Name:
Palmar Fasciectomy for Dupuytren's Cords
Description:
Palmar Fasciectomy for Dupuytren's Cords
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Duration:
T00H11M04S
Embed URL:
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Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/5a746cad-1338-4497-a52e-a8336a5b4599/v-005687.mp4?sv=2019-02-02&sr=c&sig=BNk%2BcIhYweMpfkAfx6rsGoeQ4oodGH2WjdTCe0479Ps%3D&st=2024-11-21T17%3A10%3A01Z&se=2024-11-21T19%3A15%3A01Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
JESSE MEAIKE: My co-authors and I thank you for the opportunity to present this case. We will be presenting a case of Palmar Fasciectomy for Dupuytren's contractures. All financial disclosures are as listed on the ASSH website. We present a 63-year-old right hand dominant physician with right small and ring finger Dupuytren's cords. He had undergone needle aponeurotomy for the ring finger eight years prior with good results initially, but noted progressive contracture over the past several years, resulting in difficulties flattening his hand, such as with activities like keyboarding.
JESSE MEAIKE: On examination, he had right ring finger pre tenderness and central cords associated with a 30 degree flexion contracture at the MCP joint, a small finger spiral cord with 10 degree MCP joint and 40 degree PIP joint flexion contractures and a natatory cord between the small and ring fingers. Given his recurrence after needle aponeurotomy, we discussed treatment with collagenase injections as well as palmar fasciectomy and he elected to proceed with surgical management.
JESSE MEAIKE: Preoperative radiographs most notably demonstrate the PIP joint contracture of the small finger as well as mild arthritic changes about the small finger PIP joint. Our typical indications for palmar fasciectomy are MCP joint contracture greater than 30 degrees, any PIP joint contracture and any contracture that is symptomatic for the patient causing pain, tenderness or functional impairment.
JESSE MEAIKE: Contraindications for palmar fasciectomy include non Dupuytren's related contractures, active infection and medical comorbidities precluding surgical intervention. All surgery was performed under 3.5x loop magnification and tourniquet control. Bruner incisions were fashioned overlying the cords in a way such to allow a wide skin bridge between the two incisions. The arm was elevated and exsanguinated, and the tourniquet was inflated to 250mm of mercury.
JESSE MEAIKE: The hand was placed in a hand table providing extension of the operative digit. We started with the ring finger. The skin was incised with a 15 blade scalpel through the dermis. We then sharply elevated full thickness skin flaps from the underlying palmar fascia with the beaver blade, taking care to leave all the subcutaneous fat with the skin flap.
JESSE MEAIKE: Here we perform this from proximal to distal in both the radial and ulnar directions. Blunt dissection with tenotomy scissors may facilitate this process and here you can see us performing blunt dissection distally sharply transecting the palmar fascia.
JESSE MEAIKE: We also use the tenotomy scissors to perform blunt dissection and identify the ulnar nerve vascular bundle going to the ring finger. Once identified, we use the tenotomy scissors to dissect it through its entire course. Here we perform this in a distal to proximal manner.
JESSE MEAIKE: Once it is circumferentially dissected, a vessiloop may be placed around it so it can be retracted out of harm's way. We again use the tenotomy scissors to bluntly dissect to continue the distal dissection of the neurovascular bundle. Here you can see we have identified the radial nerve vascular bundle proximally and continue a proximal to distal dissection so it can also be retracted out of harm's way.
JESSE MEAIKE: Now we have isolated the cord and retracted the neurovascular bundles on either side. The cord is sharply transected with a scalpel proximally. We then proceed with a proximal to distal dissection of the cord from the underlying flexor tendon sheath and later annular pulley system. This is performed with a combination of blunt and sharp dissection.
JESSE MEAIKE: Bipolar cautery can also be used as needed. Here we identify the natatory chord passing from the ring finger to the small finger. The neurovascular structures are isolated and protected with vessiloops.
JESSE MEAIKE: This allows us to safely continue the dissection of the natatory cord. Here, we further dissect the cord with the combination of blunt and sharp dissection. Once it is isolated, it can be sharply transected and removed. Here, we are using the beaver blade to sharply remove the natatory cord.
JESSE MEAIKE: Now we return our dissection to the ring finger again in a proximal to distal manner, separating it from the flexor tendon sheath and annular pulley system. Here we demonstrate that these structures are intact. Now we turn our attention to the small finger. In a very similar manner,
JESSE MEAIKE: we make the skin incision with a 15 blade scalpel hole through the dermis. We again use the beaver blade to elevate full thickness skin flaps from the palmar, palmar fascia radially and ulnarly, taking care to leave the subcutaneous tissues with the skin flap. Bipolar cautery may be used as needed for hemostasis.
JESSE MEAIKE: Here we identify the ulnar nerve vascular structures proximally. Note that this patient has a spiral cord which displaces the ulnar nerve vascular structures towards the midline of the digit. Once identified proximally, we can continue our dissection distally to completely free the neurovascular structures.
JESSE MEAIKE: Here you can see both the ulnar and the radial neurovascular structures and the displacement caused by the spiral cord. We continue our dissection distally. Here, freeing up the cord from the subcutaneous tissues and surrounding structures.
JESSE MEAIKE: The radial and ulnar nerve vascular structures have been identified, so we sharply transect the cord proximally. The neurovascular structures are then retracted out of harm's way with vessiloops. In a proximal to distal dissection is continued.
JESSE MEAIKE: The beaver blade may be used to sharply dissect and remove the cord from the underlying tendon sheath and pulley system.
JESSE MEAIKE: The cord is sharply transected and removed from the surgical field. Careful dissection has maintained the integrity of both the radial and ulnar nerve vascular structures, as well as the underlying flexor tendon sheath and annular pulley system. At the completion of the case, the tourniquet was deflated and hemostasis obtained.
JESSE MEAIKE: The wounds were irrigated with saline. Topical thrombin spray was applied for hemostatic effect. The wounds were then closed with 4-0 prolene and dressed with xeroform 4 by 4's and webriyl. He was placed in a volar resting splint with the fingers in full extension. The patient was splinted in full extension for five days. He returned to clinic on post-operative day five, at which time he was referred to hand therapy for fabrication of a custom orthosis with the fingers in full extension and to be worn at night time, and also for initiation of range of motion exercises and edema control measures.
JESSE MEAIKE: He returned again at 2 weeks for suture removal and initiation of scar massage exercises. At most recent follow up 2.5 years post op, he had excellent range of motion with full extension of the right small and ring fingers with a flat tabletop sign. This retrospective study performed at our institution demonstrated the efficacy of palmar fasciectomy with a 4% re-operation rate at five years as compared to 61% for needle aponeurotomy and 55% for collagenase injections.
JESSE MEAIKE: Another recent study by Radhamony et al, analyzed the recurrence rate and incidence of residual deformity following Dupuytren's palmar fasciectomy. Recurrence was defined as more than 20 degrees of contracture recurrence in any treated joint at one year post treatment, compared to six weeks post treatment, while residual deformity included those that appeared within the first year following fasciectomy i.e. noted intraoperatively or in the immediate post operative period.
JESSE MEAIKE: The rate of recurrence was found to be 3.5%. The rate of residual deformity was 30.3%, though nearly 80% of those with a residual deformity were classified as mild, with less than a 30 degree extension deficit. The complication rate was 11.9% and included three cases of complex regional pain syndrome, nine nerve lesions and 13 wound complications such as infection, dehiscence and seroma formation.
JESSE MEAIKE: We again, thank you for the opportunity to share this case.
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