy, though he had not performed the
procedure on a patient at that time. Cline’s apprentice, Astley Cooper, ultimately went on to join Cline in
practice and publish A Treatise on Dislocations and Fractures of the Joints, in which he eloquently describes
treating these contractures by means of a small incision to divide the implicated cords—a procedure that
sounds much like some of the minimally invasive options used in modern times to treat this condition. 1
Importantly, in this era before the development of anesthesia and antisepsis, very few hand surgeries
were performed for nonemergent conditions.
Baron Guillaume Dupuytren, who eventually secured the eponym for this disease, was a prominent
Parisian surgeon in the early 19th century. As was perhaps typical of a surgeon in his time and place, he
was known for being hard working, but also abrasive. In a famous lecture demonstration in 1831, he
recounted his own surgical success with treatment of palmar contractures and then performed his
surgical procedure on a patient to illustrate the technique. During the lecture, he gave little credit to Cline
and Cooper for their earlier work, and in fact may have misquoted Cooper as stating the disease was
incurable. This lecture was reproduced verbatim in the press, and from that point forward, the eponym
has persisted. 3,4
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Epidemiology
DD has been described in nearly every ethnicity, but it is certainly most prevalent in persons of Caucasian
descent. Studies of DD prevalence may be flawed by difficulty defining the exact study population, or by
variability in making the diagnosis of DD. 5 Therefore, prevalence reports tend to vary widely between
studies. For example, a 2014 meta-analysis of DD prevalence in Western countries found a range from
0.6% to 31.6%. 6 A population-based US study found that the estimate of prevalence varied between 0.5%
and 10.9%, depending on the definition of the disease used. 7 Men are affected more often than women,
with increased prevalence between two- and five-fold. 8 Onset is most common in the sixth decade of life;
beyond the eighth decade, the incidence of DD in men and women becomes nearly identical. 9 Reports of
DD in infants and children are very rare. 10,11
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Nature Versus Nurture
Similar to many other pathologies, DD has both a genetic and an environmental component. Evidence of
the genetic influence was nicely demonstrated in a large study of Danish twins, which found that the
concordance of DD in monozygotic pairs far exceeded that in dizygotic pairs, meaning genetic factors
must be playing a major role. The authors concluded that the heritability of DD was approximately 80%.
12
Basic science researchers continue to search for the genes responsible for DD. Thus far, no single gene has
been implicated, and most scientists believe the exact etiology must be multifactorial. Genome-wide
studies have suggested multiple loci are involved, including several genes in the Wnt signaling pathway
and others related to the MafB oncogene. The Wnt signaling pathway is linked to a range of diseases; of
the nine loci discovered in a genome-wide analysis of DD, six are related to this pathway. 13 The MafB
oncogene has the ability to transform fibroblasts and is abundantly found in DD tissue, where it localizes
to myofibroblasts. 14 Despite ongoing investigations into these genes, there is currently no genetic test for
DD.
Although there is strong evidence supporting a genetic basis for DD, many environmental factors also
appear to influence its development. As with studies of disease prevalence, reports of associations with
various environmental factors often suffer from bias of one kind or another, which can result in studies
that appear to contradict each other. For example, a population study in Iceland concluded an association
between DD and manual labor, 15 whereas a large survey study in England found no such association. 16
Both cigarette and alcohol consumption have been linked with increased prevalence of DD, but a
causative factor is not known. 17 Despite the increased prevalence of DD in alcoholics, for example,
patients with liver disease due to other causes do not have an increased risk of DD. 18 It is also well
documented that there is an increased risk of DD in patients with seizure disorders. Some authors have
argued that the association is not truly with epilepsy, but with the common antiseizure drug,
phenobarbital. 19 Additional positive associations have also been reported with diabetes mellitus, human
immunodeficiency virus, hypercholesterolemia, hypertriglyceridemia, frozen shoulder, and rock
climbing, though many of these have not been validated in large, controlled studies. Interestingly, the
only apparent negative risk factor for the development of DD is the presence of rheumatoid arthritis. 20
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Pathophysiology
Regardless of the underlying etiologic factors, the common pathway for development of DD is the
transformation of fibroblasts to myofibroblasts, 21 a process mediated by transforming growth factor beta.
22 Three stages of DD development have been described 23 :
Proliferative stage: nodules form as fibroblasts proliferate
Involutional stage: contractures form, collagen is produced, cellularity reduced
Residual stage: nodules regress, hypocellular cords remain
One abnormality noted in Dupuytren tissue is the relative abundance of type III collagen compared with
normal fascia. This increased ratio of type III to type I collagen in Dupuytren tissue does not appear to be
related to a defect in collagen production, but rather a typical reaction to the increased fibroblast density
in this disorder. 24
As DD progresses, physiologic bands of fascia become diseased cords, causing contractures of the digits.
The terminology used to describe bands and cords are presented in Figure 85.1.
FIGURE 85.1 A. Anatomy of normal fascial bands, relative to the native position of the neurovascular bundles. B. Anatomy of
diseased fascial cords, with consequent displacement of the neurovascular bundle.
In general, pretendinous cords cause metacarpophalangeal joint (MCP) contractures, whereas central and
spiral cords cause proximal interphalangeal joint (PIP) contractures. Natatory cords can lead to webspace
contractures; this may be referred to as a commissural cord at the thumb-index web. Deep retrovascular
cords and extensions of lateral cords have been implicated in distal interphalangeal joint (DIP)
contractures. 25 In DD, the DIP joint sometimes becomes contracted in hyperextension, as these cords are
often dorsal to the axis of rotation of that joint.
Spiral cords are particularly notorious in that they displace the neurovascular bundle as they contract.
Most authors describe the spiral cord as arising from four structures: the pretendinous band, spiral band,
lateral digital sheet, and Grayson ligament. Because of these anatomic origins, the course of the spiral
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cord passes deep to the neurovascular bundle (spiral band) toward the lateral side of the digit, and then
concludes in Grayson ligament, superficial to the bundle. Therefore, as the spiral cord contracts, it
displaces the neurovascular bundle proximally, centrally, and superficially related to its native position
(Figure 85.1B). 26 More often than not, the digital nerve appears to be spiraling around the cord, leading
some authors to prefer the term spiral nerve rather than spiral cord. 25 An ulnar spiral cord of the small
finger is sometimes referred to as the isolated digital cord. This unique cord originates from the fascia or
tendon of the abductor digiti quinti muscle, and it can cause PIP and sometimes DIP contractures of the
small finger.
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FIGURE 85.2 A. Before collagenase treatment, this patient has symptomatic pretendinous and central cords, resulting in
contracture of both the MCP and PIP joints of the left small finger. B. The collagenase procedure is done in the office under
local anesthesia. C. One month after treatment, the patient has full extension of both MCP and PIP joints.
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Dupuytren Diathesis
Dupuytren diathesis refers to the presence of certain patient and/or disease characteristics that may
indicate a more aggressive form of DD. Specifically, research has tried to identify factors that might
predict a greater risk of early recurrence and/or extension of DD following surgical management.
Hueston originally coined this term in 1963 and pointed out four distinct factors 27 :
Bilateral palmar disease
Family history of DD
Ectopic disease
Ethnicity
Ectopic disease refers to other fibroproliferative conditions that are related to DD. Typically, three
conditions are considered: Ledderhose disease (plantar fibromatosis), Garrod pads (knuckle pads over
the dorsum of the PIP joints), and Peyronie disease (fibrotic disease causing curvature of the penis).
Based on his series of 65 patients, Abe et al. proposed the diathesis criteria should also include the
presence radial-sided disease and the presence of surgical disease of the small finger. 28
In larger series, Hindocha et al. pointed out that male patients and younger patients also tended to have
increased risk of recurrence and/or extension. Furthermore, this study showed the risk associated with
Garrod pads was higher than that associated with other forms of ectopic disease. 29 This has led us to a
modern definition of Dupuytren diathesis to include these additional factors (Table 85.1):
Male gender
Bilateral disease
Family history
Garrod pads
Age of onset less than 50
TABLE 85.1
Descriptions of Dupuytren Diathesis
Hueston (1963) 39
Bilateral palmar disease
Family history of DD
Ectopic disease
Ethnicity
Abe et al. (2004) 28
Bilateral palmar disease
Small finger surgery
Early onset of disease
Plantar fibrosis
Knuckle pads
Radial side involvement
Hindocha et al. (2006) 29
Male gender
Bilateral disease
Knuckle pads
Early onset (<50 years)
Family history
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Patient Evaluation
As with any hand surgery patient, evaluation should begin with a detailed history, with special attention
to those factors identified earlier (Dupuytren diathesis). Assessing a patient’s personal risk for disease
recurrence and/or extension is important, especially when approaching a younger patient who will be
dealing with this disease for the rest of his/her life. Family history of DD, age of onset, speed of
progression, ectopic disease, environmental exposures, and significant comorbidities should all be
documented in the medical record. Open-ended questions regarding the impact of the disease on the
patient’s daily life can be helpful to elucidate the amount of inconvenience and/or disability they are
experiencing.
Physical exam should include notation of prominent nodules, cords, and careful measurements of each
contracture, preferably made with a goniometer, for maximum accuracy. Staging systems have been
developed based on degrees of contracture and joints involved, but these are rarely used in practice, as
they are not really helpful in determining a course of treatment. Furthermore, most research studies on
DD evaluate the degree of contracture correction at individual joints; the stage of disease is rarely
documented.
Patients with mild disease with minimal or absent contractures can still easily place their palm flat on a
tabletop. This tabletop test is often used as a simple tool to help patients monitor their disease: if their
contractures progress to a point where they can no longer flatten their hand on a table, they should be
reevaluated for additional treatment.
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Treatment
The degree of contracture, chronicity of contracture, associated disability, likelihood of full correction,
and chance of recurrence must all be considered before intervention. For example, isolated MCP
contractures are easily corrected by many methods, partially because that the collateral ligaments do not
become pathologically shortened when these joints are fixed in flexion for significant periods of time.
However, PIP joints positioned in flexion for long periods of time develop intrinsic joint contractures,
which limit the overall success rates of treatment. For these reasons, mild MCP contractures (less than
30°) can be observed safely, but progressive PIP contractures should have earlier intervention to obtain
the best outcome.
Treatment options can be categorized into the following:
Nonsurgical options
Minimally invasive options
Surgical options
Adjunctive procedures
Salvage procedures
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Nonsurgical Options
A wide variety of nonoperative treatments have been considered for DD (Table 85.2). 30 A systematic
review of the literature found that only steroid injection and radiotherapy appeared to offer some benefit.
Unfortunately, the studies supporting these interventions were hampered by significant sources of bias,
and lack of control groups. 31 Patients often ask whether hand therapy, steroid injections, or radiation can
be of benefit, but there is no objective evidence for efficacy of these options. Furthermore, although
radiation-induced cancers have yet to be reported following treatment for DD, this remains a potential
risk after radiotherapy. 32
TABLE 85.2
Nonoperative Options for Dupuytren Disease
Pharmacological Therapy
Intralesional steroid injection
Topical steroids
Oral steroids
Intramuscular steroids
Vitamin E
Topical aminosyn
Furazolidon injection
Hyperbaric oxygen
Dimethyl sulfoxide
Physical Therapy
Splinting
Frictional massage
Ultrasound
Heat treatment
Radiotherapy
External beam radiation
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Minimally Invasive Options
Needle aponeurotomy
Collagenase injection
Needle aponeurotomy, as the name implies, is a procedure that uses a hypodermic needle to disrupt the
cord or cords responsible for Dupuytren contractures. This is typically an office-based procedure done
with local anesthetic. It has the advantage of a rapid recovery, minimal discomfort, high patient
satisfaction, and lower cost than more invasive procedures. However, there is a steep learning curve, and
most studies have shown higher and faster rates of recurrence compared to other treatments. There is also
a small risk of tendon and/or digital nerve injury.
Needle aponeurotomy can be considered for any symptomatic MCP or PIP joint contracture with a
palpable cord, but is not a good choice for patients that have experienced rapid recurrence following
treatment or in patients with severe scarring or skin shortening. 33 The effectiveness of needle
aponeurotomy is increased by corticosteroid (triamcinolone) injection. 34
Collagenase injection, specifically with collagenase Clostridium histolyticum (CCH) emerged in 2009 as a
new option for the treatment of Dupuytren contractures with a palpable cord 35 (see Figure 85.2).
Although this is also administered in the office setting with local anesthesia, it requires two separate
visits: one for injection of CCH, and one for manipulation of the digit into extension. While the original
recommendation was for these procedures to be done on consecutive days, many practitioners have had
success with manipulation up to 7 days later. 36 In 2014, the FDA approved CCH for injection in two cords
in the same hand simultaneously; this medication is also approved for use in the treatment of Peyronie
disease.
CCH injection frequently causes localized bruising and pain, and occasional lymphadenopathy and
manipulation-related skin tears. Rarely, tendon ruptures and allergic reactions have been reported.
Although it is quite effective, this medication is expensive and is not available in much of the world.
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Surgical Options
Fasciotomy
Limited fasciectomy
Radical fasciectomy
McCash open palm technique
Upon deciding to proceed with open surgery for Dupuytren contracture release, one must still decide on
the extent of the procedure to be performed. Patient preference, severity of disease, prior surgical
scarring, propensity for recurrence, and surgeon experience may all play a role in the choice of surgical
procedure.
Patients with severe comorbidities presenting with simple, narrow Dupuytren cords may be an ideal
candidate for simple fasciotomy through small skin incision(s). While similar to needle aponeurotomy in
some respects, making a small skin incision should afford better visualization of the neurovascular
bundles.
Fasciectomy typically requires a more extensive exposure for resection of the diseased fascia and release
of contracture. Skin incisions for exposure should be carefully designed, avoiding incisions that cross
flexion creases at right angles during closure. This can be accomplished by using zigzag (Bruner)
incisions, or by using a longitudinal midline incision that is converted to Z-plasties at each flexion crease
at time of closure. Z-plasty closures can add length to the scar, and is very helpful in patients with
shortened, scarred skin. Similarly, each of the points in a zigzag incision can be extended into a Y,
allowing a Y-to-V closure for each flap, lengthening the incision (Figure 85.3).
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FIGURE 85.3 Incisions useful for Dupuytren fasciectomy. A. Classic Bruner (zigzag) incisions. B. Modified Bruner incisions,
with transverse extensions that can allow for Y-to-V flap closure at each point along the incision. C. Longitudinal incision, which
is broken up with Z-plasties at time of closure.
At the time of fasciectomy, the surgeon can choose to remove just the diseased fascia (limited
fasciectomy) or remove both diseased and nondiseased fascia (radical fasciectomy). In modern practice,
radical fasciectomy is uncommonly performed due to its increased morbidity; most surgeons perform
limited fasciectomy, concluding the operation once the contracture has been corrected.
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The operation commences with elevation of the skin edges and/or flaps (Figure 85.4A and B). Whenever
feasible, nondiseased subcutaneous tissue should be left on the skin flaps to preserve as much blood
supply to the skin as possible. Dissection of the diseased cord proceeds from proximal to distal in most
cases, starting in the proximal palm. At this location, the longitudinal fascial fibers may become diseased,
but the deeper, transverse fascial fibers remain disease-free. If dissection remains superficial to these
transverse fibers, the underlying superficial arch and common digital vessels and nerves are protected.
Once dissection reaches the distal third of the palm, the transverse fascia is no longer present, and the
neurovascular bundles should be identified before continuing the dissection into the distal palm and digit
(Figure 85.4C).
FIGURE 85.4 A. Before fasciectomy, this patient had progressive, symptomatic contractures of both the MCP and PIP joints
of the right ring finger. B. Initial palmar exposure, revealing the pretendinous cord. C. The pretendinous cord has been divided
and reflected distally, held with a hemostat. The neurovascular bundles have been identified (red vessel loops). D. The
diseased pretendinous and central cords have been completely excised. E–G. Two months after surgery, the patient has well-
healed incisions and restoration of normal range of motion.
Excision of diseased fascia should proceed until all contractures are released (Figure 85.4D). If no
palpable cords or nodules remain, and joint contractures persist, then some intrinsic joint contracture may
be responsible. This is particularly common in cases of PIP joint contracture, and there is some debate as
to the utility of additional PIP joint capsulotomy in these cases. Of note, the studies that report no
difference in outcomes with capsulotomy were neither prospective nor randomized, and the lack of a
control group makes drawing conclusions difficult. 37 In practice, it may be best to proceed with PIP joint
capsulotomy and/or ligamentous release in select cases, counseling those patients that they are at higher
risk for contracture recurrence.
At the conclusion of the case, skin closure is performed, incorporating Z-plasties or Y-to-V advancements
where necessary to lengthen the skin in cases where skin shortening is present. If complete skin closure is
not possible, skin grafting can be performed, or wounds can be left open to heal by secondary intention.
The latter is certainly not a new concept; Baron Guillaume Dupuytren himself left his patient’s wounds
open in his well-publicized surgical demonstrations. This technique was popularized in the modern era
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by McCash, and is often referred to as the McCash open palm technique. McCash advocated transverse
incisions in the palm and digits to perform the required fasciectomy, followed by weekly dressings with
nonadherent gauze until healed. 38
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Adjunctive Procedures
Firebreak skin grafts
Dermofasciectomy
Soft tissue distraction
Lipofilling
Although McCash advocated leaving fasciectomy wounds open, other authors have encouraged the use
of small full-thickness skin grafts when skin closure is not possible without tension. In fact, Hueston
believed that full-thickness skin grafts could act as a firebreak in DD, as he observed no instances of
recurrence in skin-grafted digits. 39 Ketchum reported a similar finding in 24 patients observed for about
4 years postoperatively: no recurrence was noted in any of the full-thickness skin grafts. 40 Based on these
findings, Ketchum advocated wide excision of diseased fascia and involved skin (dermofasciectomy),
especially in recurrent cases. Of note, Ketchum injected residual Dupuytren disease with triamcinolone as
part of his standard surgical protocol.
This finding was challenged by Ullah, who performed a randomized prospective trial comparing patients
closed with Z-plasty to those closed using small full-thickness skin grafts at the intended Z-plasty site. No
difference in recurrence was noted between the two groups, although these patients did not have heavy
skin involvement, nor did they have a shortage of skin at the time of closure. 41 In many ways, these
patients were very different from those requiring large excisions of skin and fascia as were reported by
Hueston and Ketchum, so direct comparison of these findings is difficult.
Because the fibers of the palmar fascia attach to the skin in multiple locations, it is not surprising that the
skin can become directly involved with DD. Indeed, it is often difficult to find a plane of dissection
between an adherent fascial nodule and the overlying dermis. This problem is worsened exponentially in
cases of recurrent contracture, when postoperative scarring further complicates the dissection. In these
cases, wide resection of involved skin and fascia, followed by resurfacing of the entire wound with a full-
thickness skin graft, may be the best option to help reduce risk of further recurrence. 42
Soft tissue distraction has been used to treat Dupuytren contractures, relying on slow steady stretch to
help overcome problems with foreshortened skin and other soft tissues. Using devices such as the Digit
Widget® (Hand Biomechanics Lab, Sacramento, California), gradual tissue lengthening can be
accomplished slowly over a period of weeks or months, making subsequent surgery easier and more
successful (Figure 85.5). Problems such as skin deficiency, vascular compromise due to stretched arteries,
and intrinsic PIP joint contractures can be overcome with the preliminary distraction. When compared to
fasciectomy and checkrein ligament release, this approach was shown to provide a better degree of
contracture correction. 43
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FIGURE 85.5 A. Before intervention, this patient had recurrent Dupuytren contracture of the left small finger, primarily
affecting the PIP joint. B. The Digit Widget® installed on the middle phalanx. C. The device connects to a hand-based wrap,
using rubberbands to generate constant extension force at the PIP joint. D, E. After 2 months of gradual distraction, the finger
position is greatly improved. At this time, fasciectomy was performed. F, G. Eight weeks after revision fasciectomy, with
restoration of normal range of motion.
Percutaneous aponeurotomy and lipofilling (PALF) has been advocated by some as a viable alternative to
standard limited fasciectomy. This procedure begins with a thorough percutaneous aponeurotomy to
disintegrate the Dupuytren cord, followed by infiltration of the area with autologous lipoaspirate
(lipofilling). Proponents of this technique believe that the fat graft may act in several ways:
Reduction in myofibroblast density and cell-to-cell contact
Inhibition of myofibroblast proliferation mediated by adipose-
 derived stem cells
Prevention of recurrence by replacing the deficient subdermal fat
In a randomized study of 80 patients, comparing PALF to limited fasciectomy, no difference in recurrence
was noted at 1 year. Although the two groups sustained complications at statistically identical rates, the
authors report that the fasciectomy group sustained more permanent complications. 44 Although these
results are encouraging, long-term studies are necessary to prove the effectiveness of this—or any—new
technique for correction of Dupuytren contractures.
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Salvage Procedures
Arthrodesis
Amputation
While salvage procedures are rarely discussed early in the course of this disease, patients who have
experienced rapid recurrence after surgery, or complications related to surgery, may have to consider
various salvage procedures. It is important for patients to understand that the risk of surgery
dramatically increases for each subsequent surgery on a digit. For example, although the risk of nerve
injury in a primary limited fasciectomy operation is around 3%, this number increases dramatically for
subsequent operations. Roush and Stern reported 68% of patients had some disturbance of sensation at
final follow-up after repeat fasciectomy; 11% of fingers had no sensibility. 45
With this in mind, the overall goal should be to reduce the number of operations on any given digit with
DD. For patients with early, severe recurrence, PIP arthrodesis is one option that can stabilize the finger
position and preserve some finger function. In patients with severe contractures and strong diathesis,
repeat fasciectomy with interphalangeal fusion has been shown to preserve total active motion similar to
preoperative status, as motion lost from the arthrodesis is offset by motion gained at other joints. 45
Amputation is considered only as a last resort in DD. Patients with severely contracted digits may
experience chronic pain, hygiene issues, and ongoing disability related to the troublesome digit. If sincere
attempts at contracture correction are met with early, rapid recurrence, then amputation may be
considered a reasonable option, especially in a patient with a strong Dupuytren diathesis, where
recurrent contracture appears to be inevitable. Elective amputation should be performed with careful
planning, especially in patients already suffering from chronic neuropathic pain. Phantom sensation and
phantom pain after surgery cannot be predicted easily, and sometimes pain related to complex regional
pain syndrome is not eliminated with an amputation of the involved digit.
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Outcomes
The physical outcome most commonly reported in Dupuytren studies is range of motion. Specifically, it is
important to accurately measure the contracture before an intervention, then define a point in time when
it is appropriate to determine the end result after the intervention. Finally, because recurrence is an
important concern, studies should consistently report the incidence of contracture recurrence over an
appropriate time frame. When one reviews the existing literature on outcomes in DD, one quickly
discovers that studies are very inconsistent in their reporting of range of motion, defining recurrence, and
in the timing of these assessments.
To help establish consistency in Dupuytren outcome reporting, a consensus group used the Delphi
method to establish a definition of recurrence in 2014. They defined recurrent contracture as passive
extension deficit of more than 20° for at least one treated joint, in the presence of a palpable cord,
compared to the result obtained at time 0. Time 0 was further defined as between 6 weeks and 3 months
after an intervention. 46
Patient-reported outcomes are increasingly used to evaluate the benefits of one procedure over another
from the patient’s perspective. Traditional tools such as the disabilities of the arm, shoulder, and hand
(DASH) questionnaire and the Michigan Hand Outcomes Questionnaire have both been found to be
acceptable and validated for Dupuytren disease. A DD-specific assessment tool has also been developed
and validated: the Unité Unité Rhumatologique des Affections de la Main (URAM) scale. 47
Many published studies have sought to compare the results of common interventions, including surgery,
needle aponeurotomy, and collagenase treatment. Not all studies use the same definitions and endpoints,
and there is potential for bias, but a review of some of these results can inform the shared decision-
making process. Although there are many large case series reported on each of these techniques, showing
very optimistic results, the discussion here will focus on the small number of high-level studies that have
been published to date.
Van Rijssen et al. performed a randomized controlled trial (RCT) comparing limited fasciectomy to
needle aponeurotomy. 48 In their initial publication, the 6-week results were reported. Improvement in
contracture was statistically better in the fasciectomy group compared to the needle aponeurotomy group
(79% versus 63%). However, DASH scores were significantly lower in the needle aponeurotomy patients
at all time points, reflecting less disability after the intervention. In a follow-up study, the 5-year
recurrence rates were reported. 49 Patients who underwent limited fasciectomy had significantly fewer
recurrences (9 of 78 rays) compared to the needle aponeurotomy group (45 of 88 rays). Fasciectomy
patients were also significantly more satisfied with their outcomes, and this was significantly associated
with recurrence. This study nicely demonstrated that the more invasive procedure (fasciectomy), while
resulting in more short-term disability, has better long-term outcomes due to a lower recurrence rate.
In an effort to compare results among minimally invasive options, several studies have performed head-
to-head comparisons of needle aponeurotomy and collagenase treatment. A single-blinded RCT was
performed by Strömberg et al. to examine the effectiveness of these two procedures on contractures of the
MCP joint of 20° or more. 50 Collagenase injection was found to have more procedural pain than needle
aponeurotomy. Final results at 1 year showed no difference between treatment groups in terms of MCP
contracture or URAM scores.
Another RCT performed by Scherman et al. looked at these two interventions in patients with
involvement of the PIP joint. 51 Reduction of contracture was similar at 3- and 12-month time points
between the groups, and collagenase was again noted to be more painful at the time of treatment
compared with needle aponeurotomy. Although correction of MCP contracture was maintained at 1 year,
PIP joint correction was not maintained in either group. These results were confirmed in a follow-up
study reporting this group’s 3-year follow-up. 52
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In summary, comparison studies show that needle aponeurotomy has early results equivalent to
fasciectomy for cases of mild contracture, but may not be as effective for contractures involving the PIP
joint. Although needle aponeurotomy has less disability and pain, it has higher recurrence rates than
fasciectomy. At least three RCTs have compared needle aponeurotomy and collagenase; all three have
failed to show any long-term difference in recurrence rates.
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Summary
Dupuytren disease is a benign—but incurable—fibroproliferative disease with a strong genetic
component as well as several environmental associations. The concept of Dupuytren diathesis has helped
define risk factors that can help distinguish patients who may have an unfavorable result after
intervention (early recurrence or extension of disease). High-level studies to evaluate outcomes show that
limited fasciectomy has better durability, but greater short-term disability, compared to the minimally
invasive options of needle aponeurotomy and collagenase injection. A patient-
 centered, shared decision-
making process is favored when deciding on interventions for individual patients. 53 Patient risk factors,
severity of disease, physician experience, and available resources may all impact the choice of treatment.
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