3-Dimensional fasciectomy: A highly efficacious common ground approach to Dupuytren's surgery

Abstract

Background: Numerous Dupuytren's fasciectomy techniques have been described, each associated with unique surgical challenges, complications and recurrence rates. We describe a common ground surgical approach to Dupuytren's disease; 3-dimensional fasciectomy (3DF). 3DF aims to address the potential contributors to the high recurrence rate of Dupuytren's disease and unite current limited fasciectomy practice that varies considerably between surgeons.

Methods: We describe the 3DF principles; raising thin skin flaps (addressing dermal involvement), excising diseased palmar fascia with a 3-5 mm clearance margin (treating highly locally recurrent conditions) and excising the vertical septae of Legueu and Juvara (providing deep clearance, hence addressing all potentially involved pathological tissue). The surgical outcomes between traditional limited fasciectomy (LF) and 3DF are compared.

Results: From the 786 operations included (n=585), postoperative recurrence rates were significantly lower for the 3DF group (2/145, 1.4%) than the LF group (72/641, 11.2%) (P=0.001), and the time to recurrence was significantly longer (5.0±0 years vs. 4.0±0.2 years; P<0.0001). With recurrence excluded, there were no differences between the postoperative complication rates for 3DF (5/145, 3.5%) and LF (41/641, 6.4%) (P=0.4).

Conclusions: Our results suggest that 3DF leads to lower recurrence rates and a longer disease-free period for patients, without increasing complications. 3DF provides a safe, efficacious, common ground surgical approach in the treatment of Dupuytren's flexion deformity.

Keywords: Dupuytren contracture; Fascia; Fasciectomy; Hand; Recurrence.

Fig. 1.. Planning incisions

Under tourniquet control, using a lead hand, Bruner’s incisions, with Y-V advancement were used for access.

Fig. 2.. Raising thin skin flaps

Relatively thin flaps are raised at intra-dermal or just subdermal levels, almost the thickness of a full thickness skin graft, in recognition that Dupuytren’s can involve or even originate from the dermis.

Fig. 3.. Excision of diseased tissue with a 3–5 mm margin

(A) The involved palmar fascia (aponeurosis) fibers are excised with a 3−5 mm peripheral clearance margin where possible to clear this potentially diseased fascia. This is in recognition of the fact that Dupuytren’s is prone to a high local recurrence and or progression rate. (B) The palmer fascia (aponeurosis) is shown with the underlying septae of Legueu and Juvara. Only the affected fascia is excised with a 3-5 mm clearance margin and the dissection continues to excise the septae of Legueu and Juvara.

Fig. 4.. Excision of the vertical septae of Legueu and Juvara

(A) The 8 vertical septae of Legueu and Juvara form 7 compartments through which either the long flexor tendons, or lumbricals and neurovascular bundles run longitudinally. The septae attach distally to the metacarpals, transverse metacarpal ligament and interosseous fascia. (B) Diseased tissue is carefully excised in a proximal to distal fashion, including purposeful routine excision of all the septae of Legueu and Juvara to provide a deep clearance margin. This step is the fundamental difference to limited fasciectomy and is what makes the technique 3-dimensional.

Fig. 5.. Digital extension of 3-dimensional fasciectomy

(A) The central cord runs longitudinally in the middle of the proximal phalanx, attaching distally to the middle phalanx. The lateral cord runs between the neurovascular bundle and skin, to which it is intimately adherent. The spiral cord is also intimately related to the neurovascular bundles. (B) The surgery extends into the digit, whenever there is Dupuytren’s involvement here, in order to achieve complete or near-total correction.